There’s movie psychiatry, and then there’s real psychiatry

The page comes from the psychiatry intern on call. “There’s a situation with patient RB on the unit. Please advise.”

We gather in the hall outside the patient’s room. There are already three — no, four — security guards standing several feet away with their arms folded. Backup. Ready. Ready for what? We whisper in hushed tones as the intern explains what happened.

He was “acting out.” He was running through the halls yelling obscene words. He was disturbing the other patients. Then he took his clothes off. He managed to punch a wall before being physically restrained. Now, the intern wonders, what about chemical restraints? We discuss medication options.

Our conversation is interrupted by new noises emanating from RB’s room: He is burping the alphabet. He wants attention, we whisper outside his door. Security stands quietly but ready, looking to the doctors for a sign, an order to spring into action. I don’t feel particularly comforted.

We enter.

You again!

The 30-year-old patient is sprawled on the bed, arms and legs outstretched. Hands are tied down; ankles strapped to the foot of the bed. The room has an odor of someone who had not bathed recently. He wears only boxers. I instinctively look away — a pitiful, moot attempt to protect what’s left of his modesty. He jerks in anger when he sees us, tugging on restraints that do not budge — then, tethered and helpless, resigns.

In the days before, he smashed the bathroom mirror, looking for hidden cameras. People on the radio have been sending him messages, he explained. One day I found him standing at the intersection of two halls staring up at the corner mirror. Did you know if I stand exactly here I can see anyone who might be coming?

You think this is funny?

I most certainly do not.

Chemical restraints are decided: An antipsychotic medication administered by intramuscular injection. I step back as two nurses roll him on his side. I step back: Back from the messiness of it all, back from the line of fire, from his protests and verbal cuts as his boxers, his last line of defense, are rolled down and a needle is jammed into his rear.

You – get – the – f*** – away – from – me

There’s movie psychiatry, and then there’s real psychiatry. There’s One Flew Over the Cuckoo’s Nest, and then there’s mental health institutions with compassionate caregivers devoted to patient well-being. The movies give us a bad name.

Here is where you’re supposed to get better, not worse. But for a patient who was paranoid, we were trapped in an loop: The more paranoid he became, the more we needed to monitor him. The more we monitored him the more paranoid he became. It was a downward spiral.

I think how clearly the sides appear to be drawn. We stand; he lies horizontal. We are clothed; he is exposed. We move our arms and legs freely; he is bound. We make decisions. He is literally helpless.

He can’t say no to needles in his rear because he is deemed incompetent at the moment — it’s best for him, he doesn’t know what’s best, he is a danger to himself. In medicine we talk a lot about the patient-doctor relationship. It’s supposed to be an alliance: Two individuals working toward a common goal of one’s health. In reality it’s an alliance until it’s not.

Nurses inject medications.

Security guards hover.

Doctors try to talk him down.

Around us, the unit goes on. The mother with depression peeks at the commotion and then retreats into her room. The college student who cuts herself makes an exasperated comment to the musician with his first break of schizophrenia.

If this were a movie, I think, we’d be meant to be on his side, rooting for him against the doctors who restrain him in almost every possible way. If this were a movie, I’d be one of the bad guys.

But there are no sides here. There’s only safety.

This is not funny. This is not funny.

This is not funny.

Ilana Yurkiewicz is a medical student who blogs at Unofficial Prognosis.

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  • buzzkillerjsmith

    I thank my luck stars for shrinks. Shrinks, both psychologists and psychiatrists, save my bacon on a regular basis.

    When I worked in southern Oregon, the only way we could get a shrink to see a pt is if the pt was acutely psychotic and (not or) suicidal. No fault of the mental health folks–they were working very hard, in the hospital and out, but the psych I was seeing in the office was killing me. For a family doc, psych is in addition to med problems, and psych does not pay.

    We have an abundance of shrinks in my new area and they let us concentrate on what we do best and what we are interested in–internal organ malfunction. People love psychologists, who have the time and inclination to listen to them.

    • Patient Kit

      My sister is a psychotherapist (MSW) at HHC (the public hospital system here in NYC). It is not an easy job. She is compassionate and very good at what she does. I think it takes a certain temperament. I couldn’t do what she does. She really cares about her patients. She’s been doing it for 15+ years and doesn’t seem burned out at all. She manages to maintain a good work/personal life balance. Believe me, HHC is a huge beauracracy. She somehow manages to avoid getting too caught up in that though. Although she does say it’s easier to buy her own pens than requisition one. Her patients are extremely lucky to be in her care.

      • guest

        Good for your sister. I did part of my training and then also worked in an HHC facility after residency. Theirs are the neediest patients, and the HHC system is highly dysfunctional, so it really takes a special person to be able to work there.

        • Patient Kit

          She vents sometimes about the beauracracy but mostly seems to let it roll off her back so she can concentrate on caring for her patients. She works out of an outpatient clinic and stays out of hospital politics. And it’s pretty much 9 to 5, so that helps. There are some truly good people who have chosen to stay working in the HHC system, who want to work with that population because they know how much they are really needed. Patients like the mother who is “depressed” having lost all three of her children to street violence. Or the working class guy who suffers from PTSD after working for years doing the site cleanup after bloody suicides. Well, I’m sure you know all to well just how deep the depths of human suffering can go. I have a tremendous amount of respect for my sis and all who work on the front lines of healthcare. She worked out of the ER on 9/11, btw. So, there’s a little context if I ever get a little impatient here if anyone minimizes psych’s importance in our healthcare system.

  • J Rizzo

    “Nurses inject medications.

    Security guards hover.

    Doctors try to talk him down.”

    I enjoyed reading how committed you are to recognizing this individual’s worth as a person and not just a product of their illness.

    However, the roles and functionality you have assigned your coworkers is stereotypical at best. While your article was dramatic, and thankfully had core principals of trauma informed care- the buck does not stop with the intern. Please don’t forget that your coworkers have been doing this day in and day out for more years than you have been in medical school. Chemical restraining is not “talking down.” I also wonder why after the patient was in four point restraints the decision was made to sedate?

    The generality could also be made that doctors write orders while social workers, nurses, and techs deal with the aftermath of a persons demoralized sense of self when you will not be present on the unit. One could say that is where the work is done, not in crisis de-escalation.

    Finally, why does your psych unit have breakable mirrors?

    • rtpinfla

      You forgot to mention that she also used the term “rear” instead of “buttocks” or “Gluteus”. These medical students clearly don’t know nothin’ about nuthin’.

    • Brunhilde

      I reread the article to see if I had missed something before I responded to this. But I didn’t. You are being way too sensitive about some imagined slight to “social workers, nurses and techs”. If you feel the need to always assess the importance of your role, perhaps you should discuss it with your therapist.
      P.S. Anything will break if enough force is applied.

    • guest

      Please explain a little further why you would think it inappropriate to medicate an agitated patient who is clearly suffering badly as a result of his psychotic symptoms?

      • JR

        This article specifically states “chemical restraint” which, if I understand correctly, should only be used when it’s considered to be safer than other kinds of restraints. I didn’t see anything telling us why it was safer than leaving the patient restrained, but I’m guessing the medical student might not have gotten the explanation as to why.

        • guest

          Medications are always safer than physical restraints, so they are preferred. Once a patient has required physical restraint, medication is administered, in order to alleviate the patient’s symptoms, which physical restraint does not do, and in order to shorten the length of time for which physical restraints are required. The term “chemical restraint” is somewhat of a misnomer and is not used in psychiatry, at least not in the places where I have practiced.

          • JR

            That’s horrifying.

          • guest

            Really? Since we all seem to be in agreement with the JCAOH standards cited in the paper you linked above, which state that restraint and seclusion events are dangerous and should be minimized, what, exactly is horrifying to you about the use of medication to minimize the use of physical restraints?

          • JR

            I think forced medication is horrifying, no matter the situation. I’m not saying it’s never justified, but I’m still horrified by it.

          • guest

            Apparently you or members of your family have never been harmed by someone whose untreated mental illness caused them to become aggressive. Also, you have apparently never known anyone with a psychotic illness well enough to understand how much suffering they experience as a result of their symptoms. Since I see that type of situation all day long in my work, I see forced medication as more desirable than untreated mental illness.

          • JR

            I’ve watched family members be medicated against their will for the convenience of others with no benefit to themselves.

            If the treatments actually worked, I might feel differently.

          • guest

            I wish that the medications we currently have to treat mental illness were effective for everyone, but these are severe illnesses and not everyone will respond fully. It’s sort of like cancer that way.

            Personally, if I had cancer, I would not refuse chemotherapy just because it had side effects and might only have a 75% chance of being effective.

            The medications we have for schizophrenia and bipolar disorder are effective in about 80% of patients. Therefore, in my opinion, it is inhumane to withhold those treatments from someone whose illness causes them, and the people who love them, to suffer.

          • JR

            I wouldn’t call treatment for schizophrenia effective. Those on medication still act bizarre, suffer from depression or anxiety, and lack attention and focus due to the sedative effects and can’t lead normal lives.

          • Deceased MD

            It beats being in an ER having an acute psychotic break or wandering the streets with paranoid delusions, or simply being put in jail for some minor misdemeanor secondary to their illness.

          • guest

            Sitting around in a drug induced stupor isn’t much of a life, either. Having seen a relative with schizophrenia on these drugs, I’m not convinced the drugged life is any better.

          • guest

            People with schizophrenia “act bizarre” and have trouble with attention and focus because schizophrenia is a brain disease, and in addition to causing “positive symptoms” i.e. delusions and hallucinations, it causes “negative symptoms” which are more subtle, chronic abnormalities in cognitive and social functioning–they do badly affect a schizophrenia patient’s ability to lead a normal life, but it is not because of the medication, although that is a common misconception.

            Our medications treat the positive symptoms very effectively, but not the negative symptoms, unfortunately.

            Still though, I don’t hear too many congestive heart failure patients saying “Even though I take medication, I can’t run a marathon, and the medication makes me cough, so my treatment is ineffective.” Or diabetes patients saying “My HbA1c is still a little up and I don’t like taking shots so I guess I’ll just stop my insulin.”

            Right? If your mother or father said these things, you would think they were a little crazy and would try hard to convince them to keep up with their treatment. But somehow, we have a different standard for psychiatric patients, and they suffer as a result of that.

          • JR

            It depends. If they believe their medicines are helping I encourage them to stay on. If I’ve seen clear improvement I’d encourage them to say on.

            If they feel their medications are making them sicker, I say: You’re an adult. You are the one who gets to decide if your medicines are helping or hindering you.

            I tend to think people are good judges of what helps and hinders them. I know those who are more successful off meds and those more successful with meds. It depends on the person.

          • guest

            Here’s where that reasoning doesn’t apply well to psychiatric patients, at least not ones with true serious mental illness: the illness itself affects the area of the brain where executive functioning takes place, and it is very common for their judgement to be badly impaired, and even for them to lose the ability to tell that they are affected by an illness. Manic patients feel that they are invincible and really, really enjoy the feelings of elation that come with being manic. Schizophrenia patients believe that their hallucinations and delusions are really happening. These impairments interfere, sometimes very badly, with peoples’ ability to make rational choices about the risks and benefits of medication.

            On the other hand, there are certainly lots of patients out there, who are not really seriously mentally ill, but have been diagnosed with “bipolar disorder” and have ended up on a lot of unnecessary meds and in those cases I think we do frequently see the medications actually making things worse for the patient.

          • guest

            The problem with that argument is that it’s too easy for you to base their resistance to treatment on their disease. Having seen the effect of some of these drugs on people, I’m not sure I would agree to take them either. If a patient has schizophrenia and doesn’t want to risk the side effects these drugs can cause, then they should not be forced to. I don’t want it to become any easier for you to force those drugs (and their subsequent side effects) on people.

          • Deceased MD

            Actually being psychotic is horrifying.

          • guest

            Thank you.

          • Deceased MD

            Your welcome. But just stating the facts.

            Maybe you might be aware of the senator Creigh Deeds, whose son was psychotic, I think Bipolar, You probably know this already, but his son was discharged from an ER after clearly needing hospitalization, but there were no psych bed so was discharged because of a law that states a psych pt can only be held for so many hours. He killed himself and tried to kill is dad.

            Anyway, my point is that people should be focusing on the risks of no care instead of the fear of getting treated.

          • guest

            Yes, that was really a horrifying case, and very typical. I consider myself lucky to work in a state where we have better resources for psychiatric treatment, and better laws to ensure that our patients get the care they need.

            But the “recovery” movement has gotten people very focused on the shortcomings of treatment, as opposed to looking at the reality that about 70% of people with schizophrenia will never achieve recovery and so not providing them with the support they need is cruel and inhumane.

          • Deceased MD

            There are shortcomings though in a lot of nooks in medicine. Look at neurology. We know where the lesion is but not much in the way to do about it. I’m sure we could make a whole list. But if there is available treatment it should be tried rather than letting these people go to prison or die. Seriously horrible. Seemed like Obama was dedicated to helping psych after Sandy Hook. Do you or anyone know what ever became of that?

          • guest

            The Obama administration has proposed a $100 million increase in the Federal budget for the treatment of the mentally ill, the only problem is that I believe it would fund SAMHSA which many believe to be a flawed agency which has been co-opted by patient advocacy groups, and so has become ineffective in terms of ensuring adequate treatment of the severely mentally ill.

            On a brighter note, a bill has been introduced by Rep. Murphy called I think the Family Mental Health Act which would provide more funding for inpatient beds, encourage states to adopt “need to treat” statutes for civil commitment (meaning that patients can be committed for treatment if they are impaired by a mental illness, not just if they are actively threatening to kill themselves or others), and would improve family’s access to information about the treatment of their mentally ill family member.

          • Deceased MD

            Just looked on the website out of curiosity for SAMHSA and at a quick glance there was no MD in sight. THen finally saw one. Don’t know anything about them other than what you shared but have to wonder how they got such a huge grant if they are largely influenced by pt advocacy groups who may or may not know how to help problem solve psychiatry.

            The latter does sound positive , although I just think that need to treat commitments will be based like everything on money or lack of it and of course public fears. I sure hope it passes though.

            BTW have you read or noticed a JAMA article called “Medical Conspiracy Theories and behaviors in the US? just came out a few days ago. It was so crazy that it inspired me to write and just complete minutes ago a short piece for Kevin that I hope he accepts on here. Wondered what you thought of the JAMA article if you had a chance to look. There have been shorter versions in LA Times and other newspapers as well. Quite eye opening. The first theory is that the FDA is purposely preventing the public from getting natural cures for cancer and other diseases because of pressures from drug companies. 37 percent of those surveyed were believers in this theory.

          • guest

            I have not seen those articles, but I would not at all be surprised to find out that the FDA and the CDC were influenced by lobbyists, since everyone else in our government appears to be.

          • Deceased MD

            Yes I agree. The lobbyists run the country and the government are the puppets.

          • JR

            Are you saying if someone is just depressed or anxious they could be committed?

          • guest

            In three years of evaluating patients who have been petitioned for involuntary treatment, I don’t think I have ever seen anyone with an anxiety disorder get petitioned, let alone placed under a court order for treatment. I can’t really imagine a scenario in which that could happen. Every once in a while we get a patient who’s been petitioned for depression. In some cases, the depression has become so severe that the patient is either catatonic, or psychotic, and has lost the capacity to make rational decisions about treatment. Those cases are actually quite rare. Occasionally we get someone whose family has petitioned them for depression because they are concerned that they could be suicidal. Generally we do a thorough risk assessment for suicide, arrange for appropriate voluntary treatment, and do not commit the patient, as they are typically willing to engage in voluntary treatment of some sort, whether it be counseling or medication. Also occasionally, we get someone who has been petitioned by family because of out-of-control substance use which the family is concerned puts the patient at risk for suicide, or other behaviors. In those cases, if the patient is actively homicidal (still threatening to kill people even after admission) or suicidal we hold them until they are no longer intoxicated, or homicidal/suicidal, then discharge them after making arrangements for them to receive substance abuse treatment, if they are willing. The commitment statutes in our state do not allow us to commit someone to substance abuse treatment. They have to do that voluntarily.

            So, in summary, not really possible to commit someone for an anxiety disorder alone, very difficult to commit someone for depression unless they are actively suicidal, or psychotic.

  • JR

    I think this is an important article that documents the here and now. For now, you’re a med student. For now, you learn what you are told to learn. For now, you do what you’re told to do.

    But some day, you’ll be able to change things. Maybe even change the school you’re currently attending.

    Don’t let med school and residency destroy your compassion.

  • guest

    The “need to treat” criterion is fairly specific, and requires that there be credible evidence that the person is unable to stay safe in the community, or meet his or her needs without treatment.

    • Patient Kit

      Guest conversations with Guest are very confusing. I think posters at KevinMD should be required to use different names. Like actors in Actors Equity, no identical names even it just means using a different spelling or a middle initial or nickname such as Gest, Guestt, Guestine, Gust, Guesty, GuesT, Guest1, Guest2, GuestV, etc. I’m assuming their are at least two different Guests posting here, yes?

      • guest

        You know, I used to be “Guest” with a capital G, which helped a little. I am not sure how that got changed.

        I do agree it’s confusing. If you click on the poster’s name, it will pull up a record of their posts which can help you sort things out…

        • Patient Kit

          I first started posting at KevinMD maybe two months ago and I’m just realizing now that “guest” isn’t always the same person. I’ve thought, at times, that “guest” was posting something that didn’t sound like “guest”. But I’m new here and just getting to know peeps so I didn’t realize that there was more than one of you until this guest to guest exchange. LOL! If somebody registers as another Patient Kit and posts things that I wouldn’t say, I’m gonna have a problem with it.

      • DoubtfulGuest

        I was “guest” too for a little while as a newbie, then I noticed the problem. I think there are at least 5 guests still, and another two or three Guests. Most seems to be physicians but not all? Only a few of those are regular commenters.

        To make matters worse, if you delete your own post, accidentally or otherwise, it leaves your Disqus profile, but stays on the thread under the name…Guest. :/

        Even just waving your cursor over their avatar will show you how many comments they have. That helps me keep track. Sort of.

        • Patient Kit

          Roughly 8 different peeps here posting as “guest” or “Guest”?!? It’s worse than I thought. And here I am thinking of every “guest” post I ever read here coming from one confusing complex contradictory poster! Adding “Doubtful” was a good idea. You are one distinct poster with your own unique voice and POV to me. I never mistake you for “guest” (or one of the “guests”. Well, at least, this is one communication problem that has a pretty easy solution.

          • DoubtfulGuest

            Always enjoy reading your insightful posts, PK.

            I may not be correct on the exact number but there are more than a few total g and G. It’s quite the hall of mirrors at times.

          • Patient Kit

            Thank you, DG. I enjoy your posts too. I very quickly grew to love this site for it’s many good conversations on important issues. When I decided to join so I could try to contribute to some of those discussions, I specifically chose my name because I wanted it to be very clear that I was speaking from a patient’s perspective.

            I love that doctors and patients talk to each other here about important big issues that effect us all. When I first found this sight, I didn’t realize that patients could participate. Initially, I thought it was doctors only and docs do dominate here. But it really is great to have a venue where both docs and patients can learn more about each others’ perspectives.

        • Patient Kit

          I love Edward Gorey’s work. For those who are not familiar with his art, writing and dark sense of humor here is a brief description of his The Doubtful Guest book: “The book begins with the arrival of a strange creature at a turn-of-the century manor house. An aristocratic family struggles to co-exist with the creature, who is by turns despondent and mischievous. By the final page, the guest has stayed for seventeen years, and ‘shows no signs of going away.’”:-D

          I used to have Edward Gorey’s art calendars on my walls. I wonder if one is available for this year. I have a sudden craving to have one. I think you’ve chosen a great name for posting as a patient on KevinMD.

          • DoubtfulGuest

            Thanks, PK. Glad to meet another EG fan. :) I didn’t mean to veer off topic. I just wanted to try to help nip misunderstandings in the bud with all this “guest” business. It’s challenging enough to talk online, but so worthwhile here. I’m just hanging out and listening/absorbing on this one, because I don’t know much about it. Great discussion, all of you.

          • SarahJ89

            Totally love Edward Gorey. And Charles Addams. Ok, I’m weird.

      • SarahJ89

        I wanna be Guestine!

    • Deceased MD

      what’s the difference between need to treat and the term gravely disabled? Is this proposed law state or federal?

      • guest

        Each state has its own individual statutes for civil commitment. The Federal legislation I referenced above contains a provision to incentivize states to pass laws allowing commitment on a “need to treat” basis, rather than just the basic “danger to self/others.”

        “Gravely disabled” is a criterion that we don’t use a lot, at least in my state. It implies that the patient is so incapacitated by their illness that they are completely unable to manage basic tasks like providing food or shelter for themselves, without assistance. I file on this statute on about one patient per year, usually someone who needs to become a ward of the state because even at their best, they will be totally vulnerable in the community. Patients for whom we file this way usually have either mental retardation, or dementia, in addition to their other psychiatric illness.

        • Deceased MD

          Personally i think these laws should be uniform not state run. What do you think? And whatever term they want to call it, it’s all about the money and whether they have it or don’t- that will influence whether pts get hospitalized or not. The cart is before the horse. if there are no hospital psych beds then the legal means to commit is meaningless. much like the senator from Va whose son committed suicide after being released from the ER.

  • SarahJ89

    Is there some reason we’re still tying people down spread eagled in four-point restraints–the very position we *know* is a favourite of rapists? Why have we not moved on to body bags?

    One place I know has a standard, graduated protocol for security that includes a show of force prior to anyone touching the patient. The patient is given several opportunities to gain control. It can move quickly with an unresponsive patient. The final step is a body bag, never four-point restraints. The patient is never left alone, either. Nothing like the place where my friend, a sexual abuse survivor, died alone after four days in four-point restraints. Our state only requires checking on the patient every two hours. She died of a heart attack.

    • EmilyAnon

      I had to google 4 point and body bag restraints for a visual. I think even Dexter would have nightmares .

    • DoubtfulGuest

      Oh no, Sarah. I’m very sorry about your friend. How awful.

      • SarahJ89

        It was an incredibly sad affair. She was in the hospital as a result of her husband’s death. He was uninsured and unable to get medical care until it was too late. Ironically, the IRS audited them posthumously. It was one of those random audits they’re required to do. I was aware of it because my husband was their accountant. Some people really can’t win for losing.

        One of the things that disturbed me is the fact the law in our state only requires checking up on someone in restraints every two hours. I would literally not leave a dog unattended in that situation.

        • DoubtfulGuest

          Yep, that is surely one of the saddest things I’ve ever heard. I agree on your second paragraph, too. I have learned a lot from this whole post, actually. I hope you have or will keep telling this story because it’s something people need to know happens and we’re often not even aware of it.

          I have a friend who I unfortunately lost touch with and can’t locate, who spent a few days in the local psychiatric hospital, which is just a mile or so down the road from where I live. I think of her every time I drive past. She was…treated roughly there, to say the least. She was threatening suicide and at one point told me she had been diagnosed with borderline personality disorder. But she never tried to harm anyone else and in some ways was one of the nicest people I’ve ever known.

          • SarahJ89

            I spent many years with “treatment refractory depression” that turned out to be a symptom of hypothyroidism. The depression vanished within three weeks of finally receiving treatment. During the decades of incorrect diagnosis, I had occasion to conduct a tour of psych wards of North America. It was most illuminating. And not in a good way.

            If you ever want to see someone experience a Miraculous Recovery from mental illness, just have their insurance lapse when they’re an inpatient. They’re “cured” and out on the sidewalk in about five minutes.

            I have decidedly mixed feelings about mental health parity, given my experiences with its practitioners.

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