Troubling Times

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These are troubling times for me as a physician and as a psychiatrist. They were even more so before I ran away… excuse me… took this… uh… sabbatical of mine.

None of this enormous mess we are all in together is brand new. We, as a nation, have grown into it rather slowly. Perhaps if this mess of a medical system had happened more suddenly it would have been easier to spot, easier for us all to perform the necessary pruning. Our entire country and all of us are buried to the neck in a quicksand that has been designed, bit by bit, over the decades. It’s deep.

It’s easy to lose energy and focus pointing at one another; pointing and blasting away. The easiest shots to make are at those closest by, the ones that are here, by your side.

It’s easy to lose power and momentum for movement toward meaningful change by imagining that psychiatry, psychiatrists and our patients are the only issues at stake; that we are the special case with special issues and that psychiatry is THE problem.

But I’m afraid we’re not the whole picture. We are important. Very much so. Every single person and their suffering is important. But psychiatry and it’s devolution to a pill model of care is only a ripple in this ocean of pill focused medical care we’re drowning in.

I keep coming back to this question, over and over:

“Can I, as one single individual physician, make any difference in where we, as a nation of about 311 million people, go from here? Can I make any difference with regard to finding ways to provide sensible and equitable healthcare for everyone?”

Although I’ve been gone from the practice of medicine for eight months at this point, I did spend almost a year back at work after I read “Anatomy of an Epidemic”. On the sunny afternoon I finished reading this book, I was certain I could not go back to work as a psychiatrist. Ever. It was a dark night of my soul in the middle of a brilliant sunny day.

I sat on the porch, watched the green trees and blue sky. I thought about many of the people I had treated with psychiatric medicines. I wondered how his life or her life would have been different if I had not given them medicines. I felt I needed to go away till I could get perspective on it all.

But the next morning a friend called and told me they were short handed at the clinic. He asked if I could come in and help out.

I thought, maybe there’s a way I can have a positive and transforming effect by working from inside the system.

I spent much of the next year saying “no” to a lot of requests for pills, saying “no” to dosage increases, explaining my concerns about the medicines to patients, colleagues and co-workers, reviewing and encouraging alternative approaches to managing symptoms.

Over that year I did not meet a single patient that did not come with a request for pills. My “no” and alternatives were met with “I’ll come back when the other doctor’s here” and “I don’t have time to exercise” and “I can’t afford therapy” and “If you don’t give me meds I’ll get kicked out” and “Alcohol’s not a problem for me” and “I haven’t used meth in two weeks and I still feel bad”. There was even one anxious pregnant woman who told me she’d already had a baby that required open heart surgery at birth. She demanded I give her the same medicine again. I did not. Patients did not thank me for protecting them from the effects of the drugs.

I’ve been happy to hear from all the people who do not want to take medicines and who want to taper to the lowest possible doses. You are not the ones I met at work. Not at all.

The system feels massive to me. The weight of the moving freight train of history embedded with clinical staff, funding managers and well marketed-to patients is bigger than me. I felt like I was bailing the ocean with a teaspoon. Galileo was jailed when he said the earth moved around the sun. I was simply overwhelmed by telling the truth every day I went to work.

I am here to use what I hope to be more powerful and wide-reaching tools than seeing patients, one by one; words on Robert Whitaker’s webzine.

I’ve known for a long time that words create the world. I mean this in both a practical sense and a philosophical one. I’ve written medical records and reports and requests for care authorization and disability claims. I understand how words on paper are used to define who and what we are. I also know that the words we speak and write and hear create our realities: angry words create an angry world and kind, loving words create a loving world.

No one who participates in this discussion comes to the table completely alone. And no one, alone, wields power sufficient to remake the practice of medicine into the cooperative two-way relationship and meaningful healing profession it could be.

 

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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Alice Keys, MD
Alice Keys, MD
Necessary Phoenix: Can one physician help heal the practice of medicine? After two and a half decades of work as a psychiatrist in private practice, community clinics and inpatient units, Dr. Keys shares her personal perspectives on the devolution of medical care and the needed resurrection.

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30 COMMENTS

  1. Alice,

    Thank you for your blog. I’m a psychiatrist and struggle with some of the issues you describe. I especially connected with your comment: “The system feels massive to me. The weight of the moving freight train of history embedded with clinical staff, funding managers and well marketed-to patients is bigger than me. I felt like I was bailing the ocean with a teaspoon.”

    Thank you for your words. Let’s hope they do indeed have an effect.

    Warmly,
    Bill

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  2. Dear Alice

    Thank you for being so honest in sharing your story. I agree with you that “words create the world” and do believe that the pen is mightier than the sword. Long live the revolution and our collective action in bringing about transformation.

    Regards, Chrys

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  3. On paper things always look easy but not so in real life. I know people always look for an easy sollution and I actually know a few people who were helped by pills to overcome a crisis. My son was one of them: the psychiatrists should have helped him off those pills when we asked them though. All the psychiatrists we dealt with were well meaning people and thought they were doing the right thing to start with. They were hampered by governement “guidlines” though and the local mental health trust policies. And then there is the modern compensation culture: I wouldn’t like to be a doctor in this modern day and age.

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    • Alix,
      I believe I’ve helped some people with pills. I’ve seen myself as a well-meaning psychiatrist. I’m also know there have been unintended bad consequences to my prescribing. It’s very complicated and not about to get simpler.

      You’re right about guidleines and rules. There is also something called “the community standard of practice” that all physicians are held to. It frequently includes prescribing drugs in “off-label” ways. There are a lot of people in my consulting room besides just me and my patient. Enough for a whole rant blog.

      Thank you for your thoughtful, caring post.
      Alice

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    • Despite how negative I am about the medication, even I would say that it came in handy for my son when he was in a crisis and was frightening everybody around him. The medications act like a tranquillizer dart and they do come in handy. The problem, like you say, is that doctors don’t see that medications are better only in an emergency. They see them as life long necessities. In an ideal world, instead of being tranquillized in an emergency, the person would be given time out in a facility that knew how to manage the situation without drugs. A few years ago I delayed too long putting my son in hospital because I knew that once admitted, he would be kept on medications far too long. After much battling on my part, he’s finally off them.

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      • Rossa,

        Thanks for your personal story. I hope your son continues to do well.

        I have been able to help people manage with less drugs by having a clear individual written action plan we make up together. They keep it where they can see it. There are specific interventions for specific symptoms. One of these interventions could be short term doses of medicines. This is certainly not the only intervention.

        Thanks again,
        Alice

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  4. I don’t think it is as simple as just say no to meds. If someone has been on medication for years, and suddenly a new doctor is refusing to give them a refill- that is quite terrifying, and a loss of power, and potentially not the best thing for them. Maybe their brain has adapted to the drugs, maybe they need them. Maybe they are one of the few who benefit. And yes, some people don’t have time to exercise- or are simple too depressed. I treat hand injuries. I have patients who come in with an overuse injury- one that I know would quiet down if they would just rest it. But some people can’t, or won’t, do this. (often new mothers or the self employed). For these people, I start talking surgery sooner rather than later, because their life just doesn’t allow them to do what they need to heal without it.

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    • Emily,

      I’m happy to see you posting here. The state of medical care in America today is not just a mental health situation. Not at all.

      You are absolutely right. Patients’ situations (like all of ours) are complicated and very individual. There’s a lot to take into account before you make your best judgement.

      Thanks again for you post.
      Alice

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      • I’m having a lot of fun with this. I’m so happy that you and others are finding value in these conversations.

        Back in the olden days when I was still allowed the time and space to be a group therapist (Imagine. A psychiatrist running a therapy group. Is there a billing code for this today? ;-)). Anyhow, back in those days, I tried to remember not to enter the group with expectations or agendas. This way I could let the process lead the way.

        Writing here, I’m reminding myself of this. I have no way of knowing where these writings will lead or what precise good things will come of it all. I write with an open heart and look for what arises.

        All the best. Enjoy your grandkids. Family of very important.

        Alice

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  6. Indeed, it is not a one person at a time kind of struggle. It is not about persuading one service user at a time to come off drugs (as service users who like their drugs sometimes accuse me of). It is not about converting one Dr at a time to prefer no or low drug treatments.

    It is about dismantling the whole drug company/psychiatry/regulatory complex which has influenced the whole of society and the way mental distress is thought about and treated. Drug company mult-million PR and advertising is a powerful force and a few well intentions physicians are but a drop in the ocean.

    It is about creating a political/social movement and this blog on this website is an important part of that.

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  7. Dr. Keys,

    Yes,we are in troubling times.
    And we must all work together to come up with a model –
    one with a solid foundation.

    IMO, we need to have dialogue.
    But we also must begin to act.
    We must first stop the bleeding.
    And begin to think big, to set our goals high, with what we want to accomplish.

    Maria Mangicaro was kind enough to place a vision on the ISEPP website, for anyone interested. Comments are welcome –

    http://isepp.wordpress.com/2011/07/25/mental-health-freedom-and-recovery-act/

    Duane Sherry, M.S.
    discoverandrecover.wordpress.com

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        • Maria,

          I hope that psychotherapists, social workers, couselors and others will begin to develop an appreciation for integrative medical practitioners (MDs, DOs, etc) who are well-versed in the arts and sciences they practice – who help people heal, by searching for and treating the underlying physical conditions (root causes) behind much of what we call “mental illness”.

          I look forward to the day when these issues are not ignored or dismissed, and people get the care they need to heal, recover, thrive.

          Duane

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          • To be honest with you Duane I feel very discouraged that mental health advocacy seems headed towards a “war” between main stream psychiatry v talk therapy and the value of so many other modalities seem to be left out.

            I understand the problems advocates have with the DSM and the labeling process but there needs to be some form of communication.

            If there is a problem, we need to call it something in order to get the right kind of help.

            We wouldn’t need alternative solutions if there weren’t any problems.

            I understand the controversy regarding the chemical imbalance theory but Dr. Peter Breggin, whose opinion many people respect, states the only known cause of a chemical imbalance are the psych meds themselves.

            http://www.youtube.com/watch?v=3lXUOnn5PiQ

            So, it is true then, there is such a thing as a chemical imbalance caused by toxic substances.

            Psych meds are not the only source of toxic substances that can affect our brain.

            Everything Dr. Breggin states about psych meds applies to many toxins, or medical conditions that cause the same symptoms of psychosis/mania psych meds cause.

            Why is this so hard for mental health professionals to recognize? It seem pretty simple and they are even listed in the DSM.

            Why would advocates ignore underlying problem of mania/psychosis and just focus on talk therapy?

            That is cruel and unethical.

            Medications are not the only cause of psychosis.

            The BMJ published guidelines for Best Practice Assessment of Psychosis.

            Why aren’t advocates united to support Best Practice Assessment?

            It seems like common sense that this is the most ethical and economical treatment approach.

            I’m really pretty sick of hearing professionals argue and debate theories while ignoring the facts and effective treatments.

            I’m looking to do more hands on volunteer work less online advocacy. It seems like a waste of time.

            I would rather be helping people one-on-one than supporting issues that are clouded by so many professional opinions who care more about writting books than getting the facts straight.

            http://psychoticdisorders.wordpress.com/bmj-best-practice-assessment-of-psychosis/

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  8. Two great posts Dr! You probably know Dr. Mark Foster who posts here as well. He writes powerfully of many of the challenges you describe. I’m very encouraged that we now have several physicians blogging, reading and responding on the site.

    I appreciate your observations that many of the folks you worked with wanted the meds and felt they needed them. This is a multi-faceted issue and one person can’t focus on everything at the same time. Let me suggest, as others have done, that your postings are far more influential than you might think. Changing a culture takes time, but if it’s to change at all people need to start doing/thinking/saying things differently. You’re doing all the above! So thanks for helping to make a difference. I look forward to your next post.

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    • David,
      Thank you very much for encouraging words. I believe in the power of words. Just think of the influence of the media and advertisements and “medical education” process that keeps us so stuck. Words are powerful.Let’s all use them to remake our medical system. Other countries have done this. We can too.

      We may have to start with outlawing advertisements of prescription drugs to the general public as the rest of the world has done. Cigarette ads were banned on TV. Marketing prescription drugs like they are breakfast cereal and box juice is a travesty. We have to break the thrall of the general public somewhere at the beginning I think.

      Trying to break free of the “pill culture” without taking away the customer base is like trying to fight the war on methamphetamines while prescribing stimulants to our children. How well it that going so far?

      Thanks for listening. There’s a lot to say.

      Alice

      What do others think?

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  9. If you look at the entire system pushing doctors and patients into a pattern that’s not good for either, it is massive, and that’s discouraging.

    Even large professional organizations with millions in lobbying dollars have to work constantly and patiently at bending the system to their interests.

    But if you look at your immediate surroundings, at your community, you can see things you can do to change things. Maybe small things, but every mite adds to the tipping point.

    I think mutual support is important, we all feel so isolated in this. I hope eventually doctors will band together in a formal organization to change their profession. In the meantime, each one, teach one is a worthy pursuit!

    Dr. Keys, how about speaking to local medical societies and community health programs about the appropriate use of psychiatric medications? And how to recognize adverse effects? This is truly grassroots work doctors can do to affect change. And you’ll find friends among those receptive to your ideas.

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    • Altostrata,
      Perhaps speaking will come about naturaly for me as a process of writing here.I’m really much better at writing than talking, though. And I do talk to people I know, one by one. I have also been emailing links to these posts to the local community mental health leaders that I know. It only seems fair to give them a chance to help. Others here may want to invite mental health professionals, physicians, friends and family to join the conversation. Every person’s voice counts and matters. E pluribus unum. Many together,one. Look at the back of a penny when you feel isolated. We are all out here.

      Alice

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  11. I empathize with your struggle. Having worked for 12 years as a psychiatric nurse in a community mental health practice, with two very competent and caring docs, I have felt many of the emotions you describe above. My biggest ethical problem with working in that setting was the concept and practice of informed consent. We stretch the limits of credibility by convincing ourselves (and the regulators) that it occurs in the psychiatric arena. In my own experience, it was most often a formality, with either subtle or not so subtle efforts to minimize the information regarding side-effects, always in the spirit of obtaining med compliance. Combine this with the mental haze (a nice way of describing it) which accompanies the array of meds which many patients are newly prescibed when discharged from an inpatient ward, and we are truly stretching the limits of not only credibility, but the actual laws in place to insure appropriate treatment. The straw that broke this camel’s back, over time, was the prescribing to children, where the consent was given by (most often) ill-advised and maladjusted parents, seeking to make up for poor family/social dynamics by scapegoating the compensatory behaviors of a vulnerable child. Just too much to observe on an ongoing basis. I teach college nursing now, Pharm in the fall and Psych Mental Health in the spring, and comfort myself with the belief I am educating a new generation of nurses who will have at least a small appreciation of the dynamics of our health care system’s pill centered approach. Credit to you for speaking your mind.

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    • Mark,
      Thanks for your dedication to the field of nursing and for your move into the role of educator. Every professional nursing student you touch will carry a bit of you out into their professional career.I hope you talk about your doubts, experiences and concerns with them every day.

      I write here today, in part, because of the guidance of a mentor of mine from many years ago. We will never know how far the ripples we make will spread.

      We have to make good ones.

      Alice

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