This week in the magazine, Rachel Aviv chronicles the story of Linda Bishop, a mentally ill woman who would not admit she was sick. Here Aviv talks with Blake Eskin about the relationship between insight—acknowledging one’s mental illness—and health, the dangers of insisting on such acknowledgements, and the challenges of writing about Bishop and the mentally ill.

Read more http://www.newyorker.com/online/2011...#ixzz1NJZPAgTp

[mgran]

Originally Posted by TheByzantine

Worth pointing out that the radio interview is fifteen minutes. Also, that it's extremely triggering (made me feel like shite) and that it is biased towards a purely biological model of mental illness.

[venusss]

I found it interesting that the woman mentions the definition of insight changes... Hopefully soon they will introduce some twitter site so we can stay updated with the right insight.

[Can't Stop Crying]

A very sad story that points out, once again, the lapses in providing what the clients truly need. It was interesting to hear how opposed Linda Bishop was to the vocabulary used to define her. Perhaps, as Rachel Aviv points out in the discussion, if acknowledging she had a mental illness was removed from the requirements to receive housing, this story would have had a very different ending. Regardless of where your viewpoints land on the spectrum of diagnoses, proper treatment, and individual rights, I think we all need to agree this woman needed help - help that was not provided for her. It is tragic that another life was lost!

[Perna]

It made psychiatrist E. Fuller Torrey sound extremist; he's a researcher in schizophrenia and bipolar disease, two mental illnesses with obvious biological roots (his sister has schizophrenia). He's head of the Stanley Institute: http://www.stanleyresearch.org/dnn/

He's looking for effective medical treatments instead of "Here, take these pills because I/society/somebody else says so and maybe you will feel better, but hopefully you won't be a problem to us anymore."

A simple "Thank You" is sufficient comment for me here--

Again, Thank You, Byzantine---great stuff.---------Be well, theo

(also enjoyed everyones' comments posted--(((VenusHalley)))!!)

[pachyderm]

Originally Posted by Perna

It made psychiatrist E. Fuller Torrey sound extremist; he's a researcher in schizophrenia and bipolar disease, two mental illnesses with obvious biological roots (his sister has schizophrenia).

In my opinion, Torrey is an extremist. He says that those illnesses are entirely biological, and strongly advocates involuntary treatment. His attitude towards those who disagree with him has been openly contemptuous.

His sister, who had schizophrenia which was never cured by medications, died June 4, 2010.

[Open Eyes]

I wish I had speakers so I could hear this video, well, maybe I would be upset or triggered by it.

I often think of JD's comment about others understanding PTSD. Her statement was often others don't know and often don't care to know. I myself have found the latter to be true.

To be honest, I care to know, we all should care to know and understand the why's behind things. I honestly do not like to see someone hybernate and even have family members who may not care to know hurt them.

I am more of the opinion of working with a person who is troubled to look at the path they were lead from the beginning and how it may have unknowingly effected them.
I know there are conditions that exist in different brains that are inherited that shoud be continued to be researched and addressed.

But I also know that many conditions are trained into a young brain or even deprived of a young brain. As I stop and look within myself, well, I can see where my brain suffered and still suffers and can't help but wonder how I am going to accept the things I cannot change, change the things I can, and to know the difference between the two. And I cannot help to strongly feel that it is important to find out what is causing trouble for us. It is not just by looking into our past that we see trauma or even an abuse or lack. But to see where we suffered in our growth and work on that.

I understand the brain to be very capable of compensating for a lack. And so that lack should be identified so a brain can be given a path of compensation. In my own experience there are ways that one can help another compensate in a positive direction. I have also seen how compensation can end in not only self denyal but anger and confusion. The key is perception and learning how to really percieve things properly.

I find this very distubing to be honest, I see how often many try to compensate for others and fail and they really suffer and often feel trapped or say "how do I?"

As long as I see people knowing that they are troubled and are afraid to ask for help or even appoligize, well, that tells me we have a long way to go.

The field of psychology is still very young yet and we must continue to listen to the crys for help and keep trying to understand what it is saying, what it means and that we must validate it.

As always, I have to say, it is very important to understand what is necessary for the proper enviornment for a brain to grow and obtain its true potential. If this is continued to be left out we will constantly be back peddling.

Open Eyes

[elliemay]

I think it is a mistake to discount the biological basis for mental illness. I also think there are times when involuntary administration of medication is indicated - especially during particularly acute situations where the patient is in danger, or administering needed medical care to the patient is being compromised.

Although the incidences are quite rare, if the patient represents significant menace to the public the medications may also be appropriate.

I'm afraid that I must reject the notion that physicians simply want people to take said drug and go away. It may, in fact, be medically necessary and proper for that drug to be administered.

I think all modalities for treatment should be on the table.

[pachyderm]

Originally Posted by elliemay

I think it is a mistake to discount the biological basis for mental illness.

There is (I think) a biological basis for mental illness -- as for any illness. I don't think it is the basis. People such as Torrey deny any possible basis except "biological" for what they deem "serious" mental illnesses, which for Torrey used to be schizophrenia, but he has added bipolar now. At least in the past Torrey discounted any other mental illness as being "serious", deeming them difficulties of the "worried well" [his term].

I also think there are times when involuntary administration of medication is indicated

It is interesting to me how different is the attitude about involuntary treatments if you have a disease that is considered "physical" as opposed to "mental". If someone is going to administer a "treatment" to me I want to feel that that person is emotionally well-balanced, to say the least, and that their judgement can be trusted. I think many people have had such bad experiences in their early lives that they resist, out of what may be misplaced fear, treatments offered to them. If the mental health system had as good a reputation for decent treatment as the rest of medicine, I think there would not be this fear of what the system may do to people -- but it does not. There are many instances in the history of treatment of the mentally ill, including some in the present, that, it seems to me, make some people fearful, and legitimately so, of forced treatment. I want my treatment to be done out of mindful awareness, not out of the fears of the ones presenting the treatment. I don't think one can universally expect that at this time. In particular, from my readings of what Torrey has said in the past, I don't think he is one of those whose emotional balance I would trust.

[lonegael]

I would suspect that one of the biggest problems is that until recently alot of the medical establishment, including psychiatrists used to talk about the "gene" that controled schizophrenia or the "gene" that controlled bi-polar disorder. Nowadays I heard that just in talking about autism we are no longer talking about one gene but in the interplay of perhaps hundreds of genes, and the same might be true of ADHD and Bi-polar as well.

Complicating this is that not all the same medication works with all patients with Bipolar disorder or schizophrenia, which suggests that while the symptoms they suffer from are similar (I would argue about this also) it would seem that the source of the symtoms come from different causes. In short, you have a name not of a disease, but of a list of symptoms, which is common when dealling with mental illness.

Added to this is th growing evidence that it is a blend of environment and genetic factors that lead to the emergence of these problems in most people who have them, and the old standard deterministic medical model is severely challenged, in some ways by a new form of itself. Some of the older doctors have a hard time with it.

[venusss]

I would suspect that one of the biggest problems is that until recently alot of the medical establishment, including psychiatrists used to talk about the "gene" that controled schizophrenia or the "gene" that controlled bi-polar disorder. Nowadays I heard that just in talking about autism we are no longer talking about one gene but in the interplay of perhaps hundreds of genes, and the same might be true of ADHD and Bi-polar as well.

So could it mean there is really no magic gene? If there are hunderts of genes it may as well be... that the "genetic" compenent is untracable, as there would be too big variety.

I have somehow problem with the genetic aspect... because... where would it lead? To gene manipulation? Would we do away with the bad bundles of genes (humans)?


Complicating this is that not all the same medication works with all patients with Bipolar disorder or schizophrenia, which suggests that while the symptoms they suffer from are similar (I would argue about this also) it would seem that the source of the symtoms come from different causes. In short, you have a name not of a disease, but of a list of symptoms, which is common when dealling with mental illness.

Well, the symptoms are different... the way one handles them is different too... tolerance of discomfort is different... as much as we like to pretend personal weakness does not exist... some people are tougher than others. Some can handle their emotions in healthier ways.

YOu cannot measure emotional discomfort. SOmebody falls apparent after a single small bump in the road... other people can live through attrocious things and rock on fairly well. Is it fair to say that the person who went through objectivelly worse thing and is holding up well suffered less than somebody who falls appart easily?

Added to this is th growing evidence that it is a blend of environment and genetic factors that lead to the emergence of these problems in most people who have them, and the old standard deterministic medical model is severely challenged, in some ways by a new form of itself. Some of the older doctors have a hard time with it.

I hope the "medical only" model is ditched. Other aspects need and should be considered.

Including spiritual and existential ones.

[ladyjrnlist]

I have explored many treatments, medical and not, for my bipolar. I find that a combination of therapies may be most effective at least in my case. I don't subscribe to simply taking a pill and making it all better. That has not been the case for me, for sure.
I still have the goal of being med-free one day. I believe it is possible for me. I don't assume to speak for anyone else on that particular matter.

[venusss]

that is precisely why forced treatment would not work. Sure you can zombify the person enough so they won't get in trouble... but is that even a life? Does such person have any value still?

You cannot force anybody to change their world view to something less harmful and self-destructive.

Psychiatry as a Clinical Neuroscience Discipline

Training in Clinical Neuroscience

The recognition that mental disorders are brain disorders suggests that psychiatrists of the future will need to be educated as brain scientists. Indeed, psychiatrists and neurologists may be best considered clinical neuroscientists, applying the revolutionary insights from neuroscience to the care of those with brain disorders.33 The study of unconscious processes, motivation, or defenses, while at one time the sole province of psychoanalytic therapies, is now also in the domain of cognitive neuroscience.34-35 Systems neuroscience will be reformulating our notions of attention and emotion in the next decade just as it reformulated our understanding of language and perception in the last decade.

Will a deep understanding of the psyche remain a central focus of psychiatry? The need for a sophisticated understanding of interpersonal relationships along with the use of evidence-based, nonpharmacological treatments (from psychoeducation to cognitive behavioral treatments) will be the tools of the effective healer in the future as much as in the past. Just as the need for rehabilitation following acute care for any serious injury or medical illness has been recognized, ideally the psychiatrist will increasingly be part of a team that provides culturally valid psychosocial rehabilitation along with medications to help those with mental disorders recover and return to a productive and satisfying life. What will be different is having the ability to target these treatments to specific aspects of the disease process.

Redefining the foundation of psychiatry as clinical neuroscience also accelerates the integration of psychiatry with the rest of medicine. The separation of psychiatry from other medical specialties has contributed to the stigma of those who treat mental disorders as well as those who have them. Even beyond stigma, this separation has led to inadequate care. The recent scientific recognition of the importance of effective treatments of mental illnesses in cardiovascular disease and diabetes36-37 mandates the incorporation of psychiatry into truly integrated and effective treatment teams.

http://www.nimh.nih.gov/about/direct...scipline.shtml

The National Institute of Mental Health seems to be addressing concerns of those who find the medical model inadequate. A more eclectic approach that merges treatments of mental and physical manifestations of illnesses having both biological and environmental components certainly seems reasonable.

New Findings Reveal New Worlds In Neuroscience
Thomas Insel

“The purpose of science is not to open the door to an infinitude of wisdom but to set some limit to the infinitude of error.”
Brecht, Galileo

This quote comes to mind with a couple of recent clinical research reports that suggest some of the broadly accepted wisdom of our field may be wrong. For instance, lack of adherence to oral medication has been widely considered the most common reason for treatment failure in schizophrenia. However, in a recent random assignment study with a two year follow-up, an injectable, long-acting medication was no better than oral medication, as measured by re-hospitalization or quality of life measures.

In another example, PTSD has been assumed to be a leading cause of the increased suicides in soldiers and veterans. Yet a recent VA study of more than 7,000 suicides found that bipolar disorder was the most prevalent diagnosis. PTSD only increased the risk for suicide when complicated by substance abuse.

Nonetheless, windows to completely new areas of research have been opened recently by research efforts in basic science. These reports may not offer “an infinitude of wisdom,” but they force us to consider factors that have not previously been thought to have any role in mental health or illness.

http://www.nimh.nih.gov/about/direct...oscience.shtml

[Can't Stop Crying]

I think involuntary treatment is sometimes required temporarily, never long term. I don't advocate turning people into to zombies, but sometimes treatment is required to admit you have a problem. That doesn't mean it will work for everyone. I am no longer blindly trusting everything a professional tells me....I frequently research medications and treatment methods for their efficacy before consenting to them. I know that I need medication to function...it doesn't make me happy or cure all my problems, but it does keep me stable enough to face what I need to face and manage daily life.

So much is caught up in definitions...It doesn't matter how you define it, some people just need help!

[pachyderm]

Originally Posted by Can't Stop Crying

I think involuntary treatment is sometimes required temporarily, never long term.

The devil is in the details. How is the treatment done? Is it done with care, with awareness, with attention to doing the least possible harm? Or is it done out of fear, which expresses itself as hostility towards the sufferer?

Details.

[Can't Stop Crying]

Originally Posted by pachyderm

The devil is in the details. How is the treatment done? Is it done with care, with awareness, with attention to doing the least possible harm? Or is it done out of fear, which expresses itself as hostility towards the sufferer?

Details.

Keep in mind..these are my personal opinions...I don't expect everyone to agree, based on a lifetime in and out of mental institutions and a myriad of misdiagnoses...

*In patient hospitalization for actively suicidal or homicidal individuals - to provide safety in the short term and help locate resources for the long term

*Medication for those stuck in dangerous delusions - if they have intentions to harm others, I believe medication is required to stabilize the individual and protect the safety of others

*Civil commitment (which is now legal in most of the US) or mandatory medication for chronic sexual offenders. Again, IMO, they lost their right to determine what is in their own best interest when they chose to sexually offend repeatedly.

I absolutely agree - the treatment needs to come from a desire to help not to harm and sometimes helping others provides safety for society.

I want to reiterate - these are MY opinions - I'm sure there will be plenty who disagree. I do not intend to start a battle of the "best method", just sharing my beliefs!

[Open Eyes]

Well, thank you for the start of this thread. And Venus I agree about the zombie aspect as well.
And I really saw that in the psychward and quite frankly I was so frightened. There was so much stress on forcing medications, I was very concerned and I did see the patients very confused about the different medications they were on, very scarey. As a person who was not the one to experiment with drugs growing up, well it frightened me. And I really felt that the only way I would be realeased is to submit to taking medications that DID MAKE ME FEEL ILL.

I see the point of everyone here. And yes Byz very good information, I do agree that many of the different disorders have to be treated on an individual basis and yes I think the psychiatrists will need to have more education on neurscience.

And patchyderm YES YOU ARE ABSOULTLY RIGHT. I myself was treated very poorly in a psychward and it did further traumatize me. What troubles me even now is that I showed all the clear red flags of someone in extreme PTSD following a very overwheming period of great loss.

And yes Venus you are right about how different people react to different illnesses and situations as well, some adjusting better than others. And I do wonder if this is because of witnessing parents and family adjust to situations while our brains grow. And I can't stress enough how some people form opinions or even feel vulnerable or angry due to perceptions pressed upon them under parents either expecting too much or not giving proper support for normal brain growth in their children.

And I almost wonder if it is our genetic predispostion to adapation to different enviornments and such throughout human existance.

I definitely feel that there is a need to NOT treat all individuals the same way and really taking the time out to study each patient. And their PAST definitely has to be considered as it can truely effect the capabilities of a patient to recover or adjust to said disorder.

I really think that what ever disorder presents itself cannot have just one bandaide or treatment. And I have witnessed that myself.

Thank you for this thread, I really needed to see these aspects being considered. And yes I agree with the other statement that to some degree we, ourselves have to consider the treatment options very carefully and not just blindly follow. Very good point too.

No, I think every post here has valid points.

Open Eyes

[Can't Stop Crying]

I just want to make it clear that these are my opinions, based on my life experiences. I don't meant to throw this thread off track and hope this is not TMI, just feel the need to clarify...

At 13/14 I was placed on an adult psych ward (long story) during that stay I was molested by an offender on that unit. There is no doubt in my mind that I should not have been on that ward, but should he have been? If not me, would his "urges" been taken out on another? What responsibility did the staff have regarding protecting me and the other clients from this individual?

At 14/15 I was was on an adolescent unit at a State Hospital. A client, stuck in delusions and refusing meds, targeted me in her delusions and was convinced that I was the source of her trouble. Keep in mind, at that time I weighed barely 100 pounds, and was very passive and quiet. The other client physically attacked me. Should she have been allowed to refuse meds when she clearly voiced her intent to harm me?

As an adolescent, I had no choices in my treatment. As an adult, I understand I need to be my own advocate.

Perhaps a better solution to finding the right treatment for each individual should be guaranteeing everyone has an advocate, if the individual is unable to advocate for themselves?

The state hospital for treating the mentally-ill and confining the criminally-insane is located in the town where I practiced law for over twenty years. During that time, I represented hundreds of persons caught up in civil commitment proceedings. It was a dynamic time in the commitment arena. My state like many at the time had enacted new civil commitment laws. It took a lawsuit brought by mental health advocates to bring about the changes needed to bring my state into compliance with the new requirements.

One of the first people I represented at the state hospital had been “guested” to the Special Treatment Ward (STW). Those guested to STW had gotten into trouble or otherwise were considered dangerous. The STW was on the highest floor of a four story building. The only aisle to get from the front to the back of the ward was directly below the peak of the building’s roof. Those guested were in barred jail cells with ceilings that slanted towards the back as the roof did.

There were no windows. Ventilation was poor. The ward was dimly lit by light bulbs dangling from the ceiling. The smell of sweat, urine and feces permeated the whole floor. In my experience, one or two staffed the ward. The patients talked to themselves, argued with others and yelled for attention. Frequently the staff told patients to shut up.

The client I was representing was naked. Earlier, he had torn apart his mattress with his hands. He had been such a problem he had not been allowed out of his cell to shower for several days. He was a big man and he was mad.

Staff told my client I was there to see him. He moved from the cell door so I could enter and I was locked in the cell with him. He covered himself with sheet. Since the cell was an absolute mess, we stood next to each other. I started trying to get some information from him. He said nothing for awhile. Then he asked me if I was afraid of him. I said, “No.” He said, “You should be.” Nonetheless, he started answering questions and shook my hand when I left.

I was one of the commitment lawyers that did all that I could to get a patient out. That STW client was ordered back to the state hospital despite my efforts. Even so, he shook my hand again and thanked me for trying to help. He had been in the system for awhile and eventually figured out he had to be in compliance to get out.

Being a hard-nosed advocate had its interesting moments. Sometimes relatives would call me upset when they found out I had talked to a patient who they thought needed to remain hospitalized. Several times, representatives from the state hospital would get angry with me for getting a patient released. I would tell them they needed to do a better job.

Perhaps the oddest case is one where I got a patient released and he got mad at me. He wondered what he was going to do now? He had no place to go. So, he got into the state hospital vehicle, went back to the hospital and voluntarily committed himself.

As this thread affirms, dealing with those who do not think they need treatment is no simple matter. A lot of people have worked hard to address the concerns about involuntary treatment and right to be free. Here is one state's version of the rights of patients:

25-03.1-40. Rights of patients. Each patient of a treatment facility retains the following rights, subject only to the limitations and restrictions authorized by section 25-03.1-41. A patient has the right:

1. To receive appropriate treatment for mental and physical ailments and for the
prevention of illness or disability.
2. To the least restrictive conditions necessary to achieve the purposes of treatment.
3. To be treated with dignity and respect.
4. To be free from unnecessary restraint and isolation.
5. To visitation and telephone communications.
6. To send and receive sealed mail.
7. To keep and use personal clothing and possessions.
8. To regular opportunities for outdoor physical exercise.
9. To be free to exercise religious faith of choice.
10. To be free from unnecessary medication.
11. To exercise all civil rights, including the right of habeas corpus.
12. Not to be subjected to experimental research without the express and informed
written consent of the patient or of the patient's guardian.
13. Not to be subjected to psychosurgery, electroconvulsive treatment, or aversive
reinforcement conditioning, without the express and informed written consent of the
patient or of the patient's guardian.
14. In a manner appropriate to the patient's capabilities, to ongoing participation in the
planning of services.
15. Not to be required to participate in the development of an individual treatment plan.

25-03.1-41. Limitations and restrictions of patient's rights. The rights enumerated in subsections 5, 6, 7, and 8 of section 25-03.1-40 may be limited or restricted by the treating physician, psychiatrist, or psychologist trained in a clinical program, if in that person's professional judgment to do so would be in the best interests of the patient and the rights are restricted or limited in the manner authorized by the rules adopted pursuant to section.

http://www.legis.nd.gov/cencode/t25c031.pdf If you have time to read it and are curious, this link is to my state's current commitment chapter.

The article that follows talks about the American experience with civil commitment. I am well aware of how other countries have used commitment proceedings for political purposes: http://www.psychiatry.org.il/upload/...JP-43-3-14.pdf

This article talks about the sexual predator law: http://www.nytimes.com/2010/05/18/us...offenders.html

It is unlikely there will ever be a civil commitment process that does not raise the ire of someone. That said, requiring the least restrictive alternative for one who needs some help has proved beneficial. Those with capacity may refuse treatment. Most professionals try to have the patient involved in the treatment plan. The process certainly is better than when people were being guested to STW.

You make valid points, Can't Stop Crying. What happened to you is criminal.

[Open Eyes]

Well, that was terrible dispicable, should have never taken place. And a clear example of how each patient has to be considered.

Though I didn't experience the severity of events in the psychward, yes I was very frightened by the other patients that were combative and delussional. Even had them approach me when I was alone in a room. Should NEVER be allowed, they seem to disturb my sleep every fifteen minutes but didn't notice that?

And I thought I had advocates, my husband and sister. But they did not listen to me, they just told me to follow the rules. So, infact, they too were just thinking that the staff there knew what they were doing.

What a terrible thing for any young girl to go through, makes me mad as hell to be honest. I seriously hope that changes are taking place.

I have just recently gotten the confirmation of how bad the doctor is that was in charge of me.
And the problem it that it can only be given on the QT. How awful is that. At the very least my husband now knows that I wasn't kidding when I asked him to get me out of the ward and I was getting frightened and not getting help. Oh, they all say, thats over just forget it, gone, well, it doesn't work like that. At the very least I want to get my records straight, after all they are MY RECORDS AND THEY SHOULD BE CORRECT.

Open Eyes