Psychiatry After Ferguson

Started by Ibid
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Ibid

Posting total rubbish
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http://somatosphere.net/2014/12/psychiatry-after-ferguson.html

Yet even while there is a clear need for healing, history provides an important caveat that mental health communities would do well to keep in mind. In times of racial political crisis, mental health rubrics have in the past been used to locate social “pathologies” in the minds of oppressed persons, while bolstering the very power structures that their protests fight against.

Consider the psychiatric response to the protests during the civil rights era of the 1960s and 1970s. A number of psychiatrists aligned with calls for racial justice and equality, decried the lack of “racial integration,” and critiqued how “white norms” produced psychological oppression. And the profession itselfbegan its first slow steps toward training and hiring more black psychiatrists and psychologists.

During the same era, however, under the guise of “treating” mental anguish in African American populations, a number of high-profile research articles in psychiatric journals blatantly defined civil rights participation as a form of mental illness—or worse, depicted racial protest as a form of psychosis that produced anxiety…in whites.

The best known practitioners of this approach were psychiatrists Walter Bromberg and Frank Simon, who, in the aftermath protests in Detroit, Newark, and Los Angeles, wrote articles in the Archives of General Psychiatrythat detailed how black anger was fuelled by a “protest psychosis”—a condition in which the rhetoric of the Black Power movement drove “Negro men” to forms of insanity (“…the stress of asserting civil rights in the United States these past ten years and the corresponding nationalistic fervor of Afro-American nations during the same time period has stimulated specific reactive psychoses in American Negroes”) marked by anger, hostility, and acts that Bromberg and Simon shockingly called “racial antagonism of the Negroes to the Caucasian group.”

another quotation

These and other nascent interventions suggest the possibility of a new politics of mental health, and medicine more broadly, in the aftermath of Ferguson. In this new reality, psychiatrists, psychologists, and social workers continue to empathically treat psychological distress. But they also recognize ways that the very health systems of which they are a part can contribute to disparity and inequality.

Psychiatry propping up the status quo isn't a new idea but an interesting article from Proff Metzl imo.
 
Not a hallmark period for medicine in general, but toward the end of slavery in the US a doctor came up with a mental illness called drapetomania, which entailed a slave wanting to escape slavery (which the doctor considered to be irrational):

http://en.wikipedia.org/wiki/Drapetomania

As for the Ferguson case, I think there could be a type of prejudice in which the possibility of mental illness of Michael Brown was not discussed, at least not that I saw in the media. If everything that Darren Wilson said about him is true, I think the questions of suicide by police or other types of mental illness would ordinarily have been raised. Nothing about that case seemed normal, and then there was the possible racial element on top of it. But in spite of it seeming abnormal, people tended to talk about everyone involved as rational actors.
 
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What is this blog post doing in a psychiatry residency forum?
It might be a blog but thats how its done these days.... this very forum is evidence of that....

Some very influential people write blogs and some people get influence by being bloggers..... everything is up in the air.... MIT has its course work on line.... knowledge is being democratised.... it comes with a new set of challenges not least for academia.... with people writing books before they publish in journals and students getting everything they think they need from wiki.... but thats just how it is now....

Time to hang up that powdered wig I think..
I meant Ibid's.

It's all cut and paste from the blog im afraid...
 
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There are several aspects of psychiatry that negatively impact people on the lower end of the socioeconomic status. The overdiagnosis and underdiagnosis of mental illness are issues I'm seeing causing huge problems.

Two typical cases I see.
1-Young male with behavioral problems is diverted to a behavioral program designed to get such a person, in a demographic where the risk of becoming a criminal is significant, with resources. Turns out in many of these programs you can't get significant help unless you're dx'd. Some do-gooder social worker and psychiatrist dx the young man with bipolar disorder even though they don't even believe he has it.

Leads to 1-use of meds that aren't justified 2-Patient is now rewarded for bad behavior and in some of those cases the patient is given even more resources (e.g. monthly checks, more attention) when he commits more inappropriate behaviors such as beating up other kids 3-When these people show up to a forensic unit or ER, the doctor just continues the dx, furthering the inappropriate medication. 4-If someone like me comes along and stops all the meds and stops the dx, the family gets all ticked off, asking why another doctor dx'd them with a disorder and that they need the monthly check.

I've had cases of the above where I even talked to people at the program and they even told me over the phone they didn't think the person had bipolar disorder but they gave him a dx for more services. This would, of course, put me in a situation where if I went to court, I had to divulge what was told to me.

I had one case where literally about a dozen psychiatrists wrote a patient had schizoaffective, schizophrenia, or bipolar disorder, and the guy didn't have it. I took him off all of his meds and he was stable for 16 months. About half of the doctors even admitted to me they never saw enough sx on the guy to justify the above dx but were just continuing a prior dx. Some of them even didn't believe in the dx they wrote on paper but put it anyway.

While I was in Cincinnati, I think a reason why the local probate court liked me was because I just told what I thought was going on as-is. I would state that I didn't think the person had a disorder despite that they had several dx the person with such, or there wasn't enough to dx. Other doctors would try to be diplomatic and side-step the real issue.

I'm on a soapbox because I think a truly pathetic aspect of our field that we all see but do not talk much about is the amount of psychiatrists that all of us encounter that continue to practice with very poor regard to accurate diagnosis. Everywhere I've worked I've seen them, in NJ, Ohio, KY, NYC, PA, Illinois, and St. Louis.

2-Patient cannot get services and is truly mentally ill, or cannot get enough resources to pay for the meds they need. This is especially true of psychotic patients in poor areas. Many of them are put on typicals despite the newer data showing such medication is neurotoxic.
Many areas do not have community psychiatric treatment for such patients.

As for Ferguson itself, I live in St. Louis and that case shows no signs that psychiatry was involved as far as I can tell, unless you want to consider nicotine abuse and stealing cigars as somehow psychiatrically related.
 
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There are several aspects of psychiatry that negatively impact people on the lower end of the socioeconomic status. The overdiagnosis and underdiagnosis of mental illness

I'm on a soapbox because I think a truly pathetic aspect of our field that we all see but do not talk much about is the amount of psychiatrists that all of us encounter that continue to practice with very poor regard to accurate diagnosis. Everywhere I've worked I've seen them, in NJ, Ohio, KY, NYC, PA, Illinois, and St. Louis.

2-Patient cannot get services and is truly mentally ill, or cannot get enough resources to pay for the meds they need. This is especially true of psychotic patients in poor areas. Many of them are put on typicals despite the newer data showing such medication is neurotoxic.

As for Ferguson itself, I live in St. Louis and that case shows no signs that psychiatry was involved as far as I can tell, unless you want to consider nicotine abuse and stealing cigars as somehow psychiatrically related.

This is where I empathise.... the societal expectation that psychiatry should badge what are at root social problems as medical ones and then expect medical answers that will work.... forgetting that the medical badge was only a way to get resources and provide a framework to get help to someone.....

My opinion is that some psychiatrists want to stick their heads in the sand about it because its such a can of worms, another group take a rogue view and just take the cash/blood money.... and then their are the honest ones who are frustrated that the problems are being ignored.... or perhaps honestly don't see much of a problem...?

A diagnosis in psychiatry is a political device..... ignoring this element and focusing on diagnosis for its supposed (ok thats a bit rude but argueably accurate....) utility value is a problem... imo

I've seen a horrible psychiatrist .... Ablow??... on Fox news being pretty offensive but thats another matter....

Should just clarify that I don't watch Fox news.... I'm not a perfect human specimen but one of my crimes isn't watching Fox "news"... the only channel that leaves you less informed after you watched than before you watched....
 
I think we need to look at things from multiple perspectives and integrate all of the information we have. The biopsychosocial formulation tries to capture this. But it seems many of us lose track of it after training.

We need to protect the mentally ill and make exploiters more accountable. I have no problems revising a diagnosis to eliminate the get-out-of-jail free cards. Unfortunately from an administrative standpoint it's extemely difficult to "decertify" individuals once they have been given a diagnosis.
 
That could have been better attributed, I suppose.


I thought he was when I met him. A pretty good example of a social sciences scholar in psychiatry.

I should have been more clear at the start of the post that it was a gratuitous cut and paste..... instead of relying on the fact that it was written in standard prose, totally devoid of invective, circular reasoning, properly punctuated, had no capitals in the middle of words, points followed logically from one to the next..... all big clues that I'm not the author.... maybe I should be flattered!

I need to come up with sort of health warning for my sig I think...... for the unwary....

Occasionally I go to conferences/brain blaming cult rallies to hear about the latest research..... you know.... to heckle... but people always turn out to be so nice and polite...in person..... even the lizards..... I usually just sit on my hands and content myself with the fact that some one else is buying me lunch today....
 
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For me, this Social Justice Warrior type blog stuff by Metzl trying to link Ferguson to psychiatry in some convoluted way and mobilize psychiatrists for his cause isn't particularly helpful as far as I'm concerned.

I'm not a conservative, nor do I watch Fox News, either. I'm just not interested in trying to make Ferguson in particular about psychiatry, as important as these events are in U.S. society at large and how law enforcement treats minorities.
 
I think we need to look at things from multiple perspectives and integrate all of the information we have. The biopsychosocial formulation tries to capture this. But it seems many of us lose track of it after training.

We need to protect the mentally ill and make exploiters more accountable. I have no problems revising a diagnosis to eliminate the get-out-of-jail free cards. Unfortunately from an administrative standpoint it's extemely difficult to "decertify" individuals once they have been given a diagnosis.

Why isn't it bio psycho social spiritual ? It seems to me that the spiritual dimension is massively important to people in how they conceptualise personal matters.... even non religious people....

Yes.... a diagnosis follows you to the grave.... even if it turns out you had a brain tumour..... that bi-polarism label isn't coming off....
 
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For me, this Social Justice Warrior type blog stuff by Metzl trying to link Ferguson to psychiatry in some convoluted way and mobilize psychiatrists for his cause isn't particularly helpful as far as I'm concerned.

I'm not a conservative, nor do I watch Fox News, either. I'm just not interested in trying to make Ferguson in particular about psychiatry, as important as these events are in U.S. society at large and how law enforcement treats minorities.

Would you agree that their is a parallel problem though.... on the one hand the problem with the police is that they come from outside communities to police them and are seen as an outside force.... with all the attendant problems... and on the other hand in psychiatry if you are black you are much more likely to get a diagnosis of schizophrenia, more likely to mandated to take medication long term, spend long in inpatient settings, and be more likely to be subject to a coersive device like a community treatment order...?

I'm lucky where I live the police are locally appointed citizens and represent the crown.... they live in the communities they serve for the most part and don't routinely carry guns....(and neither do criminals for the most part)...
 
What is this blog post doing in a psychiatry residency forum?
I hate it when people post an OP consisting of nothing but quoted text by someone else. If they want to have a meaningful discussion, they should have the decency to contribute themselves.

Psychiatry propping up the status quo isn't a new idea but an interesting article from Proff Metzl imo.
This is an example of the kind of extreme left-wing thinking which dominates our elite institutions, in which even moderate liberalism is seen as right-wing extremism. When has psychiatry ever "propped up the status quo?" Psychiatry has been culturally subversive since its inception. Freud's greatest contribution to our culture was to popularize the idea that normal, white, Western European, Christian family relationships were shot through with some secret pathology.


I thought he was when I met him. A pretty good example of a social sciences scholar in psychiatry.
By "one of the good guys," you mean a leftist?

Would you agree that their is a parallel problem though.... on the one hand the problem with the police is that they come from outside communities to police them and are seen as an outside force.... with all the attendant problems... and on the other hand in psychiatry if you are black you are much more likely to get a diagnosis of schizophrenia
You think we can assume that blacks don't have a higher prevalence of schizophrenia than other racial groups?
 
I hate it when people post an OP consisting of nothing but quoted text by someone else. If they want to have a meaningful discussion, they should have the decency to contribute themselves.

Well now we know.... anything else you hate..? Like when your corn flakes go soggy..?

This is an example of the kind of extreme left-wing thinking which dominates our elite institutions, in which even moderate liberalism is seen as right-wing extremism. When has psychiatry ever "propped up the status quo?" Psychiatry has been culturally subversive since its inception. Freud's greatest contribution to our culture was to popularize the idea that normal, white, Western European, Christian family relationships were shot through with some secret pathology.

Asking when has psychiatry ever propped up the status quo is a bit last asking when did the inland revenue ever collect taxes... its just an inevitable result of the way it functions..... you know.... helping people to function in society as society exists..... not as one might wish it to be..... gee.


By "one of the good guys," you mean a leftist?

Well I took it to mean not on the payroll of a pharm company.... but otherwise just that he was personable....


You think we can assume that blacks don't have a higher prevalence of schizophrenia than other racial groups?

Well....yeah.... I think we can assume that they get this diagnosis in a disproportionate manner.... given the evidence. Comparing rates of diagnosis in home countries with rates of diagnosis to first generation immigrants and that sort of thing.... evidence and stuff....that seems a fair assumption....? The alternate assumption seems a bit well you know.....errrr....gee I feel bad saying it..... not sure I want to actually spell this out for you....

Anyway not changing the topic I was at this get together the other day.... and lets just say it was in an ethnically diverse part of town and all the people there said psychiatry was institutionally racist..... now thats quite an accusation.... im not saying it isn't..... but clearly some of the people at the get together felt that way based on their experiences of he system..... that was their view.....All I will say is frankly its probably a good thing you were not there because some of the attendees were big.... I mean big.... and while you have a point of view that you are welcome to I don't think it would have gone down very well.

Peace.

EDIT: Just a note at the above shin dig their was a psychiatrist present but he said he had given it up to become a community organiser.... I think it was a good plan to say that as he knew what the vibe was going to be and saying this community organiser thing mean't his chances of getting in and out of the room in one bit was enhanced.
 
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There are several aspects of psychiatry that negatively impact people on the lower end of the socioeconomic status. The overdiagnosis and underdiagnosis of mental illness are issues I'm seeing causing huge problems.

Two typical cases I see.
1-Young male with behavioral problems is diverted to a behavioral program designed to get such a person, in a demographic where the risk of becoming a criminal is significant, with resources. Turns out in many of these programs you can't get significant help unless you're dx'd. Some do-gooder social worker and psychiatrist dx the young man with bipolar disorder even though they don't even believe he has it.

Leads to 1-use of meds that aren't justified 2-Patient is now rewarded for bad behavior and in some of those cases the patient is given even more resources (e.g. monthly checks, more attention) when he commits more inappropriate behaviors such as beating up other kids 3-When these people show up to a forensic unit or ER, the doctor just continues the dx, furthering the inappropriate medication. 4-If someone like me comes along and stops all the meds and stops the dx, the family gets all ticked off, asking why another doctor dx'd them with a disorder and that they need the monthly check.

I've had cases of the above where I even talked to people at the program and they even told me over the phone they didn't think the person had bipolar disorder but they gave him a dx for more services. This would, of course, put me in a situation where if I went to court, I had to divulge what was told to me.

I had one case where literally about a dozen psychiatrists wrote a patient had schizoaffective, schizophrenia, or bipolar disorder, and the guy didn't have it. I took him off all of his meds and he was stable for 16 months. About half of the doctors even admitted to me they never saw enough sx on the guy to justify the above dx but were just continuing a prior dx. Some of them even didn't believe in the dx they wrote on paper but put it anyway.

While I was in Cincinnati, I think a reason why the local probate court liked me was because I just told what I thought was going on as-is. I would state that I didn't think the person had a disorder despite that they had several dx the person with such, or there wasn't enough to dx. Other doctors would try to be diplomatic and side-step the real issue.

I'm on a soapbox because I think a truly pathetic aspect of our field that we all see but do not talk much about is the amount of psychiatrists that all of us encounter that continue to practice with very poor regard to accurate diagnosis. Everywhere I've worked I've seen them, in NJ, Ohio, KY, NYC, PA, Illinois, and St. Louis.

2-Patient cannot get services and is truly mentally ill, or cannot get enough resources to pay for the meds they need. This is especially true of psychotic patients in poor areas. Many of them are put on typicals despite the newer data showing such medication is neurotoxic.
Many areas do not have community psychiatric treatment for such patients.

As for Ferguson itself, I live in St. Louis and that case shows no signs that psychiatry was involved as far as I can tell, unless you want to consider nicotine abuse and stealing cigars as somehow psychiatrically related.
I wanted to write this post, but luckily whopper was nice enough to write it first so that I didn't have to. Including the part about living in St. Louis (especially that part). As an aside, my favorite mechanic is based in Ferguson, and I have no intention to stop going to him. I was talking to him about the issue overall, and he was mostly proud of how well the majority of the community had stuck together in context of all of the stuff that's going on.

And my favorite McDonald's is also in Ferguson. Haven't been there in a long time, but I spent a year at the University of Missouri in St. Louis, which is in that neighborhood. I love that McDonald's - served me a lot of wonderful Big Mac Meals when I stopped by on my way from class to work.

As for psychiatric effects that I've seen as a result of the events - it's minimal. I did have a patient from Ferguson whose mood symptoms are exacerbated whenever she has to see some of the destruction in her neighborhood. Aside from that, the only way it's affected my professional life is that I had a patient (also from Ferguson) who would distract my CBT groups by bringing up the issue, but he had an appropriate level of frustration for the events - nothing psychiatrically relevant.

I expected to encounter some PTSD around the events, or maybe some patients with delusions about what was happening, but haven't seen that yet despite being at the nearest academic center. But we're not the nearest hospital.

Overall, I don't see why those events need to be treated differently from any other sad event. It was a tragedy for the St. Louis community as a whole, not just one ethnicity.

As for ideas of pathologizing anger in context of anger-inducing events - I think we moved past that as a profession when we accepted the establishment of more reproducible diagnostic criteria along with the advent of the DSM-III. I highly doubt that Ferguson will be any sort of watershed moment that affects the way that we practice in the future.
 
Anyway not changing the topic I was at this get together the other day.... and lets just say it was in an ethnically diverse part of town and all the people there said psychiatry was institutionally racist..... now thats quite an accusation.... im not saying it isn't..... but clearly some of the people at the get together felt that way based on their experiences of he system..... that was their view.....All I will say is frankly its probably a good thing you were not there because some of the attendees were big.... I mean big.... and while you have a point of view that you are welcome to I don't think it would have gone down very well.

Peace.

EDIT: Just a note at the above shin dig their was a psychiatrist present but he said he had given it up to become a community organiser.... I think it was a good plan to say that as he knew what the vibe was going to be and saying this community organiser thing mean't his chances of getting in and out of the room in one bit was enhanced.
Ah, so when somebody disagrees with you, you start making veiled threats about his opinion, saying he ought to be scared of angry, big, black people? And then say "Peace"? Like that somehow wins the discussion.
Come on, man.
 
Ah, so when somebody disagrees with you, you start making veiled threats about his opinion, saying he ought to be scared of angry, big, black people? And then say "Peace"? Like that somehow wins the discussion.
Come on, man.

Well... coming clean I did feel the suggestion that black people are more likely to be mad was a little awkward ... so I decided to ridicule the idea.... big angry black people being exactly the stereotype that goes along with thinking that black might be more likely to be mad.

When one ethnic group gets a diagnosis of schizophrenia more often than others.... combined with spending more time in coersive environments, combined with being more likely to be subject to community treatment orders.... I tend to think their is a problem..... that isn't explained by suggesting those people are just more likely to be crazy, suggesting that context has nothing to do with it....

For what its worth at the event I attended where this issue was discussed.... no one got angry.... it was just stated rather matter of factly that the mental health system operates in a racist way and no one demurred..... it was just accepted... sadly.....

Yes, finishing with "peace" was a bit of absurdism.....
 
I've not seen any significant effects of Ferguson in regards to psychiatry. I see some collateral but not much. A woman in the jail that I'm treating frequently yells at staff members, things like "Michael Brown!" so they thought she had bipolar disorder. She in fact likely does have it but the above behavior is not enough to dx given that it's not out of the norm to be upset about the case. I believe she has bipolar disorder because she's had several episodes in prior incarcerations where she was up for days, screaming, and hyper-religious. She's most likely in-between manic episodes.

I'm sure there are several cases I'm not seeing. I'm sure many of the people whose businesses burned down are very upset or depressed about it. I can say that most of the African-Americans I know, but I'm in a biased situation, don't agree with the violence, several don't even agree with the protesting. Most of the African-Americans I know work at the jail with me, are in law-enforcement, and all of us lived for about 2 weeks in fear that we would get attacked or our car windows smashed because the same buildling where the grand jury convened is where the jail is located. They're not the same demographic of person that was protesting.

As for psychiatric misdiagnosis, IMHO this could be a major area of study. Some of the biggest studies in our field are about misdiagnosis such as the Rosenhahn study. I keep saying to myself someone ought to try a modern day version of it. Maybe I'll get to it someday but not right now.

There is a study from the 80s where social workers, in anonymous polls, freely admitted to over and underdiagnosing people simply to affect the services the person received and it was quite prevalent and occurring often. I see the same thing going on with psychiatry. Such behavior should be targetted, exposed, and brought up more often as a problem in our own field more so than it is IMHO.

As for Keith Ablow, Fox's psychiatrist, and without trying to get poltical, the guy has crossed the line on professional ethics several times and it's not a grey area he violated. It's readily apparent and transparent he's trying to hype-up anything he comments on and adds to the political spin. The APA, finally, condemned him in the form of president Jeff Leiberman condemning his unprofessional beahvior. I think it should go a step further. He should have his license in NY and any other state he has it revoked or at least put under review. Fox should also fire him but I doubt they will.
 
I've not seen any significant effects of Ferguson in regards to psychiatry. I see some collateral but not much. A woman in the jail that I'm treating frequently yells at staff members, things like "Michael Brown!" so they thought she had bipolar disorder. She in fact likely does have it but the above behavior is not enough to dx given that it's not out of the norm to be upset about the case. I believe she has bipolar disorder because she's had several episodes in prior incarcerations where she was up for days, screaming, and hyper-religious. She's most likely in-between manic episodes.

I'm sure there are several cases I'm not seeing. I'm sure many of the people whose businesses burned down are very upset or depressed about it. I can say that most of the African-Americans I know, but I'm in a biased situation, don't agree with the violence, several don't even agree with the protesting. Most of the African-Americans I know work at the jail with me, are in law-enforcement, and all of us lived for about 2 weeks in fear that we would get attacked or our car windows smashed because the same buildling where the grand jury convened is where the jail is located. They're not the same demographic of person that was protesting.

As for psychiatric misdiagnosis, IMHO this could be a major area of study. Some of the biggest studies in our field are about misdiagnosis such as the Rosenhahn study. I keep saying to myself someone ought to try a modern day version of it. Maybe I'll get to it someday but not right now.

There is a study from the 80s where social workers, in anonymous polls, freely admitted to over and underdiagnosing people simply to affect the services the person received and it was quite prevalent and occurring often. I see the same thing going on with psychiatry. Such behavior should be targetted, exposed, and brought up more often as a problem in our own field more so than it is IMHO.

As for Keith Ablow, Fox's psychiatrist, and without trying to get poltical, the guy has crossed the line on professional ethics several times and it's not a grey area he violated. It's readily apparent and transparent he's trying to hype-up anything he comments on and adds to the political spin. The APA, finally, condemned him in the form of president Jeff Leiberman condemning his unprofessional beahvior. I think it should go a step further. He should have his license in NY and any other state he has it revoked or at least put under review. Fox should also fire him but I doubt they will.

I'd hope the Rosenhan study to be harder to replicate these days.... just saying thud wouldn't get you an admission in any hospital that I know of.... http://en.wikipedia.org/wiki/Gert_Postel the Gert Postel story is sort of the opposite side of the coin where a former patient decided to impersonate a psychiatrist and got away with it for quite some time.... being exposed by someone who recognised him rather than not doing a proper job.... obviously he broke the law but he was well respected while he did the job.... a replication study would be interesting if you could get ethical approval though..... given the study nearly broke the back of psychiatry i'd imagine your motivations would be called into question and you would get a lot of heat....

Diagnosis as a political device by the psychiatrist Joanna Moncrief..... http://www.palgrave-journals.com/sth/journal/v8/n4/full/sth200911a.html I think this article backs up what you are saying.... although she says it in a different way....

I didn't know ablow had been censored.... I wondered if he really was a psychiatrist at all and perhaps calling him one was just artistic license on the part of Fox....
 
IMHO a Rosenhan type study these days would show dramatic improvements in dx compared to what happened in the original studies, but there would still be pockets of serious misdiagnosis and inappropriate medication prescribing.

While I worked at the state hospital in Ohio, that was a long-term and forensic facility, some of the psychiatrists simply continued a prior dx without scrutinizing it for themselves, and some of them kept the patients in the hospital indefinitely without doing anything to significantly improve them. E.g. place them on Risperdal 2 mg daily and kept them at the same dosage for over a year with no increase without any rational reason for it.

Short term units definitely put the flame under a psychiatrist's butt to discharge within days, but in the state facility in Ohio (as with several long term state facilities) the physician has nothing to gain in terms of financial pressure to get them out quicker. Getting them out quicker, if anything, only opens another bed so you have to do more H&Ps and DC summaries, that we all know leads to more work than simply doing a progress note, and the PNs in long-term facilities were often only done once a month, sometimes even less.

I was on a forensic committee in the state hospital, where it was my job to review cases, and about 1/2 of the psychiatrists there were writing notes less than once a month, not doing anything for their sick patients that was significant (e.g. low dose med or no med at all and keeping them that way for months, even years), and the management never fired these doctors for this low level quality of work. They would fire them for doing something like having sex with a patient, but it had to be something on that order. One of the doctors was even caught swiping her ID to work, leaving, being found working somewhere else, then coming back to the state hospital and swiping her ID again to leave the impression that she was there all day. The hospital management didn't catch her for years.

Someone at work was ticked off with the doc above so they called a local news station, and a reporter followed her with a camera and caught her doing the above and that's when the hospital finally did something and fired her, but like I said she got away with it for years.

If that study was done in the state facilities in Ohio, I'd bet a significant portion, maybe 1/3 of the doctors there would've done the same mistakes in the original study by keeping patients showing no signs of mental illness there indefinitely, and without intervention those people could've been there for months, even years. Several state hospitals across the country operate the same way. I'd bet less than 10% of the short term facility doctors would make those errors due to the financial pressure to get patients out and they'd likely be discharged within a few days.
 
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IMHO a Rosenhan type study these days would show dramatic improvements in dx compared to what happened in the original studies, but there would still be pockets of serious misdiagnosis and inappropriate medication prescribing.

While I worked at the state hospital in Ohio, that was a long-term and forensic facility, some of the psychiatrists simply continued a prior dx without scrutinizing it for themselves, and some of them kept the patients in the hospital indefinitely without doing anything to significantly improve them. E.g. place them on Risperdal 2 mg daily and kept them at the same dosage for over a year with no increase without any rational reason for it.

Short term units definitely put the flame under a psychiatrist's butt to discharge within days, but in the state facility in Ohio (as with several long term state facilities) the physician has nothing to gain in terms of financial pressure to get them out quicker. Getting them out quicker, if anything, only opens another bed so you have to do more H&Ps and DC summaries, that we all know leads to more work than simply doing a progress note, and the PNs in long-term facilities were often only done once a month, sometimes even less.

I was on a forensic committee in the state hospital, where it was my job to review cases, and about 1/2 of the psychiatrists there were writing notes less than once a month, not doing anything for their sick patients that was significant (e.g. low dose med or no med at all and keeping them that way for months, even years), and the management never fired these doctors for this low level quality of work. They would fire them for doing something like having sex with a patient, but it had to be something on that order. One of the doctors was even caught swiping her ID to work, leaving, being found working somewhere else, then coming back to the state hospital and swiping her ID again to leave the impression that she was there all day. The hospital management didn't catch her for years.

Someone at work was ticked off with the doc above so they called a local news station, and a reporter followed her with a camera and caught her doing the above and that's when the hospital finally did something and fired her, but like I said she got away with it for years.

If that study was done in the state facilities in Ohio, I'd bet a significant portion, maybe 1/3 of the doctors there would've done the same mistakes in the original study by keeping patients showing no signs of mental illness there indefinitely, and without intervention those people could've been there for months, even years. Several state hospitals across the country operate the same way. I'd bet less than 10% of the short term facility doctors would make those errors due to the financial pressure to get patients out and they'd likely be discharged within a few days.

Its sad that the whole enterprise boils down to a lottery.... it seems to me that its possible to get away with very shoddy work in mental health in a way that it just isn't in other fields....

One thing I think would help would be if the general public thought that they might go mad one day..... rather than buy into the collective delusion that mad people are a specific identifiable group..... imo thats a conceit driven by a very selective scan of the evidence..... while mad people are "othered" like this..... I don't see the public taking a great deal of interest in the circumstances of people who go crazy.... not really....
 
I see shoddy work in other fields of medicine every day. I don't think mental health is any worse.

I'm sure you don't want to use that as an excuse though.... another way to look at it would be to say that psychiatry has some unique powers.... you can compel people to have treatment. That would seem to me to suggest a duty to provide something that was uniquely outstanding..... and I don't think anyone is going to argue thats the case as a general rule.

My observation is that one of the reasons its hard to talk about the issues that are specific to mental health is that while its easy to talk in general terms..... things move very fast towards people feeling that their own work might be questionable in some way.... totally understandably but it does impede conversation.... thats what i've found.

On the other side of the coin people who have been hurt move very quickly to feeling that their concerns are being dismissed as not that important....
 
I'm sure you don't want to use that as an excuse though.... another way to look at it would be to say that psychiatry has some unique powers.... you can compel people to have treatment. That would seem to me to suggest a duty to provide something that was uniquely outstanding..... and I don't think anyone is going to argue thats the case as a general rule.

My observation is that one of the reasons its hard to talk about the issues that are specific to mental health is that while its easy to talk in general terms..... things move very fast towards people feeling that their own work might be questionable in some way.... totally understandably but it does impede conversation.... thats what i've found.

On the other side of the coin people who have been hurt move very quickly to feeling that their concerns are being dismissed as not that important....


Powers? Compel people?
Yes.. of course! You're in my power! You are a rooster!

:wtf:
 
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Powers? Compel people?
Yes.. of course! You're in my power! You are a rooster!

:wtf:

I see.... you are trying to shiki ma leg.... trying to pass yourself off as a spring chicken....

Well... I'll get my friend Col Sanders to pay you a visit if you don't behave...

And why are you waving that sign... have you fouled your cage again.... that will not please the Colonel..... I'd get to work with a sponge if i were you.....
 
The best critique of Rosenhan that I read went something like: if a patient drank a liter of pig blood and showed up to the ER vomiting up blood, they would be admitted to the hospital immediately. There would be a huge workup with imaging and scopes and the patient would probably be in the hospital for several beyond the point of no cause being found. What do you expect doctors to do with malingering patients?

And malingerers like in Rosenhan with this kind of symptom (single symptom, not dramatic, not over-endorsing) are the hardest to detect.
 
The best critique of Rosenhan that I read went something like: if a patient drank a liter of pig blood and showed up to the ER vomiting up blood, they would be admitted to the hospital immediately. There would be a huge workup with imaging and scopes and the patient would probably be in the hospital for several beyond the point of no cause being found. What do you expect doctors to do with malingering patients?

And malingerers like in Rosenhan with this kind of symptom (single symptom, not dramatic, not over-endorsing) are the hardest to detect.

Yes, but the study was not just about being able to detect sanity or not (in the second half of the experiment hospitals claimed to have detected pseudo patients when none were sent) it was also about the experience which was one of depersonalisation and powerlessness.

The other findings were that all the pseudo patients behaviours were interpreted an pathological when straightforward explanations would have sufficed and that as patients nothing the pseudo patients said was taken as credible. (some staff abused the pseudo patients with impunity).

It was far more damning than just demonstrating that medical staff are prone to type two errors.

EDIT: They were also all discharged with a diagnosis that was unwarranted given the presenting single symptom.

The ghost of Rosenhan still haunts psychiatry....
 
Note that this doesn't mean there weren't malingerers there anyway.

yeah...but no...but yeah....the study didn't set out to show that malingers don't exist. I think what the study showed was that it would be better to focus on what might help any particular person rather than divine the presence or otherwise of a ghostly disease entity.

But to follow through what you seem to be suggesting is that the study showed that detecting real malingers is just as unfeasable as detecting pseudo patients, it seems to add up to the same thing...
 
yeah...but no...but yeah....the study didn't set out to show that malingers don't exist. I think what the study showed was that it would be better to focus on what might help any particular person rather than divine the presence or otherwise of a ghostly disease entity.
Well what did that second half of the study set out to show, and did it actually show that?

I also feel you still have such a skewed view of psychiatry. It is the specialty in medicine that most focuses on the individual patient instead of some diagnostic category. It's the one specialty I've seen that does more than just pay lip-service to the social history.

But to follow through what you seem to be suggesting is that the study showed that detecting real malingers is just as unfeasable as detecting pseudo patients, it seems to add up to the same thing...
That is not what I am suggesting at all, and I don't know how you read that from my post. All I was saying was that just because the study didn't send any malingerers doesn't mean no malingerers showed up, so when the psychiatric staff thought they had malingerers, we can't assume that they were wrong.
 
Well what did that second half of the study set out to show, and did it actually show that?

I also feel you still have such a skewed view of psychiatry. It is the specialty in medicine that most focuses on the individual patient instead of some diagnostic category. It's the one specialty I've seen that does more than just pay lip-service to the social history.

As I understand it the second half of the study was at the request of the authorities who were annoyed at being made to look foolish. They requested that the experiment be re run and that given warning they claimed they would be able to detect the pseudo patients. After a period of time the authorities presented who they thought the pseudo patients were.... it turned out none had been sent. So the second part showed that the claim that pseudo patients were detectable was shown to be false.

That is not what I am suggesting at all, and I don't know how you read that from my post. All I was saying was that just because the study didn't send any malingerers doesn't mean no malingerers showed up, so when the psychiatric staff thought they had malingerers, we can't assume that they were wrong.

I think the study showed that they couldn't be sure about anything at all..... and then of course all the other findings about the social circumstance of being a patient in a mental hospital which is just as salient....

We all have a bias one way or another..... I'm not trying to de-legitimise your point of view just because you have a certain amount of skin in the game..... I don't mind you saying I have a skewed view even if I would reject that characterisation.... maybe you would chose a different word if this wasn't a forum.... I dont know...
 
As I understand it the second half of the study was at the request of the authorities who were annoyed at being made to look foolish. They requested that the experiment be re run and that given warning they claimed they would be able to detect the pseudo patients. After a period of time the authorities presented who they thought the pseudo patients were.... it turned out none had been sent. So the second part showed that the claim that pseudo patients were detectable was shown to be false.
No, the second part did not show that the claim that pseudo patients were detectable was false. As mentioned already, just because the study didn't send any fake patients does not mean that malingerers didn't show up all on their own. But I already said this. Is it not clear somehow?
 
As I understand it the second half of the study was at the request of the authorities who were annoyed at being made to look foolish. They requested that the experiment be re run and that given warning they claimed they would be able to detect the pseudo patients. After a period of time the authorities presented who they thought the pseudo patients were.... it turned out none had been sent. So the second part showed that the claim that pseudo patients were detectable was shown to be false.

I'm awed by the way your mind works. How you reached the conclusion in the bolded text above is not something I'll ever fathom. I could only hope that you're not involved in the institution of research, psychiatric or otherwise.
 
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No, the second part did not show that the claim that pseudo patients were detectable was false. As mentioned already, just because the study didn't send any fake patients does not mean that malingerers didn't show up all on their own. But I already said this. Is it not clear somehow?

Well... if you accept the premise that their is some sort of difference between pseudo patients and genuine malingers.... which I would suggest is a pretty thin suggestion..... I think you just don't want to face the perfectly easily understandable result of the experiment which was that psychiatrists were not able to do what they claimed. Which is exactly why it caused such a stir.... being the conclusion that anyone who looked at the experiment dispassionately would conclude.
 
I'm awed by the way your mind works. How you reached the conclusion in the bolded text above is not something I'll ever fathom. I could only hope that you're not involved in the institution of research, psychiatric or otherwise.

Wow... who would have thought this study would continue to hit a nerve....

Anyway... see my response above. The results of this study are not that hard to understand.
 
If a patient shows up saying they hear voices, then starts taking antipsychotics and the voices stop, what is the doctor supposed to do? You assume the treatment worked. This sounds like a psychosis NOS diagnosis that is in remission with treatment. If this happened rapidly, over the course of a day or two, I would certainly question the diagnosis and the veracity of the initial presentation, especially if there weren't other symptoms of psychosis. But the voices could certainly be symptoms of a first break with more symptoms to follow. How could I be sure? I could not be sure. I wouldn't stop the medications. I would advise the person stay on antipsychotics for several months, and only consider tapering off of them very slowly under the close supervision of an outpatient psychiatrist. If I did this, Rosenhan would claim to have tricked me. How could a psychiatrist keep a person on medications like this when their symptoms had completely stopped? Right? Right? Well, the nature of psychiatric diagnoses is that it amounts to a lot of observations over time. Once there is reasonable suspicion a patient has symptoms of psychosis, which the experiment established by patients lying, it is going to take several months of no symptoms while off medications to convince me the psychotic symptoms are resolved.

So all he really showed was if you lied about your symptoms you could get admitted to a psych unit in the 1970s. And the insurance industry back then didn't care if they kept you inpatient for weeks or months for some reason. I guess they had money to burn.
 
Given the discussion of Rosenhan,
and aw nuts, I can find the darned article despite that I used to carry it into court whenever I had cases like this....

If one of you know the article, cite it here for me (will ya please?)
The study showed that about 40% of people dx'd with bipolar disorder don't have it, and it followed these people quite diligently for five years to make sure.

But the silver lining given this Rosenhan bummer is that the same study showed that those subjects that were diagnosed with bipolar disorder using an actual structured method (they used the SCID) were about 90% correct in their diagnosis.

The point is with all of this justified negativity with Rosenhan, if a clinician were to used actual structured and objective diagnosing, none of the BS Jedi techniques that some idiots employ such as being able to "feel" the person has bipolar disorder, the diagnosis usually was correct.

I bring up my criticisms and negative experiences because IMHO the intention is to inoculate students and residents to a reality in our field and to inspire them to stick to regimented and objective diagnostic methods.

I've been in the unfortunate situation of having to tell a judge that a person was misdiagnosed, and when the lawyer cross-examined me, they tell me why I thought so. Most of the psychiatrists that did the misdiagnosing were my colleagues that I worked directly with one-on-one.

The good thing, however, was the forensic director at the state hospital where I worked damned knew what was going on so when I testified, he made sure none of the other doctors were there while I pretty much just point blank stated they were being lazy and not diagnosing correctly. There was no good way to say it so I just stated it factually without interjecting any judgmental comments.

Me: Dr. X diagnosed this person with bipolar disorder but never recorded anything that met the DSM-IV criteria for the disorder. Further, at the time the person was observed to be manic, he was on cocaine. Use of that drug would mimic the signs and symptoms of mania and would put the clinician in a position where it would be difficult to tell between the two. While the patient was under my care I took him off all psychotropic medications and he's been off of them for 16 months and we've seen no signs of mania or depression. I discussed the case with Dr. X and asked her if she believed he had bipolar disorder and she told me no."

Lawyer: Why did Dr. X put the diagnosis of bipolar disorder if she told you the patient did not have it."

Me: I asked Dr. X and she responded "Well you know."

In the local probate court the judge knew I was putting my head on the chopping block by giving that level of honesty so she never demanded Dr. X come in. Besides, these judges, like psychiatrists, once they're doing it for several months, they know who the good ones are. She didn't want me putting myself in a position where I got screwed for telling it like it was.

Another positive note is at that same hospital the current head psychiatrist replaced the one during my time there. The new chief clinical doctor is sharp and a very good guy, Yes a lot of the same problems are happening, but that guy is doing his best to fix it. A major problem is the state bureaucracy. The hospital can't hire a new brood of good doctors because they don't pay much and there's a shortage of psychiatrists in most places, forcing their hand to keep with what they have.
 
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