Too Ill to Treat

rAn article posted in the Augusta Chronicle newspaper on January 13, 2017 by Bianca Cain Johnson, Staff Writer, has left me no option but to write this blog post today. I would like to quote some parts of the article, then address some of the comments in turn, as they are provocative or distressing to me.

I should say right away that this is my personal mental health musings blog, and that my opinions are my own, in no way reflecting the policies or procedures or opinions of my employer. I should also state that there was very little factual or historical information in this article about this particular case, but for me it just brought up several broad issues of the treatment of mentally ill persons, our approach to violent behavior and other broader issues that I wanted to address.

From the article:

“According to a sheriff’s office incident report, the 31-year-old had been at the hospital for several days, but because of his mental illnesses and history of being violent, the hospital was having trouble finding a mental institution to take him.” (italics mine)

“A doctor re-evaluated him on Tuesday morning and determined he could be released.”

“…the patient stated, “the only way to get attention is to show out”.”

After he had allegedly injured a guard and nursing staff, “the patient was restrained and given medication to calm down, (and) employees heard him comment “this is what I wanted”.

Remember “too big to fail“, as it pertained to banks or motor vehicle manufacturers? Well, in mental health nowadays we run up against admission and placement issues for those patients who are “too ill to treat”. It may be because they have some element of intellectual disability. It may be that they are floridly and actively psychotic. They may be actively suicidal with access to a lethal method and a serious, specific plan. It may be, like the patient in this article, that they have a previous history of violence. For these and other related reasons, what you find is that some facilities among our dwindling number of mental health hospitals now cherry pick the patients that they want to take. If patients are too sick, too acute or too potentially violent towards themselves or others, they are denied admission and treatment, and are often stuck in emergency departments for days or weeks.

Can you imagine the outcry if a patient with chest pain that was too severe was denied admission to a cardiac care unit, or if a patient with a stroke that left him prone to emotional outbursts was denied neurological treatment?

A doctor re-evaluated the patient and made the determination that he was ready to be released. We do not have nearly enough information about that determination to be able to comment on it all, but we can say that we as physicians are notoriously bad at using our (non-existent) crystal balls to predict violent behavior. Of course, there are known risk factors, characteristics, static points of history, and previous episodes of violence that might sway one towards thinking that there was a better than average chance that some violent behavior or acting out was coming, but to be able to predict that with any significant degree of certainty is fraught with problems.

Please see this article on mental illness and violence for more detail about these related issues.

The issue of the patient knowing or learning or figuring out that in a busy emergency department the best way to be heard or to get drugs or to be assessed is to act out is another huge issue. This involves separating out acutely ill patients who act out unwittingly or because of lack of control, versus those persons who know exactly what they are doing and plan to be violent or agitated with a specific goal in mind (to be separated from the general population or to be given injectable medications, for example).

The comments about this article, which I will leave you to read on your own if you wish, were predictable. This issue is politicized, psychiatric patients are called nuts and commenters express nostalgia for the days when they could just be locked up “for a long time”. One commenter stated that the evaluating doctor should have his license pulled immediately. In my opinion, none of these kinds of comments is helpful.

What do I see going on here as a medical director for a mental health center, and even more so as a telepsychiatrist who sees patients in over two dozen South Carolina emergency departments? What did this particular case make me think about?

First of all, we know that deinstitutionalization was a real thing. Hospitals were closed, patients were discharged to their families, to supervised living situations, or to the streets, and the local mental health centers were supposed to pick up the slack and treat them as outpatients, all in the name of streamlining care and saving money. When I started medical school thirty eight years ago and did my very first psychiatric rotations as a junior and senior student, state hospitals, VA hospitals and mental health nursing homes were still very full of patients who were too ill to function well in society. Many were there for long term stays of weeks, months or even years.

Gradually over my career I have seen many inpatient facilities cut back and close beds and finally close their doors entirely. The ones that survive are much smaller, treat patients for much short length of stays, and are run via much more stringent business models than ever before.

Many patients now get their medical care and most of the psychiatric care in an emergency department, not from their own personal doctor. Once admitted there for evaluation, it can sometimes be a very difficult and complicated ballet to assess the patient for his primary illnesses or presenting problems, available resources, need for inpatient versus outpatient treatment, payor sources and requirements, and family involvement. Add to that the hospital administration’s take on treatment, as well as pressure from ED doctors to get patients in and out as rapidly as possible, and it becomes somewhat overwhelming.

In those past years, patients who were truly psychotic or actively suicidal or a danger to others could simply be committed to the state hospital and held there as long as necessary to achieve remission, or as close to it as possible. This is not nearly as easy or smooth a process now as it once was.

As I mentioned above, we do not have crystal balls, but we do have fairly detailed screening procedures for harm to self or others, for example. We can assess, apply evidence based guidelines, offer the best recommendations we can based on these parameters, and decide if a patient must held or can be released. Recommending and treating based on numbers alone, administration goals, or by algorithm rarely work well.

If a patient is acting out of his own volition, is cognitively processing things appropriately, is not overtly psychotic  or in withdrawal from substances, and he still destroys property or intentionally  hurts others on the staff or other patients, then he should be charged for these actions accordingly and would perhaps be better served in the county jail than the emergency department.

I would welcome stories of  your own experiences in this area, your opinions and ideas for how to make these tense situations more rewarding and beneficial for both staff and patients.





Child’s Play

Dr. Kenneth Azar, a mentor of mine at the old Georgia Regional Psychiatric Hospital in Augusta, Georgia, told me something once that has always stuck with me.

He told me that in the early years of his practice, when he was living and working out in Idaho, that he was one of a very small handful of psychiatrists who served the whole state. If an adult with psychosis needed to be stabilized, he would write orders for medications and restraints. If a probate court hearing came up and needed testimony from a psychiatrist about the need for further inpatient treatment versus release to outpatient follow up, he would oblige. If a child was mentally ill and needed to be assessed for depression or trauma or sexual abuse, he was called on. If a forensic case could not go forward without an evaluation by a mental health professional, he would get that call too. He was basically, in this early part of his career, a jack of all trades and a master of none.

Fast forward several decades, when Dr. Azar had been on the faculty of the Medical College of Georgia School of Medicine, Department of Psychiatry and Health Behavior for a few years. He was teaching me, and a steady stream of medical students, interns and residents, all about acute inpatient psychiatry. The North Unit, as we used to call our stomping grounds in those days, was the perfect backdrop for real world learning about mental illness, its diagnosis and treatment. No textbook could have ever provided the rich tapestry of mood disorders, psychosis, substance abuse, personality disorders and rapid-fire triage of mental disorders that this unit did. I probably learned more there, when I think about it now, than I did anywhere before or since in my long association with the field of psychiatry and mental health.

In those early days, I developed my love of the treatment of severe, chronic mental disorders such as bipolar disorder and schizophrenia. I have gravitated towards jobs and positions that allowed me to continue interacting with and caring for patients who have those disorders. Even on the days that I was stressed to the max, wondering how I was going to pull it all off and get the work done, I was happy in that element of chronic illness. I really did, and still do, enjoy learning more about the progression of illness over decades, how we treat it, and how we try to limit the debilitation that often comes from a lifetime of major illness that affects the brain.

Now, fast forward a few more years, past my own stints as associate faculty and mentor and teacher and lecturer to my current duties as the medical director of a busy mental health center, a clinician for four days a week during the daylight hours, and a phantom telepsychiatrist another two or three nights a week on top of that. I am still in my element, seeing chronic illness in some of my clinics that has allowed me to see how depression and psychosis and substance abuse can play out through the years and through multiple generations of the same family, all of whom I have treated.

The twist?

I am now, as Dr. Azar once was those many years ago in Idaho, a child psychiatrist by default.

Now, I did my four years of residency in general psychiatry, to be sure, including a rotating internship year and a chief residency year. I learned about psychiatry as a field, including the treatment of adults, children and adolescents, mood disorders, personality disorders, substance abuse and trauma. I am certified by the American Board of Psychiatry and Neurology. I am well trained, and I have decades of experience in systems as varied as local family counseling centers to Veterans Administration hospitals to state hospital systems to the private sector.

All that being said, I have never seen so many children with so many mental health problems in so many venues presenting with such severe disease.

Children do not scare me. I do not feel uncomfortable around children. I have helped raise three of my own, I have three grandchildren now, and hope to have more in the future!

Even so, there is something quite distressing and disconcerting to me about the fact that I, and many other psychiatric clinicians like me, must now, in 2014, see, evaluate and treat children as young as two-yes, TWO- who might present with symptoms as disparate as mild separation anxiety to florid psychosis. I am humbled by the fact that as I get older, I know what I do not know, and I am striving to increase my knowledge base daily so that I can provide the best care I know how to my charges, adult and child.

It breaks my heart when a child tells me stories of being bullied mercilessly by his peers because he is thin or fat or smart or talented or effeminate or likes to color his hair orange.

It makes me angry to hear stories of abandonment by fathers who are nothing more than biological and care not at all for the fragile lives they help bring into the world, leaving them to flounder with overwhelmed, poverty stricken mothers ignored by political systems that simply don’t care about them.

It makes me physically ill when I hear stories of sexual trauma, rape and molestation that go on for years, with other family members turning a blind eye or simply accepting that this is how it is.

It brings tears to my eyes when the little eight year old girl in front of me tells me that she attacked her teacher because “the voice of the bad man in my head told me that I should kill her”.

I never considered myself a child psychiatrist. That was not my first love clinically. I did not seek my Board certification in that specialty area. I never solicited patients who rode skateboards instead of cars and rocked Beats headphones and iPads instead of printed newspapers and transistor radios.

If I look at my schedule for the past week and read over the consults I’ve done in the emergency rooms all over the state of South Carolina in the past week, though, the picture is pretty clear.

I am a child psychiatrist whether I chose to be one or not. It’s a big part of my job and my professional life at this point, and with the shortage of child psychiatrists coming out of training programs around the country, I don’t see it changing anytime soon.

My take on this state of affairs?

I will never stop learning to be a resource to my patients, especially the small ones. I will never stop growing professionally. I will always pay special attention to the stories that the children tell me, because after all, they are our future.

I know that by seeing children who suffer from mental illness and trying my best to help, I can change the world, one little child at a time.

Is there really any more awesome reason to get up and go to work in the morning?


Two of my grandchildren, when they were first learning to use an iPad mini.

Still Waters Run Deep

There was an article in today’s Aiken Standard, my local paper, via the Associated Press wire. The title was “Robin Williams’ autopsy found no illegal drugs”. Aside from my annoyance at the misuse of the possessive, I did think about some things after reading this article.

The autopsy showed that Williams did indeed have evidence of therapeutic levels of his prescribed medications in his bloodstream. It is not a secret to anyone now that he had struggled for years with both mental health and addiction issues, and was in treatment at one time or another for both. He was being prescribed medications to help him with these conditions, and it appears that he was taking them.

He did not have any alcohol or illegal drugs in his system at the time of his death.

His wife, according to this story, was most likely home when he decided to kill himself and completed the act. He killed himself by hanging with a belt.

Even those with money to burn, success, achievements, loving family support, and ongoing treatment and medications can feel terribly isolated, alone, and hopeless. Depression can be devastating. Help can seem light years away.

I see so many hundreds, even thousands of people who struggle with addictions. Life on drugs and alcohol is sometimes overwhelming, fraught with relationship problems, legal problems and financial ruin.

On the other hand, sometimes life without drugs is just as hard to bear, maybe even more so if you have been addicted for years. The raw emotion of it, the demands and stresses and trivial annoyances of daily life seem just too big, too complicated, and too much trouble to deal with. They seem unsolvable.

For Robin Williams, even with treatment, fame, fortune, and family, it was all just too much. He decided that he could not go on.

I cannot and would never judge him or anyone who committed suicide. I have not been inside their heads, and I do not know what final thought they have right before they decide that they must die.

I do know that if someone needs help, if life is just too hard and whatever they are doing is not enough to sustain them, then action is imperative.

Sometimes still waters run deep.

Hope Springs Eternal


One good thing about doing anything for three decades or longer is that you get to see cycles and repeated events, things that fail and things that work. I hope that over the last thirty years of learning about psychiatry and mental health ( and yes, I am still learning and hope to acquire that one last little piece of knowledge on my deathbed) that I have paid attention to the things that matter and have become inured to the things that don’t.

I have read many books and articles, and I have listened to great lecturers and attendings pass their knowledge on to others who come after them. I’ve been the lucky recipient of some really good training and have watched some very compassionate people, trying to emulate them as I make my own way through the medical landscape that is my working world.

My best teachers, hands down?

My patients.

She was a handsome but world-weary middle-aged woman, short bright red hair and sparkly glasses distracting the onlooker, part of her not-so-conscious attempt to keep any outsider from seeing the darkness in her soul. She sat partially slumped in the chair across from me, a nondescript sweater and well-worn jeans hinting at the casual comfort that she did not feel. When she tried wanly to smile, the corners of her mouth didn’t rise as much as the rest of her face fell to meet them.

Like so many of my patients, young and old, rich and poor, educated and not, she had been horribly, unspeakably abused throughout her life. Speak about it we did, though, and I found myself in one of those office consultations that are so horrific that nothing but excellent training can help maintain composure. Some of the stories are just too painful. Too raw. Too excruciatingly real to be true. A compassionate doctor wants to forego the promise to do no harm and hunt down the perpetrators and make them pay.

She was no better today. Well, not entirely true, because she had come back to see me, after all. My potions and elixirs had helped her imperceptibly if at all. Like many of my patients, she did not want to hurt my feelings by telling me that I had not helped her yet. Can you imagine that? A horribly scarred woman, contemplating suicide, depressed, feeling as worthless as she’d ever felt, wanting to protect her doctor’s feelings? Some things are hard to understand.

We talked.

I talked mostly, feeling impotent, trying desperately to find the rabbit in the silk hat that I could pull out and hold up triumphantly to her and say,”See! See! There is some magic left in the world!”

Alas, there was no hat, no rabbit, no magic. She was in pain, and I was in pain, for like it or not, if you love this job as much as I do, you hurt right along with your patients. Don’t let the blank-slate, silent treatment, sit behind you and never show any emotion shrinks convince you otherwise. If you’re a good doctor, you don’t rest until you’ve fixed it. It’s in your DNA. Some of us just don’t ever want you to know how hard this job really is.

We did the easy parts, the side effect inventories, the dosage reviews, the checklist of symptoms. I decided on the course of action I was going to recommend to her and put it out there. Was it going to make her better? I didn’t honestly know, but I was going to do my best.

She got up. I got up. Our time was over.

I said something that I’m sure was lame at best. I would get her back to check on her soon, and I would be optimistic that this depressive episode had reached its high water mark and would now mercifully recede.

She went through the door, started up the hall.

She turned to glance back at me.

“Thank you for seeing me today. I still have hope.”

It is springtime in my town. We are recovering from the most devastating ice storm in the last decade. In spite of the destruction all around us, trees are budding joyfully, grass is greening, and flowers are dotting the landscape with vibrant color.

It is springtime.

If we can do nothing else in this season of rebirth, we can certainly dispense hope.


Now I Know My ABCs


So what is the one thing that I see over and over and over again in the management of emergency room psychiatric patients that makes me fear for our survival as a country and even as a species?

Is it the severity of psychotic illness? The rampant drug and alcohol use that starts now when kids are pre-adolescent? Is it the broken families that are producing another generation of children who have one parent or no parents and are raised by distant relatives? Is it financial poverty? Is it reliance on government assistance?

Well, I could write about any of these and make a case for all of them, but that’s not what keeps hitting me right between the eyes most days that I sit in my chair and talk to people via the Polycom screen.

The problem?

Lack of education.

One of my standard questions when taking a medical history is “How far did you go in school?” I ask everyone this question because it is so very important in understanding someone’s frame of reference and their ability to assess a problem and deal with it realistically, be it a kidney stone or an episode of depression. I get answers to this question that are all over the map. I have seen teens who have graduated college already. I see old women who never graduated high school but raised entire families on their own. I see proud aging men who ply their trades, hard workers with calloused hands who had formal schooling up to the third grade and no further. I have seen professionals with decades of formal training and multiple degrees who are as psychotic as they can be, completely out of touch with reality due to drug use or mental illness.

Two things come to mind here of course. One is that mental illness is no respecter of educational level. I have written about this before and I will write more about it I’m sure. The other is that many people do not see the need, or are not given the opportunity, to further their education beyond the very minimal level that gets them by in the world.

This is not a prescription for growing a strong, healthy society.

Often, the answer to my question about education, “How far did you go in school?”, is answered exactly like this:

“All the way.”

That person almost always means that they finished high school.

In many parts of our society, and among many sociocultural levels, finishing high school is the ultimate achievement. The peak. The Holy Grail. You are expected to make that level of education and then to get out, find a job, make your own living and support yourself in the world. Many of the families I see are more than happy to kick their kids out of the front door and onto the street the minute, the second they turn eighteen, never thinking twice about it. The problem is that economic considerations, lack of parenting, lack of role models, early drug and alcohol use, the necessity of working to help support the family and other issues get in the way and take precedence over getting a good education. Kids are passed to get them out of one classroom and into another to avoid further negative behavior. They are still socially promoted, something that might eventually get them a degree but that might be worse than useless to someone who cannot read, problem solve or think critically.

When one thinks nowadays that getting a high school degree is going “all the way”, educationally speaking,  then we have a real problem. There are many other countries (Japan, China, and India immediately leaping to mind) who are producing generations of kids who are hungry to gobble up degrees from our colleges and universities and take high-level and high-paying jobs that Americans are not aspiring to at all any more. It is a sad state of affairs indeed.

It breaks my heart to see a hardworking middle aged man, my own age, in the emergency room, who has a third grade education and is embarrassed to tell me that he cannot read or write.

We have become a nation of people who value smart phones more than we value smart people.

I know that mental illness is a strange beast, hard to ferret out and even harder to diagnose and treat some times. I know that its causes and precipitants are multiple, some genetic, some economic, some cultural. I know all this. I also know, as surely as I know my own name, that if we do not pay attention to the education of our society in America, and our society globally, that we are going to slowly slide down the slippery slope of ignorance, class warfare and division that will be the end of us.

We must turn this around.

We must make it a priority, starting now, to educate our children.  We must teach them to see things as they are, think critically about problems, think creatively about solutions, invent new wonders, and leave the world a better place than they found it.

This is not a luxury for us in the twenty-first century. It is a necessity.

It’s a Family Affair


I’m disturbed by a trend that I’ve seen in emergency departments across the state of South Carolina over the last four years that I’ve been doing telepsychiatry. It seems that many families, instead of talking amongst themselves when trouble arises and trying to work problems out, resort to going to the local probate court to take out an order of detention to have the offending family member committed for a mental health evaluation.

In South Carolina, as in many other states in the United States, a system exists whereby a person who is experiencing severe mental illness may be picked up by local authorities, taken to the nearest receiving facility, usually a hospital ED, and evaluated by a physician. If the person is found to be an imminent danger to themselves or to someone else, or if they are so mentally incapacitated that they are not able to make good decisions concerning their own self care, then they can be held for a specific time in the facility for observation or treatment as indicated. This is usually for seventy two hours. Now, if a psychiatrist like myself is called in to see them, either in person or on camera, and we decide after further evaluation that these dangerous conditions do exist and the person needs further mental health care, then we can either order (if on site and privileged at that facility) or recommend (if acting in a consulting capacity as I do in doing telepsychiatry) inpatient admission for further treatment.

Obviously, this system is in place to insure that people with severe mental illnesses such as bipolar disorder and schizophrenia get the care they need when an exacerbation occurs. It is also in place to make sure that people who are not truly mentally ill are not incarcerated against their will and held for no good medical reason or on a whim. You may have heard about families sending someone off to a psychiatric hospital (variously known as being sent “up the road” or to the “crazy house” or others) simply because they had an argument or felt they needed to be punished. This happened in my home state of Georgia when folks were sent to Milledgeville, the site of a huge mental health hospital that was in its heyday a small city unto itself, with tens of thousands of patients in residence. It also happened in my adopted home state of South Carolina, where its citizens would be sent to “Bull Street”, a notorious and fearful address in the heart of Columbia where you might be sent and kept for months if not years to walk the halcyon grounds and to be kept sedated and tranquilized after your family had “got shed of you for good”.

We think of those days as the Snake Pit times of mental health treatment, when people could be sent off by relatives who hated them or spouses who were jealous of them, when they were sedated and shackled and kept against their will for years, sometimes literally until they died in the facilities they had been sent to. I still hear stories to this day from patients who have a relative who died living at Bull Street. We like to think that these days are gone, that we have passed this era of inappropriate commitment and unnecessary treatment forever. Have we?

I have seen families send “patients” to the emergency departments in South Carolina and have heard too many stories about arguments between spouses and between parents and children that have lead to someone being labelled as “crazy”. When evaluated, of course, they are no more crazy that anyone else walking the street, and they certainly do not need to be committed against their will to a mental health facility for “treatment”. When I sometimes tell an angry and frightened parent that their acting-out latency age child does not need psychiatric admission but instead needs a more firm hand and more structured discipline from a loving adult who clearly shows who is in charge in the home, they look at me like I’m the crazy one. When I intimate that the family needs to step up and take charge in the care of an elderly adult who is showing the signs of deterioration related to an established diagnosis of dementia, they think I have lost my mind. Many modern families, I am very sorry to say, seem to be willing to lock someone up and throw away the key because it is the easiest, most expedient thing to do. The hard work of talking things through, problem solving, making amends, and living life with all of its trials and tribulations is foreign to them. It bothers me tremendously that someone would come in wanting to wield “the big stick” and in essence take away their right to self determination by exercising my power to incarcerate and “treat” when it is clearly not appropriate to do so.

In this age of what I have previously called “fast food medicine”, patients and families seem to be looking for the fastest, easiest way out of scrapes, arguments and episodes of illness. In mental health, some illnesses bring with them life sentences. Not the kind of sentence that means you spend the rest of your life walking the grounds behind a ten foot ivy covered wall, shuffling and drooling after your last Thorazine injection, but the kind of life sentence that requires supervision from caring professionals, attention by loving family members, and the understanding of society at large that the normal rough and tumble problems of life in the twenty first century do not always portend mental instability and illness.


This post was previously published on another of my blog sites in modified form two years ago. I hold that we have not made much substantial progress since then. 

Thou Shalt Not Steal


Okay, I’m a little late getting saddled up this morning, but this is the pet peeve that’s stuck in my head and needs to find its way out today.

Just because you have a mental illness, you don’t get a free pass when you make bad choices and get yourself into trouble. (Yes, of course there’s a story or two or three or five that have spurred this thought in my brain today, but you know I can’t share those with you, so don’t ask, okay? Thanks) You don’t get a Get Out of Jail Free card.

I’m sorry if this is news to you.

Get over it.

This is how it goes down, among other ways. These are just the ones I can remember on 1 1/2 cups of coffee.

Mom brings little Johnny in. Little Johnny has been dancing on desktops and throwing books at his teachers and giving other little Johnnies and Jillies wedgies on the playground. He is a hellion. He can turn this behavior on and off at will. He is not psychotic. He does not have a brain tumor. He is, at seven years old, not under the influence of alcohol or street drugs. (Oh, yeah, I’ve seen that even at six years old. Another story for another day) He sits in my office as mother goes on and on and on about her frustrations, smiling a little sly smile as he listens to her and shoots me that see, what would you have me do? look that kids can shoot you.

Mom wants me to declare him terminally attention-deficit-ed, conduct disordered, defiant, learning disordered. Impaired. Damaged. Unable to conform to playground or classroom rules, much less the extreme sport of being a productive and cooperative family member in a loving home. She wants a pass. So, at the tender young age of seven, does the kid. He may have a conduct problem, but he is certainly not stupid.

The other one that sticks in my craw (I don’t actually have a craw, which is the crop of a bird or an insect, but I have always really loved the graphics that term conjures up in one’s mind) is the thirty-something lady who comes crying into clinic and demands that I release her from the clutches of a policing and legal system that found her shoplifting at Walmart or some such. Why? Because she is bipolar, by God, and bipolar people are not responsible for their actions. Especially when it involves pilfering nail polish, packages of glitter, and small cartons of half and half.  Really?

(Wait. Brb. Checking DSM V.)

I can’t find it anywhere. I don’t see it. I don’t see the out that you earn by wearing the Red Badge of Moodage. The invisibility cloak imparted by your mental illness that allows you to run red lights, drink and drive, and steal at will until caught, immediately followed by an outraged cry that you are Sick, sick, sick I tell you all!, sick to the point of not knowing what you are doing.

I am not responsible for my actions! I cannot be trusted to make decisions. I cannot be faulted for lying, cheating, stealing, pilfering, pandering, and jaywalking. You cannot touch me, because I am ill!

(clearing throat).


So sorry, but come on, people, there is no other word that gets the point across better, is there?


As you start your day, remember these things.

People with mental illness, legitimate mental illness, deserve the very best evaluation, diagnosis and treatment.

People with mental illness sometimes do things that are outside of the expected social dance. They can be forgiven for these faux pas, if they are actively engaged in trying to get treatment for their symptoms and make their way through life the best way they can given their skill set, talents, and limitations.

People with mental illness who break social rules, commit crimes, abuse others, steal things, disregard the normal boundaries and dignity of others, and trample the system do NOT get a free pass just because they have an Adjustment Disorder or PTSD or Generalized Anxiety Disorder.

Last time I checked, most of my patients with schizophrenia had never heard voices that told them to hot wire a candy apple red Mustang, steal it, and drive it at a high rate of speed across state lines and show it off to their friends (true story).  Come to think of it, none of my patients with schizophrenia. Zero. Zilch. Nada.

Come up with a better story for me, Skippy. Try again.

Mental illness is bad.

It is sickness, just like diabetes and migraine and hypertension.

It impairs ability to live a normal, happy life.

It does NOT act as a universal excuse for bad behavior.

As we say in the South, that dog just won’t hunt.




One of the standard questions I ask every patient as a matter of course is this:

“What’s your normal day like? How do you spend your usual day?”

Now, think about how you would answer that question if I put it to you. 

If you’re a well-to-do type, you might spend an hour in the morning walking your standard-cut poodle around the block. Then you’d go to the club for some tennis, have lunch on the veranda afterward and clean up for an afternoon shopping trip into town. On arriving home, you’d tip the yard help and the pool guy for their services, go inside your air conditioned house, and catch up on the last week of soaps recorded on your TiVo. A nap would definitely be in order after that. 

If you’re a member of the wide but shrinking middle class, you’d do laundry and last night’s dishes in the morning, get dressed and strike out for the local Walmart, shop for specials for a couple of hours, then go past the frozen yogurt place and indulge in a sweet treat to beat the summer heat.

Either way, your affluence drives your lifestyle.

“I’m not affluent!” you protest, maybe a tad too loudly. 

Yeah, okay, whatever. I watch you respond to the ding of your iPhone like Pavlov’s dog, fish your Ray-Bans off the top of your head and walk outside to get into your shiny new Ford with sync, leather seats and optional moon roof. 

Maybe I overgeneralize just a tad. Maybe I put you in a box that you don’t exactly fit in, but you see my point here.

How about my psychiatric patients? The standard, run of the mill folk who come to see me for panic attacks, chronic depression and schizophrenia. Do I get the same pet-studded, iPhone spangled, new-car-smell answer from these guys?

“How do you spend your time? What do you do all day most days?”


“No, really, what do you do all day?”


I’m a little frustrated now. Do they not understand the question? Am I making this too hard? 

“Okay, let me change that a little. Do you have any activiites that you enjoy? Any hobbies?”

“I used to fish, maybe go play some bingo,” answers the obese lady with bad hair and worse clothes. She had bipolar disorder before bipolar disorder was cool. 

“I used to hunt, but I haven’t been in the woods since W was President,” says the man wearing faded jeans and a flannel shirt against the summer heat. 

“I just sit on the couch,” says the rail-thin woman with a penchant for Percocet. 

“Do you watch TV, or read, or crochet or anything?” I ask, searching my brain. 

Trailer Park Activities for two hundred, please, Alex.


“You just sit on the couch.”


“That’s it.”


“All day.”

“Yeah. All day.” 

You know, people-in-the-don’t-know usually think that those with mental illness scheme and connive to get their six hundred bucks a month free and easy disability money so that they can sit around and do nothing all day and live the good life. 

I’m here to tell you that the ones who sit around all day doing nothing, and that’s exactly what it appears that they do sometimes, are not happy with it. They’re not happily raking in the dough, pulling contentedly at the government teat and feeling smug and satisfied.

They’d much rather be like you and me, rushed to pick up the kids after school or planning birthday parties and taking the occasional drive up to the lake for a barbecue. Their schizophrenia and the voices that come with it tell them to sit tight. Their panic attacks are so bad that they never step outside the front door. The heavy wool cloak of depression draped over their shoulders is oppressively hot in the summertime and weighs them down to the point of furnertia. 

That is, they sit on the couch and do nothing.

Frustrated by the business and busyness of your day? Too much on your plate? Too many places to be today? 

It could be worse.

You could be doing nothing today.

And tomorrow.

And the next day.