What is it like when people talk with you, a psychiatric patient?
How do all the areas we are contending with in stigma affecting your interaction with others? – Demonic possession, shame, violent tendencies, weak character, and poor moral choices?
We want to hear from you. Some stories please.
One patient told me that her parents were angry at her teachers when they were advised to consult with a psychiatrist for my patient’s depression. Her parents were so angry, in fact, that they removed her from her private school and enrolled her somewhere else.
I wanted to ask my patient, let’s call her Brianna, how people speak to her now that she has finally engaged in treatment, as an adult! How do her parents reconcile it? How does her church speak to her?
Briana is among many who suffer at stigma, but her best approach would be to ask how she, first speaks to herself, a psych patient. Does she have biased self talk? We need to start with “Me.”
What are the common myths? Get the myths out there.Some of what the community says are true myths and some are not myths.
Treatment skepticism – no recovery, there’s less hope for them
Punishment from God for evildoers.
I am lessened by my affiliation with the mentally ill
The patient is sick after all. We agree. Brain illness and all that. This is Brianna’s identity; her emotions and behaviors paint what she and others see. Perhaps, Briana identifies herself as someone with depression; someone who went over her church and parents directives. That takes a chunk of courage to do.
Self Care tip: Discuss and discover the self stigma we have about our mental illness.
Why do you get out of bed every morning? To go to work? You think, “Life i is about working and then, someday I’ll die.” Are you living to go to school? Perhaps a student for life, the best is to gather and gather. A klepto of information. Ma skzwybe you live, instead, to stay home and not leave. That can be worth it. Leaving home feels like going to one’s death for many, in fact, with anxiety.
Is what you are living for, worth “living for?” Why didn’t you kill yourself last night?m I’m not asking for “13 Reasons” or glamorizing suicide in any way, like it ois, unfortunately, being done in the media these days. I’m just asking. (Straight face. Eye contact.) Why?
Suicide is increasing, this year up by ~30%. It’s sad but I’ve heard the ignorant say, “When our world is being overrun by humans, this is just one more way to improve population management.” Why anyone would say that, let alone to a psychiatrist, speaks toward the unfortunate person saying it more than anything. Even so, these are the people that contribute to our cultural stigma and sentiment, like the wrong colloid for growth. This stigma is best diminished by peer-to-peer influence. Your voice; you speaking up is the painting over the foul-language graffiti. You speaking of your own journey with suicidality or any related diseases changes the ignorance into empathic knowledge.
We are in the mental health equivalent to the industrial revolution. Fortune. We are wealthy in mental health treatment options. Bling! Bling! It wasn’t too long ago when we were trusting depression medical therapies to crude agents bulky, and bluntly stunning our neuroreceptors. These were a big stick coming down on a flower.
Think of the cart and horse transforming into the automobile; course into sleek and refined; slowly moving and grossly impacting changes, contemporarily working rather as specific rapid responses. Now remember your parent, or mine, who never had the opportunity to receive a treatment that would work in a matter of weeks, and without turning her/him into a zombie-blimp.
A child stands there going through his own vasovagal experience, scared and confused while watching his favorite person in the whole world performing like a broken toy. The child tries to make sense and restabilize their once clarified existence. The parent goes through this at first for about six months and then somehow “gets better.” Was it the prayer that worked? Was Momma finally able to “pull through it?” Was it because the child’s behavior finally became “good enough” to please God who then condescended to make his momma better? Momma does well for another 2 years. She’s connected. She’s filled with purpose. The memory turns into something like, “Boston’s worst winter in fourteen years;” briefly print-worthy and then thankfully, not much more.
Then momma is again dark, hopeless and staying in bed whenever she can. The child, Teddy, is now a preteen of ten. This comes back, like finding another letter from his cheating dad’s girlfriend under a magazine in the back of the closet where his golf clubs are. And instead of six months, Momma’s change lasts about two years. (Can we even call it a “change” when it lasts two years?)
The amorphic improvement comes again though, like a miracle, but who can trust it. Miracles aren’t gotten in vending machines after all. I We can’t buy them with a paycheck.
Sadly, as Teddy feared, another some many months later, Momma drops again. This time she plummets rather than drops, into a drunken, more terrible condition. For longer, and the boy is now a teen. He at first appears more calloused. Yet, if questioned, he will show his grief and bewildered young self, just there behind a gentle touch, or a cluster of inquiring kind words. He loves her well. Why can’t she love him? Moms who love their kids will get up in the morning. They’ll shower and they’ll talk. They don’t write suicide notes or leave their son’s to find them half conscious when they get home from school. Not mom’s who love their kids.
Our moms, yours and mine in the seventies, didn’t have the privilege of taking treatments that worked or worked well, and rapidly. We are so blessed. How to grasp the immense difference in our Age; this Age of mental health revolution.
Now a little boy sees this change in his favorite person in the world. She is fortunate enough to receive medical treatment, and within weeks is “back to myself again.” This little family escaped years of decomposition by the ravaging damages from brain illness.
My grandma, Elsie Louise, (isn’t that a great name!), was washing her laundry in a new machine that decreased her labor by many hours. One day, when she was daydreaming about her young handsome husband, or maybe it was the chicken she lost to the fox, when she screamed, jerking out from a terrible pain in her hand. Her fourth finger was gone. She lost it, pulled off by the twisting force of the machine’s internal grips.
Now we place our laundry in a closed lidded box we just walk away from. We don’t even think about the appendages we are allowed to retain. We don’t imagine the privilege.
In psychiatry, it is like this. The treatments we had generations past were better than none. But, enter now into 2018, and we don’t realize how good we have it. We forgot most of the print-worthy stories back then. Not to use the treatments from this revolution, is going back to the darker ages of medicine. The treatments save lives. They bless. They make us rich in life. Bling! Bling! Look at your wealthy character. Healthy.
Why are you still alive? Whatever you answer, fight for that. Take advantage of the mental health revolution and live well.
Questions: What are some stories of those you have loved who missed out on mental health treatment? What are some stories of those who did not? Where is the difference?
Self-care tip: Speak! We need to hear you. You are painting over the foul-language graffiti of ignorance!
Think of walking in a rainstorm. Your clothes and hair hang heavily. They provide no protection. They offer no remedy. You take a hand towel out of your bag and try to mop up your icy wet face. Wring it out and continue to wipe.
This is like choosing to do all the psychosocial efforts in your life, but missing the biological. Until you treat the underlying illness, much of our efforts to heal are like using a hand towel to dry off in the rain storm. We think that we can get better without medication. Or, we may reject other treatment options, like ECT or TMS. We think false thoughts.
It’s not healthy to take pills.
I’m better than that.
All I need is God.
My parents would be upset, so I shouldn’t.
If my work found out, I’d lose my job. So I shouldn’t.
THC is better.
Exercise is better.
Some of these are entirely false. But some are just partly false, encased in a disconnected truth. This “rain and the hand towel” idea is not an analogy meant to minimize or bring shame to those who choose not to engage in treatment. It is not meant to talk down. Please forgive me for the crudeness and limitations. It is just meant to crack open this idea.
Yesterday, Louise commented that her physician told her taking sertraline, or Zoloft, was like taking “a vitamin for my brain”. That clicked for her! Vitamins were ok.
Question: How has your physician helped you get past not wanting to take treatment? How could your provider do better with this?
Self-care Tip: Allow healing with medical treatment for medical disease.
Why do I feel so horrible when I start a treatment that is supposed to help?
Medication treatments for depression and anxiety, and some other brain illnesses, often worsen how you feel before you feel better. I can’t tell you how many patients have told me that if they had known this before, they never would have stopped their mediation(s).
Yesterday, our post discussed a Dr. Jones and Presley.
Presley fired Dr. Jones when after following her directive, he subsequently experienced an extreme panic attack. Dr. Jones may not have done anything wrong in her treatment recommendations. Presley was just an individual, as compared to a “number on the curve” of treatment responders. Escitalopram, the medication discussed as an example yesterday, (one medication option out of many), may have been dosed at an initial amount that Presley’s body couldn’t handle “straight out of the gait”, so to speak. But likely, if he had started at a lower dose, maybe ½ or even ¼ of the tablet, and then waited for his body to accommodate to the medication. Then Presley would have tolerated it. Presley would have tolerated slowly increasing the medication if approached, rather, piece-by-piece of a pill. I’ll even joke with patients,
I don’t care if you lick the pill. Just get on it.
When slowly titrating a medication, it allows the individual’s neurotransmitter receptors to down-regulate whilst the agent floods the receptors. If there is a neuron targeting another neuron, there’s a baseline balance in time. There is a baseline understanding between these neurons. An agreement, of sorts. “I’ll sit here and receive your messages,” (neurotransmitters, or chemical messengers such as serotonin, norepinephrine, and/or dopamine). “I’ll then carry those messages on your behalf to their intended recipients,” (such as the amygdala or hippocampus). But then this person artificially takes a higher quantity of these messengers, for example, by way of medications, and floods the system. The receivers, (or neuroreceptors), have to adjust to this to establish a new healthy baseline.
In this initial time of treatment, when 1st introduced to the increased neurotransmitter-load, (ex: as released by a tablet of Escitalopram), there can be a negative response, such as panic and/or depression emotions. We call this, “initiation side effect’s.” Once the neuroreceptors get used to the new load, then the response improves.
After accommodating to the new pharmacology, the brain is allowed to experience the blessing that comes from treatments, and heal.
Some individuals are outside of the curve and cannot tolerate the standard initial treatment dosage, like Presley was. Some are inside, and can without much difficulty. The point in treatment, though, is that the person just needs to get on it.
Get on treatment. However you do it. You have to make the treatment work for you, an individual, in your own way. The prescriptions are there to serve you. You aren’t there to serve the medications. I like to analogize Jesus’ statement,
The Sabbath is there for man, not man for the Sabbath.
Make it yours as an individual and reap the benefits; the blessings inherent there. (See Mark 2:27).
If you don’t get on the treatment, you won’t get better. Anything less than this will be inadequate. It’s like drying water off your face with a hand towel while still walking in a rainstorm.
What is your agenda in treatment? List it. Write it out. Then, go get you some!
Outside a medical approach is like flicking water off in the context of a rainstorm. If your agenda is getting to your healthy self. Get out of the storm and get dry. Then go get it.
You have a medical condition. Treat it with the assistance of a medical professional.
I don’t go to a plumber to help with my electrical home repair. I don’t go to an accountant or a church counselor to treat a medical one.
The plumber, the accountant, the church counselor are what they are.This is not minimizing their efficiency in their own fields of excellence. But why do we seek care in psychiatry from those who haven’t studied this? From those who are not experts in this? Maybe stigma keeps us away from psychiatric care. Maybe misinformation directs our search for mental health treatment elsewhere.
Self-Care Tip: Get you some medical therapy for medical illness.
Question: What are further concerns you may have about taking medications? How would you prefer your medical providers to work with you? Please tell us your story.
Nora’s family lashed out angrily at her. “Why are you so horrible!”
Her husband had left her for another woman from their church, a “friend” of Nora’s who used to come to their house for movie nights. He said, “You’re like poison, Nora. I’m not happy any more with you.”
Nora had now lost her job. She couldn’t focus and cried too much at work. Her supervisor told her, “You are not the same.”
Nora decided she wasn’t going to take her medications any longer because what she needed was more faith to be well and to get her life back. Her plan for recovery from debilitating depression and paralyzing anxiety was to be more dependent on God by way of certain practices, mainly not taking her medication. Although she didn’t see her plan for recovery quite so transparently. She thought it was through prayer and sincere intention to be God’s rehabilitation appurtenant.
Nora did say she was still taking her anticholesterol medication. And so we spoke about the important related perspectives between what Nora saw to be “medical” verses “spiritual” illness.
First to lead into the matters, “What are you taking your Crestor for?”
Where does cholesterol come from in our bodies?
Where do emotions and behaviors come from?
Is there a spiritual element that has a relationship to high cholesterol? How about to emotions and behaviors?
Is there a medical change that causes the disease of hypercholesterolemia? How about emotions and behaviors?
Why be willing to take medication for a spiritual illness of hypercholesterolemia? Wink.
Nora, it turned out, loved where this conversation took her thoughts. It was hard to encounter inconsistencies in her religious beliefs and practices. But she did because she is a woman of courage!
It got me thinking about what role our cultures, related to religion, play into our emotional health. Is there a source of stigma against getting life saving medical treatment for mental illness that we are missing simply from the religious culture we are quietly woven into through life? Randy Travis’s song lyrics, “I hear tell the road to hell is paved with good intentions…” implies that we in religion justify the collateral damage, such as death and ruined lives by mental illness, by the belief in the greater good. I’m sure I do this too in my own unconscious way. And isn’t that what this post is all about? I want to take a big stick to this glass and shatter it! (Aggressive much? Smile.)
When I think of Nora, sometimes I can’t believe she actually is taking medication and doing so well now in her life journey. It’s a miracle.
Self-Care Tip: Explore the role religion is in your opinion toward medical treatment.
Questions: How does religion interweave into your stigmas? Or those you’ve broken through?
Or maybe it’s the opposite. Religion has contributed to your self care and medical choices?
Supposedly, I’m peaking. And this isn’t about egg yolk and marenge pie. I’m 43 years old, have been in medical practice for fourteen years, and am looking at a canyon in 360-degrees from where I stand. That’s what the data says. I wonder if I am going to do the electric slide or how I’ll boogie through the next years of medical practice. I try to think, “This is the best moment of my life, right now,” any time self stigma and fear of mortality creeps in. (That’s not saying, “This is as good as it’s going to get!” Ha!) I want to cherish the gift of practicing medicine, for however long I am blessed with it.
It’s a popular discussion amongst my colleagues these days, about how long a physician should practice. There’s a newer’ish respected program called, PACE, that evaluates physician competency to practice as they get old. This is a huge shift in the culture of medicine. It’s meant to respectfully assist rather than discriminate with ageism. I try to imagine what it might feel like if I were approached and asked to take the test.
So what does a psychiatrist rocking her best jeans have to show for herself anyway, you may ask. Well, (tapping the mike), “I’d like to first say thank you to my sponsors….” Wink. I mean my patients! Thank you.
…Hey! This peak is crowded! Give me some room!
Ahem. But at my “peak,” at the best of my career, I thought it would be fun to play around with, “Why?” What’s in my doctor’s bag that is so special?
Ask, “Why do you want to be alive?”
Start all work-ups with a medical work-up.
Give full informed consent with the 5-Treatment Paradigms of Psychiatry:
hospitalization (inpatient and outpatient),
alternatives (such as acupuncture, massage, sleep hygiene, lifestyle change, etc.),
stimulation therapies (such as ECT or TMS). There’s nothing else (that I know of 🙂 ) that anyone is going to offer you in psychiatry, no matter who’s clinic you go to.
Push to full treatment response.
Work toward quality of life, not cure, not perfect. Ask again, “What makes like worth living for?” Design treatment toward those goals.
Routinely and deliberately consider the flow of patient’s treatment agendas with physician treatment agendas.
Mood journal. Nobody believes they were “that bad” after they feel better. Everyone wants to stop treatment when they feel better. (This is why there are so many repeat pregnancies, for example!). We all need our own voice (mood journal) to look back on and speak the truth.
Fight for oxygen. If your patient has sleep apnea, don’t stop working toward treatment compliance. There are no medications that can take the place or make up for oxygen to the brain.
Community. More community.
The third eye – a therapist. None of us can be a mirror into ourselves. We all need someone outside of the “triangle” to speak.
I’ll be thinking of more as I try to go to sleep tonight, but it’s bed time. I’m off! Sleep hygiene! Arg!
Self-care Tip: Evaluate your position in your lifeline, and treasure where and who you are with deliberation. Keep on!
Questions: Where are you in your lifeline? Are you struggling with ageism? What gives you value? Please speak! I, and the rest of us, really need your voice.
One of the difficulties we have in talking to psych patients is realized with the dawning truth that we are not curing anyone. Working in those conditions of not curing, you both, patient and psychiatrist, have to come to terms with each others’ agendas. The physician says, “(‘I’m a failure.’) I can’t cure anything.” Now eye contact is even tough.
“If I don’t look them in the eye, some other emotion will surface and they’ll stop crying.”
Rachel was crying and crying hot and hard in the emergency room. She was unable to stop the lava flow. It was bewildering to her. The people around her shifted their gazes. Those who didn’t, looked angry instead, as if to say, “Pull yourself together, Woman!”
Psychiatrists have the advantage perhaps to these others in the lobby and receiving rooms and gurney shelves. Supposedly psychiatrists can grip and tug at the corner of the large sweater that is human behavior and say, “Emotions and behaviors come from the brain.” They can imagine, if not entirely believing at a visceral to cognitive level, that the person they observe is responding to symptoms of what is happening biologically, at a cellular level. When they are tempted to avert their eyes, or look back impatient with the messy emotions, they can say, “This is medical.” Impatience with emotional chaos from psychiatrist to patient, is equivalent to the ER doc saying to the trauma patient, “How dare you bleed in a public area?”
When someone cries on the medical unit, you may hear, “Nurse! Call the psychiatrist! There’s an emotion on the ward!” Later when things are calm, I walk out and they say, “Doctor! You’re amazing! What did you do?”
“Well, I bit off the head of chicken and sacrificed a goat on the patient’s chest. Then I said, take this pill and everything will be as it should.”
Luckily I have several chins now, and when I gesticulate, their quiver contributes to me looking very capable. As if I could cure something. I don’t know much about art history but, The Thinker, a bronze sculpture by Auguste Rodin, is probably what that Frenchman’s psychiatrist looked like when they both came to terms with the fact that psychiatrists don’t cure anything. (Heresy.) At least he got to get nude while he did it.
Talking to psychiatric patients can be that difficult.
There are studies on patient satisfaction that demonstrate that patients don’t like us when they think we give them bad news.
You see the predicament here, don’t you? So, some of the difficulty the world at large may be having with talking to psychiatric patients is that we have distorted perceptions of good and bad news. We may have difficulty with our own humanity, frailty, infirmity, and seeing it out there “without a scarf on” for decency, is a hard reminder.
We will never be cured of so many things. All of us. And the best we can hope for…
What is the best we can hope for?
(We are all gluttons and all hope for many unpublishable things but please! Just humor me.)
Say: “I hope to be healthy with disease.” There. Now we will all speak better to each other. It all starts and ends with Me.
Questions: Have you ever had difficulty talking to a psychiatric patient? Have others had difficulty speaking with you? Why do you think that is? What could help? Please tell us your story.
Self-Care Tip: Hope to be healthy with disease.
(I bet Carl D’Agostino could make an excellent cartoon with this rich irony to work with! That’s right Carl! You heard me! Maybe a blue ribbon with a hole in it?… Ah heck. I’m sticking with practicing psychiatry and leaving the toons to you!)