Questions From Someone Important – On ECT

Hi. I was hoping I could ask you a couple questions about ECT for a research paper I am writing.

  1. How do you address the issue of cognitive and memory impairments?
  2. What are your top 3 reasons for being an advocate for ECT?
  3. What are the differences between ‘old’ ECT and ‘modern’ ECT?
My thesis statement is:
Although there are many different treatments for Bipolar Disorder, Electroconvulsive Therapy (ECT) has proven to be the most effective therapy, treating both mania and depression.
Thanks in advance,
Priscilla

Good morning Friends!

What would you answer to Priscilla?  Do you have personal experience with ECT, primary, secondary, etc? Where did your beliefs and attitudes about ECT come from?

Last week I almost lost control of my functions when my patient told me about his sister’s comments.

Frank, my patient, had called up his sister, asking her to help drive him to ECT in the morning. Frank’s sister hadn’t even known Frank was getting ECT. She was alarmed but didn’t say anything until they were in the car together, a California dawn and sleep in their eyes for context.

Is this for real Frank? Where are we really going?

Frank was straight faced in his pragmatic style.

She thought maybe we were either going to doughnuts or the devil.
I don’t want this to sound bad or anything, but you know how people go, like to TJ, Mexico, to get some sort of cancer therapy that makes their skin fall off, that’s what she thought. Or we were going to get the psychiatry equivalent of a coat-hanger abortion in someone’s garage.
Don’t judge me for peeing a little.

One of my secretly favorite comedians, Amy Schumer, has a way of taking the worst negative biases in our community and denuding them w/o remorse. She did this with “rape.” The internet exploded that, demonstrating that sure enough, our community doesn’t get it. We don’t understand what rape is!

Then Schumer did it again with women. The idea is that we lose value because of age. Sure enough, the world started talking. For example, a few someone’s noticed when Maggie Gyllenhall was told she was too old, at 37, to get the role of a 55 year-old man’s girlfriend.

I wish Schumer would do a skit on electroconvulsive therapy, (“ECT.”) I wonder what she’d play with. Because there is awesome material there!

First introduction to ECT, some people wonder where the leather straps are. Dr. Schumer, in her white coat would say, “Oops! I forgot them at home.”

And what do you wear in an operating room, really? Scrubs for spine surgery. Scrubs for gastrointestinal procedures. And psychiatry?

Dr. Schumer, psychiatrist: “I’m a surgeon!”

Funny how you celebrate things you would otherwise not…”Hey, what a great seizure!” (High fives all around.) Never Say say, “I just push a button.”

Adding to the list of things not to say in the operating room (“OR”):

  • My Bad
  • Who is this?
  • Whoops!
  • I hope this works

ECT patient: “I want to be the placebo guy.” Patient (an older man:) Lifted his head, slightly, after the procedure was over, and asks, “Can I still have children?”

Patient: Being wheeled out of the OR (operating room) on the gurney, she stares up at the ceiling and mutters, “I can see why I need a driver.”two steering wheelsHow do People learn how to drive a gurney?! I just touch the thing and it’s like solid objects appear everywhere. The patients get nervous. One said, “Doctor, there can’t be two steering wheels.”

Dr. Schumer: “I want to reduce staff work load, and since I’ve proven to be an unsafe driver of gurneys… I now control the Tylenol. I am a physician and I hate it when people say that I just ‘push a button.’ They can hardly trust me not to shock myself…. But the Tylenol, the Tylenol is mine!”

Anesthesia: “Versed isn’t really an abused street drug—if you have a good time using it. You don’t remember anything anyway.”

Dr. Schumer: “Yes, I’ve put vaseline on my nipples to help with chaffing.” (Patient: In his ‘twilight’ sleep…we thought, bursts out laughing.) Dr. Schumer: “Yeah, try and not picture your doctor in pasties… It’s not good for your healing.”

Patient to Dr. Schumer: “You’re pretty good at this.” Dr. Schumer: “I’ve watched this on the Discovery Channel.” (Then, all of a sudden, she realized “I am not perfect. Such a shame.”) Dr. Schumer: “I really don’t do a whole lot in the OR… In fact, can we just get another gurney in here so that I can lie down?”

Cheap medical service, do you really want that?

NAMI: National Alliance on Mental Illness

Hello Friends,

I’m enjoying this all too fast passing time at the APA annual meeting in Toronto. What I am most enjoying is the education, the community and connection with new and old friends, and the reminder of what this is all about – you and I. In honor of us, I’m “pressing” this excellent post from our national advocators and stigma-fighters at NAMI.

NAMI: National Alliance on Mental Illness | NAMI: The National Alliance on Mental Illness.

Check it out and let me know your thoughts. How does this resonate, or not, with you. We need to hear!

Be well and keep on!

Q

Dr. Sarah Lisanby on ECT | Psych Central

I worked with this amazing lady, peripherally, when I trained in ECT at Duke. She is articulate and is a leader. I’m proud of her from woman-to-woman, psychiatrist to psychiatrist, person-to-person. She is moving soon to NIMH and I bless her life journey. Our world has been blessed by her. Keep on Dr. Sarah Lisanby!

Dr. Sarah Lisanby on ECT | Psych Central.

Handout – How to Talk to a Psychiatric Patient.

duck

Finished the CME talk I did last week and thought, you might find some use for it.

I’ve received bad press many times for not being, in so many words, legit or academic enough. Check out the comments on my ECT book on Amazon.com for examples :). Maybe this one leaning into that bosom of greatness will turn public opinion. (Sneeze.)

…Formatting has been a real bear.

As you go through it, please talk out. Tell me what you think. I may do it again. (That’s right. I’m not afraid to threaten. You heard me.)

Keep on, Friends.

How to Speak to a Psychiatric Patient

Introduction:

  • You quack like a duck, avert your gaze, and then hold a fetal position. It’s good for core.
  • Be sure to carry your portable speakers playing zen chakra music in the background.
  • Offer cigarettes.
  • Bring a healthy white chicken to sacrifice over their chest for the exorcism.
  • Introduce yourself with an alias name. Hopefully a superhero.

This is a fail safe method of communication to pretty much hit all the difficult misperceptions we are contending with in psychiatry – demonic possession, shame, violent tendencies, weak character, and poor moral choices.

I’d like to give you the 1,2,3’s on how to talk to psychiatric patients. But as I researched this topic, it became apparent that this wasn’t the direction for us to go in. You have better algorithms, systems, and manuals based on research for this in your own departments. I know you have people who are specialists in the administrative side of things.

For us today, we are going to turn rather toward the innuendos that interplay in communication between caregiver and patient.

The is the first place for us to start, let’s just talk about it here.

What is it like for you to talk with a psychiatric patient?

  • Identifying Me in the mental health treatment paradigm.
  • Not implying that we have skills but no awareness. We are just deliberately putting the practitioner into “it.”
  • It’s a “how to,” but first we need to address our personal limitations.
  • Why do we have these limitations?

I: Clinician/Caregiver barriers

II: Patient barriers

  • What’s over-scored is that the problem is on the patient’s side. The patient is sick after all. We agree. Brain illness and all that.
  • Even so, what is underscored is our side. And that’s what this talk is going to be about.
  • We want to focus on our own thoughts about this. What it says about ourselves. Who am I if my identity changes with how I feel and behave? etc.
  • And then, how do we respond to that?

III: Understand Personal Biases – Likes and dislikes

  • Figure out where we are at. What makes it difficult to talk to patients?
  • What are the common myths? Get the myths out there. 
  • Some reasons are true and not myths.
  • What are some personal biases about working with psychiatric patients?
  • (Bias means – likes and dislikes)

IV:   Define Stigma

1. Prejudice – Attitudes, feelings/emotions (Amygdala)

2. Discrimination – attitudes lead to actions

1: Prejudice

  • Weakness of character
  • Supernatural explanations. (Statistically significant association with superstitions.)
  • The word “patient” not talking about disease, perhaps, but rather about character – something of moral value.
  • Religion. (But only a few believe that spiritual leaders can play a role in treatment! People don’t relate stigma issues to biology.  i.e., It is not biology or medicine that increase the problems, but belief that the person has a personal weakness as demonstrated by their behaviors – A conflict in beliefs, or prejudice, worth exploring.) (…But where do emotions and behaviors come from? The Brain. Thinking they come from a cloud by day or a fire by night fall into the category of prejudice.)
  • Time consumption.
  • Danger
  • Treatment skepticism – no recovery, there’s less hope for them
  • Punishment from God for evildoers.
  • Demonic possession
  • I am lessened by my affiliation with the mentally ill

What are our fears? Fears are an emotion and/or attitude…

  • Brings into play, how do we identify ourselves? …And that part of us that remains even when we are in a changing body (identity).  I call this, “Me,” with a capital “M.”
  • Think about this when we look at responses to prejudice; “discrimination.”

Caregiver stigma – “self-stigma” comes when we internalize public attitudes and turn it onto ourselves

  • We perceive stigma from others due to those we care for.
  • Shame/Embarrassment
  • Fears of what it says about ourselves

2. Discrimination – How we act on those prejudices.

Example:

  • Take “Caregivers Stigma.” We can bring this into our work place as well, from what we glean in our community.
  • We avoid patients who make us feel uncomfortable.

Who has Stigma?

Everyone.  It is in our community, including we who serve and are involved in mental healthcare services.

1. Patient

2. Clinician

Patient

Example: Mr. Whineheart misses his medications approximately three times a week due to logistical reasons. However, we know that Mr. Whineheart has had a long history of difficulty with treatment noncompliance. As we explore further, we discover that Mr. Whineheart dislikes taking medication. It makes him feel like he is weak. Not taking his medication is Mr. Whineheart’s discriminating behaviors against himself in response to his prejudices, (emotions and attitudes of shame.)

Clinician

Examples:

  • Refusing care for psychiatric patients.
  • Starting with Questions:  How do we respond to challenges to our identity? When our identity’s confronted by seeing our patients with psychiatric illnesses, our patients who demonstrate changes in their emotions and behaviors since brain illness set in, we ask, what part of us remains even when we are in a changing body and mind (identity)? How do we respond?
  • If it is positive, it is not discriminatory toward ourselves. If it is negative, it is discriminatory to ourselves and inevitably to others.

V: What are the barriers to talking with psychiatric patients?

  • The tension is when the patient and the clinician’s personal views, life stories come together.
  • Where those thoughts collide is where the tension is.
  • That’s where the barrier is.
  • Once this tension is resolved it’s easier to go into action

VI: Why bother about Stigma?

Because:

  • Stigma is a feature and a cause of health problems. (Both clinician and patient)
  • Belief —> action.
  • i.e., In caregivers, emotional toll can be devastating – may lead to injury or illness of caregiver

Because It Affects:

  • How we speak to psychiatric patients. (Human Value.)
  • Choices in our clinician-patient relationship.
  • Perceived quality of work experience.
  • “Me” and QOL (Quality of Life).

Because It Engenders:

  • Social distance. (Comes from fear. But connection is healthy for “Me.”)
  • We are robbed of opportunities (Think – Agendas, Connection, etc.)
  • Avoidance. (Comes from belief of danger.)
  • Treatment skepticism (What is “recovery” anyway?)
  • We need to ask, “What are our treatment goals?” (Agenda)
  • Frustration and anger, negative emotions.

Responsibility:

  • There’s an unequal level of power (Us v. patients/clients) – inherently increases our responsibility toward others to overcome this.
  • What about us?
  • Identify that. Then fear can become strength. Presence. Actions of discrimination change to actions of hope.

VII:  Agendas

  • Part of our “belief systems.”
  • Exposing agendas, leads us toward action. 
  • Just like exposing prejudice leads to actions of hope.
  • Just like starting with Me leads to actions of accountability and presence.

1.  Traditional agendas in the medical model:

a.  Serve altruistically.

  • Saying we don’t have an agenda is grossly dishonest.
  • Maybe we are uncomfortable speaking about agendas because it creates tension with the classic view that practicing medicine is supposed to be Altruistic.  Altruism is just another “pressure.”
  • It’s a perfectionistic model. It’s false. To ally ourselves with it is a mistake. Brings discriminatory behaviors toward ourselves, driven by prejudices of shame.

b.   Healing

  • The paradigm that never fits for psychiatry – cure, getting rid of something bad, not joining it and integrating it. (Presence.)
  • Can’t stop disease even with appropriate treatment – Treatment agenda changes to center around QOL experience rather than cure.
  • Caregivers in long-term care are not looking for recovery in their patients.

c.  Serve patient (Service)

2.  Traditional agendas of business

  • $, Profit

3.  Quality of work experience

  • Not only do we get money, we get other stuff (biopsychosocial needs).  That affects how we talk to people.

VII:  Solutions

1.  Start with Me. Own that we have stigma: prejudice and discrimination.

  1.  Protest
  2.  Put own selves in the way of these treatments
  3.  Rely on evidence (biomedical conceptualization or education), not ideation (prejudice, emotions, religious causation…)
  4.  Pay more attention to emotions, senses, thoughts.
  5.  Reconsider your agendas e.g., Not necessarily recovery but rather QOL
  6.  Engender a culture of expectation (ex: We expect ourselves and each other to participate…)

2. “Contact based” solutions.

  • The impact of experience and exposure
  • Best treatment is contact with the mentally ill vs. Educational approaches, which, although are helpful, are not as effective. Nor are psychotherapeutic approaches.
  • Maybe we overemphasize education in our culture and undervalue human relationships.
  • We see this anecdotally, but also notice that nearly all interventions studied, (multiple metanalysis, etc.,) used educational interventions primarily.

3. Education (Still important and demonstrates degree of efficacy)

4. Collaborate

  • Involve family

5. Collaborate

  • Involve community, Partnerships with community resources

Conclusion

  1. Start with at Me.
  2. More contact and exposure to people with mental illness.
  3. More education.
  4. More collaboration.

Continue reading

Why do I Keep Living? – Chronically Suicidal.

trainwrecklife

Carl D’Agostino is a retired high school history teacher. His interests include woodcarving and blogging. Cartoon blog at carldagostino.wordpress.com.   Cartoons published in book, “I know I Made You Smile, Volume I.”

Marvin lived hard for years, used up his bank, his talents used up like putting a flame to his wick.  He was wired to live in the moment. Living that way, when he had gifts galore freely given, living was different than when those gifts were used, diminished, and broken. Marvin was smart enough to rationalize his way into a chronic suicidality thereafter.

What is the point of living, after all? Marvin asked this question, answered it, and asked it again, to the point that it separated itself from Time and place. It is a question that is infinite anyhow.

Sometimes Marvin, with this infinite question, this question that occupies the time of God, kings, and beggars, Marvin would sit in my office with this infinite question in his nicotine-stained and inked fingers, and he would in this bring together the infinite with the finite. I remembered that the whole point, the meaning of the infinite and finite, is increased in value by the other. Marvin, living in the moment, even now years after his coin was thus reduced, was living in the infinite.

Why do I have to keep living? I just need someone to tell me it’s going to be ok if I die.

Marvin, If you are looking for a doctor to help you die, you need to go somewhere else. I will always choose life.

(It seemed like that “FYI” was in order.)

“We” made a plan …that Marvin wasn’t entirely in agreement with. I told him he could not come back to my clinic if he wasn’t engaged in that plan.

Marvin, we are just going to do what the data tells us will work. We don’t have to feel it or even believe it. We have the data at least.

Every time I have ever seen Marvin, I took a hard look, memorized him, knowing this may be the last time. Setting boundaries with him was freaky. It felt like trying to hold broken glass. Would Marvin be back? If not, I knew I’d be hurt.

The patient-doctor relationship is unique to each patient. It is unique to each doctor. For me, in my patient-doctor relationships, if it wasn’t for the hard grip I keep on the seat of my chair, I’d have too many of my patients in a big, but likely awkward, (and my Academy tells me, “Inappropriate”) hug.

This flashed through my mind in fair warning again. I compromised, saying instead,

You matter to me, Marvin.

I think Marvin’s lip actually curled and his canines grew. And I quote,

How can you say that? I just don’t get it.

This was a moment of road’s diverging, 31 Flavors, coins in your hand in front of a mother-loaded vending machine. I could see philosophers, all over the now and then of the ages, slobbering like they were at a nudie bar.

Once, when I called 911 on behalf of a patient who needed to go into the hospital for safety, the police person looked like that, bouncey even, on her toes. I had to check her feet to see if she was actually standing on a pedestal, she sermonized my poor patient so thoroughly. I think she was even eating a candy bar as she left my office, satisfied, (without my patient, by the way. Apparently she thought her tonic words had medicinal powers.)

Marvin was fishing me. There were so many ways to lose with that question. He was hoping I’d flop around with straining gills sucking air for hours while he tugged on the hook.

I’ve done that often enough, and will do it many more times. We can count on mistakes. What took me by surprise was, this time I did not.

Well, I’d guess it has something to do with me and something to do with you.

Yup. It surprised me. The surprise brought a wave of gratitude. “Thank you God.”

And if you aren’t as surprised or grateful by that liner, I can only explain that it was right at the time. Marvin lost his handlebar lip curl. I lost my grip on the chair. Marvin’s still alive, (I know everyone’s worried about the “for now” part of that.) And our universe cares, finitely and infinitely.

To the Marvin’s of the world, the wasted, the used, and the squandered, work your programs.

To the lonely and distorted, to the ones who have tried to die, to you who don’t know why you keep living, follow what the data offers by way of direction.

To you who may not get the same freely given gifts in this life that are now gone, you have good things coming.

We choose to live with you, than without. We choose you again. We choose, every time, what Love will bring. Keep on.

Questions: Have you ever asked yourself and/or others, “Why do I keep living?” What has your answer been? What is your answer now? For yourself. What would you tell your own Me?

Self-care tip: …I think I waxed on and off enough already with that – smile.

Stigma and Me: Me-on-Me Crime

who me?

Me-on-Me Crime!

I was doing my speed walking thing on the Balboa Beach cottage lined shore. Gorgeous, it was. Fluffy thoughts were everywhere. I was purposely passing under the low hanging docks to upscale some lower body muscles. Some string bean teens with their fishing poles moved into the water’s leisurely lipping edge ahead of me. Who wouldn’t be distracted by such poetry?

Can you guess what I did? I looked up. I lost my squatting waddle.

When someone driving on the freeway slows down to look at an accident on the shoulder, we call them “rubber-necks.” What do we call someone who walks taller, someone who loses her shorter self under a low dock when “speed walking” at approximately four-miles-an-hour?

Me.

This was more painful than my three cesarean-sections. Of course, there was no anesthesia when I sped into the solid, immovable wood. I loosely figured, with physics being what it is, that I received in return the equivalent to someone slamming me with a baseball bat. I was never great at physics but I remember that Force = mass * acceleration. I am not telling you how much “maaaass” was involved, so, for the disgruntled forensic’s enthusiasts out there, we just won’t know how hard I was hit back.

As the blood was pouring down my throat, out of my mouth, down my face, and as I gargled the words, summarily “help,” to 911, I thought, “That wood was not there before, because, why would I do this to myself?!”

How are we our own enemy? I’m learning a lot about stigma these days, in preparation for a couple CME talks coming up. Stigma is a molded and remolded term, but for our purposes, we’ll say that it can be broken down into, prejudice and discrimination.

Prejudice refers to our attitudes, beliefs, and emotions.

Discrimination refers to action, what we do about it, and behaviors.

I really like this. It helps to see where “Me” plays into our own stigma behaviors toward our own selves. For example, skipping our medications on and off.  That would be, discrimination, when it is done in response to a conscious or unconscious prejudice about taking medication. Maybe taking medication induces feelings of shame or blame. Then we behave with missing pills.

Another example of stigma, is seen in our aging “baby boomer” population. Turns out, psychiatric patients are living longer too. Social workers and other professionals are admitting more and more psychiatric patients into senior facilities, e.g., assisted living, nursing homes, home health services at home, hospice, etc., and the staff at these agencies do not know how to work with psychiatric patients.  So, the senior facilities try to send these patients to psychiatric hospitals or hospital emergency rooms, and the nursing home or senior facility won’t accept them back into their program afterwards, stating “We don’t have the staff or programming to work with psych patients.”

Senior nursing home/assisted living facilities are realizing that they need to hire/train their staff to work with psychiatric patients in their senior years and that this is part of their growth as an organization and their commitment to providing quality care to seniors.

The prejudice comes from feelings, such as inadequacy, on the part of those serving psychiatric patients. The discrimination is when the patients are turned away. Everyone loses.

It’s an exciting time for senior facilities. It’s an opportunity for their staff to learn new skills and understand that with even some basic training on communication skills, therapeutic interactions, some do’s and don’ts, they CAN admit and care for psychiatric patients in these senior facilities. Everyone wins.

The most important message in learning about stigma, is we hurt ourselves any way it turns. And why would we do that to Me?

I still have a headache, three days later. My teeth hurt. And I’m not as pretty.

Self-Care Tip: Break it down – What are you feeling? How are you behaving to yourself?

Question: How have you been prejudiced and acting out toward yourself? How have you eliminated stigma toward yourself? Please tell us your story!

Keep on!

5 stars

cried my eyes out.

Laughed too loud.  #gratitude

watch “Danny Collins” 

Question: Which character do you identify with?

Keep on.