By: Eitan Schwarz, MD FAACAP DLFAPA
There’s a lot at stake these days as mental health professionals are living through challenging times, with boundaries and functions shifting (mostly from economic forces and territorial disputes), and not always to the good. So I want to share some personal thoughts as a 40+ year practitioner and student of my profession who has worked with the gamut of mental health pros in many settings. As we explore new models of care, current practices must be considered.
My intent is to provoke discussion and positive actions in these seemingly unrelated areas that are matters of concern in our society. The topics are all connected around professionals being human and humane today and the importance of language. This blog is updated occasionally, last 9/18/2013. I cite a variety of sources, but favor more recent news reports to illustrate some points.
ROBOTS AND LANGUAGE — WHAT IS HUMAN?
Are we confusing ourselves about what it means to be human beings? How we interact with our machines tells a lot about us.
Besides being the main way our brain receives and sends information that connects us to our fellow humans, language also structures and organizes our high level social and intellectual functions and governs our healthiest behaviors. Language is a principal element of the mind. So language, mind / brain, and behavior are intimately connected.
Progress in neuroscience is dramatically accelerating our understanding of the brain and its collective functions, which we know as the mind. These two nouns refer to the same organ. Such an intimate connection between an organ and its activity should seem as intuitively obvious as, for example, the familiar relationship between the musculoskeletal system and its activities — movement, support, and posture. “I use my leg muscles, therefore I move,” is familiar.
Yet, there is no such comfortable identity for brain and mind: Mind / brain unity is confusing because each feels intuitively unique, in different domains or realms of experience, even to those who see and work with these miraculous, strange-looking organs. “I use my brain to think / feel / have consciousness, etc., therefore I am,” feels unfamiliar and even uncanny: “I use my brain to be?” “I use my brain to move my feet,” is easier to reconcile, but less personal and more in the nature of a learned factual statement.
How about, “I use my brain to have a mind”?
Spoken language is a key factor, leading to one more recent problem with “I”. Thinking machines speak to us as if they are beings endowed with “I”s, as do Apple’s Siri or most automated airline reservation phone systems: “I dont understand what you are saying, Eitan. Shall I search the Internet?” Does Siri really have an “I” in the broad sense we use the personal pronoun? Our “I” is now insidiously claimed by our nonhuman tools, our disembodied robots. And the uncanniness of Hal, the supercomputer in Kubrick’s 2001, is now weirdly part of being called “you” by Siri and her family of disembodied robots. I still find it creepy when Siri calls my name and addresses me as “you”. And I resent it, because I am human and Siri is not.
Are we back to childhood animistic thinking ? Yes, we are actually now finally really interacting with The Little Engine That Could. So the relationship between your mind, your “I”, and its material basis, your brain, is now even more complicated. (That’s something to keep in mind about our kids’ futures as enormously engaging life-like robots enter their lives increasingly, as are now iPads and other tablets and described in my CRIB ROBOTSarticle.)
Should we be more careful about the boundary between us and the inanimate world? Dr. Sherry Turkle has studied how our children are trying to resolve this difference .
PSYCHIATRY AS APPLIED NEUROSCIENCE
Language and its supporting infrastructure is one of the human brain’s main functions and a royal road to understanding its workings. It is essential to understanding individual people’s minds and connecting with them. In fact, the profession I was trained in — modern psychiatry — was built on the careful and caring art of listening to speech and language in all their nuances as a central element of psychiatric practice. Medical and non-medical psychology pioneers have worked brilliantly for over a century to free the mentally ill from stigma and to understand and treat them humanely. These pioneers tried to base their practices on systematic notions of the brain / mind that made sense. They tried to infer brain function and structure from mental processes and behavior in the most humane ways — talking with and intensely listening to patients.
Neuroscience offers another route for understanding the mind / brain’s language behavior. Even without the awesome tools we have today, neuroscience has interested us for generations as we have attempted to understand the mind in terms of its physical home base, the brain. In the 1930’s the Canadian neurosurgeon Dr. Wilder Penfield stimulated the living human brain directly in conscious people and elicited thoughts and images described in language (Like Volta’s stimulation of frog muscles centuries earlier yielding movement?) In the past half century, this knowledge has even led to new procedures and medications to help people.
Even earlier, in fact about 120 years ago, Sigmund Freud himself started his career as a neuroscientist with his “Project”. He wanted to understand the severely mentally ill, and tried to understand and treat inpatients with another physician, the Parisian Dr. Pierre Janet, the illnesses of the hospitalized mentally ill.
Freud was first to predict the existence of neurotransmitters, the bases of current psychopharmacology. He also posited a distinction between the neurophysiology of traumatic and “ordinary” memories. Freud never abandoned this fundamental belief that mental health is rooted in science.
But he also understood that the science is just the beginning of understanding people, and, lacking the technology to continue his investigation, he and his colleagues struggled to picture the mind / brain from careful observation of language-based and non-verbal data. He brought the idea of the unconscious into the mainstream of Western thought, i.e. that most mind / brain activity is outside of our direct awareness. He also emphasized that language-based functions dominate when we address social and intellectual challenges. In part, his “making the unconscious conscious” means putting urges into words that can delay, encourage, or substitute for behaviors. Obviously, nuanced language and its myriad speech expressions provide the highest level of our intra-species interactions.
In a way, today’s psychiatric practice is to neuroscience as, say, chemical engineering is to chemistry. So the histories of psychiatry and its basic science, neuroscience, are intimately connected. Indeed, many of the pioneers of modern neuroscience were steeped in Freud’s psychoanalytic methods and teachings, and similarly became curious about the mind / brain connection. For example Dr. Paul Schilder studied how our body image is produced in the brain, and his wife Loretta Bender MD and her outstanding colleague atBellevue Hospital, Barbara Fish MD , tried desperately to understand and treat children severely ill with psychosis as suffering from brain disorders, even before we really understood the differences between autism and schizophrenia, and their papers show true wisdom about brain and mind development.
Our National Institutes of Mental Health became the most important international neuroscience resource as research and training blossomed in psychiatry departments in medical schools the world over until the early 1980’s. Many psychiatrists and scientists trained in such programs, which always contained heavy emphases on “talk therapy” language and play (language in action) therapy with children. Basically, this training was in applied neuroscience.
In fact, in recent years, energized by Columbia University’s psychoanalyst / neuroscientist Dr. Eric Kendal’s Nobel Prize winning findings several decades ago, neuroscience soon exploded when technology gave it the tools. Dr. Kendal demonstrated that relevant environmental events can cause a physical alteration in brain structure and function we otherwise call learning. Learning, and therefore psychotherapy, are in fact brain changes visible under the microscope.
Thus was the mind / brain duality finally breached by Dr. Kendal. Serious mental health professionals and scholars are now justifiably excited about repeated brain type confirmations of clinical wisdom about the mind part of the mind / brain entity accumulated over the past 120 years. American psychiatrists are scholarly leaders in current neuroscience research, especially brain functioning and its applications in the diagnoses and treatments of the mentally ill.
Technology now allows us to co-relate very limited aspects of brain and mind. But let us remember a significant limitation. Knowing how muscles and bones make movement does not get us anywhere near explaining the wondrous art of the piano, ballet, or gymnastic performer. Or superb knowledge of telephony or computer science does not bring understanding of the rich language-based communication and information handled by the machines. (But this type of knowledge does help us understand and “fix” broken “brains” and minds and substantially help people.)
While we all hope that the most impactful medical value of neuroscience will come soon to prevent, diagnose, and treat people with mental illness, it is also already bringing wonderful new opportunities in education, child development, and even law. Neuroscience is way more significant than its current faddish brain training sideshow. For example, neuroscience shows that the elderly playing some videogames slow down the aging process of their brains. Dementia is slowed in the elderly by greater exercise of their mind / brains in an engaging everyday life. The declining brain thrives on exercising its highest functions, including language.
So, this suggests that we must also challenge our kids’ brains and minds well with disciplined language and its uses in math, social studies, and science. Let’s show them the best of esthetics in poetry, music, dance, and painting, etc. if we want to develop their mind / brains and whet their appetites for more of these truly effective brain foods.
One final opinion: I firmly believe that the actual form and contents of the creative living brain’s nuanced complexity will always, if not for a very long time, remain awesomely mysterious, and its ever changing, shimmering gossamer (Penfield’s description, I think) a totality and elegance unexplainable.
To learn about neuroscience and its applications today, Charley Rose’s The Brain series is a unique resource.
PSYCHIATRY IN BEHAVIORAL HEALTH
We are facing a solvable crisis in how we treat our neighbors, and neuroscience and language use are intimately involved. I base my comments on work in a small number of units. I realize — and so should the reader — that drawing major conclusions about a whole industry from a small sample is not valid.
Paradoxically, at the very same time that neuroscience is confirming the biological bases of much what we have learned clinically in language-based therapies in the past century, actual American psychiatric practice in most areas away from rare metropolitan pockets israpidly drifting too far away from its intelligent, disciplined, humanistic, mindful, language-based roots bridging the mind and brain. This trend is especially true of inpatient and outpatient care reimbursed by Medicaid and Medicare on behalf of poor people who are mentally ill.
I now know all this first hand from recent immersive stints as a temporary substitute physician in inpatient Behavioral Health units of privately owned hospitals. I served for several months for 10-27 hours weekly, taking over care already started by others or admitting new folks, and so came to examine hundreds of people who are poor.
In popular culture, psychiatric facilities are portrayed as either bucolic places for resting (in fact, most units are locked and insurers and security concerns disallow passes or off-unit time with such short lengths of stay) or as snake pits filled with agitated, violent, people and sadistic nurses. These are fictional stereotypes. The reality now about some Behavioral Care inpatient units is more complicated and difficult to fully understand. And it can also beshocking to anyone close to it who cares to think ethically about it.
In the facilities I have worked, each occupying a part of a floor in a larger hospital, a unit held 30 patients, usually roomed in clean, suicide-safe, unlockable double rooms with special window glass, basic furniture bolted to the floor, and no mobile phones or computers. Common rooms include a large comfortable lounge where patients are encouraged to spend their time.
When you are buzzed into a unit, you see a spartan hospital wing once the solid steel door gently locks behind you. It is generally quiet and peaceful. Some staff work in their offices, often with doors open. People can be found in the halls, their rooms, an activity room, community therapy meeting, or watching TV, always with doors open, and some must always remain in the line of staff’s sight. Staff members, including nurses, are fully dressed in street clothes with badges or in nursing “pajamas”. Doctors often wear ties. Patients can be wearing safety-screened street clothes or bundled in layered loose hospital gowns over surgical “pajamas”. Nursing and other staff and patients often congregate around, either wide open or enclosed and locked, nursing stations.
Patients are screened medically before admission or by hospitalists later quite well. Street clothes and personal belongings are stored. All patients attend group and occupational therapies. Psychiatrists see patients during daily rounds, practiced in a private conference room with the doctor and a nurse and at least one computer. The patient sits across the table from the doctor and closer to the door. This is an effective arrangement because it does add efficiency and promote communication.
Security is tight and unit hygiene fair. Patients or staff can be injured rarely by sudden violence, and staff avoids sitting in chairs just occupied by some. For example, a man who just learned of a brother’s death became violent in his despair. Many can become more agitated, especially initially, and require energency injections after frightening staff and patients. A uniformed, unarmed, often friendly security officer (often an actual retired or off-duty policeman) can appear when the buzz and actuvity level are high. Some staff visibly carry a device to activate the general sound and light safety alarm. Male staff capable of restraining people are scheduled every shift.
Behavioral Health inpatient units I have seen are tightly administered according to insurer preferences, especially Medicare and Medicaid, and must balance expenditures on providers and their expensive time with shrinking reimbursements . The basis for care is driven by economies, eliminating essential medical options in comparison with private insurance . Often, units cannot survive financially, especially these days, leaving serious gaps in the safety net of too many Americans.
Census is the topic most often discussed. Everyone is relieved when units are full and resources really stretched. Unit nursing and other staffing commonly expands and contracts every eight hours shift with unit census to avoid waste, so jobs and income are at stake to keep census high. Charting is a crucial activity, and staff and doctors closely monitored by specially trained utilization reviewers to comply to the letter with the language of rules imposed by the insurer to avoid raising red flags and assure reimbursement.
Key language must be included in nursing and medical notes to allow for smooth coding and reimbursements. Doctors are like queen bees, urgently essential to the viability and smooth-working of the system, but are de facto restricted to specialized, narrowly defined roles: Providing signed admission, daily progress, and discharge notes. In fact, that is their only activity that is monitored by anyone.
This is about our neighbors and about getting to know them through language.
People are brought in, mostly in the evening hours, by ambulance or police, family members, or from emergency departments far away, nursing and group homes, and transferred from other hospital medical units. Some allegedly just tried to jump off a bridge. Others overdosed and are admitted after medically cleared. Others were drunk. Many have some abused substance in their urine. Some are described by nursing homes as violent, but are actually dumped for some unknown reasons, probably economic.
Hospitalized folks can include: Ex-executives or other once-employed people fallen on hard times or people who were never employed; illiterate and the markedly retarded or demented; those with graduate degrees; African-, Latino-, European-, Asian-, other-Americans; immigrants and asylum refugees; parents of infants and grown children; residents of inner cities, farms, and suburbs; housewives; voluntary sign-ins or certified; homeless people; substance abusers and alcoholics denying; substance and alcohol abusers detoxifying and resolving this is their bottom; felons under indictment; violent sociopaths; the meek and shy; beautiful, cachectic, obese, athletic, and /or toothless people; those with poor personal hygiene and those well groomed first-timers; and there are the neurodevelopmentally disordered and the “frequent flyers”.
They are desperate, dispirited, demoralized people who live in extreme stress with extreme fear, hurt, and anger and yet retain an amazing amount of dignity. They mix together on the units, all vulnerable and mostly frightened, lonely, and disempowered. Some are more engaged once their medications are adjusted. Some are newly admitted and still heavily sedated from their admission ordeal.
These unique individuals have a lot to say: Most believe in God and / or would like a visit from the chaplain. Some have a sense of humor. Most welcome a personal fist bump or shaking hands with the doctor and a discussion of their past and future. They appreciate a conversation about how this hospitalization could be a turning point in their lives. They like being asked what they need or what name they prefer to be called. Many want their own clothes returned to them ASAP and have important wishes and plans no one asks about. Men ask for razorblades because they do not use eletric razors. An 18 year old could be coaxed into showing off his rapping talent and then appreciates the chance. Some ask for a roommate who does not snore. Some are quite engagable and capable of participating in their own care.
Mealtime is important to many patients, especially the homeless or those from group homes. All eat together from hospital trays in a dining room that doubles as an activities room. Many ask for double helpings, and it is not usually allowed.
BECOMING A BAD FIT
So this is what happened: I did not fit in. A senior nurse spotted my stumbling and suggested warmly that I just “go with the flow”, but I resented the message because I didn’t really understand it until much later.
I was aware from the start that time was a main issue for my employer. I was sometimes scheduled to see as many as five or six complicated and poorly communicative patients an hour, for up to five to eight hours consecutively. In fact, admissions took more time, but I also spent more time with about 2/3 of patients who already had nicely typed admission notes by another practitioner already in the chart. Why? I preferred reading nursing notes and raw lab data and interviewing these patients more fully myself. And what’s more, in a squeeze, I prioritized young patients with even more time because the younger the patient, the bleaker their future and greatest the difference good doctoring could make now. Why? Nobody else was doing what decent medical care called for.
That was not all. What I did with patients during this seemingly extra time really made me a a major disruption. In retrospect, my naiveté seems embarrassingly clear. How could I have missed it? Everybody, including me, assumed I knew what I was getting into.
I had not noticed, nor did anyone ever spell it out for me until I worked in several places, that I had been assuming, as usual, that I was hired simply to do my best as a doctor. That meant practicing as competently as possible and advocating for the best medical care of my patients. That is the basic deal I have made implicitly with administrators wherever I had worked in the past 40 years, and it generally worked for everybody, sometimes for as long as eight years. It never occurred to me that any aspect of my professional commitment or practice would ever fit poorly with caring for psychiatric patients.
And this was not personal. Yes, my sometimes abrasive style and reputation of “suffering no fools” (earned over a lifetime of moderate effectiveness) did not help. I now understand the scope of the problem: It had never occurred to me, nor to colleagues who recommended me for jobs, that I was supposed to seamlessly substitute for permanent “Behavioral Health medical providers” in lockstep.
I see now, how, from an administrator’s POV, everything I did was disruptive: “Imposing” my own diagnoses and treatments, prioritizing, encouraging a collaborative atmosphere of learning and teaching, and largely “interfering”. I suspect that a major unspoken worry was how the contrast with my practice “methods” placed the permanent doctors, who are hard to find and whose daily signatures are desperately essential for the system’s financial viability, in a poor light. I was expected to understand automatically that I was also expected to cover up my own basic medical standards as I was covering these practices. But iI took me a while to figure this out because it was very new to me. I had worked in public settings and covered for colleagues many times, so it was an eye opener.
So the administrators who saw a loose cannon did gently try to steer me. They knew what they needed — someone like their permanent providers. But legally, they cannot tell a doctor how to practice. I don’t think any administrators even thought much about it, and themselves assume that one doctor is as good as and can cover for another easily. That they did not anticipate problems with my hire is in itself is quite telling.
Fitting into these facilities had as little to do with my being a doctor practicing with competence or humaneness or the healing uses of language. It had mostly to do with facilitating billing and smooth patient flow. While as shocking, it’s not the same as the old state hospitals: These days, facilities are mostly decent physically, medications can work pretty well when used correctly, and there may be some very fine programs, staffed by well-trained psychiatrists, staff, and administrators struggling to give the best possible care in an abysmal climate.
But how could I fit in? I was supposed to cover for providers that patients and staff recognize as mostly gatekeepers who will re-prescribe medications and sign notes, and not as healers, nor as users of language. These providers refer or routinely dump patients to inpatient units. They admit, see patients, write progress notes, and discharge in the shortest possible times, expending least resources, especially their own or nursing time. They meticulously dictate beautiful notes sign off on each step of the revolving door, cookie cutter, assembly line process and document, document, document to the letter compliance with the insurer’s language. These providers are apparently interchangeable and can easily travel among hospitals and nursing homes and outpatient practices, and they maybe major clients for some medical placement firms.
So until I figured out what was happening, I practiced the best I could. I figured that I was doing the right thing for these folks. Nurses very quickly and competently translated my medical recommendations into effective actions, and there is a large amount of respect shown for each other as a partner and colleague. I relied heavily on these professionals, and they never disappointed. (Sometimes, FYI such nurses buy patients clothing or other needed items to enable their success after discharge.)
WHAT ALSO HAPPENED
This is the second thing that happened to cause me to misfit in the places I worked. And it was more obvious. How I was using language seemed to some folks — patients and nurses — to work quite well:
There were moments of genuine synergy. Maybe that’s why these two very different groups of people marveled at the sight of a psychiatrist who actually dignifies, empowers, and converses seriously with patients and uses language as a demonstrably powerful diagnostic and treatment tool and fine tunes medication treatments using the latest knowledge. Nurses and patients both reacted with pleased surprise, as people do when they unexpectedly discover a new way to improve something vital but frustrating. They actually saw a psychiatrist try to connect and engage ill people in colloquial conversation about their pasts, explain diagnoses and treatment, identify strengths, assess medications and alternatives, and assist patients to plan personal goals for their futures and articulate and make sense of their personal stories.
These veteran experts in modern Behavioral Health trenches were fascinated to discover how language can be one of our most powerful neuroscience tools to bridge mind, brain, and behavioral change. Some patients were eager to know what their diagnoses mean and what medications are supposed to do, and were pleased to have enough information to make their own decisions.
The nurse, patient, and I learned together that doctors and nurses working together still can have very powerful effects to the good. We learned that when patients and staff understood the same narrative, hope and compliance increased and progress accelerated. We learned that a language-based psychiatrist’s signature can also guarantee competent care. “You are the first doctor to ever do this,” many said many times.
And we thought I was doing my job pretty well because patients were dramatically improving and nurses were learning. This point came home dramatically when one “frequent flyer” proclaimed proudly, after three months of her deliberate medication refusal (so I was expected to get her to take it), that her mind was now clear for the first time after 40 years “in the desert”, and mostly that she finally has “a name “, after the America tune. And I did thank her sincerely for teaching me the song.
Additionally she had been seen daily for many days by other psychiatrists, with little change until her visits with me. We made a decision with the patient to support her resolve because this was a woman finally making her own choices towards health, and the medical risk was quite low. As the nurse and I planned with her how to succeed, she volunteered “anxiety” as her main problem, so we reviewed her psychosocial options and planned her discharge accordingly (with medication she trusted). And there are many other stories and similar moments, even with less healthy folks.
And, BTW, I was not that expensive: I was actually able to see about 4 (up to six) an hour and do a competent job (once I learned to triage who was most likely to benefit after a lengthier first meeting, and once I learned the ropes and Epic.) Altogether, working with this woman took maybe 60 minutes of my and the nurse’s time spread over several days. It would have taken less had a proper history been obtained by her admitting provider.
(This is sarcastic.) Administrators and investors: Please note — Do the math. Language-based psychiatry is a wonderful invention. Any novice entrepreneur today would understand that the business challenge now is to scale this proven concept. Why? Because a woman finding her name can be a bargain, costing altogether, say, $80-250 for language-based psychiatric and nursing times spent with this patient. And there are millions of missed opportunities for such cheap interventions daily in your multibillion dollar potential market.
SOME CARELESS / INCOMPETENT PSYCHIATRIC PRACTICES I SAW FIRST HAND
Being a bad fit was fine with me. I did not realize this at the time, but the Behavioral Health psychiatric practices I saw were actually somewhat cleaner versions of bankrupt old ideas. The use of language as a psychiatric tool seems to be a central issue. Here are specific examples to illustrate what today passes for psychiatric practice in at least some inpatient Behavioral Health units.
- Historically, legitimate medical encounters consist of several or all of these actions: Connecting with the patient through language, reviewing history, examining the patient, evaluating current functioning, confirming a diagnosis, initiating or adjusting a treatment plan with nursing and social work, writing orders or prescriptions, calling other specialists for consultations, and charting the above. But not in these facilities nor apparently in general practice everywhere because too many psychiatric medications are prescribed without validating a diagnosis . Very ill and poor psychiatric patients in some Behavioral Health facilities get the almost-random pick of the same few medications for years without validated diagnoses.
- Things can look a lot better on paper than they actually are. Thankfully, I have not seen anyone lying or using language dishonestly or misleadingly. It is more subtle: On initial readings of a few random patient charts, writings by one of these doctors would seem complete and nicely detailed. However, seeing more and more charts and the patients themselves reveals another picture: In fact, many of these records are empty facades that show little clinical thinking. But they do comply with insurance language, These writings are insidiously too alike in language, wrong diagnoses made and wrong medications prescribed over and over. I would guess that they could easily escape random routine audits and that this is already an epidemic, in spite if staying meticulously within the law.
- Too many post-traumatic or child abuse survivors, people 18 to 55 year old who had sustained severe psychological injury, are now suffering additional and probably more crippling abuse from an incompetent medical work up (that fails to diagnose and treat correctly.) Even today, no doctor seemingly ever bothers to use simple language to ask most the obvious questions, such as “Has anybody ever hurt you physically or touched you in private places against you will?” “What happened then?” And so, nobody ever listens to a story many badly need to tell to know themselves as human.
- People whose illnesses were initially triggered by severe losses are not diagnosed as grieving because nobody got the facts available for the asking or listened. Instead, these folks are prescribed strong meds for years. If you are a poor mentally ill person, your grief is treated as part of your illness. If you are a poor person you will also probably be diagnosed incorrectly if you have learning disabilities, dyslexias, ADHD, or dissociative disorders, and even hysterical symptoms like Freud’s first patients. Here’s a main problem: Most share the same few recurring diagnoses and treatments, despite their actual diagnostic diversity.
- Children, reacting merely as normal children would to severe emotional turbulence, violence, stress, possible abuse, and chaos in their homes, receive heavy multiple medications they do not need, given a wrong diagnostic label that might last a lifetime, are returned to their homes with no other assessment or services, and are likely to become future “frequent flyers” (see below). If you are seven and unfortunate enough behave in ways that tax your mentally ill mom, you will be admitted and treated with medication instead of her without seeing a child psychiatrist or even any collateral history.
- I have seen how some youngsters survive their train-wrecked lives as wards of DCFS since early childhood, hanging on to sanity and humanity by finding strength in themselves through drawing. They bring their notebooks into the hospital. When asked, “How do you get yourself to feel better?” they show their work proudly and appreciate a kind but honest reaction. These are diagnostically important clues too. Some work shows personal resources and talent. The interaction sparked by a simple question provides opportunities for empowerment and dignified human contact with a doctor. No medical provider, and few other staff members to my knowledge, ever asked the question nor showed an interest of these kids’ art.
- “Did you ever hurt your head so badly that you passed out?” is almost never asked of folks who live in a culture of violence and are therefore more vulnerable to closed head injury and its sequelae. That your symptoms could be related to a closed head injury could be overlooked if you are a poor person.
- Visits by devoted chaplains is often what can make the difference in providing a personal connection and improvement. Individual helpful conversations also happen with nursing staff, but usually around immediate practical needs. Occupational, group, and family therapists do what they can with extremely small budgets. Individual therapy is rare because privacy is rare.
- Polypharmacy (unless clearly justified, the practice of prescribing together several very similar medications to treat the same symptoms — considered sloppy practice because of increased side effect risks) is rampant in these medical practices, except where hospital IT systems question the order. Patients discontinue medications they need because of side effects. Side effects can add additional symptoms or might need treatment with yet another medication if you are a poor person.
- Children are admitted and treated by providers without specialized training in child psychiatry. So if you are a non-psychotic five year old boy, you would be prescribed a mood stabilizer immediately upon admission without a verified history or a qualified psychiatric examination.
- Medication non-compliance is formally often blamed on patients for relapses and frequent readmissions, but outpatient facilities can often be inaccessible or care also cookie-cutter and social services marginal. Some patients know the medication they are prescribed hurts them, so they refuse it or stop it after it runs out. Some stop because they are too disturbed to see its value. Many of these folks are not even aware of their current, let alone, valid diagnoses, or if asked, what the currently commonly used cookie-cutter labels “Schizoaffective Disorder” or “Bipolar Disorder” or “Borderline”, masquerading as legitimate diagnoses, actually mean, other than justifying the medications they are asked to take and their hospital admissions. So if you are poor, uninsured, or homeless, you might have the wrong diagnoses and be taking the wrong medication for years without knowing it.
- Electronic medical records are typically administrator-centered and awkward and more time consuming for psychiatrists than some patients. Available health records often only go back a year or so for folks who suffer lifelong chronic illnesses, so nobody really has the entire history to see the context for the present. Doctors don’t seem to trouble looking at the whole picture. This means that one illness episode can last a lifetime with care so fragmented that it appears to be for a series of acute illness episodes in the record That you are not improving is not necessarily visible to doctors if you are poor.
- And this is a chronically medically ill population with a predicted life span decades less than most of us. Decades from medical neglect, accidents, and suicide. Yet access to inpatient specialists like rare child neurologists, child psychiatrists, psychological testing, long-term histories, EEGs, endocrinologists or even gynecologists is spotty in such facilities and is postponed until after discharge, but rarely happens then because the links between outpatient and inpatient care are so poor that too many just fall through the cracks. If you are a poor child who might have a learning disability that gets you into trouble, don’t count on a doctor to check it out before diagnosing and treating you as needing medication. If you are a poor person, don’t count on ever getting a thyroid or kidney test (24 hour urine collection), even though you have been taking lithium for decades.
More instances of systemic, medical, and ethical failures in no special order:
- Too many poor mentally ill people use their now 6.8 days or so as inpatients as a lifestyle choice as the only safe havens and shelters from their crises-filled lives. So, known by many staffs as “frequent flyers”, some of these patients have told me openly that they claim to “hear voices that tell them to kill themselves” to get admitted, and do easily get admitted without anyone even inquiring into the nature, location, and history of the alleged hallucinations. Often, someone on the inpatient staff then says something like, “It must be getting really too cold out,” as they are admitted. In fact, several have revealed to me that they have not hallucinated for years. Yet, some insist on carrying the wrong diagnoses that guarantee Social Security Disability payments. Some are dumped by nursing or group homes and become homeless. It is really difficult to say how many such patients exist, but I would estimate that proportion can be as high as 1/4 of total admissions.
- Hospitals defer to doctors to monitor each other, but this hardly happens in any regular way. Nurses often “go with the flow” rather than advocating for patients, and have suggested this to me in a sincerely friendly way. Citing professional boundaries — each profession must monitor and discipline itself, some administrators seem almost too quick with, “We are not doctors and must rely on doctors’ professional self-governance and self-policing”. However, actually, there often is no functioning medical leadership, no routine clinical conversations among covering doctors, and no oversight procedures to monitor medically sound quality of care of the mentally ill. Not belonging to the local state Psychiatric or Medical Society can also keep such practitioners safe from peer review and censure.
- So the admission charade continues 24 / 7, as too many seemingly “financially strapped” inpatient Behavioral Health facilities, claiming they have a hard time recruiting, uniformly settle for doctors who consistently seem not to need to communicate thoroughly with their patients. A routine medical conversation that might provide crucial information hardly ever happens.
- – Too many doctors in this current system seem to forget that every patient encounter is an opportunity for screening for general health and improvement and verification of diagnoses and treatment plans, but instead perpetuate unproven incorrect psychiatric diagnoses and pile the same sets of powerful ineffective medications into ill people, no matter the age, often discharging them into a therapeutic vacuum.
- Well-meaning folks at all levels who work in such facilities are incentivized to keep the system going as is. Administrators scramble and compete in a hot market to fill medical positions in order to keep needed beds open and budgets positive. So they must retain some doctors with marginal skills for understanding speech and norms of patients of diverse American cultural backgrounds, further handicapping any healing relationship and distancing practitioner from patient.
- And are these units really “financially strapped”? Many, all over the US are closing . But I also heard grumbled things like that these “full units actually earn such substantial revenue that they can sometimes carry the whole hospital financially”. So, if that’s true, what could make them so profitable at the very same time when LA’s famed Cedars-Sinai had to close the very same services? If true, how can services already reimbursed at bare bones leave anything over? Are poor mentally ill people being ripped off?
These examples illuminated for me aspects of psychiatry’s stunning professional and social failure, especilally as it turns away from language-based therapeutic interactions.
WHAT I THINK HAPPENED
Something bad happened in the past few decades that few speak openly about.
Of course, it is all about priorities, values, money, governance, ethics, morality, taxes, etc., and there is plenty of blame to go around for anyone who wants to sling it or accept it. But let’s be real — the buck has to stop somewhere, and more than a few cents stop with psychiatrists, individually and as a profession. If you are poor and mentally ill, no matter anything else, you will get relatively little personal attention, little psychiatric expertise, and it is rare that anyone really knows you or speaks with you seriously about your past and future. Efficiency in some of these facilities often has little to do with monitored medical quality or accuracy or humaneness or competence or the healing uses of language.
Such production line taxpayer-supported psychiatry is not that different conceptually from the bankrupt old style warehousing psychiatry. It is even legal now, faster, and more efficient. The provider provides the service at bargain rates. But the tragedy is that even so, a patient is lucky to get a fraction of the value taxpayers buy. Except that these days, facilities are mostly decent physically, subject to modern hospital standards, medications can work pretty well when used correctly, and there are some very fine programs, staffed by psychiatrists and others, struggling to give the best possible care in an abysmal climate.
This is my main point: Psychiatric care is minimal and substandard in the units I saw, and as long as that is the case, such Behavioral Care units will not be truly competent, humane or optimally efficient. I have come to believe that patients in these facilities depend on too many of our Behavioral Health provider colleagues, who knowingly, intentionally, or not, are “keeping their heads down” and contributing to profound social injustice, as had doctors in state hospitals fifty years ago. What we might have now is a failing system, featuring third-world medical standards, that actually perpetuates social injustices and prejudices against our society’s throwaway peoples. It is a silent blight in our midst.
Nor is this an overnight blight, but decades old. In fact, one of my most senior mentors, actually a pioneer department chair and psychopharmacologist, accurately predicted in the mid or late 1970’s or so, because at that time the National Institutes of Mental Health was stopping subsidies to psychiatry residency training in teaching hospitals, that the profession would sink seriously and move away from its best traditions. I remember the moment I heard him (on a beach in Miami after a professional meeting), much as people remember what they were doing just before a bomb goes off. It has been in the back of my mind ever since, and now i see what my mentor meant as the trend is really accelerating and has become industrial strength.
We all saw psychiatric services in general hospitals bleeding money, especially those serving many poor people. Less than 20 years ago, I remember sitting in budget meetings in my doctor coat with growingly impatient fidgety administrators wearing suits. We always lost money, especially children’s programs, because no insurance scheme paid enough to take care of sick families and children. And we had to account for every pencil and eraser in our programs because the hospital carried us as a goodwill service to the community.
Another piece of history (not frequently discussed openly, but always a big elephant in the room: Not all doctors are alike): Looking back, there has always been a big divide within psychiatry, with mostly US medical school, university hospital-trained graduates serving employed and insured (even if poorly) Americans and their families. Our practices and settings were language-based, generally lower volume / customized service, higher quality / higher profit margin / less errors.
But we all knew about “the state system” and very few of us engaged with it, or with private practices serving the poor that eventually became known as Medicare or Medicaid Mills: Non-language based production lines for poor people –administrative nightmares / high volume / less quality control / lower profit margin / more errors. The mostly western-trained medical graduates continued naturally an identity, relationships, and other educational and practice activities. Historically, there wasn’t much mixing among psychiatrists from these systems. However, there were some nice collegial connections between biological psychiatry researchers and the non-language based practitioners.
Precision in language can make a big difference in legality.
Some doctors — at first mostly western-trained in all specialties — innovated the earliest, Medicaid and Medicare mills a few decades ago. These doctors were sometimes investigated and even indicted and jailed for fraud and other illegal practices that sometimes even caused hospitals and nursing homes to close. The problem of how to deal with bottom-feeding colleagues flirting with ethical boundaries is not unique to psychiatry nor to any profession, while the absence of language as a treatment tool is absolutely crucial to psychiatry.
(This is sarcastic, but how I see it:) If history is any judge, a now-retiring generation of innovative psychiatric specialists was highly successful. These doctors deserve bravos and special awards from some in the Behavioral Health industry: No one realized at the time how pioneering these millers really were.
Yes, they were a rough crowd, those millers. But these pioneers deserve kudos, not only because some were mostly ok doctors after all, but because they invented the first working mills. Long before Behavioral Health was an MBA’s challenge, these millers labored long hours in the sewers of psychiatry to perfect a streamlined, cheap, non-language based psychiatric production system. They came up with the concept that, like highly specialized queen bees, whose essential function is efficient reproduction, the valued role of a psychiatrist was merely to sign as many patients through the system in the cheapest way. (Only thing was, they couldn’t make the scheme work linguistically and therefore legally, so they worked at great risk to their own personal freedoms and reputations.)
So we can see how visionary systems that were once illegal parasitic growths on the public body are now seemingly mushrooming into legal symbiotic and synergistic partnerships with the host. Our colleagues’ daring innovations might be lurking within some newly revitalized, improved, alive and well, profitable, and totally legal Behavioral Health practices . Our entrepreneurially gifted colleagues have blazoned a way for the hijacking of a profession by some large corporations and hospital systems that use language very carefully and precisely. (An ironic twist: Some Behavioral Health units are functioning and seemingly legal now in large part because the exceptionally precise use of the right billing language is now guaranteed by signatures of nonlanguage-based psychiatrists.)
WHAT IS NOT RIGHT
What shocked me was this: Poor mentally ill folks are being served the dregs of the dregs of what psychiatry can and should offer them. Shameful psychiatric neglect or incompetence in the units I saw with my own eyes and many outpatient services and nursing homes I learned about reminds me of what I had seen in the large old state hospitals as a medical student well over four decades ago, when these places were widely considered the sewers of American medicine. And many who work in these facilities don’t seem to know or care or to believe they are capable of changing things.
Early in my work in Behavioral Health units, a permanent “psychiatrist” practitioner admonished me to comply with his standards (polypharmacy, diagnoses in perpetuity, etc.) because I was now working in his type of practice, and not in my suburban practice. He insisted with all seriousness to me in the same meeting (and we were not alone) that it is wrong to review and change patients’ diagnoses because “so many good doctors (in such facilities, practices like his own, or similarly staffed outpatient programs or nursing homes) have already diagnosed the patient”.
As it turns out, he was just telling me how it is. In his own way, he was orienting me. But at first, before I had worked in another, very different, Behavioral Health inpatient setting, and saw how identical psychiatrists’ roles and practices actually were, I even started the process of reporting this man as an impaired physician. And that’s not something that I had ever done before.
But he was in fact pretty typical. To him, apparently, “continuity of care” meant not making waves while perpetuating continuity of wrong diagnosis and wrong treatment for years. This doctor even knew that suburban doctors practice differently, and he may have had some idea of how. However, while I was initially mostly troubled by the way doctors in this system function, I have come to see them also as naive followers, who do work long and hard and are devoted in their own way to the patients they serve and staffs, rather than being merely impaired or greedy perpetrators. There are, apparently, more powerful but invisible owners and operators, who crave these doctors’ signatures so intensely, and who know exactly what’s going on, or should know, who qualify for the latter distinction.
The knowledge base of postmodern psychiatry is rapidly expanding , especially as its basic science flourishes. But let’s not forget the obvious dark side — nerve gas is a major military application of neuroscience. Not as immediately obvious, but in a way more catastrophic to more people, applied neuroscience is in bad trouble: if what I saw was typical, millions of Americans are hurting in facilities that deliver neuroscience’s main civilian benefits. Medicaid- and Medicare-funded Behavioral Health systems are a main funnel of today’s neuroscience applications, and these are badly broken.
While we psychiatrists are celebrating the wonders of the human genome and neuroscience, we are also justifiably losing our credibility as physicians because too many of our colleagues practice extremely poorly in some Behavioral Health hospital units and outpatient settings serving poor chronically ill people.
IMHO the reality has become a national disgrace and crisis : Too many fellow Americans, especially the poor and their children , are tragically not receiving the care they need simply because they are receiving the wrong care. The system is seriously and dangerously broken, even as everyone seems to choose words carefully to comply to the letter with reimbursement .
This is not simple and part of major social problems in our country. But as citizens and individuals, each professional must search their own conscience to decide where they stand on this issue and how much, by deed done or silence, they are perpetuating or enabling this travesty. That’s the least we can do. Many who work in the system have become dulled to its egregious norms. But that is not an excuse.
The wider context has been a general decline in medical practice competence , especially in specialties demanding careful medical thinking and treatment planning, for example cancer care. Private practices, where a doctor owns his own place, is on the decline, and many experienced doctors are pulling away from a devoted engagement as someone else’s employees. Another factor today is how the economic crisis causes increased stress on the poor and damages safety nets serving them. Yet another factor is that doctors have lost their sense of neighborliness to patients and their professional communities, as hospitals turned away from the local practitioners that gave them quality and professional accountability to become production lines. (Hospitals were centers of professional life. We used to have staff meetings and department meetings and doctor dining rooms. We used to talk to each other. We used to monitor each other formally and learn together from our mistakes.)
Nevertheless, last time I checked, psychiatry was still a fully credentialed medical specialty. So what happened to the American Oslerian ideal of rational medicine applied humanely that so many top medical students in my now retiring generation signed up for? What happened to the fundamental medical principles of “do no harm” and to the professional, ethical, and moral obligation to practice at least competently, if not creatively? What happened to following carefully made diagnoses with appropriate, thoughtful and effective treatments? What happened to the term “psychiatric treatment” in a world of “behavioral health”? How did I get to be a “behavioral health medical provider”? Can the promises of neuroscience be delivered by this broken system?
The non-poor and their children seem confused by a burgeoning, mostly unregulated, “therapy industry”, where everyone is an expert and few are sensitive to skills, experience, professionalism and credentials. The expert, therapeutic use of language is no longer known or studied by the best and brightest medical practitioners. In this world, psychiatrists are frequently known only for prescribing medications. In this world, it turns out that few people have access to psychiatric treatment based on careful use of language and modern brain science and nuanced professional understanding.
SO, IF NOT NOW, WHEN?
The words “Behavioral Health” now signal a new context and redefinition for psychiatry, and is now what passes for who we are to many people. The above language can hopefully give rise to thinking about actions that might begin to remediate the situation.
Here we are today, in the age of the human genome, neuroscience, and technology, still with one foot in the sewer. We are all morally soiled by the muck. Looking forward, I doubt that poor mentally ill people will ever get many resources as they compete in a public service economy also struggling with broken physical infrastructures and educational systems. But they can get more if we stood up for our profession and its standards.
Things have changed in psychiatry and can be unchanged: Psychiatry board exams used to require a live patient interview to assess doctors’ language-based skills. So now, many more board-qualifying psychiatric residencies now give only lip service to teaching language-based skills, once a deficit reserved for the least competitive training programs).
Under the thin facade of moving psychiatry closer to the scientific medical mainstream, actually we have shamefully abandoned essential medical practices and values that make doctors healers. Instead, our professional signatures enable systems very few of us would have our own family members go near.
And maybe there are many more creative solutions possible we have not considered, especially since as US medical school graduates we are supposed to be America’s best and brightest. In the general context of what is happening in medicine: If psychiatry wants to continue its humane leadership as the best hope for the mentally ill, we’d better examine our roles ASAP in this mess. Neuroscience is a basic science and cannot fix it directly (except if we all wake up use our brains), but its applications need our engineering skills. As the best trained and placed scholars and professionals bridging the mind, the body, the brain and everyday healthy functioning, we must speak out from our credible history of compassionate intelligent care and design worthy systems. We psychiatrists must review our own roles in this shameful destruction of our profession and its humane — that means competent — treatment of poor mentally ill people.
We must shift our attention back to the severely ill in the facilities that treat them. We must advocate for our patients, provide and police better standards, support well-trained professionals of whatever discipline in the best professional and ethical tradition of medicine, and educate our colleagues. (For example, we can welcome, empower, and help better train the new wave of eager, compassionate, talented, and diligent behavioral health RN+ nurse practitioners in the US, who do still practice in the best traditions of the nursing profession and evidence-based medicine and serve the disenfranchised mentally ill as a “last line of defense” and advocacy. Too few are learning the power language-based practices today.)
We must try to influence policy makers to shift entrenched basic economic incentives driving this shameful system so that good medical practices dominate. I am not an expert in that, but our civil service and private industry have plenty of credible talent. A shift to greater professionalism should not be that expensive.
Here’s a silver lining: At least, we are not burning mentally ill people at the stake any longer in our country, as we were doing just a few hundred years ago. We have laws against that now, I think. Here’s another: We all know that people and institutions in crises are actually more accessible to positive changes. We definitely have a crisis. Another: Behavioral Health units today are located nearby, inside cities, not exiled and isolated to the far-away countryside.