stuck in the middle…

Posted on Monday 21 April 2014

What should be done? Returning to the asylum system — which could be regarded as turning away from the goal of recovery — is not the answer.

As a late adolescent, there was something in the world I lived in that was wrong in an absolute sense. Once that dawned on me, I never had a moment of doubt – the segregation of races in the South where I lived was wrong. In those times, that was not an easy realization, but there was a comfort in knowing something without reservation. My closest friends to this day are others who had that same awareness early on and involved themselves in doing something about it. But that may have been the last time I was ever completely sure about anything.

When I came to psychiatry from internal medicine, my first rotation was an acute service at an urban charity hospital – the emergency receiving facility for in-town Atlanta. It was at the wrong end of the deinstitutionalization process when all of the outpatient resources left over from the Community Mental Health initiative were disappearing along with the evaporation of inpatient beds. It seemed as if the patients that I thought needed to be in the hospital didn’t want to be there; and the patients that I thought didn’t need hospitalization were lobbying to get admitted. The same thing was true of medications. It felt as if I was always positioned against the flow, and I was never "sure" about anything.

One thing I learned in those days was to listen to people who had been there in person. An apt analogy would be the  difference between civilians and veterans. There is an intrinsic impossibility in psychotic illnesses felt by both the afflicted and their caretakers that is a required ingredient in any cogent discussion of the topic. In my case, later I ran that same service for a year or so and then spent a decade directing the training program that staffed it and several others like it. The most important part of both jobs was helping the residents learn to make sensible decisions based on the individual patient in front of them, rather than becoming polarized in the confusion of chronic impossibility. I had seen that happen to two fellow residents [in different directions], both with disastrous results.

I have nothing but respect for those who stayed in public psychiatry where most psychotic mental illness is treated. It’s a very hard road. But even those with these more informed opinions vary widely when it comes to the inevitable conflict between patients’ rights and the need for treatment and/or restraint. In fact, it’s almost impossible to find any discussion that doesn’t turn the problem of psychosis towards one or the other of these priorities, often implying that the other party is ignoring the more important side of the equation. And that’s not meant as an indictment – it’s just in the nature of the problem as I see it. An observation: among people in the business, independent of what they might say in an armchair discussion, they are usually indistinguishable in how they approach a given clinical situation or case.

There are two psychiatrists from the public sector commenting here, Dr. Dawson [Real Psychiatry] and Sandy Steingard [Mad in America]. I would recommend following what both have to say. Their views and temperments differ, but they both speak from the trenches of experience and are the kinds of people we need to be listening to. Another reference you might want to look at is the article After Newtown by E. Fuller Torrey, the author of the report Dr. Insel was referring to in the last post [lamentations · long passed…] to fully digest his point of view. That brings me back to the quote from Dr. Insel I started with: "Returning to the asylum system — which could be regarded as turning away from the goal of recovery — is not the answer." I found that odd when I first read his post, but I passed over it because I had something else I wanted to say.

The dichotomy between the asylum system and the goal of recovery uses phrases that have too many layers of meaning for that simple sentence. The asylum of Philippe Pinel or Dorthea Dix was as sanctuary for the humane treatment of the severely mentally ill. The asylum of the 1940s was an overcrowded snake pit where the severely mentally ill were essentially warehoused to keep them out of sight – forgotten people. While it’s hard for me to imagine not having the goal of recovery for all patients, that has to be defined for any given person because it varies over the a wide spectrum of possibilities. In this instance, I’m talking about the people with chronic psychotic illness who live in our prisons because there’s no other place for them that they can manage, and many are there by their own hand for that very reason.

I said at the outset that the Civil Rights Movement may have been the last time I was ever sure of anything, but I’m thinking that’s not really right. I’m sure that putting chronic mental patients in prison isn’t right – certainly not as a standard operating procedure. And that’s not an invitation for rounds and rounds of the divisive and blaming arguments that always swirl around this topic. I’m old and have heard them all. When I was suggesting a Task Force, I wasn’t thinking of the usual suspects – the mental health policy wonks from either side of any number of fences. I was thinking of people who have spent their lives among these patients and have a sense of what might work and what won’t. I would include judges, their jailers, and the patients who could participate. In my view, the blaming and arguing that invariably arises has actually interfered with any progress in the humane care of these patients. I’m sure that there’s something we can do that’s much righter than what we’re doing right now, and we’re obviously not doing it yet. I should actually say some things, because these patients are as varied as the rest of us even in their disability, and we need flexability to meet that diversity. There are templates aplenty to guide us. We are at the bottom of the heap among the countries of the developed world in this area, and I expect they’d fall all over each other trying to help us do things better.

I wasn’t kidding when I said "I applaud Dr. Insel for reading that report and bringing up the problem." He may or may not be the person to assemble such a Task Force but he gets an A+ for speaking up. It was a surprise. And right now, we might be hard pressed to know who could muster a quorum of non-polarized right-thinking people to take a long look this problem. And that’s just the first of many stumbling blocks. But if we can land on the moon and build the Internet out of existing materials, surely we can tell the difference between "misfortune" and "crime" and create a viable approach to honoring that distinction…
    April 21, 2014 | 11:00 PM

    Our medical system and it’s relation to our psychiatric system, combined with our criminal justice system is a patchwork of competing interests with no holistic standard or common goal.

    The case of Andrea Yates is one example of the mess that goes into the legal decisions of whether or not a person is “mentally ill” or capable of knowing that their actions are “wrong” which involves different criteria in an adversarial system that aims to win, not to find the truth. The systems also vary from state to state so that the standards are quite vulnerable to political and regional influences that may or may not serve the public good.

    If all the people involved in such decision-making were drawn into a task force, who would be in the role of mediator? Who would openly challenge the biases and self-interests of different actors? And once all conflicts of interests are laid bare, then what?

    Can anyone say with absolute authority that Andrea Yates or Charles Manson is or is not insane? Those are the extreme cases, it seems that it should only be more controversial the less apparently insane and/or criminal a person is.


    Looking at what a mess the case of Andrea Yates was, what would be an approach that would make all the issues in this case make more sense? Is screening mothers for depression and giving them antidepressants that may cause autism in order to prevent a homicidal post-partum psychosis a realistic way to deal with a possible threat? Is giving a woman overwhelmed with her quiverfull of five young children a diagnosis and drugs an adequate response to what anyone should see is an overwhelming situation of a woman with a new infant, three children in diapers, and a fundamentalist and isolating husband? What about drugs making a person behave in a way they otherwise would have not?

    What would it take to create a structure that would take all considerations into question and work toward a policy of using the least force and coercion necessary to intervene, and to help people get the services they need to keep themselves from being overwhelmed and becoming dangerous?

    Funding would be primary, and a better system would, no doubt, save money. But how would the power be apportioned and held to what standard?

    April 21, 2014 | 11:36 PM

    Dr. Nardo,

    I am glad you brought up the subject as well. It has been bothering me for some time. It started from reading the articles/comments at Mad In America. After reading there, I realized that something was really wrong with the current system. Even knowing that complaints run something like 10 to 1, negative to positive, on the internet, there was too much substance to write them off. I read their solutions too, with most in favor of removing all psychiatric labels, disbanding psychiatry, and generally letting people live however they wish to. So, I considered what that would look like.

    Let me first say that the general public, unless they know someone severely mentally ill, is largely clueless to any of this. They go on about their lives knowing some people are mentally ill, and they think that the government, mental health workers and psychiatrists are taking care of them. That they pay taxes to support this, is in their minds showing compassion. They’re aware it isn’t perfect of course, they may know a friend of a friend where something turned out badly or read horror stories of shootings or people being pushed in front of trains. But, I have yet to meet anyone that thinks these are anything but exceptions to the rule. However, if you place someone near them that is experiencing psychosis, I can guarantee you, the police will be called. I don’t think they do it because they think mentally ill people are inherently violent, I think they do it because they think they are unpredictable or because they feel harassed.

    Knowing this, I exchanged comments with some of those that are vehemently against forced incarceration and medication. I gave some examples of situations in life where actively psychotic people would be disturbing or harassing others, and I asked what should be done. All of them said that the police should be called. Their argument was that being arrested was far better than going to a psychiatric hospital because you would have a trial, you weren’t going to be forcibly drugged and that if you broke the law, you should face the law.

    So, yes, I am looking for solutions. I can’t accept the default answer of ignore all the issues of the mentally ill until it impacts me then “call the police” from the public or the push from the anti-psychiatry crowd to destroy psychiatry and then when members of the public are impacted, let them call the police. I don’t like the idea of an answer from the government, but they are the ones with the power and the resources to get things done. How to keep them honest, I don’t know. But, I agree with you that the solution lies in an examination of what actually works. Plus, a commitment of funds. I would also add, an involvement of those who call themselves psychiatric survivors, because I know that the general public will never care as much as they do. Where psychiatrists and mental health workers fit in, I don’t know. I’d like to think they would be the leaders in all this.

    April 21, 2014 | 11:46 PM

    Wherever I referred to calling of the police in my previous comment, I should have made it clear that I meant arrested and taken to prison, not a mental hospital. I know police are called in that situation too, but that wasn’t what i meant. My apologies; it’s late and I’m tired.

    April 22, 2014 | 2:52 PM

    Excellent post, Arby. I agree that incarceration is a terrible solution for confused people causing public disruption.

    I view the role of psychiatry in this regard much as I view police: Society delegates to them the responsibility to deal with people in extreme situations. Much some people might dislike psychiatrists or cops, they have a place in society — despite excesses or abuses in either field.

    As a society, we are now prone think of “mental illness” (whatever that might be) as a tendency towards criminality, which (given the vagueness of the term) is very dangerous. Or, post-hoc, we think all criminals are “mentally ill” in that they seem to lack the judgment to keep themselves out of trouble. Maybe the way we look at anyone who doesn’t quite fit, one way or the other, is very primitive.

    Steve Lucas
    April 22, 2014 | 4:40 PM

    The point has been made, and I agree, that we have expanded the definition of mental illness, but we have also expanded the definition of criminal behavior. The result is we now have the police involved in situations where they are limited in their response by the very laws we are asking them to enforce.

    Sometime ago I read a comment by an ER person who spoke of their regulars. We need to do better. Jail is not a good place for the drug addict, nor is jail a good place for the known mental patient.

    They both need supervision, but maybe a place with the help they need to reach level of competence prior to returning to public life. This may mean forced confinement to a care facility, but this should also not mean jail or forced medication.

    Steve Lucas

    April 22, 2014 | 6:16 PM

    Thanks for the comment above but I have to say I am pretty muddled on this topic. I have been in situations where I do not know what to do other than intervene against a person’s will yet I am so discouraged by the failure of psychiatry to acknowledge both the profound limitations of the drugs we use and the remarkable possibilities of non-drug interventions, that I am not comfortable with turning people over to my profession. I just came from a workshop with Ron Coleman and Karen Taylor.
    We should all be listening very carefully to what they have to say. We dismiss him because there is no RCT at our own risk(and that of our patients). As David Healy has so eloquently pointed out, you do RCT’s to find small differences between interventions, you do not need RCT’s to find large differences.
    We all say we use forced treatment as a last resort but what constitutes last resort is more arbitrary than people may realize. At least that is how I see it from this particular trench.

    Bernard Carroll
    April 23, 2014 | 4:19 AM

    Sandra, I watched the 10-minute video of Ron Coleman and Karen Taylor via the link you provided. I applaud them for what they do but I saw nothing conceptually new, nothing that advances our understanding of the psychotic disorders. Of course people experiencing auditory hallucinations will benefit from associating with others similarly afflicted in a therapeutic group. Let’s use every tool we possess to help them.

    Then I watched another video ( featured in the sidebar. This articulate woman discussed her experience of auditory and olfactory and visual hallucinations while in a manic episode, and she reflected thoughtfully on the benefit to her of maintenance antipsychotic drugs. Are you going to dismiss her views because she hasn’t given us a randomized, controlled trial? The Coleman-Taylor perspective does not in any way negate the lived experience of patients rescued by medications.

    April 23, 2014 | 6:56 AM

    Dr. Carroll,
    There is nothing in the message of Ron Coleman that is fundamentally anti-drug treatment. He happened to find this kind of approach after being on drugs for 10 years and deriving no benefit. But one can take drugs and still use this. Sadly, there are many people who take them who still are bothered by voices. There is nothing in what I say or they say that negates the experience of people who have benefited from drug treatment. However, I see overwhelming evidence that these drugs are overused and inadequate attention is paid to trying to lower the dose. I have discussed this in multiple blogs.
    What you do – in claiming there is nothing new – is disingenuous. It is similar to what Ron Coleman (and others like him) get told often which is that they really did not have schizophrenia or that we always have known that there are people who recover so this is nothing new. First of all, you watched a 10 minute video. I spent a day with them plus I have done extensive reading. Among other things, I recommend Gail Hornstein’s book, “Agnes’ Jacket”. I can tell you that what they do in their groups is not part of standard practice. It goes a bit further than having a group where people get together and admit they hear voices. There is a fairly specific practice of identifying the voices, mapping them out, trying to think about what they remind the person of, engaging with them and trying to work with them in a way to “detoxify” them. It has many overlaps with Narrative therapy which is not CBT or psychodynamic therapy.
    I am sorry if I am once again getting the wrong end of the stick but I have heard this kind of response from my colleagues so often; we quickly dismiss something as nothing new when in fact standard practice clearly promotes a very different kind of approach.
    We had over 200 experienced mental health clinicians in the room. Most of them came away thinking they had heard something new. One psychiatrist with 25+ years of experience told me this was the best training she had ever attended.
    This is why my last blog was called “The End of Psychiatry”
    I do not find that psychiatry is asking the interesting questions. But that is just me down at the wrong end of the stick. I am happy to go off in my own little journey of discovery. It has been quite fascinating.

    April 23, 2014 | 10:04 AM

    Sandra, you’re definitely not going down the wrong end of the stick and in my opinion, are doing an excellent job in asking the right questions. Great response.

    April 23, 2014 | 1:56 PM

    The discussion has broadened and I have no issues with it. Even if I did, it wouldn’t be my place to weigh in on it.

    I only wanted to share that I perceived the “wrong end” end of the stick to be that some of the comments were several steps ahead of the thrust of the article. I know they were in relation to my comment.

    Bernard Carroll
    April 24, 2014 | 5:04 AM

    Sandra, I am glad that we agree Ron Coleman and Karen Taylor do not negate the experience of people who have been rescued by drugs. But I have to say I am puzzled by your calling me disingenuous. About what? I did not say Ron Coleman doesn’t have schizophrenia. I don’t know Ron Coleman from Adam and I would never presume to diagnose him from a distance. I do say, however, that his presentation contained nothing fundamentally new. If his approach resembles Narrative Therapy, fine. Please tell us why we should give credence to Narrative Therapy.

    April 24, 2014 | 5:59 AM

    Dr. Carroll,
    I picked a short interview to give a flavor of what they are doing. It goes beyond the scope of this section for me to explicate Narrative Therapy. I recently read Michael White’s Maps of Narrative Practice.
    I found it straightforward, easy to understand, and easy to integrate into my work. It did not appear to be the same thing as psychodynamic psychotherapy or CBT-P.
    While I have never been one to buy into the notion that only psychodynamic psychiatrists actually talk to people (I honestly know of no way to engage with psychotic individuals without talking to them!). I also think that I have always valued being straightforward, down to earth, and respectful. These are all embodied in the Hearing Voices and Narrative Therapy approaches.
    I also find that there are overlapping aspects to many of the approaches that intrigue me: Hearing Voices, Narrative Therapy, Dialogic Practice, even Bertram Karon’s descriptions of his psychoanalytic work with people who are psychotic, motivational interviewing. I find that reassuring. I do not believe we are any more likely to find a “magic bullet” in the talking cures than we are in the drugs.
    What is conceptually different is the emphasis on the psychosis being an important psychological experience and that understanding that experience can be healing for the individual. When we conceptualize these experiences as brain diseases with symptoms that need to be eradicated we are not giving credence to their psychological meaning.
    Now, I am not convinced of any of this. I think this may be more or less true for individuals and we may not be good at discerning who is in which group. My own approach is to share my uncertainty with the people I see. My friend and colleague calls this “radical humility”. But I think it is intriguing and worth paying attention to. I also do not think this is part of the mainstream thinking or teaching of our field. Maybe disingenuous is the wrong word. But saying there is nothing new is a way of dismissing the ideas.
    There is more I can say but I think it goes beyond the scope of the comment section. If you want to read more on open dialogue, here are some posts:

    April 24, 2014 | 6:15 AM

    Yes, I was wrong in the word choice. Disingenuous should be dismissive. Also, I did not imply that you were re-diagnosing Ron Coleman. I was making an analogy (and I hope I have the word choice right!). I said that others have done this. That is what he (and many others who have recovered from psychosis) report. Fred Freese – a psychologist, NAMI activists, Torrey ally, experiencer of psychosis labeled as schizophrenia who does support the use of drug treatment – says the same thing.
    By doing this, this then negates what they say about their experience with this thing we label schizophrenia because we “know” that they were not actually experiencing schizophrenia (even though this is what they were told for the many years they were struggling with symptoms).
    So dismissive. I apologize for my poor word choice.

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