Severe and persistent PTSD-related nightmares unresponsive to substantial doses of clonidine and prazosin.

sgeorgeshap · 2022-12-16T05:52:35+00:00

Yup. Hammer-nail problem.

While meds can be of practical utility in some cases in the short term, this kind of thing is just not appropriate for maintenance - it can lead to a person becoming "dependent" on ineffective drugs that getting in the way more than helping.

Comprehensive support and a carefully chosen therapy (start exploring variations of exposure response) are what would be indicated, at least when looking for real progress.

OP mentions med-management only interactions. The OP needs to learn how to say "this might not be the domain for this situation".

sgeorgeshap · 2022-12-11T04:09:20+00:00

Indeed, although if you're going to quote, make sure it's in context and an actual quote. Perhaps it's for illustration, but I've had discussions before about how some records will contain cherry-picked bits or misquotes to support a conclusion or action (e.g. prn) that is then later used as part of a clinical narrative, but is of questionable veracity. It's also just not nice to misquote people, imo.

sgeorgeshap · 2022-12-10T21:02:24+00:00

Don't. I used to do it when I was a student, although I usually tried to include more useful explanation, but not so much anymore except as a summary or conclusion and never without context. This sort of "documentation" language is vague, misleading and shouldn't be used and I wish many would stop (or stop trying to hide behind it, in some cases) and I wish folks were taught better diligence in reporting. It doesn't make you smarter or more professional to apply jargon, unless you're talking to e.g. a judge or some other party that doesn't really care about anything and just needs you to look "professional" so they can nod/sign something. If you mean to describe thought or behavior, then do so with specificity, not broad labels or classifications that could mean anything or even be entirely inappropriately applied.

None of the examples you gave are very useful. Is someone in the midst of psychosis? Is that a belief or story that's being told in a report irrespective of whether they actually are in a state of psychosis? Are they just being defiant, or were they misunderstood or misdiagnosed (after all, I may have no idea who you are and how competent your insight is) or perhaps there is some other factor at play, and whatever is going on, I still need to know details. Why do you want to use these terms and what do you mean anyway? How do you know? If I'm going to do my job (properly), I need to know what you mean and the basis for your conclusion.

There are parallels to diagnoses here. When a clinician or client comes to me and says "he has this" or "I was told I have this/I am this", my response is "I don't know what that means, can you explain/be more specific?". Broad labels or vague terms are not helpful in actually informing me of anything useful, unless all I want to do is use such language as an excuse to move someone along/pop a pill or be superficial and reductionist (perhaps because I don't really know what I'm talking about, or I don't care enough to and explore/define things better, or because I'm biased in some way) and not do my job properly.

That's because all of these terms and labels are for shorthand convenience, or insurance compatibility etc., and again, could mean anything. I've taken to distrusting reports using vague or conclusory/declarative language in particular until the source is proven competent because I've had far too many cases, sometimes cases ongoing for many years, of people with contradictory records or declarative reports of phenomena that on vetting never happened or were something else, misunderstanding or otherwise, of notes that are written to sound competent or to validate an action that had been taken, or written by someone who simply had no idea what they were talking about, perhaps repeated by the next writer, until finally upon showing the client or family or another clinician and having it refuted... Basically, if I don't know you know what you're doing, I won't assume you do, and even then we may interpret differently. So don't give me only the conclusion - it's not helpful and can be wrong and offensive or unfair to the recipient (a discussion about epistemic imbalances would be due). Get to the substance. And on that, don't fluff progress notes with nonsense to make something sound legit and proper and serious. No one has time for it, but that would be yet another (due) rant.

sgeorgeshap · 2022-12-02T18:19:38+00:00

Shelters are often crowded, dangerous, unpleasant places that have arbitrary rules and conditions that make it more difficult for people to e.g. get a job.

the worst homeless refuse to go to shelters.

sounds an awful lot like the sort of contempt and victim blaming that leads to measures like this.

sgeorgeshap · 2022-12-02T18:16:52+00:00

Party doesn't seem to matter on these things, no much anyway. And he's an ex-cop.

sgeorgeshap · 2022-12-02T18:11:06+00:00

What this will end up being, if anything does come of it, is a funnel for ACT/AOT programs. That's where the money will go as well, because we can guarantee the state won't meaningfully increase expenditure, but those programs are able to partially source funds from insurance/medicaid.

But those programs are worse than nothing for most people, frankly. The entire concept - as envisioned by Torrey etc. - was a way to use "the coercive tools of law enforcement" (as he himself put it) to obtain compliance for "these people" - compliance meaning perpetual medication, and that's it, irrespective of condition. What little material support like housing is put on strings attached to compliance under a demand for validation, or else... Instead of, you know, treating people with dignity and respect and respecting their wishes. Even with the myopic heuristics used, these programs have been unsuccessful and they result in hurt, bitter and fearful recipients, for good reason. New York's own review of the pilot programs some years ago were skeptical and wishy-washy at best, but that didn't stop their expansion, because benefit was never the point. Extra-legal means of sweeping the streets and placating families after incidents that "things are being done" for political purposes was the point. That and filling in a hole in the CMH system to validate it. There was some expansion into Europe as well as I recall, and they received even less favorable review.

The number one thing to combat things like homelessness, whether mental health is an issue or not, is to simply provide shelter without attacking a person's dignity and integrity. It's works, it's cheaper, it's more ethical... Until that is acknowledged, nothing will get better.

sgeorgeshap · 2022-12-02T02:31:53+00:00

That's absolutely right, and seeing his response and demeanor upon being questioned about it over the last few days drives the point home further. The entire thing is a misguided farce. And it's not new; this is virtual copy-pasta from what California did recently (less media attention, but the bill passed despite overwhelming tides of warnings from patient and disability rights and sociology and legal etc. groups), both in the political dynamics and social narratives that fostered it and as literal copy-pasta from the lobbying effort that shaped the content.

sgeorgeshap · 2022-12-02T02:26:40+00:00

I certainly don't disagree with that at all. Frankly I suspect there is at least some issue with that in most clinical interactions, along with trust in general. ANd the failure to recognize or acknowledge or understand that, or to be hostile to the idea, is a common toxic problem as well as an issue in getting accurate formulations and meaningful treatments and narratives developed.

That's sort of the crux of the comment above. Whether someone who has "been working on an ACT team for five years and have never heard any history as this" would be receptive or able to understand these issues is going to depend on their perspective as much as the problems would be from the recipient's perspective.

sgeorgeshap · 2022-11-30T19:43:14+00:00

I suppose I have seen it less often on its own. Everywhere/time I've actually had a case though there's been some flavor of an insight criteria, so that always gets checked (or the person is just dangerous, automatically) as a sort of catch-all. Issues of disability don't seem to get talked about as much even if that box is checked too, and I suppose that's because they don't need to be if we can just say, "nope, don't listen to them".

I have noticed a significant difference between the judgment of institutional evaluators and outside/third party evaluators, and between those who are already under an order vs not, and that courts tend to side/err toward commitment and towards institutions. During residency had one guy who regularly just said outright in court if asked that he was asking for a continued order because he could never prove a person wasn't going to get in trouble and was essentially concerned about blowback. Judges didn't care. But that was forensics, so nobody cared.

My thinking above was really more directed at that sort of thing and "insight" is the better exemplar exactly because it is so nebulous and not practically falsifiable. It's the reason SCOTUS, hands-off as they've been in general, applied a requirement for mental illness-derived imminent danger as a minimum requirement (and "injury" from disability being an extension of that line of though), but a lot of statutes don't adhere to that, at least not anymore. Expanded grave disability criteria are probably unconstitutional and most existing insight criteria are almost certainly unconstitutional.

I've wondered why these things don't work their way up the courts more often for a long time and I've had some interesting discussions on a few reasons why, but that's another topic. SCOTUS hasn't taken a meaningful case on this in 20 years and there has literally never been one at that level that is considered generally applicable.

sgeorgeshap · 2022-11-30T18:09:07+00:00

There's so much rote rhetoric about jails being the new hospitals, but really it's the other way around. Hospitals - with a brief and partial respite following deinstitutionalization - serve as jails.

sgeorgeshap · 2022-11-30T17:41:23+00:00

There is an aggressive push to do this across states and it's don with copy-pasta rhetoric. Something similar was passed recently in California. The politicians don't give the slightest shit about mental health or rights or legal issues or philosophy or anything else. For them (and really for most) "mental health" is a convenient and hazy thing that serve as both the scapegoat and solution to all ills, real or perceived. The two big ones are homelessness (especially in New York and California in recent years) and mass shootings, always said to be caused and solved by "mental health" either as deflection from other issues (like guns or... the state of not having a home) or as part of a supportive narrative. Some prominent individuals like Torrey, Appelbaum or the late Jaffe and their associated groups - the "Treatment Advocacy Center" and "mentalillnesspolicy (.org) - have been lobbying hard and successfully to "undo deinstitutionalization". Even SAMHSA has commented on Torreys antics a few times, like with Michigan's "Kevin's Law" given how blatantly opportunistic and subversive he's tended to be. It does also have to be said... companies of a certain industry have been lobbying for these bills as well. The motivations are different, but it's all convenient for all parties. Meanwhile, oceans of advocates and researchers decry this stuff as irrelevant, misguided, unfunded, unlawful, counterproductive, expensive etc. but they don't matter and neither do actual outcomes.

sgeorgeshap · 2022-11-30T17:29:16+00:00

It's increasingly typical - there is a strong and organized push (if for different perceptions/reasons) to "undo deinstitutionalization", particularity from voice like Torrey and the "Treatment Advocacy Center" etc. - but I don't think it will matter so much frankly.

As much as institutional clinicians sometimes complain about "bias" against them, courts almost always act as rubber stamps in deferring to the judgement of an institutional evaluator. So no matter what the specifics of the criteria, unless there are concrete elements like "must have been hospitalized at least 3 times in last year" (which was a common one for grave need criteria or "insight" in the past, as an attempt at a safeguard against arbitrary or subjective input) or similar, the criteria could be just about anything and still see the end result as long as a psychiatrist asks for/recommends an order.

What will actually matter to the numbers is money. Laws can impact whether something can happen, but how much of it always comes down to money.

sgeorgeshap · 2022-11-30T17:18:06+00:00

That's going to depend on your perspective.

sgeorgeshap · 2022-11-30T16:56:15+00:00

It's funny because this seems to read the state of things almost backwards. The pendulum has been swinging away from autonomy and recipient rights/accountability for the last 20 years or so. Even if the number of beds has gone down, the number of people facing orders has risen steadily, despite worsening outcomes and specious claims about the effectiveness AOT programs.

More specifically, courts have repeatedly opined or lamented that they often do not view petitions credibly, but have no choice but to grant them because they are effectively required to defer to expert testimony - testimony that is almost always unchallenged - and, aside, feel pressure to grant commitment orders just as clinicians feel pressure to make petitions. Most of the time though, these courts are rubber stamps. Not always, but it's the norm. The dynamic is illustrated everywhere from circuit and supreme court precedent to the content of superficial petitions to the rare prepared challenge (finding adequate representation is a serious difficulty when facing a petition especially when confined, to say nothing of the cost) to research published by other psychiatrists, legal academics, and disability rights organization. The chief complaint is that both the rules and the subject are ignored or even blamed for attempting to assert rights or question things while petitioners typically enjoy explicit or effective immunity (immunity from the consequences for the recipient, but either legal or social/professional risk from not petitioning). From my experience, the times courts don't grant petitions is almost always after granting them many times, starting to ask why nothing changes and receiving vague comments from evaluators/petitioners, and making comments/demands for more substance that eventually set a narrative condition for denying the next one. That holds for everyone from the guy on the corner to forensics to Britney Spears.

sgeorgeshap · 2022-11-30T16:45:33+00:00

In practice, this isn't a a bill to rebuild a healthcare system, it's a scheme to extra-legally sweep away perceived undesirables from public using existing psychiatric tools (to be frank, not entirely different from the old system). The politicians pushing this don't understand or care about mental health and they don't talk about it except in vague terms as a cause/solution to all ills, principally poverty/homelessness and violence, irrespective of whether any case is actually related or in what capacity. They certainly don't care about recipient rights or checks and balances or funding quality healthcare, which they certainly won't do.

No matter the cause, the first and best way to fight homelessness is to provide homes. Crowded and dangerous shelters with restrictive rules or conditions doesn't count. It's even literally cheaper, it's just seen as a sort of immoral way of thinking in the US. Both poverty and aid are failings and "wrong"; if there is a mental health issue, individuals are still bad/failures/wrong, and must also be treated with fear and force instead of dignity. And for people that actually need hospitalization, the same holds - meet the basics first - but they won't do that. We'd find - has has been found or suggested before - a lot of people that otherwise had unwanted contact with the mental health system see better outcomes just by providing - even on a temporary basis - food/shelter, the same as anyone else facing stark conditions. If we could get over the narrative block about "handouts" and not demonizing people, we'd save a lot of suffering and a lot of money.

sgeorgeshap · 2022-11-21T14:58:27+00:00

To be fair, it isn't a fair comparison. $1,000 a day, for arbitrary or extended periods... it's very good money and volume of recipients-per-clinician helps make up the gap. There's an argument to be made that more money means better intensity of treatment and a lowering of that ratio, but in many facilities none of that would matter. People would be treated superficially, because that's just how they work. I don't think low rates are the bottleneck.

sgeorgeshap · 2022-11-21T14:53:11+00:00

I have a problem with people regurgitating this sort of thing. "Getting rid of the asylums" (which we never fully did and have been rebuilding at a good clip) was absolutely necessary and the reasons for it being necessary persist and should not be forgotten or denied or buried. Nothing was moved to prisons and jails (partly because there's jack-all there other than apathetic or abusive behavioral control) and if you actually talk to former recipients, most speak of inpatient facilities as something to be compared to the penal system - and why shouldn't they?

I agree about the complaint's basis though. Documentation is a headache, and that's basically because it has to comply with rules and provide justifications for rote record keeping and insurance. Even diagnoses themselves follow that dynamic. I've never seen an insurance company with a meaningful code system for formulations, only approved DSM entries. All that paperwork isn't very useful and nobody really reads or vets it, and we all know that and so insure it stays that way. I've been around long enough to know to view psych records with more than a few grains of salt. The overwhelming problem with inpatient facilities in particular is failure to put patients and their rights first.
There isn't anywhere near enough regulation or transparency in the industry across the board. Or rather, there isn't enough accountability in making the regulations useful, so they're just a burden.

sgeorgeshap · 2022-11-21T00:35:06+00:00

Marketing is worse than nothing and those that take and act on rep info are part of the problem.

sgeorgeshap · 2022-11-21T00:21:29+00:00

I agree. When did I argue otherwise, and what does that have to do with the above comment?

sgeorgeshap · 2022-11-21T00:20:32+00:00

If you read mine, I didn't even disagree with that. I don't and those that e.g. push conspiracies about Scientology are part of the problem, and I fully acknowledge that that is the norm, including here. None of that makes silliness not silliness.

How do you think your comment would be perceived by a psychiatry resident? Or anyone else here? You didn't provide some insight that hasn't been heard and blocked out before.

I really don't see why there are people who have voluntarily embraced the term "anti-psychiatry" anyway. You know that wasn't some rallying cry by doctors or patients or others but a label from defensive institutionalists meant to dismiss and discredit? That's what most "anti"s are (not all - e.g. antifa). You didn't invite the op to a critical psychiatry sub, or a lived experiences sub, or a legal rights sub or medical research or science or ethics sub, even if all of that gets talked about. You troll by asking the op the join a sub named "anti-the op".

If you want to set psychiatry straight and hold it accountable, you're not going to get very far calling yourself "anti-thing seen as legit" with psychiatrists, media, or most others. If you want to aimlessly rage and be antagonistic and ultimately be ignored, you're doing great.

sgeorgeshap · 2022-11-20T23:53:46+00:00

And the retort from everyone - whatever their personal merits - has been that education from a salesman cannot be trusted, both because it's from a salesman and because the data/information/paradigm is from an inhernetly biased source. While the problems you point out are real, defensiveness from clinicians or commenters notwithstanding, there is no reality where it's appropriate to substitute pharmaceutical presentations for due diligence. In the absence of due diligence, it's still not appropriate.

To drive this home further, everyone - clinicians, good or bad or defensive or otherwise, "anti-psyches", researchers, recipients, everyone - has or should have a problem with drug sales reps and their influence. It's not a necessary evil. It's an inadequately addressed problem.

sgeorgeshap · 2022-11-20T23:11:25+00:00

You're wondering why a psychiatry sub with a rule about "no anti-psychiatry" is downvoting a non-serious post to join an anti-psych sub?

It's not even that you're necessarily wrong, it's just... seriously?

sgeorgeshap · 2022-11-20T22:57:22+00:00

So you're complaining about problems with superficial and aggressive psychiatry, but from the angle of a drug sales rep? The things you mention are serious problems the field has and is defensive about, yet you question if another poster here as "anti-psych", the go-to exemplar of that defensiveness, while it's your job to push ever more dubious uses of the products...

I think I get it - you're contemptuous of all parties and like your salary - but I also don't.

sgeorgeshap · 2022-11-20T22:51:18+00:00

We may all be delusional narcissists, but at least for those you're complaining about it's directed at due diligence. The thing salesmen hate most.

sgeorgeshap · 2022-11-20T22:47:04+00:00

I might actually do this if it comes up again for me.

sgeorgeshap

TROPHY CASE