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.

How to Talk to a Psychiatric Patient: Post-test

Mrs. Albritton is a caregiver at Grace Landing for Mr. Bluhm, who has dementia and yells whenever she is around. Mr Bluhm’s daughter comes to visit him once a month. Mr. Bluhm’s daughter, Margaret, smells of cigarette smoke, has crooked teeth, and her grooming is limited. Margaret visits for only a short time even though she doesn’t have a job.

The caregiver wants the attending physician to better control the patient’s behaviors. She also secretly tries to maneuver the patient assignments so she doesn’t have to work with Mr. Bluhm as much as possible.

1. The most important problem for Mrs. Albritton to address is:

1. Daughter smokes.
2. She can’t believe how unkempt Margaret is and suspects her of taking her father’s money.
3. She knows that Mr. Bluhm was a violent drunk before.
4. She is avoiding her patient.

2. The best thing is to address at this point in treatment is the:

1. behavior of the daughter
2. behavior of the patient
3. behavior of the caregiver
4. behavior of the physician

3. This behavior is an example of:

1. prejudice
2. stereotype
3. discrimination
4. bias

Since Mr. Bluhm was in-house, Mrs. Albritton has worked at Grace Landing for five years now.

She just returned from a CME on the aging mentally ill population and is pleased to reflect that her work has been less stressful since the days of Mr. Bluhm.

4. This is because:

1. The patient population has improved
2. She has been in contact with this patient population for five years
3. She has been getting cognitive behavioral therapy on how to interact with this patient population group
4. She has received three salary raises since she began

5. This is an example of healing in:

1. prejudice
2. bias
3. discrimination
4. stereotyping

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