The Perfect Doctor – Healthy With Disease

looking

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!)

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

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!

Starting With Your Own Answers to The Big Questions Leads to Reducing Stigma In Others

Alexander Ostuzhev as Quasimodo, 1925.

Image via Wikipedia

Question:  How do you see the paradigm of spirituality intersecting with the paradigm of biology?

As a psychiatrist who blogs that behaviors come from the brain and not a theater script we voluntarily revise to perform, this is a good question.  As readers, and perhaps subscribers to this same belief, this is a good question.

In church, Bible study, or circle of any kind, there are fewer things that goad me more than listening to descriptions of the moral value in emotions and behaviors.  I have found myself visiting the lady’s room more often, carousing the fellowship hall-kitchen and fridge, or thrusting myself on a poor unsuspecting soul loitering by the door with my fervent uncomplimentary words.  I do this before I stand up and pull rank on the speaker.

(I know.  The words “pull rank” sound just as arrogant, and probably are, but they were said in the heat of the moment.  Please understand that the emotion behind them and including the words came from my brain.)

It wasn’t so long ago that suicides were thought to be the ultimate separation from God.  Oh wait.  That’s still happening isn’t it?  It wasn’t so long ago that anger and sadness were thought to be from separation from God.  Oh wait, they still are.  Ok.  I’ll stop.  This is childish.

The hunched figure of Notre Dame comes to me now, ringing his bell, gazing at Esmerelda – pure heaven in flesh.  He offers up his humble life force, begging to be near her despite his biology.  He is ugly.  He is different.  He is separated by his own beliefs that he is forgotten by God.  His answer to our question is his own isolation.

This pithy topic has no boundaries across the world but yet I reduce it down to Me, one apparently arrogant psychiatrist, kicking up dirt where I stand.  I realize that the best way to protect us from stigma, to help you (again arrogant me swaggers in), is to start with my answer to this marvelous question.  I have to answer it for myself.  I have to start with self-care, spiritual care, relationship care, physical care – I have to start right here with Me.

These kinds of imposed opinions have never been reduced quickly.  We can’t take care of everyone before we take care of ourselves.  We must be patient.  We have the privilege to answer thoughtfully.  It is our freedom.  It is our right.

Self-Care Tip #193 – Answer the big questions in life for yourself, deliberately, and see that a secondary benefit is that it will protect you from the prejudice of others as well as reduce their prejudice.

The Spider Sat Down Beside Her – Mental Illness

Self-Care Tip #178 – Find your courage and answer to stigma.

The Little Miss Muffet scenario explained by D...

Image via Wikipedia

Something as simple as taking pills can sabotage us.  The act of putting it in our mouths signifies all sorts of things from religion, to freedom, to personal identity and beyond; even someone who is trustworthy versus not.  Pill – take away her children.  No pill – could be president.  Pill – discredit whatever he says.  No pill – worth listening to.

Martha is a mother of four lovely girls.  Her husband is divorcing her and she wonders what he will do in the process.  She’s been depressed in the past and anxious with a history of panic attacks.  She took two years to get over them using breathing exercises and other therapies. She didn’t use medication.  I don’t need to tell you what her husband thought of meds or of her during that time.  It was a miserable time for her.

Now, during this new stressful time, she has relapsed in mood and anxiety problems and is terrified that if her husband finds out, he’ll take the kids.  Martha sees mental illness as a bullying tool for anyone to dump her over.  Little Miss Muffet is a story she often has compared to her situation.  The spider is the mental illness she feels is dangled over her to her demise.  Martha is bullied and scared away.

Taking pills makes me feel like I’m crazy!

Note: it’s a type of crazy she interprets as being something different from the crazy of mental illness.  For Martha, the crazy that comes with medication therapy is more sinister and discrediting than the worst experience of terror any of us have ever gone through, i.e. panic attacks.

Every day, we who take medication for emotional illness have to answer to those accusations.  We contend with the fingers pointing our way, the jeering in our memory of loved ones and the boxed presumptions we find ourselves in.

This may sound a little dramatic to some out there, although familiar.  To others, it is an understatement of what they courageously confront to take care of themselves.  Each of us must come up with our own answers and find our own courage.

Martha finally decided on medication treatment and within two days she was amazed to find that she could eat without throwing up and no longer felt anxious.  She still insisted that taking medication was only temporary but getting a pill dispenser had helped her get past some of her daily battle with stigma.  She just opened the lid and poured the pills into her palm, threw them back and swallowed without looking.  Martha found it easier not to dispense each pill each day out of each bottle.  It was also easier for her to keep this information secure in the confines of our office.  For Martha, for now, this was how she answered.

Question:  How do you answer to stigma?  How do you maintain your sense of freedom when other forces tell you that you are not free?  Please tell me your story.

Leave Space in Your Beliefs to Grow

 

standing up to stigma - mambo.org.uk

Self-Care Tip #144 – Leave space in your beliefs to grow.  Be a friend to yourself.

Madeline brought her son in.  He was born male but has always allegedly believed he was female inside.  It was Madeline’s appointment with me, not her son’s.  But he came in with her and I could either listen to her concerns about her son or ask him to leave against her wishes and still hear her talk.  So I listened.

The issue was a matter of salvation.  Madeline was fighting for her son’s salvation as a mother might.  That part was lovely to watch.  I thought of God hearing her and being present with her pain and being The One behind her fierce love in the first place.

We talked a little about the biology of homosexuality.  What is transgenderism?  If God’s Word is absolute, what part does a progressive understanding of biology play in our perception of truth?

Madeline’s son asked to leave.  I thanked him for coming in and he shrugged.  His whole family abused him, Madeline said, gulping and losing form.  She had spent many years defending him even though in her heart she was terrified that her son was damned.

Some of you may have read the powerful blog-post, “My son is gay” in which a mother described her halloween experience.  Her son dressed up as Daphne from Scooby-Doo.  She and he were promptly abused. As a mother I empathized, and as a scientist, I wanted to scream things like, “You thought the world was flat too!”

But Madeline was worried not only about bullying.  She was worried about the Last Judgment.

Stigma comes from all directions.  Inside of us, our homes, our churches, our schools, our government, up, down, sideways, this way, that…  Stigma is everywhere and it is usually a painful encounter for everyone involved.  Perpetrator included.

So here’s the scoop folks.  Homosexuality is biological. We have as much choice in it as the shape of our nose.

I’ve seen kids be mean about noses.  I’m half-Lebanese and believe me, I know what big noses are.  The nose that makes you wonder how the head escaped the vaginal canal without injury.  But I’ve never heard anyone hate someone’s nose and believe that he’s going to loose his salvation for it.  I’ve never seen someone turn her back on her brother and leave him to die without the love of family around because she thought she was condoning his nose if she did.  I’ve never heard about moral judgment being attached to a culturally incorrect nose.

In my son’s church class the other day, the teacher was trying to get him and the rest of the other oppositional three-year-olds to wear angel and shepherd costumes for the song they were going to perform. Only the stage-hams garbed up.  She kept giving the rest of us parents her pleading eyes, pleading words, and pleading emotions. She was making the wrong people feel guilty.  The kids were unfazed in both compliance and emotion.  The ones who were genetically inclined to get energy from performing that way, were.  The others were not.  I could have said to my son, “Get this on!…!”  And made him feel like he was bad if he didn’t.  But attaching morality would never change where he gets energy.  That part is genetic and it won’t change despite his conditioning.

It’s a bummer that Paul’s letters were translated the ways they were in the 1950’s using the word homosexuality.  A lot of people are scared when they read it.  Fear has threatened and hurt a lot of people.  Reverend Mel White posts about this.

I don’t know if Madeline was given anything she came looking for.  I’m not always the best teacher or student myself.  But I do know that we, all of us, will continue to learn through all eternity.  We will never know enough, love enough, or be sinless and perfect enough to take over that awesome job of being Judge.  I once heard of a beautiful beloved angel who tried.

Question:  What has been attached to morality in your life that you know is not?  How have you dealt with stigma?  Please tell me your story.

Stay Connected For Your Sake and For Theirs

Members of Bound4LIFE in Washington, D.C. symb...

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Self-Care Tip – Stay connected for your sake and for theirs.

We have all seen “kids” who stop talking.  Driving by, their faces in the car window a little strained, their bodies postured away, maybe their hand fisted under their chin.  Their parents lost their chance.  Whatever they now want their kids to do, they’ve lost more than their authority.  As have the kids.  The kids lose out on having their parents voice in their lives.

It is the same with us in the world.  When the world stops speaking to us, we lose our influence.  When we stop speaking to the world, the world stops listening.  We loose our voice.  People won’t listen when we want them to.

Some of us may not be in that place now, but there will come a day when we want the world to care what we say.  I’m not talking just about leaving a legacy, or having people care about what we’re going through when we are in crisis.  This includes all the other times of life.  The in-process times.

When we are angry at whoever graffitied our neighborhood.  When we survive prejudice.  When we share our child with the world.  We want to have a voice.

And if we stop speaking, we will lose.  If we don’t respect the opportunity to connect, if we don’t treat it as the treasure that it is, not only will the world miss out on the “Me,” we miss out on the world at large.  It goes both ways.

We have a choice.  Get friendly with yourself.  Speak.  Listen.  Connect.

Question:  When have you wanted to be heard?  How does it affect your life to be connected?  Please tell me your story.