Wednesday, December 28, 2016
Monday, December 26, 2016
Every year, roughly 400 doctors and medical students die from suicide. To put this in perspective, there are roughly 100 medical students in a medical school class, and schooling takes four years: each year in the United States, we lose an entire school worth of doctors to suicide. For more perspective: there are 141 medical schools and 31 osteopathic schools in the country; educating students takes time, money, and a tremendous amount of resources, and we have a doctor shortage. Losing a school worth of physicians each year is an awful thing. Furthermore, surveys have shown that about 30% of medical students have significant symptoms of depression, a percentage notably higher than the general population.
This seems a bit odd: medicine is still a profession that is held in esteem. People work for years to get into medical school and it's a very competitive process. Those who have made it are, for the most part, lucky. Academically, they are the cream of the crop: motivated, hardworking, organized, driven, and among the few who get the privilege of working in a field where you help people and earn good money. And as someone who treats patients, I will tell you that it truly is an honor to be a doctor and a psychiatrist; I am grateful for the career I've been able to have and for the flexibility and diversity it has afforded me as both a healer and writer.
So why the high rates of suicide and depression? The blame has been put on the rigors of training, the demoralization of doctoring, the disappointments and the tremendous stress. And doctors are people, they get psychiatric illnesses for the same reasons others do: genetic predispositions, personal losses, stress and a fear of failure, sleep deprivation, or devastation over a bad personal or professional event. We still don't know why some people are resilient in the face of difficulties and others are not.
And doctors hesitate to get help: after all, mental illness is stigmatized and doctors may be asked about their mental health issues for licensing and for jobs. I knew one medical student who took Prozac-- it helped with anxiety and irritability, though she never had a full blown episode of disabling depression-- and said so on health forms when she started residency. She had to explain and get documentation that she was capable of working. Obviously, we don't want someone in the throes of a disabling psychiatric episode treating patients, but we also don't want people to avoid getting care because they might be called out on it, or even lose their license when they have treatable conditions. It seems it might be better to encourage people with psychiatric and substance abuse disorders to get help rather than to have them treating patients when they aren't at their best or to have them die from suicide. It's a mixed bag, because many psychiatric and substance abuse problems can be hidden, especially by someone who is able to show up at work and function reasonably everyday, and treatment is generally available to this group of professionals in that they have insurance and resources.
The 'stigma' of quiet mental illness is still a bit odd to me. As a medical student in New York City in the 1980's, psychiatry wasn't just about being mentally ill, it was, to some extent, about self-examination. Psychiatrists who did psychotherapy were expected to have psychotherapy, and psychoanalysts were required to undergo an analysis.
As students, we were told that the school had a mental health service which provided an evaluation and 10 visits with a private practice psychiatrist (and then the student could pay for more if they wanted), or treatment with a psychiatry resident for very low fees. Many of my classmates were very open about being in treatment, and people went because they were stressed, disturbed about relationships, or having more serious psychiatric issues. During my psychiatry rotation, the chief resident wrote his analytic hours on the board in the nursing station so he would not be disrupted, and I sat in a class where one resident said to another, "Hey Bob's not here because he's starting therapy today." One of my classmates had a serious suicide attempt and was treated in the ICU. It wasn't someone I knew very well and I know none of the details. What I do know is that this classmate graduated and went on to a prestigious residency program. Google let me learn that my classmate is now, over 25 years later, a physician at a top academic institution. Today, I'm not sure if that outcome could happen.
This month, I saw an article in one of the psychiatric newspapers calling on licensing boards not to require doctors to report past episodes of psychiatric illness, only present episodes, in an effort to encourage doctors to get treatment. Really? Why single out psychiatric disorders? Shouldn't reporting requirements encompass all disabling disorders? Do you want your surgeon seizing while he's operating on you? Or having his blood sugar drop? Do we really care about the fact of an illness? Shouldn't we care more about whether it impairs a physician?
So I was pleased to read this month's newsletter from the Maryland Board of Physicians: there was a specific discussion on mental health/substance abuse treatment that noted that Maryland's licensing board asks only about current conditions (including physical conditions) that impair a physician's ability to practice. It lists some resources for getting care, and notes that this is not the same as mandated treatment in the case where it's come to the attention of the Board that someone has a health issue which obviously impairs them-- one that has been reported by a third party to the Board as being a risk to patient safety.
So Maryland docs, if you are quietly depressed, anxious, suicidal, or wonder if those happy blips in your mood mean you have bipolar tendencies -- go for it and get help. Tell who you want, and don't tell who you don't want. Will decreasing stigma or reporting requirements lower suicide rates? I hope so. And finally, if you're in Maryland and need a private practice psychiatrist to see you quickly, don't forget our resource at MarylandPsychiatrists.net where psychiatrists with availability within two weeks may list their practice. It's a free service for both shrinks and patients.
Sunday, December 18, 2016
Home Inspection and Double Billing: Two Kindle Novels for Free, and Happy Holidays to Our Shrink Rap Readers
At this time of year, I like to set up free downloads to two of my novels. You can get these books for free on your Kindle from Sunday to Thursday.
Double Billing is the story of a woman whose life changes when she discovers she has an identical twin. It's a quick read with a little psychiatry sprinkled in. One reviewer said:
The book was a page-turner because of elegant structure and pacing. I really cared about the author’s take on things –because she is a psychiatrist? because I’ve followed her blog for a while?– which meant that I was interested in the protagonist’s thoughts, feelings and actions. At times I ached for the mess her life was in, at others I wanted to shake her into action, and then she’d find her backbone again, just in the nick.
Home Inspection is a story told through psychotherapy sessions in a format that is similar to the HBO series In Treatment. Dr. Julius Strand is a psychiatrist who plods along in his already-lived life until two of his patients inspire him through their own struggles to find meaning. One reviewer wrote:
I like to read all sorts of books, but books where there's something in it that reflects a part of me, a part of my life, a part of my experiences, are something I go out of my way to find. I have not found any fiction book that does nearly as much to show what psychotherapy is like.
There is is a single link to my Amazon page with all my books here.
If you don't own a Kindle reader, you can install a free Kindle app on your computer, tablet, or cell phone by going here and then you can read any Kindle book. You don't need to buy a Kindle to read on your computer, tablet, or smartphone.
Both novels are also available as as paperbacks from Amazon, but not for free. And our two non-fiction books can also be found on that page, but again, not for free.
I'm more than happy to have people download my novels at no cost -- I'll be keeping the doctor day gig -- so please tell/tweet/blog/share the free promotions to anyone you think might be interested.
Finally, If you do read any of the books, please consider putting a review on Amazon.
Wednesday, November 30, 2016
The third time scheduled was a charm and we had a wonderful time going in to Washington to be on Diane Rehm's talk show. Okay, so the car wouldn't start at first, and I missed a turn, but we got there without event. The show included our friend, Pete Earley, and two people who had experienced involuntary psychiatric hospitalizations, Lily and Jaime -- they both did a great job of talking about their experiences. Pete, the author of Crazy: A Father's Search Through America's Mental Health Madness and more recently co-author of the novel Treason, added a lot of life to the issue by talking about how hard it was to get his son care during a psychotic state years ago. The nice thing: Pete's son is doing great, as are the two women who called in.
If you'd like to listen, the link is here:
And Pete Earley wrote more about the show, including some of the Facebook Q&A after, on his blog.
As far as the photo goes, we took a vote and Diane Rehm definitely looks the best. What a great host and what a privilege to be on this marvelous radio show before she retires.
Sunday, November 27, 2016
Involuntary Psychiatric Care-- a Discussion on NPR's Diane Rehm Show on Tuesday : the Third Time's a Charm
I've posted twice about how we will be discussing our new book, Committed, on the Diane Rehm Show on National Public Radio. Well, national politics have gotten in the way, and we've been rescheduled for more time-sensitive issues.
So I'm excited to tell you that we will be on the Diane Rehm Show this Tuesday, November 29th, during the second hour of the show -- 11 AM if you're listening on WAMU, 88.5 FM. Only it's gotten better -- while the show was originally supposed to be just the two authors, the programming has changed: Pete Earley, who wrote the foreword, will be joining us in the studio, and two people who have been hospitalized involuntarily will be participating by phone, including one of the wonderful women we traced through the book -- Lily.
Diane Rehm makes a point of saying:
While we hope you can listen live, we'll publish a link to the show after it airs.
While I'm here, please let me mention that Committed was listed on Scientific American's Books to Read in December!
Link to information about our segment on the Diane Rehm Show Here.
Sunday, November 20, 2016
Saturday, November 19, 2016
If you've already read the beginning of this, you can scroll down to the Addendum added on 1/17/17, or to Addendum #2 added on 1/26/17, or Addendenum #3 added on January 29, 2017
Please note that while this is usually a psychiatry blog, today I am using it to vent for my own personal psychotherapy. Please feel free to offer words of support, to make helpful interpretations to improve my insight, or if you know CBT techniques that may help me, I'm open to that. Is there a 12 step group for iPhone users? Medications to treat Post Traumatic iPhone Seven Disorder?
Dear Mr. Jobs,
I know you've died and left the job and I should leave you to your death in peace, but I imagine you are spinning in your grave at a mind-boggling rate where there is no peace to be had. You used to run an amazing company with great products and great service, and since you've left, it's gone to hell. I don't know where you are but perhaps you might know this?
Let me tell you my iphone 7 story.
~First I'll start from way back: I loved my iPhone 4.
~At some point I upgraded to an iPhone 5s, it had terribly short battery life of 3-4 hours. I thought I'd cracked the screen (it was a plastic protector) so it looked pathetic. Touch voicemail didn't work, and since this is my only phone and I run a medical practice from it, it was often difficult to retrieve messages, and I spent about an hour on the phone with support figuring out how to change my greeting for vacations. Simply put, it was time for an upgrade many months ago, but I waited for September for the latest model: the iPhone 7 which came with many promises.
~I went to the Apple store to buy my iPhone 7, which is constantly advertised on TV. Ha! No such product. Order it, the color I want will be available in 3 months, I opted not to.
~There were ways to order it online, but I really wanted a live person to help with set up, oh, and what I want still wouldn't be available for months.
~I gave up on the color and began calling Apple every few days. They repeatedly told me to check on line at 8 AM everyday for availability, but I could not figure out how to do that on the website (all those Ivy League degrees for nothing).
~One day, I was told that a gold (meh) phone was available at a mall 30 minutes from me and I could reserve a time to come get it. Yes! I arrived at 5:30 to get my iPhone 7, I brought my MacBook Pro because my phone was not backing to the cloud. They got me the phone, backed my phone to the computer, erased my phone (despite my suggestion that they wait until the new one was set up) and handed me off to the next guy to set up the new phone; I was told this would take a few minutes. I was able to cash in my old phone for $90. The new phone with Apple Care plan cost over $1,000.
~I remained at the store until 9:30 when it closed. My 4 year old MacBook Pro has Lion and it was incompatible with the new phone, and try as they may, 2 set up guys and 3 geniuses could not get the information transferred. At one point, the genius just vanished for half an hour (maybe on break, but he could have said so?). The geniuses were helping several people at once. There was little sympathy for my plight, but occasionally, my genius offered a reassuring word that it would eventually work. My operating system could not be updated because I was not sure if the computer was fully backed up, and when I suggested they use an external drive to do this, they said they I could buy one. No one suggested that I pay 99 cents to get enough storage space in the cloud to back up there.
~At 10 AM the next morning, I arrived at an Apple store closer to my home with my new phone, my old phone which I had purchased back, my MacBook Pro, and an external drive so the computer could be backed up. Now a new operating system could be installed that would compatible with the new phone. I was told to come back at noon because there was a wait. I did so and was told to come back at 3 PM because there was still a wait, at which point I asked to see a manager and be given special consideration since I had been trying to get the phone set up for many hours and was on day 2 now. They did expedite me, and by 5 PM, my phone was set up and my computer upgraded to Sierra. I also learned that I needed more RAM on the computer, which Apple does not do, but they suggested outside business which could help me. Really, they can't add RAM to their own computers? In all, 11.5 hours including an entire business day in Apple's stores for a process I expected to take 30 minutes. And no, I would not have purchased the phone if I was aware that it would be this difficult. And that was the beginning of the story.
~The new phone has good battery life. I'm told it has a better camera. The fingerprint unlock sometimes works, I finally turned it off. I can now back to the cloud for 99 cents a month.
~The phone itself does not work -- people are constantly telling me I am breaking up. At first I thought it was a connection issue, but then I realized it happened everywhere, on every call. I'd touch the phone and it would get better. But every call is stressful and people often hang up on me frustrated that they can't hear me.
~I called Apple support, the technician immediately knew I was on the phone that didn't work because she couldn't hear me breaking up. Diagnostics revealed a problem that would take 40 minutes to fix. I had to go to work and arranged for a call back time later. They had me re-hook to my own network, but the phone doesn't work even when I'm not on my home network. Still, it was better: fewer people complained I was breaking up, but in the middle of almost every call, people continued to tell me that they've lost me. "I can't hear you, can you hear me?" (Yes I can hear you). Have I mentioned that I run a doctor's office off this phone, and that I have a new book out and planned to be doing a live radio interview from it on Monday for a Sirius XM show --Ah, I will stay near a landline.
~I tried to make a Genius Bar appointment on the website. There used to be an option for Get Help and Make A Genius Bar Appointment. No more. It took clicking through many many screens, some repeatedly, to get to that point where you can actually schedule and I would not be able to find it again. The contact info all wanted me to chat or call, which I'd done. At this point, I now dream my Apple Password because I've entered it roughly 100 times in my many hours of iPhone 7 hell. Appointments were all 4-5 days away during times when I have patients scheduled. Plus, I know that if I enter the store, I may never leave, so I am scheduling an unpredictable amount of time. I was later told that if I had the Apple App it would be much easier to make the appointment -- I suppose I should have magically known that? It does not suggest that on the website.
~Yesterday I prepared myself: I went to the iPhone store steeled for however long it might take. The next technician could see me as a walk-in in 3 and a half hours, at 6 PM. Too long to sit in the store, but I could buy some groceries, run them home, and come back, no problem. I talked to him about what if they called me earlier, he said they probably wouldn't, and said I would have the option to delay the appointment. I said I would return by 5:30.
~Forty-five minutes later, I'm checking out of Sam's Club with space heaters and a rotisserie chicken, among other perishables when my phone texts me that they are ready. I try to delay the appointment by pressing the button for 60 more minutes, but after repeated texts to me, they cancel my appointment.
~Perishables in the car, I return to the mall where I'm told the wait is 3.5 hours. I rant about how they told me that and then called me after 45 minutes, and oh by the way, I spent 11.5 hours having the phone set up over 2 days. There is no sympathy, I'm told there is a line, but I'll be moved forward, have a seat.
~I sit. I'm soon texted to check in. I check in with the guy with the gray cap and am told to have a seat.
~I sit. I'm soon texted to check in. I check in with the guy with the green cap and am told to have a seat. I sit. Maybe an hour since I've been back, maybe not quite.
~I rant at the guy sitting next to me. Then I get the guy with the green cap and the gray cap together and see if they can help me. These employees are robots. They have a line and a procedure. No one apologizes, no one empathizes with the frustration, no one thinks it's odd that I keep getting to texted to check in after I've checked in. I see other people in the very crowded store with 3-4 slow moving 'geniuses' and other people also rant at the intake guys. I know I am getting distraught as well, and I apologize to the young men because I realize that neither the system nor the problematic phones are their fault, they are just the messengers. I just want my thousand dollar phone to hold a call. I think they hire Apple store employees from the poker tables at the local casinos.
~I ask to speak with a manager and they say yes, then send over a security guard. The security guard listens to my saga, he actually expresses a degree of kindness and sympathy. I feel sorry for the man across from me (his phone heats up to the point where it's untouchable then goes blank), who has now heard the tale four times.
~A manager comes over. She apologizes (much appreciated) and gets a technician who asks what would make me happy. I tell him I want my phone to make calls without going silent in the middle. He offers to exchange the phone for a new one. I ask if mine can be fixed. He runs diagnostics and says there is a problem with the phone. So a new phone it is, but they don't have another phone in stock. He'll order it. He doesn't know when it will come-- a few days-- and he doesn't know if it will take 11.5 hours to transfer my information but he says the usual is 10 minutes. I ask if I can have a different color since gold was never my preference and I've been through a lot. I can't, it has to be the same phone. And for some reason I had believed there was a 30 day return policy--- since I still have my old iPhone 5s which I repurchased from the store when they couldn't transfer the information. Nope 14 days, I can't just return it and buy an Android.
Mr. Jobs: You need a better product. And please don't constantly advertise a product that is so unavailable. You need more employees. You need to train them to express some sympathy and kindness to those who have unexpected delays and waits and poor quality products. You need to tell them not to tell people to come back in many hours, then call them in 45 minutes. It's a mall, if I knew it would be a 45 minute wait, I wouldn't have sushi in my trunk, I'd have wandered around or gotten a cup of coffee. You need to instruct them to be kinder to people who've already had problems with the product and service and to have a mechanism to put people to the front of the line who have been there multiple days and have had hours of frustration. A restaurant would have offered a free dessert, and not that I want dessert or that that makes things all better, but it does acknowledge that the customer is right in expecting something for their money. Your staff acts like they are doing me some great favor in providing their expensive, malfunctioning product, with no concern about customer satisfaction. Given my awful experiences, some empathy and a willingness to provide timely service and to change the phone color would have been appreciated. And yes, we sold our Apple Stock this week.
I still don't have a fully functional phone, let's hope I'm not back venting about problems picking up my new iPhone.
Thank you for your attention to this matter, Mr. Jobs, and I hope you are in a better place.
-----Addendum to my iPhone 7 + fiasco
(please note I am ranting as therapy.)
The story above began in November, and I was soon provided with a new phone and an easy transfer of data --I was in the Apple Store for under an hour. End of Story? No, the second phone didn't work either. The reception was poor and calls went in and out for no reason. I called Apple, they said to call my carrier. I called my carrier, they said there was in fact an issue and they did something that made things better: my reception was better, but phone calls still went to mute periodically so that the other party was left to say, "Are you there? Are you there?" I was there. I'd touch the screen or push a button, and things would improve. In the meantime, since the Apple folks had backed up my phone to my computer and had to upgrade my system from Lion to Sierra, I lost access to iPhoto, and the newest version doesn't seem to exist. And my MacBook is now more wonky than ever.
I had to let it rest; my $1,000+ phone was driving me crazy and I felt like I was in a feedback loop that was always my fault. Make a genius appointment: how? The website used to be so clear. If you had the app it would be easier. I downloaded the app. It took 50 clicks to get to "Make a genius bar appointment" and it was always a week away with the ability to set it for one device only. I had to take a break for my own sanity.
Today, after a conversation the other day that dropped three times, I decided I had the time and resilience to deal with my iPhone issue again. And I want to see my photos. Three months ago they were on iPhoto and I could see them for free. When I got the new phone, I figured out the cloud and paid 99cents/month for storage. Today, if I want to try to see my photos in whatever app is on my computer, it will cost me $2.99/month. Whatever, I clicked yes. Have I mentioned that I can't always access my voicemail? Or reliably change my outgoing message? The battery life is much better, the screen is bigger, but otherwise, I hate this phone. And the touch unlock doesn't reliably work -- I use the password and still find myself swiping to turn it on. Also, no jack-- you need to hook it to a separate thing through the charging port to use headphones: one more thing to keep track of and you can't listen and charge at the same time. But for $159 they'll sell you new Apple bluetooth earbuds (another thing to lose).
I tried to schedule a genius bar appointment. None until Sunday, but I have time on Thursday, and after all I've been through, can't they be accommodating? -- I'm on phone #2 with 16 hours logged sitting at the iPhone store. I call Apple Support. Oh, the diagnostics run in November showed a software problem that had transferred to the second phone. Really? They didn't want to mention that then? They could restore my setting to store bought and walk me through this if I have a reliable internet connection and another phone to talk on, but my Macbook does NOT reliably connect to the internet, it's iffy and comes in and out and is very slow, and if I didn't hate Apple at this point, I'd gladly buy a new MacBook. Is it funny that I'm worried about what I could lose? Option #2 is they can charge me for a third new phone, send it to me, and refund me when I send the second phone back and I'm on my own for transferring my information. I don't trust me either with this.
I ask for a supervisor. I rant some more. What would be helpful? I'd like her to make a genius bar appointment for me. She can do that on Saturday. I'd like her to call one of my local Apple stores (there are two within 25 miles) and schedule an appointment for me on Thursday, and know they'd have another phone available, and that they could look at my Macbook at the same time. She can't do that, I can't be moved because other people have scheduled appointments to have their screens replaced and have issues dealt with. That I'm on my second poorly functioning device, have spent 16 hours in Apple Stores over this, and have had many conversations with Apple Support doesn't matter. She's sorry, but obviously, she's not. Ah, and the call ended when my phone dropped it. She didn't call back.
In therapy, it's not unusual for people to talk about their frustration with technology. By this point, you probably think I'm a madwoman (I think I've lost it, so feel free) but I bet you aren't surprised to know that I'm rather sympathetic to my patients who are frustrated with their devices.
So I don't know where Mr. Jobs is, but I do know that Apple has gone to hell. Mr. Cook, please do feel free to contact me.
26 January 2017. The saga continues: I decided I needed to be able to talk on the phone, and I made a Genius Bar appointment for yesterday at 4:30 pm. It was a short wait and I a very pleasant young genius named Jeff who felt that the problem had to be a transfer in a software issue from the first phone to the second phone because it would not make any sense for two phones to have the same problem. The solution, to reset the phone to factory settings and start fresh, individually downloading my apps. My calendar is on google, the contacts and voicemail remained, but I lost all my texts (I often use them to track when I've called in medications, to find pharmacy phone numbers, and to keep track of communications, but oh well). Set the phone up from scratch. Log another hour at the Apple Store and a couple in set up. Trying to find the Contacts App, which shows up in the search window but not on the Screen. Trying to figure out why some people are in the Contacts App but not in my contacts within the Phone App. Oh, well, I'm managing, but everything is just a little different. And I wish I could tell you the phone works reliably, but it doesn't, still having people say, "Are you there? Are you there? Can you hear me?" Yes I can hear you. No clue where to go from here. Yes, yes, I know I should have gotten an android, and No, apple feedback does not respond.
I think the count: 17 hours in the Apple Store.
Not sure how long on the phone with Apple Support: I'm going to guess 2 hours. And countless hours of aggravation. Aren't you glad you asked?
Inspired by the inability to hold a cohesive conversation with one of my kids calling from out of town, I tried a new format for reaching out to Apple Support: Text. Dan couldn't help me but he passed me along to Janae. We chatted for one hour and she had me reset some phone/cellular options on the phone, but she was convinced the problem was with my carrier, AT&T. I then called AT&T and talked to Uba in the Phillipines for some time. Because the problem is intermittent, Uba insisted the issue was with my phone, not the carrier. But Janae had wanted AT&T to open a case number and thought the issue could be with my SIM card. Uba first said she'd send a new SIM card, then she insisted the phone was fine (right, tell that to my kid who cut out 6 times over 2 calls in a matter of minutes) and said she couldn't. She sent me to a supervisor in Kansas who had me make a voice recording, "because if the voice recording is muffled, then it's the phone." The voice recording was not muffled so a new SIM card is on it's way and there is a case open to be resolved (whatever that means) by 1/31. And actually, since I was told to alter the settings to WiFi ON and Data Only (remember, the phone was swiped clean a few days ago), I have been able to have 3 conversations without anyone yelling "I can't hear you !".
The nice thing: when I reset the phone I picked much nicer wallpapers than I've been using: A photo through an arch at a castle overlooking the beautiful parliament building in Budapest for my lock screen, and the Grand Tetons in Jackson Hole for my home screen background. Makes losing all records of all my texts worth it?
Saturday, November 12, 2016
Something surprising happened on Tuesday : despite the predictions of the pollsters and pundits, Donald Trump was elected President. During the campaign, Mr. Trump was often unkind. For a short list, he poked fun of the press, dubbed his opponents with nasty nicknames in the way a middle school student might, was belligerent at times, refused to release his tax returns, picked a fight with the parents of a dead marine, talked of building a wall to keep Mexicans out, and made the Muslim members of our country feel unwanted as though they all might be terrorists. He accepted support from the Ku Klux Klan, and the list goes on and on. His history is no better: he has been accused of violating women and a tape of his conversation is vulgar. While he minimizes it as "locker room talk," he seems to say he sexually assaulted women. Three marriages, and a profound emphasis on the appearance of women as though that determines their worth. Finally, and perhaps most egregiously, despite having no relationship to the case, he took out ads in the New York Times calling for the execution of teenagers who were implicated in the rape of the Central Park jogger. They were later found to be innocent. The execution of teenagers? Oh, black teenagers. This all bothers me a great deal. And he sees himself as a supporter of women who has a wonderful temperment.
I'm going to ignore all the policy issues: Donald Trump has changed political parties 7 times in the last two decades and 3 years ago he was a Democrat. He started to reverse his stated plans on the day after the election and he's already named and unnamed the head of his transition team. This week, many of his policies are policies I would hate to see enacted. But politically, I have no idea who he is or how much irreparable damage he'll do to this county, and half of our citizens believe his policies might help. In terms of policy, by all means, work with him or work against him, as a democracy is meant to be.
Personally, I feel he puts energy into being cruel and he is erratic and undignified.
This is what is bothering me, if you're interested. While some supporters may share Mr. Trump's xenophobia, his objectification of women, disdain for illegal immigrants, and general lack of dignity, it bothers me that many Clinton supporters are fiercely angry at those who voted for Trump, as though they share all of his personal characteristics. We've divided as a nation. And while many people have talked about what damage it does to have their children see an unkind leader, I don't think it helps to now have those children frightened that all the boys in the class will see girls as objects, or that he has created the hate we are seeing. And the hate is not just on the Trump side, Clinton supporters are venting their anger/hate towards Trump supporters and have been violent as well.
I was absolutely appalled to read yesterday that a website was created targeting African American students at the University of Pennsylvania in a site that named them, called for 'daily lynching' and showed violent images. The site came from Oklahoma, not from Penn, and Penn was perhaps chosen because it's Trump's alma mater. Oh, it's mine, too.
The KKK held a parade for Trump. As disgusting as that sounds to me, the truth is that the KKK existed before Trump, there has been bullying during the Obama administration, and there have always been cruel and unkind people, racists, and haters. I imagine the Trump victory has unleased this for the moment. but kind people did not become evil overnight, and it's possible that the media was not covering every racist comment spray painted on a wall before the election, or every KKK activity.
It takes energy to be kind and it takes energy to be unkind. It takes no energy to quietly go on with your life. We are all living in America, and if this plane goes down, it takes us all. If you're not happy, fight the system. While we should certainly prosecute criminals, don't call for hatred against your neighbor because he supported a candidate you don't like-- he's with half the country-- unless you know that he's propagating unkind acts against others. Don't scare your children by telling them that they will now be subjected to hatred and discrimination, and don't give them permission to hate. Don't demonize those who voted for a candidate you didn't want, and don't equate every supporter with his candidate, people vote for for many reasons. I know there are those who feel so strongly that their ideology is right that they shun friendships with anyone who doesn't share their exact values. So be it.
Half the nation is not Donald Trump and every Clinton supporter is not an angel. I'd ask you to be kind, even to those who supported a candidate you didn't, be it Trump or Clinton, but if you can't be kind, at least don't be unkind. We need each other, and in the coming years, we may need each other a lot.
Finally, over on Clinical Psychiatry News, I wrote a rather personal article : One Psychiatrist's Take On Election Anxiety.
Thursday, November 10, 2016
As I mentioned in the last post, we were scheduled to be on the Diane Rehm NPR radio talk show this morning to discuss our new book: Committed: The Battle Over Involuntary Psychiatric Care.
And then came the Presidential Election where the predicted winner lost, and the world is asking why, and what will it mean to have Donald Trump as our president. Today, no one is thinking very much about forced psychiatric care and the NPR producer asked if we would reschedule to later in the month as they felt it was important to continue with election coverage.
Stand by, we will get back to you with a new date soon.
Sunday, November 06, 2016
You're Invited to Listen to Us Talk About Our New Book on NPR's Diane Rehm Show this coming Thursday
- Dinah Miller, MD psychiatrist in outpatient practice; instructor in psychiatry, Johns Hopkins School of Medicine.; co- author of "Committed: The Battle over Involuntary Psychiatric Care"
- Annette Hanson, MD assistant professor of psychiatry, University of Maryland School of Medicine and Johns Hopkins University School of Medicine; director, University of Maryland forensic psychiatry program; co-author of "Committed: The Battle over Involuntary Psychiatric Care"
If you want to listen but don't have that time available, we'll post a link to the show afterwards.
We won't be talking about the presidential election.
Thursday, November 03, 2016
Wednesday, November 02, 2016
Yesterday our book, Committed: The Battle Over Involuntary Psychiatric Care was officially released. Our publisher, Johns Hopkins University Press, asked if I'd write a post for their blog, which I was more than happy to do. With permission, I've asked if I could reprint the piece on our other social media venues, including here at Shrink Rap. I hope you enjoy reading about what went into writing this book, and please do visit the JHUP blog over at https://www.press.jhu.edu/news/blog; they have some terrific authors writing about all sorts of topics.
Monday, October 31, 2016
Happy Halloween everyone! Please don't dress up as a psychiatric patient, it's not funny, and depicting people with illnesses in harsh ways is...harsh and insensitive, promoting stigma and fear.
In addition to Halloween --and yes there will be candy at my house tonight --- tomorrow, November 1st, is the official publication date of our new book, Committed : The Battle Over Involuntary Psychiatric Care. The printer got a little excited and released the books to Amazon (and maybe some libraries) a bit early, but our hard-working publicist, Gene Taft, at the Johns Hopkins University Press has been trying to keep things under wrap and he's done a fine job.
As the publication date has approached, there have been some reviews, and I'd like to list them in one place.
Dr. Damon Tweedy wrote a wonderful review in last Sunday's Washington Post: The Heated Battle Over When to Commit a Patient Involuntarily to Psychiatric Care
Dr. Rebeccah Twersky-Kengmana wrote another terrific review in Clinical Psychiatry News called "Committed Takes a Non--Patronizing Approach to Involuntary Care."
Blogger Kazen in Japan writes for Always Doing --Because Thinking About Reading isn't Enough. I do hope you'll read the Always Doing review because it really captured what I wanted the reader to get from the book. (Feel free to also purchase the book).
And one of our colleagues, whom I believe wishes to remain nameless, wrote the nicest review on a Facebook page, so I'm stealing it hear, namelessly:
I just finished this book, written by two people I am proud to call friends and colleagues, and one which highlights and tells the story of many of my other friends and colleagues, on all sides of the issue that the book covers. It is a marvel of balance and completeness, and of shared ideas and vigorous debate regarding differences in opinion. In a world that seems to be becoming increasingly polarized, this book is an object lesson in how to discuss contentious issues while still getting along.
None of us has a monopoly on "the truth" because in the area of involuntary treatment, there is no single, unitary "truth." I recall struggling as a psychiatry resident with issues of autonomy versus my rudimentary ideas about what would be "best" for a patient. I recall losing sleep - for patients I let go, and also, differently, and over a much, much longer term, for patients I may have wrongly retained.
This book forces the reader to confront issues related to self-direction, to the adverse impact of mental illness on decision-making, to the battles being fought over where the line is that should legally permit the involuntary treatment of a person who does not want it.
Buy it, and read it. You will learn much, and perhaps, just perhaps, get a sense of where the "other side" is coming from.
Updating on 11/1/16: a Wonderful review on Pete Earley's blog:"While books of this nature often are text book boring, COMMITTED is not. One reviewer credited the “care and consideration” that went into the book for its readability."
I'll add more as reviews come in, and on Thursday I'm going to write a bit about the process that went into writing this book in a post for the Johns Hopkins University Press blog, which I'll post over here as well. Before I even do that, I do need to thank so many of our readers, both here and at Clinical Psychiatry News, who first made us aware of what a troublesome and complicated issue forced care is, and who opened themselves us to telling us their stories and sharing such painful parts of their lives with us. You know who you are, and thank you so much. If you were an integral part to the book, a copy was sent to you with the pre-release batch weeks ago.
So if you're interested, Amazon is happy to sell a good quality, hard copy of of our book, representing many years of work by two psychiatrists for the low price of $15, or $12.99 on kindle.
More soon, I'm just sharing my excitement. More fun than thinking about Anthony Weiner's laptop and the upcoming election.
Saturday, October 22, 2016
So often I write blog posts about topics I read about in the paper. I take a few quotes and expand upon them. Today I want to look at book review by Dr. Damon Tweedy, a psychiatrist at Duke University and author of Black Man in a White Coat: A Doctor's Reflection on Race and Medicine. Only this is a little different. Dr. Tweedy is reviewing a book that We wrote! And a fine job he did, if I do say so myself.
So from the Washington Post, to appear in print tomorrow, Tweedy writes about
Committed: The Battle Over Involuntary Psychiatric Care
Here, they explore forced psychiatric care, perhaps the most polarizing aspect of a controversial profession. The result is a highly informative and surprisingly balanced book that should be read by anyone with a personal or professional stake in how the mental health system provides care to those with chronic severe illnesses and those in acute crisis.
Miller and Hanson take us on a journey across America, where we witness significant variability in how states approach the issue of forced care. In some states, patients must be deemed imminently dangerous to themselves or others (i.e. high risk for suicide or homicide) for forced treatment, while in other states an inability to provide for basic needs due to mental illness is sufficient. The process of commitment also differs. California, for instance, does not require a formal psychiatric evaluation before patients can be involuntarily admitted to a psychiatric hospital, while in Maryland an evaluation must be done before admission and requires the input of two physicians or psychologists. Until recently, doctors in Virginia could not use the input of family members in assessing a person’s potential dangerousness.
Although “Committed” explores a complex subject, Miller and Hanson make a great effort to humanize this discussion. In each section, they introduce us to individuals — patients, family members, advocates, lawmakers, emergency-room doctors, psychiatrists, police officers and judges — involved in some aspect of forced treatment.
Thank you, Dr. Tweedy!
Thursday, October 20, 2016
Ah, technology. The Scattergood Foundation is having an all day conference on Ethics and Correctional Mental Health today in Philadelphia. No the conference is not free, but I imagine there will be time to get a cheesesteak (whiz, please) and if you've lived in Philly, you'll understand the reference to Cheese Whiz.
The Conference is being lived streamed, so you want to learn about ethics and mental health care in our jails and prisons, do consider attending, in your pajamas if you'd like.
Here is the information:
Sunday, October 09, 2016
When I was in high school, one of my friends got mono -- infectious mononeucleosis or kissing disease. He had a minor sore throat and, because his girlfriend was quite sick with mono, he went to the doctor and was tested. He tested positive, but unlike his girlfriend, he never got sick and said, "Well, I haven't tried to run a mile, but I'm pretty sure I could." Still, there is no doubt that both young people had been infected with the virus and one got sick while one did not.
One of the things I learned from the extensive research we did for our forthcoming book, Committed: The Battle Over Involuntary Psychiatric Care is that not every has the same experience of the same illness or the same treatments. Okay, I didn't have to write a book to tell you that, I see it in my office every single day with every single patient. Why does one person get a severe tremor to Wellbutrin while another with similar symptoms just gets better with no side effects? Why do some people need psychotherapy while others get better from a pill? Clearly psychotropic medications don't agree with some people, and clearly they don't make everyone with psychiatric illness all better, but there is a contingency of people who feel that since medications were for bad for them, they are bad for everyone. They are wrong.
I wrote a blog post about a NY Times op-ed piece last week called "Medicating a Prophet" by Penn psychiatrist Irene Hurford. She works with young people with psychosis, and I'm going to guess that she seen patients with a range of experiences. In her op-ed piece, Dr. Hurford makes the point that there are people who like their psychotic symptoms, who gain some comfort from them, and who suffer when they lose their delusions and get smacked with the awful reality of their illness. She doesn't say that there are not patients who are tormented by their psychosis and I'm going to make the assumption that she has met many paranoid, uncomfortable, and suffering patients -- psychosis is not fun for most people. Dr. Hurford further makes the point that forced care can be traumatic-- and, as we write in Committed, it can be for some people, even if it is appreciated by others. I read from her article not that psychosis never leads to violence, but that rare, extreme acts of violence are rate and extreme and shouldn't be what sets public policy. She is not the only psychiatrist I know of who is not gung-ho on making forced care easy policy, and I know several forensic psychiatrists who work with the most violent of patients on a daily basis, and still don't see involuntary treatment as the way to prevent these acts.
DJ Jaffe has an article over on Policy Madness in response to Hurford's NYTimes article. He writes in "Policy Madness: Serious Mental Illness is Not Enriching:"
The New York Times recently ran an op-ed declaring that being psychotic is “enriching,” and arguing against involuntary treatment of the psychotic. “The assumption that someone else’s reality is invalid can foster distrust; it sends the message that we don’t respect this person’s experience of his or her own life,” wrote Irene Hurford, an assistant professor of psychiatry at the University of Pennsylvania. This romantic, Pollyannaish, and false view of psychosis is rampant in the mental-health system, regularly parroted by the media, and dangerous to both patients and public.
Jaffe goes on to talk about people with psychosis who have killed, and how assisted outpatient treatment can be live-saving. He talks about how nurses who treat psychiatric patients have emergency buttons, but those who treat psoriasis don't. Well, there are several cases, at Harvard and at Johns Hopkins, where surgeons have been shot by disgruntled family members. Maybe everyone needs emergency buttons.
I want to borrow these articles to make the point that there is no single reality. Some patients find their psychotic symptoms to be tormenting. Some may find their private reality to be enriching, especially during a mania. Some patients with psychiatric disorders are dangerous. Some people get in cars after they've been drinking or using drugs and are dangerous. And some people are just angry and dangerous. Please, let's not assume that the experience or the needs of all people with mental disorders are the same. And let's not even assume that psychiatrists are the same -- some are quicker to prescribe, and some are quicker to commit patients to hospitals. Often studies of violence outcome look at acts like slamming doors or shoving someone. While I have no doubt that psychiatric treatment, especially treatment done with with the doctor on the same team with the patient, saves or at least enriches lives, there is no evidence beyond the anecdotal that forced outpatient care prevents murders, mass murders, or even suicide, or that other, more collaborative methods might be more effective.
And please, don't even consider reading this and thinking that I believe there aren't situations where the only option is to force a very sick patient to get involuntary care. I just don't think we should assume all people with psychotic disorders have the same experience.
Tuesday, October 04, 2016
For years -- over 10 to be a bit more exact-- we've had controversy here at Shrink Rap when we've talked about forced psychiatric care. It's a controversial topic not just for patients -- some who have benefited from it and some who feel injured by it, but also for psychiatrists who vary in their own views about civil liberties and medical paternalism. Ah, as I'm sure our regular readers know, it inspired us to write a book, Committed: The Battle Over Involuntary Psychiatric Care, and I do hope you'll read it.
I was pleased to read "Medicating a Prophet," in this past Sunday's New York Times. Psychiatrist Irene Hurford adds to the idea that there is not a single truth about involuntary treatment as good or bad, and that this is a complex topic where there may be more than one reality. Dr. Hurford writes:
Proponents of enforced treatment often point to horrific but rare events, like mass shootings, committed by people with mental illness. But psychosis alone is only a modest risk factor for violence. A 2009 study of more than 8,000 people with schizophrenia found that those who did not abuse drugs or alcohol were only slightly more likely than the general population to be violent.There are several studies that demonstrate that assisted outpatient treatment can reduce the risk of hospitalization, arrest, crime, victimization and violence. Few, however, are based on high-quality randomized controlled trials. A 2014 meta-analysis of three randomized-controlled studies of more than 700 people found no statistically significant benefit of enforced outpatient care in reducing hospitalizations, arrests, homelessness or improving quality of life.It can be devastating for families and doctors alike to watch psychosis seemingly claim the lives of those we love or care for. And in some situations, brief episodes of enforced inpatient or outpatient treatment may be necessary. But in my experience, weeklong inpatient stays, or yearlong outpatient treatment regimens, can do more harm than good when they engender distrust. Perhaps we must accept a new reality — to truly engage people in treatment we need to understand their own experience of psychosis and its treatment.
Thursday, September 22, 2016
We're getting ready for the release of our new book, Committed: The Battle Over Involuntary Psychiatric Care on November 1, 2016 (~great reading for after the election, if I do say so myself) and I found this to be very relevant.
My friend, blogger buddy, and mental health advocate Pete Earley went to India recently for a few days. That sounds tiring -- but Pete is full of energy and so what's not to like about a few days on the other side of the world? He's been blogging about mental health in India, and the first of his 3 part series is called Patient Rights is a New Concept in India, I learned. Pete talks first about how little psychiatric care there is in India: 6,000 psychiatrists for 1.3 billion people. It's an unthinkably low number, and there are roughly the same number of total beds there as the public system has in our country. What a disaster. And patient rights?: unheard of. It's a different culture, one in which patients don't question doctors, but also one in which the mentally ill are chained, abused, or left to starve on the streets (ah, tragically we do that part here, too). Pete was the keynote speaker at a conference on Rights of Homeless Persons with Mental Health Issues.
In his post, Pete talks about his own experiences with his son and involuntary care and his belief that this is a band-aid, not a solution, and that it helps to come to view the world of the patient through his eyes for a longer-term solution. So it won't surprise you if I mention that Pete wrote the foreword for our book. His few pages are an amazing piece of writing, and they draw you in and round out the book because he really does a wonderful job of capturing the desperation of a family member watching helplessly as his beloved son became so desperately ill.
I wanted to tell you share our excitement over the upcoming release of Committed, and I also wanted to send you over to Pete Earley's blog to read his stories about India.
And of course patients should have rights, what kind of nonsense is my title?
Tuesday, September 20, 2016
Okay, so we all have our strengths and our weaknesses. I get calls from people all the time and they tell me their problems over the phone, but sometimes we don't end up scheduling or they don't end up coming, so at this point, the story isn't the story until the patient is in front of me. But once there is a real live person in my office, often in pain, with a unique personal history, parts of which I hear over and over with time, the story gels. I remember sons and daughters and mothers and fathers and spouses, and deaths and pets and who cheated and who left someone feeling so very badly. Sometimes I have to hear it twice or I forget the precise details, or I cheat and look at my notes between sessions, but the big picture stuff: I get it and I remember it. It comes naturally, there's not much trying.
I live in a family where everyone is really excited about sports. My kids played sports. I went to their games. I had no clue what was happening, kids who all looked alike in uniforms and helmets ran around the fields. Sometimes someone hit a home run or scored a goal and that was exciting (if I was even paying attention) and sometimes I knew the other kids, so that helped a little, if I could tell which kid was which in rapid motion in all their gear. Whole games went by where I watched my kid only to discover, oops, not my kid.
Okay, so my family isn't just a little into this. Season's tickets to the Ravens games and my son writes for a fantasy sports website (this is a real job). My daughter went to every college football game and also loves the Ravens (and particularly ex-Raven Torrey's Smith's baby). They all know the rules. They all wait for Sunday. And Monday night. And Thursday. And college football on Saturday. They know all the players. They dress in purple. It's fun. Fun? I know a few of the players, but these big guys in funny looking costumes are hard to keep straight. Flacco, I got you. Ray Lewis, #52, but he's no more a Raven. Suggsy...T-sizzle...are you even still here? And it's not quite the game...I know the basic rules: the purple guys run one way to a goal and the other guys run the other way. 4 downs to get 10 yards, and then it resets to the next first down. MOVE THOSE CHAINS!! (I'm good, right?). To get a goal, you get to the end zone and have the celebration dance. If you don't get far enough by the third down, you can try for a field goal or punt to the other team and hope that you get it down far enough on the field that they start with a lousy position. Time outs, hail Mary's, I mean I'm golden. Still, I have no idea, and if I know the score and which team has possession, I'm doing well. The details of every play, might as well be speaking Swahili to me. And those yellow flags everywhere-- the calls and the penalties all seem so random.
So by some family quirk, we root for the Ravens and we root for the Red Sox. This is serious business. Today we went to a Red Sox -Orioles game. Both teams vying for first place and the stadium was empty. Big Papi, Mookie Betts (did you know he's a professional bowler too?). Xander Boegarts, now there's a great name. The rules, I have down, but again, I'm doing well if I know the score and who's at bat. Sometimes I remember who hits a home run. But unlike my family members, I don't remember each player's performance on the field and at bat for each inning. Someone slid into second and he got his uniform very dirty. The Red Sox won, my family was happy.
So I have tried to memorize the line up, to make the players real so they would come to life and maybe I'd remember their stories. But they are like the people on the phone who may or may not show up, and the truth is it's hard to find much personal information about them. I want each each player to do a YouTube discussion, a few minutes of "here is my life," with some stand out things, interactions with their family members, parents who helped them become pros, what they aspire to, and maybe then, if football was more like psychiatry, I could feel invested in the players and their professional performance.
I mean really, what could be more exciting for pro sports?