Wednesday, January 30, 2013

Until the next Newtown....a psychiatrist's frustration.

It has been more than a month since the tragic shooting in Newtown Connecticut. I have been listening to the pundits and newsies talk about what could have possibly prevented the tragic murders.  One huge faction is arguing that better gun control will prevent tragedies and one strong rebuttal to that argument has been that more attention to metal health issues will save us. I hear the arguments that gun control isn’t going to prevent any tragedies, and it is not my intention to prove or disprove that notion. As a psychiatrist currently working in community mental health, I just want to mention you might not want to put all your eggs in the mental health basket either. Let me explain:

Today at a community mental health facility I had two patients. One patient is a charming good looking young man, who on the surface doesn’t look like anything is bothering him, but he has auditory hallucinations that torment him and tell him not to trust his family and to kill them before they kill him. Today I spoke to his mother who told me her and her kids and grandchildren sleep in locked rooms afraid of what he may do on a whim.  When medicated he is pleasant cheerful, and very funny; but he isn’t taking his medication and today in this state he is anything but, and quite scary.

The second patient I had only one brief encounter and didn’t know very well. The report I got was he had been reportedly discharging a firearm in his neighborhood 2 days ago. I was told that he had been refusing his medication for weeks, and was held up in his apartment talking to the walls and yelling out the windows. The field agents who are charged with visiting his home and making sure he is ok were able to get him to come to the clinic by telling him they were taking him grocery shopping. Through a lot of hard work the community agents were able to bring these two men into the clinic for evaluation. Given the report of how these men were acting in the community I decided it would be safer if they were admitted to the hospital to have their medications adjusted. They both demonstrated demonstrable danger to others and potentially themselves. Sounds simple enough. Wrong. 

It is usually the job of the sheriff's office to pick up involuntary commitments in the community, so I filled out the paperwork for involuntary commitment and called the sheriff's office. My call was answered by a less than courteous dispatcher who told me they were in middle of shift change and they would not be able to send someone out until 7pm. It was 4:30 pm.

I explained that I had a staff of mostly females and that the patients were potentially dangerous when agitated. I let her know they were only here begrudgingly and it was only a matter of time before they became agitated. The dispatcher then transferred me to a shift manager whose disposition made the first person's curtness seem pleasant by comparison.

I again explained the situation and asked if someone could please transfer the patients to the nearest hospital. She rudely told me that shift change wasn’t until seven and even then I would have to demonstrate the patients had been given medication to calm them 30mins prior to their arrival.  I attempted to explain that as a private clinic I have no medication to give the patients. We are not a hospital or ER with shots to give agitated patients. She said then she would not send anyone. "So, you want me to send my deputies into danger with a violent 'crazy. person?" ,she asked. I explained these people with mental illnesses (not crazy people) were in need of medical help. The people who went into the community to get them were not trained, nor armed. Yet they went into the community to retrieve them, even with the knowledge that one may have been potentially armed. But she was telling me trained police officers with weapons and restraints could not handle two unarmed men?

As she was refusing to help one of the patients turned to the other and said "It's a trap, they're trying to lock us up". At which point both men began to get irate. I explained this to the person on the phone who heard this but still wasn’t moved one inch towards caring.

I then hung up with her and called 911. The 911 dispatcher, who at least was pleasant, explained that it was the sheriff's department's responsibility to transport involuntary commitments and that by law they could not. She said she would at least send a patrol car over to assess the situation.

          The patrol officer did arrive promptly, and he too was at least polite. By this time one of the two men saw the police, thus confirming his suspicion that he had been duped. He began cursing and pacing angrily. He was now visibly agitated, but thanks to the great community worker was able to be calmed. The officer who witnessed this suggested that now that the patient was calm and one of my workers should transport him to the hospital. When asked if he could at least follow them to the hospital he, again politely, said no. 

We then had to call off duty male staff in to ride with the female staff and patient to the hospital. Meanwhile the other patient, who introduced the idea of a mass conspiracy, began to rock in his chair, mumbling how he’d be damned if he was going to the hospital.  The police officer and I were sat and berated the sheriff’s department for not doing their job. The officer agreed that it was a shame that mental health services were in shambles. He talked about the time he spent as a community support officer. He went on to say that the sheriff’s office should have sent someone urgently despite being in the middle of shift change. It was in the midst of this conversation that the empathetic officer who just spent five minutes talking about his understanding of the broken mental health system informed me that he was leaving.  He told me he had to get back to his patrol. I asked him what I was supposed to do if these patients became violent while we waited the still whole hour left until 7pm. He responded that if they did become violent we could then call 911 and THEN someone would come.

Around this time some of our male staff arrived and the calmer patient was able to be taken to the hospital leaving me, two female staff members, and the patient who 2 days ago was reportedly shooting in his neighborhood.  Some more male staff came and I had to leave them untrained, unarmed civilians with the patient to wait for the trained armed sheriff’s office. Time 7:05

I wish that I was just venting about one bad experience with one bad county with one bad system, but I can’t. In my short career I have worked in two states three cities and numerous different counties and it is sad but I have had the same experience with the relationship between law enforcement in mental health in each of those settings.

I don’t want to touch the gun control debate that has come up since the last mass shooting, but I do notice that each time one of these tragedies comes up people mention mental health as the failed barrier that should have protected society from these tragedies. And I only mention the gun control debate in the same breath as mental health because I feel it is futile to say the current status of mental health care in this country will offer any help in the same way that it is viewed the status quo with regards to gun control will offer any addition safety to society at large. The major similarity between both discussions is that as soon as a great tragedy occurs we get really amped up to change the world. We posture and talk really grand for a moment and then nothing happens.

Why nothing really happens is because the problem is very complex and difficult to solve. In this story better communication between law enforcement and mental health services needs to happen. It can’t be just one department that is responsible to responding to a crisis if that department can’t be responsive 24 hours a day, and then an emergency department who is trained to handle potentially violent situations abdicates that responsibility to civilians when the situation is inconvenient for scheduling.

Coordination is one small facet of the problem but it is deeper still. Even when law enforcement agencies are cooperating there is no place to take acutely agitated patients. Mental health institutions have gradually been decreased over the last three decades. There are fewer and fewer long term treatment facilities. As a result, most acute inpatient hospitalizations are for less than a week and then patients are sent back into a community that is ill equipped to support them.  Because they are poorly supported with poor outpatient care they bounce back very frequently which creates a jam in ER’s across the country. Because ER’s are overflowing, there is more pressure to discharge patients quickly (not to mention the financial pressure to discharge quickly, but a separate conversation). Poorly stabilized patients decompensate quickly and end up back in the ER which starts the cycle all over again— leaving mental health providers very frustrated.

The legal system is equally frustrated because the patient who aren’t in the revolving door of ER->hospital->community->ER often make detours in the justice center. Jails aren’t equipped to handle serious mental illness so they try without success to access the above mental health system and find it just as jammed as described.

I really started this article to vent about a horrible incident I had, but my frustration wasn’t because of the time I lost that day or necessarily with the rudeness of some of the people I encountered. My main frustration was that as I sat and reflected the day’s event I came up with more problems than I had solutions for. Ultimately all of the solutions I could come up with involved the expenditure of monies. Most of this country considers things that improve living conditions for poor and indigent (which most of the severely mentally ill population falls under) entitlement spending. But I cant help to see it differently.  Money spent to decrease social stressors (assisted living, vocational training, community support staff etc, and access to medical care, etc) is not philanthropic, it is self preservation. Poor social support and substance abuse more than triples the likelihood of violence in mentally ill population.  Yet if I suggested spending money on the above no bills or referendums would pass, no media outrage would occupy the 24 hour news cycle, nobody would care—until the next Newtown. That’s what frustrates me.

Thursday, August 16, 2012

The Race Card:Politics "Draw Four"

Lot of talk right now about Joe Biden's most recent 'gaff'. Joe said the following
“We got a real clear picture of what they all value,” Biden said. “Every Republican’s voted for it. Look at what they value and look at their budget and what they’re proposing. Romney wants to let the — he said in the first hundred days he’s going to let the big banks once again write their own rules, ‘unchain Wall Street.’ They’re going to put y’all back in chains.”
There has been a lot of talk about the context of the comment having racial under tones. People on the right have been in an up roar about the comment being an under-handed way of calling their ticket racist. Was it?

MMMmmmm, Maybe.

   Let's go back to 2008 when many on the right accused Obama supporters of "Drinking the Kool-Aid" when referring to people overly buying into the "Hope and Change" rhetoric of his campaign. Now there was a lot of people on the left that felt "Drinking Kool-Aid" was hidden racism because of the association between blacks the derogatory "Chicken and Kool-Aid" stereotype of African Americans. People on the right defended that comment stating "Drinking the Kool-Aid" was a reference to cults that would carry out suicide pacts by drinking poison laced punch. Which is a true allusion, and an apt metaphor when applied appropriately.

  During that time people on the right where pleading, "Please don't automatically assume racism when we make statements!". And people on the left were just as adamant when insisting "Please don't ignore the undertone of statements made".

   Flash forward four years.... and my-oh-my what a role reversal we see here. Now we have people on the left saying "Hey look at the context of what he said before assuming it was racist!" And people on the right playing the same race card they once claimed was over played! Could Joe Biden have been insisting that Romney/Ryan ticket was intent on reinstating slavery and there by racist? Yeah, if you believe conservatives call Obama Socialist because saying Nigger is passe. Or could he have been making an allusion to financial slavery as he claims? Well Yeah, if you believe "Drinking Kool-Aid" is simply an allusion to following with blind faith and was not used with any racial undertone.

   Let's face the truth there are plenty of racist people on both sides of the isle, and from time to time their views will seep into the nation discourse. And there is some real racism that has to be confronted. The only way we are going to be able to get to the point where we all realize things can be taken many ways depending on context. And we have to address each issue with empathy and understanding, not over-reaction and defensiveness.

  As for "the race card", and who gets to play it. Think about it like this: when it comes to politics the race card is just like the "Draw Four" in a game of UNO. It is best played when you are behind in the game to change the color of the game. And no matter if you are sitting to the right or to the left, anybody at the table will play it if it helps them win.

Makes common sense to me.

Thursday, December 15, 2011

Unpopular things that need to be said about the hazing incident at FAMU

First of all I have to say I am truly saddened by the loss the family of Robert Champion has endured. It is truly tragic when I young life is prematurely ended for any reason. I think many are finding solace in that it is shinning the light on a tradition that has being going on for years and definitely needs to be addressed.

That being said I think there are important parts of the discussion that are being left unsaid.

First off there is a difference between a victim and a participant. If a person is walking down the street and some nefarious character jumps out of the shadows and beats you, then you are a victim of assault. On the other hand if you sneak out in the black of the night to go to a secret meeting where you know you will be beat, and you submit yourself to dangerous activities then you are a participant in that activity. Both end in injury, but only one scenario has a victim.

Some have suggested that Mr. Champion and other participants in hazing rituals, though willing participants, aren't responsible for their actions because of the intense peer pressure they face trying to gain acceptance by those already in the organization. Some have even gone as far as to liken the drive to belong to these organizations to a woman who is an a abusive relationship. It has been said that a woman in an abusive relationship is so endeared to the abuser that she submits to and even defends her attacker. And so will people desperately trying to gain social acceptance to various organizations

However the analogy lacks validity for two reasons. One dating is not an illegal activity you don't enter into a relationship knowing that you are doing something you shouldn't be doing. However the same cannot be said about hazing. All participants, the hazer and hazed, know they are doing something illegal. In most cases they have signed documents acknowledging not only will they not participate in hazing, but also that they would report it if they encounter it. I don't think any rational woman would date a man if he handed her a paper saying "Warning I may beat you"

The second reason dovetails from the first. Since the activity is illegal how is peer pressure a justifiable excuse for breaking the law? What other crime can you commit and blame peer pressure: burglary, drug trafficking, prostitution? Could a person who is found with a stolen TV in his car stand in front of a jury and say he stole these things to fit in with his friends expect leniency for his crimes? That was rhetorical, ignorance of the law isn't even a justifiable defense in a court of law in America; so peer pressure definitely can't be.

Speaking of peer pressure, Mr. Champion was a 26 year old man, and a drummajor. That is important for two reasons. As a 26 year old he was not a child. The 19 year olds he allowed to haze him are children. He was an adult (at 26 I was in residency responsible for lives of my patients). As an adult he should have been setting the example for the youth other parents assumed a leader of the band would set. The responsibility goes even farther in that he was a drummajor, a designated leader of the band.

Another issue I would like to address is the school's culpability in this manner. Again it depends on the details of what happened, and I admit what I say here maybe later not the case. But if the case is that Mr. Champion allowed himself to be hazed is the school responsible?

I have heard the argument that the school knew about the culture of hazing on its campus therefore it was negligent in protecting the students from hazing. I agree that the school has a responsibility to protect its students, and I fully understand America's outrage at the perception that the school should have done more to ensure Mr. Champion's safety. And if it turns out the school was negligent in anyway to protect that safety they should be held accountable.

But what if the school provided anti-hazing workshops to educate the students on what hazing is and what to do if you encounter it, and all members of the band sign documents acknowledging they understand these rules; and what if the school appropriately disciplines all students found to be participating in any of these activities--if all this is true what else could have been done?

Would we be having this same conversation if Mr. Champion had overdosed on heroin, even if a fellow student had sold it to him? Of course we would still be saddened by the loss of life. And yes, we would still want justice brought to those who supplied the illegal drugs. But we would be openly acknowledging the bad decisions that also contributed to his untimely death and we would be only holding those directly involved in the transaction responsible.

Suing a school because you got hurt by the hazing you chose to participate in, is like suing your drug dealer because your crack made your teeth fall out. If you decide to smoke crack and you overdose you don't get to sue your drug dealer. So how come you can if you choose to submit yourself to hazing and you get hurt?

I am not trying to vilify Mr. Champion. His death is a tragedy that should not have occurred. Nor I am in anyway trying to justify the practices that ultimately led to his death. However, I do not believe we can begin to have an honest discussion about how to end hazing with out addressing all of the issues in the problem.

Educating the public against the dangers of breaking a law and punishing those who break it are about the only two things a society can do to protect its citizens. You can't punish with out educating, nor can just punish some involved and not others; and expect your solutions to work. And despite doing both of those well, there will be times a society still breaks those rules.

Just make sense to me

Thursday, June 9, 2011

Why I Dont Care About Anthony's Weiner, and Neither Should You

I think it is sad state of being to have to admit my wife has probably seen Anthony Wiener's penis more times in the last week than mine. I mean that thing has been everywhere the last week. I think yesterday it surpassed Hannity as the biggest dick on the air.

But, I don't understand why this is a scandal. If I were his wife, I would get it. You sent half naked pictures to bunch of women....scandalous. But I am not his wife, so why do I care which part of his anatomy he sent to which person? Oh, I understand why politicians make a spectacle about it. Using any chance to use any situation as an opportunity to shift political leverage makes sense, politically. I get that, but what I don't understand is why the American people go for it every time.

This isn't a partisan issue for me, it isn't even a political issue. I said the same thing about all the hoopla made over Brett Farves 'friend' showing up all over cyberspace and in punditry. People's personal life and professional life should be separate, but we don't allow that. Why?

Honestly, the last time you went to Subways and ordered a sandwich were you more concerned with how well your sandwich was made, or whether or not your "sandwich artist" had looked at porn the night before? I am betting you were watching your food. And you should be. What does what Jared did when he is at home have to do with making me a 5 dollar footlong? Absolutely nothing. So why is it we get so concerned about what other people in other professions are doing in their personal lives?

Personally I think it is because we all need to get a life. Or specifically pay more attention to the one we have and not the one we feel we should. I guess I need to clarify. The reason we hold these celebrities, preachers, politicians, athletes etc to these higher moral standards is we know we could never obtain them ourselves. We project these subconscious desires for moral perfection, we unconsciously know are unobtainable, on to external representations of ourselves and call them "role models"

So when these role models inevitably fail, they become representations of our own failures. But since we cant vilify our own iniquities we turn on our fallen heroes with a righteous indignation. I mean who wants to look at mirror when they can look out a window?

The psychology of it makes for excellent mechanism to distract people, but it shouldn't. If you are an athlete all I want you to do is show up an score points. If you are an actor all I want you to do is show up and entertain me. If you are a politician all I want you to do is show up and vote the way you said you would. What depraved thing you do on you own time does not, should not concern me; unless it interferes with you showing up and doing said task.

Role models will all at some point fail us in some way. I wonder why this is surprising to anyone. Human nature is predictable. No one is above it. Politicians, athletes, preachers, actors, etc are just people and are going to make the same mistakes that all people make. I think the folly in all of this is that we as a society expect them to be superhuman in their ability not to.

Common Sense to me.

Tuesday, February 8, 2011

Why is it constitutional to force doctors to treat someone, but unconstitutional to ask people to pay?

Not a long one from me today, but a serious question. Everyone has the right to emergent health care. No ER can turn anyone around based on their ability to pay. Which means that the law is forcing physicians to provide a service to people regardless of their ability to pay. And this is true if you go to a private ER or Public so you cant say people's taxes help prop this.

So it is ok, nay constitutional, to force private citizens to perform a public service, yet one cornerstone of the argument against the health care reform is that it is unconstitutional to require individuals to buy insurance that would cover their utilization of this service? What about the people: nurses, doctors, and administrators, responsible for providing that service? Why do they bare all the responsibility for the cost of providing these services, but not the people utilizing them? I don't understand.

Right now there is much debate about protecting the individuals right to their financial sovereignty. Some argue "The government has no right to make someone buy a product", right. (I don't get since I have to buy car insurance). But if it is the case and the government shouldn't be saying how we spend money, shouldn't they also not be allowed to say what service private citizens and businesses provide?

I don't think most people would argue that we should turn away people in emergent situations. Most feel as a society we owe it to people to provide them life saving measures when needed. But let's keep the equation fair. If we feel this is something we as a society should be providing our citizens, let's be equitable about how we spread the burden of providing these services. Or we could decide as a society we don't want to provide that service at all. After all if you are starving, there is no law saying a restaurant should feed you, our medical system could work the same way. If some had their way it would.....

Wednesday, June 23, 2010

Does Obama hate White people?

Actually for some, I think this question shoots to the heart of one of the problems in our political climate.

Before in history when someone disagreed with the president it was assumed it was because of policy. No one had to wonder if it was because of race. Well most Americans didnt have to worry.

Now we are at the first point in American history where the majority race is confronted with the concept (real or imagined) that the president may not have their personal interests at heart because of race.

Deep down inside we all have parts of us that feel a certain way that is unacceptable to our conscious self. We protect our conscious self from those feeling through various defense mechanism. One of my favorite is projection

a defense mechanism that involves taking our own unacceptable qualities or feelings and ascribing them to other people.
In other words. If you deep down inside feel like you hate your sister, but consciously you know it is unacceptable to hate your sister. You may begin to feel your sister hates you.

We all have prejudices that are born of our life experiences: how we were raised, our past interactions with other, and how we perceive others have been treated. Yet in many instances society tells us that our prejudices are inherently wrong-- evil. When truth of the matter its not the prejudices that are wrong, but how we condition our responses to them.

Yet these prejudices do exist in all of us, but consciously we feel that is wrong. Prejudice is a bad word right? Synonyms with racism and bigotry, right? Therefore I can understand how if that is lurking beneath the surface of our minds whenever those thoughts creep up near the conscious we have to do something before it pops up. And we do. We get rid of it, even better we give it to the thing that is causing us so much discomfort.

I would be guilty of grossly over generalizing if I stated I felt that this was the reason for all of the disagreement regarding the current administration, but I would be equally remiss if I didn't wonder how much it contributed to the intensity of the dissent.

Listen up Libs and cons: There is enough hyprocisy to go around

I sat playing with my two year old while CNN was playing in the background during the Senate vote to bring the healthcare reform bill to the floor. Not the nail bitter I think it was made out to be, but interesting enough. As I listened to the punditry dribble what constitutes post-election debate, I heard abortion was once again a line being drawn in the sand as, Tina Fey's 30 Rock character would put it, a "deal breaker".

This is nothing new; the topic is divisive and a hardline issue for many who are single issue voters based on abortion alone (which I think silly, but to each their own). But there I sat listening to the panel discuss the vote along political lines "Conservative" senator this and "Liberal" senator that. I began to wonder something. And maybe its just me; but isnt there a lot of contradiction within these political ideologies?

Ok. the right of the spectrum is against abortion. Yet the same group that professes the inherent preciousness of each life is the same group that is the biggest proponent of the death penalty. Is life only precious at the beginning? This is also the same group usually opposed to welfare which in most cases is designed to help take care of the "not aborted" babies. The right professes to oppose government intervention yet endorses heavy regulations when it comes to drugs,gambling, prostitution, abortion --the areas where the most intimate decisions regarding personal choices are involved.

Now the left side of the spectrum supports abortion. Yet the same group that does not feel life in womb deserves ultimate protection quivers at the thought of people taking the life of those which have committed heinous crimes against others. The left proposes that people should have personal liberty, based on personal responsibility, when it comes to drugs, prostitution, and abortions, but baulks when it comes to guns and again when asked to enforce personal responsibility when it comes to crime and welfare.

As ideologies liberalism and conservatism seem to have predetermined stances for the majority of issues facing this country. I always find it interesting that a person could be wholly one or the other on each of these issues without running head on to some of these inherent contradictions.