Guest Blogger Dr. Jesse Hellman: More Thoughts On Rachel Aviv's Article on Involuntary Treatment

Jesse has wanted to do a guest blog post for a while now, and The New Yorker article finally got him blogging. I wrote a brief post yesterday, but he does a more thoughtful analysis of this complicated and provocative issue. Clink is off somewhere.. I am looking forward to hearing her thoughts after the holiday.
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In “God Knows Where I Am” Rachel Aviv sees the protagonist Linda’s
refusal of treatment as an expression of her illness. The moral
impasse she describes for our profession, though, is real: denial of
the need for treatment, or of one’s illness, can be an expression of
that illness; the refusal of treatment can also be a valid position
which we understand and support.

Mental functioning can be variable, at times better and at times
worse. At times the craziest thoughts are held in check, or do not
manifest themselves, while at others they hold total sway. The
underlying assumptions of our society are shared by us, and these
shape our reaction to the illness that Linda has. Other societies,
with different traditions and philosophical underpinnings, are
comfortable with very different stances.

Before Linda was discharged from the hospital the staff did everything
they could to dissuade her, and to provide for her safety. She
rejected every effort to provide housing and support. The hospital
argued that she was too sick to make decisions which even included not
allowing the staff to notify her sister and daughter. After her death
the family sued, stating that insufficient effort had been made to
protect her. The hospital then argued she was not sick enough to
justify stronger measures. What was true?

When we look at a complex issue, or event, we naturally can only see a
part, and our response is shaped both by what we see as well as the
assumptions we carry. What weight to we place on independence versus
the rights of others? What extrapolation can we make to an unusual
thought, in that do we see it as the harbinger of insanity or of
artistic creativity? Do we value religious musings or find them
suspect?

Aviv lets us see that while a part of Linda’s functioning might have
been creative, artistic, perceptive and so on, it was increasingly
shaped by an imagination which was not tempered by reality. It was as
if she was in a dream but could not awake, a dream which increasingly
dominated the most important parts of her ability to survive.

So what is the proper role of society when confronted by such illness?
What if her fantasies had shifted from thinking spies were all around
her to imagining the world could only be saved if she were to shoot
her congresswoman?

The Unwilling Patient: New Yorker Article

In balancing rights against needs, though, psychiatry is stuck in a kind of moral impasse. It is the only field in which refusal of treatment is commonly viewed as a manifestation of illness rather than as an authentic wish.
-- Rachel Aviv, God Knows Where I Am, The New Yorker, May 30, 2011

In the May 30th issue of the New Yorker, Rachel Aviv writes about the plight of a woman who does not believe she has bipolar disorder, or any psychiatric illness for that matter. It's a poignant and tragic article about a woman who is incarcerated for a crime, spends a year and a half in jail before she is found incompetent to stand trial, then goes to a psychiatric hospital where she remains until she is discharged with no plans for housing, money, follow-up, or notification of family--- it's not that the hospital wouldn't offer any help, it's that the patient wanted her freedom and would not allow interventions. Aviv gives examples of the woman's psychosis as a motive for her behaviors. Free, she finds a vacant farmhouse and breaks in. She is fearful of being re-captured, and remains hidden in the farmhouse, subsisting on 300 apples. She journals, she appreciates nature, and she reads books she finds in the attic. In mid-January, three months after her release from the hospital, and 39 days after she ate the last apple, she dies of starvation. Her body was not found until May.

Aviv's article focused on two aspects of the psychiatric system: the emphasis on the patient's insight as a focus, even requirement, of treatment, and the issues of involuntary treatment in patients who aren't posing an imminent threat of violence. I couldn't quite tell where Aviv stood on these issues--she seemed to waiver from condemning a system of forced care, to condemning a system that would let an ill patient leave untreated with no money and no notification to family members. She definitely does not like that the system would have provided for housing for this patient, but the patient wouldn't sign the requisite forms because they noted that she had a mental illness, a fact she did not agree with. Aviv mentions the concept of "thank you theory" --the idea that once patients get well they will agree that the treatment was in their best interest. She notes that only about half of patients who are involuntarily hospitalized later believe it was necessary. It's a difficult statistic to work with--because it means the other half did believe that treatment was necessary, so how, as a society, do we know what we should do? She talks about advance psychiatric directives.

I'd like to share parts of the article, but I had to buy the issue online to read it and it doesn't seem to let me copy and paste. You can listen to a podcast with the author on The New Yorker's website at:
http://www.newyorker.com/online/2011/05/30/110530on_audio_aviv

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Read more here: http://www.newyorker.com/reporting/2011/05/30/110530fa_fact_aviv#ixzz1NbdWI6sM
So really, this is a ClinkShrink article. Maybe she can read it and post again?

Like Looking in a Mirror

Sometimes, I treat people who have the same problems I have in my personal life. It's hard. Oh, it's really hard. If I'm really distraught about something and a patient calls seeking treatment with a similar life circumstance, I will sometimes turn them away and recommend another shrink. But I don't always screen so carefully on the phone, and often "I'd like to make an appointment," will simply get a time and date.

The feelings get really complicated here.

If I feel I've had a role in creating my circumstances, then I wonder as my patients seek my counsel, Who am I to be making any suggestions, much less giving advice? Why are you looking to me, I've screwed up the same situations. Oh, you say, Dr. Jeff said on KevinMD that healthy's Shouldn't Give Advice, but you know, some of us do, and even when we don't, our feelings are often relayed through the questions we ask or the comments we make or don't make, or perhaps by the expressions on our faces, even if we don't say "You should do X." I told a friend once that I feel uneasy, guilty even, in these situations, and he replied, "How do you think I feel?" Did I mention he does family work and was in the midst of a stressful divorce? And I have yet to ask a colleague who also does family work how he managed during the years his own children wouldn't speak to him. Oy, life can be tough, for shrinks just like everyone else.

So perhaps I listen to someone talking about his most personal feelings about a situation, and you know, if I've been there before, perhaps it's good that I can empathize. If I'm in the middle of it, sometimes I listen and the patient's words seem so unreasonable, so unjustified, and yet I recognize them as being exactly my own--it's like having my own anxieties bounced off a wall only to ricochet straight back into my face.

Do I tell the patient that I've been in the same place before? Generally, no. Therapy is about his problems, not mine, and I think in these situations my empathy is clear. I say things that are more poignant and resonant than I might in circumstances where I feel removed. And patients never ask if I've been in the exact same place. On some of the harder things-- things that have no precise quick and easy answer-- I've taken to saying, "Not only don't I know what will fix this, I don't know anyone else who does have the answer." This I can say because I've done my own searching.

I hope I'm reassuring and comforting to people who find themselves in the same places I dwell. Certainly, tripping over a few stones on the path makes one walk a little more gingerly and judge a little less harshly those who walk more slowly. Mostly, though, I worry that I'm a little bit of a fraud just for being in the room.

This Medicine Might Kill You, But....

We all believe in Informed Consent and ClinkShrink likes to write about it. See Is It Malpractice to Lie...or better yet, read our book when it comes out where Clink talks all about the history of Informed Consent and many other such things. And one of the things people get angry at doctors for (? and shrinks in particular?) is when they have side effects or adverse reactions, and the doctor hadn't told them this might happen. People seem to get really mad about this, especially on blogs or on anti-psychiatry sites (sorry, no links here, find your own anti-psychiatry sites).

So I've wondered, does it matter if a patient is forewarned that they may get a side effect? There are many icky responses people have to meds, some are not very common, and sometimes it's hard to tell if it's the medicine causing the problem. And side effects can be uncomfortable, are they less uncomfortable if you were forewarned? You need a procedure and they make you sign a form saying that you know you could get an infection, hemorrhage, or die. Everyone has to sign or no procedure. If something bad happens, you can still sue, but if you're dead, you're dead. It's become so rote that it almost lacks meaning.

I do tell people about the more common side effects of medications. The pharmacist gives them a longer list. Google has it all for the curious, and I certainly don't discourage Googling, I sometimes suggest it. But I've wondered, does informed consent change things? Here's what my non-scientific observations have revealed.

There a medication that is associated with a rash that can be fatal. I tell people this, and the precautions they need to take to avoid croaking---slow titration, stop med/call if there is any rash at all. A shrink friend prescribed the medication to a patient who had a rare ?never heard of reaction and ended up in an ICU with liver toxicity and nearly died. The patient didn't die, made a full recovery, but the shrink was pretty traumatized and said she wouldn't use the medication again. After my friend's patient had this problem, I told every patient I prescribed this medication to this story. No one flinches. No one has said, "I don't want to take that medication that nearly killed someone." On the other hand, if I say, "This medication is associated with weight gain in some people," the resistance becomes huge. Even though weight gain is gradual and can be monitored, and I tell people they must get weighed twice a week and we can stop the medication if their weight increases by 4 pounds (that's my non-scientific cutoff for beyond the realm of fluid fluctuations). And I know skinny people who take lithium and zyprexa and stay skinny; not everyone gains weight. And I know people who feel so much better that they are willing to tolerate some weight gain.

Just my thoughts this chilly Saturday morning. By all means, tell us your stories.

Identity Crisis!

So I was born a Gemini. It's been part of my identity, always. I'm not much for astrology, and I don't check my horoscope, but it's something everyone knows about themselves, and sometimes it's fun. And interestingly enough, Gemini fits me to a tee.

Here, see if you agree. From Ganeshaspeaks.com:

Ruled as they are by the Planet Budha (Mercury), Mithuna ( Gemini ) exhibit a delicious brand of mercurial energy. They are quick thinking, quick-witted and fast on their feet. It's their curiousity and cleverness that make them such a hit at cocktail parties. But they are not just good talkers - they also love to listen and learn. However, any social setting is good enough for a Mithuna ( Gemini ) since these folks are charming, congenial, and love to share themselves with their friends. Mithuna ( Gemini ) mind drives them to talk, to converse and it is not always just idle chatter. They need more and more information to feed their intellectual inclinations. They probe endlessly for more information as the more it collects the better. They are supremely interested in developing their relationships. Sharing that knowledge later on with those they love is also a lot of fun. Mithuna ( Gemini ) are bright, quick-witted and is at the centre-stage in any party. Although rational and practical, they also have a surplus of imagination. However the fact that they are unsure which twin will show up half the time they are often considered fickle and restless. They can be moody and act on simple whims. While their effusiveness may be misconstrued as scheming by some, Mithuna ( Gemini ) generally have their hearts in the right place. It is this ample energy, which can also paint them as scatterbrained and unfocused but, behind all that restlessness, they are usually busy filing all that information away. Funny, brimming with life, full of ideas, adorable, inconsistent, capricious, superficial, they are a bundle of maddening contradictions. They may deal in everything and are 'know-alls', but at the same time they also have the ability to master skills. Mithuna ( Gemini ) are versatile and have an amazing grasp of the subject they choose, although it may not interest them for long. They prize intellect and consider it to be the key to all things. At work, they are the clearest of thinkers, suggesting logical and well-thought-out ideas which make them an asset to any team. Their greatest strength lies in their ability to communicate effectively and to think clearly. Adventures of the mind are what the Twins are all about. Bestowed with a cheerful face easily detectable from signs of anxiety, tension or unhappiness the Gemini face is a dead give-away when they try to hide sorrow behind their brand of wit and humour. If even for a short while, romancing a Gemini is likely to be interesting, adventurous and fun, but the fickle, almost uncaring attitude will manage to break many hearts before they finally settle down. Although affectionate Mithuna ( Gemini ) can be extreme flirts, But be sure that the partner shares the Mithuna ( Gemini ) sense of humour. Mithuna ( Gemini ) never stray if the family life is satisfying. However it is best not to rush headlong into marriage; give adequate thought before popping the question.

So apparently, Parke Kunkle, some guy in Minnesota (homeland of ClinkShrink, no less) decides that it's all wrong. Everything is off. Now I'm a Taurus. But I'm not a Taurus, I'm a Gemini. They want to stick me and ClinkShrink under the same stars? No way.

And here are the new dates:
Here are the new zodiac dates:

Capricorn: Jan. 20-Feb. 16
Aquarius: Feb. 16-March 11
Pisces: March 11-April 18
Aries: April 18-May 13
Taurus: May 13-June 21
Gemini: June 21-July 20
Cancer: July 20-Aug. 10
Leo: Aug. 10-Sept. 16
Virgo: Sept. 16-Oct. 30
Libra: Oct. 30-Nov. 23
Scorpio: Nov. 23-29
Ophiuchus: Nov. 29-Dec. 17
Sagittarius: Dec. 17-Jan. 20

Have you been blown away, too?

What will this mean in psychiatric practice? Will everyone's personality change? Will people come to talk about the shift between who they are and who they thought they were? Will they fight back? I know that I'm staying a Gemini.