My Post on KevinMD.com Today

http://www.kevinmd.com/blog/2013/08/evaluating-mental-health-patients-snap-decisions.html

Please read and share.

Thanks!

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Despicable You

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Good morning, all.

And to my new friend Dr. Jocelyn Lowinger, who lives and writes down under, good night. Check out her site here

One of you asked me a very intriguing question the other day. (I paraphrase, of course)

“What happens when someone despicable, someone who has committed some horrible act or made some terrible decision, comes in for evaluation or treatment and you have to see them?”

Hmm.

Well, you know, I’ve told you in previous posts that I now believe I’ve seen and heard almost everything over a career in mental health that has lasted a quarter century and counting.

I have been asked to see child molesters of the worst kind, men (usually) who have done things so vile to children that it would make your stomach turn to hear about them. Having raised three daughters of my own and now having two grandchildren and another on the way, these things brought forth such a visceral reaction from me that it was all I could do sometime to continue the interview and not just scream “Enough!”.

I have sat three feet away, close enough for the toe of our shoes to touch, from a murderer in little interview rooms in a county jail. The feeling is almost surreal when a murderer tells you about his family, spending holidays with his wife, his love for his Chevy truck, and the day he got his first job. You listen and you piece the story together and you do your job, but somewhere in the deep recesses of your brain that little protective, self-preserving blinking red light warns you. This man shot another person at point blank range with a twelve gauge shotgun. He could kill you too

I have interviewed husbands who beat their wives so badly that they sent them to the hospital, jaws broken, ribs cracked, bleeding, faces blue and puffy and swollen. I have heard them blame their wives for the beatings, explaining to me in plaintive, sincere, pleading tones about how she asked for it, she provoked it, she wanted it, she needed it. Again, stomach-turning stuff, my friends. 

Your question made me think about these people I’ve interviewed over the years in hospitals and emergency rooms and county jails and clinics and courthouses. What is the common denominator here? 

This will not surprise those of you have have been reading my musings for any length of time. 

All of these people, the child molesters, the murderers, the wife beaters and all the rest, are people just like you and me. They are people who, for whatever reason, are in great distress.

Some of them feel great pain and remorse; some do not. Some feel guilt. Some have no conscience. Some, oddly enough, are trying desperately to connect with another human being, but have such a skewed view of what that looks like that they hurt the very person they are trying to connect with. 

They all deserve the best care possible. The wounded assassin gets the same trauma protocol as the man he just shot. 

I guess it’s the training we get that protects us. The hours of grilling by supervisors. The case presentations that get picked apart by professors and peers. The thousands of patients we see. The gut checks that we ignore at our peril. The things we’ve read. The stories we’ve heard and the patterns they make that give us a heads up when one more patient walks in fitting the mold. 

I don’t judge people. I will leave that up to God. I think He’s up to the task.

I ask questions.

I listen for answers.

I try to understand.

I do my job. 

 

The picture above shows the graves of the six ringleaders of the group known as the Raiders in the cemetery at the Andersonville National Historic Site. These despicable men took advantage of their fellow prisoners in Camp Sumter, Andersonville Prison, robbing, cheating, abusing and sometimes even killing their fellow enlisted men. Even in death, they are set apart from the graves of those they abused, forever ostracizing them from their fellows.

Sixth Sense

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People often ask me if I can really connect with patients via telepsychiatry.

What they mean, I think, is this:

Are you able to really listen to and see and evaluate someone when you’re sitting hundreds of miles away from them in another room and only seeing them on a screen, albeit a large, high definition one? 

The answer of course is yes, but there are drawbacks. 

The use of my Spidey Sense is dramatically decreased when I’m in my Virtual Shrink superhero role as opposed to sitting with patients in the clinic consulting room as a Dr. Peter Parker wannabe. 

There is something to be said for face-to-face, real-time, in-the-same-room discourse. When you’re in the same room with a patient, you can smell last night’s alcohol binge as surely as if you were there with them for every shot at the bar. You can pick up on tiny physical fasciculations or tremors that might be missed on camera. You see the writhing, circular gyrations of the foot of one crossed leg that might not be picked up if the camera is focused in too tightly on the patient’s face. You can see a patient’s nervousness, twitchiness, and physical desire to move about when they are uncomfortable being in the same room with you. 

The thing that is hard to replicate on camera is that sixth sense that stands every good shrink in good stead. 

The feeling that someone is not really telling you the truth. The sense that the mild paranoia that a patient presented with is about to dramatically increase, and the decision to back off and not ask just one more question. The feelings of tension between therapist and patient that have been described as transference and countertransference in the psychodynamic literature. The feeling that you are about to be assaulted in some very real way. (Yes, I have been hit three times in my psychiatric career, and it’s never a fun thing to go through)

Telemedicine allows us to see patients hundreds of miles away in a timely fashion, providing needed evaluation and treatment services to those who might otherwise go without. it is a wonderful advance in modern technology, but it is not perfect. 

Until we can plug completely into someone’s world in a virtual sense, we may miss bits and pieces of their story that would help us provide the care they need. 

Through a Glass Darkly

For now we see through a glass, darkly, but then face to face…

1 Corinthians 13:12

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I have been asked one question about my work in telepsychiatry more that any other, hands down.

“Can you really help a mental health patient like that, through a television screen?”

The quick and dirty answer? Yes, absolutely.

The extended answer? Read on.

Psychiatry is an intensely personal specialty. It requires knowing yourself as a doctor, as a therapist, as a consultant, and as a person more than any other kind of medical practice I have ever been exposed to.

It requires four years of residency after four years of medical school to train to become a psychiatrist for a reason. You must not only master the big picture and the fine points of the specialty. You must understand what makes you tick. You must know how you respond to stress, challenge and adversity. Without this knowledge and training, one makes a very marginally competent psychiatrist at best.

As a psychiatric consultant, I ask questions that in normal social discourse would be considered forward, intrusive, even bordering on abusive. I ask about the intimate details of your medical history. I ask about your work history and why you were fired from your last job. I ask about your sexual history and yes, I usually want to know if you’re straight or gay. Not to pry, but because it gives me a tremendous window on your life, how you perceive yourself, and how others perceive you.

I want to know about your legal history. I ask how many DUIs you’ve had and what lead to the Criminal Domestic Violence charge. I want to know the details of your last suicide attempt. Why did you cut yourself instead of overdosing this time? Was your intent to die, or just to reach out and make a statement to someone who had wronged you?

Think about the last really deep conversation you had with a very close friend, a sibling, a parent, a spouse, a lover. What made it special? What made it real? What made it possible for you to let that person have access to a very deep part of you that no one else knows about?

It is the connection, the intimate connection between two people that allows these kinds of conversations to happen. Pure and simple. You know it. I know it. In our friendship, if you are not willing to let me in, to share your hopes, your fears, your dreams with me on the very deepest levels, we might as well be two strangers who met in an airport bar and had a chat during a layover.

Now, several of you have argued with me over the last few years that relationships on social media cannot be real in that sense. You cannot have that kind of deep, emotional and spiritual connection with another human being over Facebook, Twitter or any other social media platform. Many of you have said the same about telepsychiatry. You can’t possibly talk to someone and learn enough about them over a television screen to help them.

All I can tell you is that over the last four years my colleagues and I have done almost fifteen thousand consults via high speed lines and high definition video monitors. Personally, out of the thousands of consults I have completed myself, only two patients that I can recall now refused to talk to me over this medium. Both were very ill and their level of paranoia precluded them connecting on a meaningful level with anyone, in person or via video.

The flip side of that coin? I remember very well, with great pride and a very deep sense of fulfillment, the father of the emotionally sick child I had just interviewed. He was at the end of his rope. His child was suffering, dying in a very real way before his eyes. He did not know what else to do.

After our interview I went over the treatment plan with him. I told him that there were things that could be done to help his child, and that we were going to do them, starting at that very moment. His face changed. He smiled a very weak smile. I could see the hope in his eyes.

Spontaneously, he jumped up out his seat, two hundred miles away from me, and reached out to shake my hand.

I knew at that moment that the medium was powerful, the connection real and the intervention worthwhile.

We had seen each other through a glass darkly, and then face to face.

It’s a Family Affair

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Is there a place for family members in the emergency department?

Yeah. 

“Go down the hall, take a right, go through those double doors, behind the vending machine, against the far wall. There’s a double row of hard plastic blue seats where you can sit. Coffee machine down the hall from there. Gift shop on the first floor. We’ll call you when you can see Aunt Mary.”

Of course. We’ve all been there, done that. I’ve spent some time in those egg-shaped butt-numbing receptacles, as have you. That’s not exactly what I’m talking about, though. 

How do families fit in when mental health patients come to the ED seeking help for the suicidal thoughts, the voices, the depression that plague them?

First of all, right out of the gate, family can be invaluable in providing information that the mental health patient cannot or will not give up themselves. 

Some patients are simply too distraught, too disorganized and too psychotic to give any meaningful narrative of how and why they showed up. They are too preoccupied with seeing dead people to speak with live people. They are too deeply focused on themselves and their pain to turn their focus outward on the doctor who is asking what seems like an endless stream of silly questions. 

I can’t make a meaningful diagnosis or recommend anything helpful to an ED attending physician if I have incomplete information. This is why my consult procedure more often than not involves making at least one phone call after I finish the patient interview. A spouse can give me insight into this new-onset psychosis in a seventy year old. Mother knows best when separating acting out from mental disturbance in a six year old. A father has a different perspective on a teenager’s angst than a mother does. 

Families can be calming in times of crisis. 

The ED is a scary place, full of hustle and bustle and lights and portable x-ray machines and lab techs and white-coated scary people. Having one’s clothes and valuables taken away, given air-conditioned scrubs to don, and being placed on a gurney and told to stay there and not move can be very uncomfortable and downright upsetting to a person who is already panicking and contemplating suicide. 

A family member at the bedside, when allowed and appropriate, can be better than Q 4 hour injections of Haldol and Ativan any day. A kind word from mom, a firm hand from dad, or confirmation from a spouse that everything will be okay are balms for the raw nerves and grating irritation that is the emergency department. 

Now, you know as well as I do that this is not always the case. Supportive, loving families are wonderful and helpful in the ED, but there are other times that having family members in the vicinity of the mental health patient is nothing but trouble. Sometimes, it can be a disaster. 

Take for example the nine year old who presents with abdominal pain. Workup is negative. There is nothing “wrong” physically with the child, but the ED doc, rightly so, feels one of those gut checks that tells her to go further. The child is anxious, fearful, more so than would be expected in a normal ED encounter for belly pain. She is anxious, scans the room, cowers and shrinks away when touched. She has a couple of bruises, incidental findings on an otherwise completely normal physical examination. 

The doc calls for a mental health evaluation and a social work consult. During this process, the child’s father, nowhere to be found on initial presentation, shows up at the triage desk demanding to see little Suzy. He is big, scary, belligerent and smells strongly of alcohol. He demands that she be released and says that he is taking her home. There’s nothing wrong with her, he insists, a little too forcefully. 

You know where this is headed. Social services, psychiatry and child advocacy get involved as afternoon turns to evening to night and shift change in the ED comes and goes. This little child, who came in complaining  of belly pain, has a pain in her heart and an injury to her soul that her abusive father does not want made public in this place of healing. While a sanctuary to the abused little girl, the ED points an accusing finger squarely at the man who is the abuser. He knows, even in his intoxicated state, what it will mean if this history sees the light of day. So does the ED staff, who are charged with keeping the child safe.

I have seen other family members abuse the system of mental health evaluation by taking out what are nothing more than false probate court orders to have a patient picked up and brought to the ED for certification for admission to a psychiatric hospital, even when they clearly don’t need it. This might be because of a deep-seated family feud over money or land. It might be a controlling husband looking to have his wife “put away” in a mental institution (something that thankfully doesn’t happen today as it did years ago). This abuse of power by one family member over another, whether or not they have a true mental illness that needs treatment or not, can be frightening to the patient and eye-opening to the hospital staff, who are not accustomed to being pawns in this kind of game.

As a second-year trainee many years ago, I had a supervisor in the outpatient clinic who was a child analyst. Dr. Finch told me something one day that has stuck with me for almost thirty years. 

“Dr. Smith,” he told me in his gruff but smooth bass voice, “you cannot, you will not see this child for therapy unless the family agrees to be here, to be active, and to be involved in his treatment. Period.” 

That lesson from my old clinic supervisor is just as valid for me today as I see ED patients as it was when I was learning to do play therapy with emotionally disturbed children. 

I can talk to families and glean valuable information, good and bad, positive and negative, and do a better job of helping the suffering soul in front of me.

Or, I can ignore input from family members, tuning out the very people who know my patient and her struggles the most intimately. 

I do the former because it is good practice and is best for my patient.

I do the latter at my peril.