I am a psychiatrist who has deep concerns about the short and long term effects of neuroleptic drugs.
I am a psychiatrist who does not believe in the fundamental validity of the DSM.
I am a psychiatrist who is deeply troubled by the distortions of the pharmaceutical industry.
I am a psychiatrist who believes some people can recover from psychosis without the use of medications.
I am a psychiatrist who is working actively with my patients to reduce their use of neuroleptic medications.
I am a psychiatrist who is working side by side with my patients and I am eager to learn from them.
I am a psychiatrist who believes people in extreme emotional distress should have options for non-pharmacologic treatments.
I am a psychiatrist who believes that involuntary treatment is rarely effective in the long run.
I am also a psychiatrist who sometimes forces people into hospitals against their will. I have patients who are on court ordered outpatient treatment and this may include the requirement to take medications that I prescribe.
I do not select or screen the people I treat. I work as a community psychiatrist and I am sometimes asked to see people who do not want to talk to me.
I do not want to overly dramatize or assert that all people who are in extreme distress are dangerous, but I do know that there are some who are.
Some of the people who I send to hospitals against their will would be in jail if they were not in a psychiatric hospital.
I attended a talk by Jim Gottstein and I was relieved to learn that we agree on many points. Doctors are given enormous power and authority and the bar for civil commitment needs to be high. I have worked in states where the commitment hearing was perfunctory. This is not fair and I try to remain cognizant of the imbalance of power. I try not to assert as fact ideas that are conjecture or speculation. I am aware that my ability to predict dangerousness is low. We need to insure that people who are poor and disenfranchised have access to adequate and aggressive legal representation. This is likely to be an ongoing struggle.
I also know that some psychiatrists are less circumspect about the risks of medications and the limits of psychiatric expertise than I am. I understand that laws give equal power and authority to all psychiatrists – even those with whom I disagree. I know that the system is arbitrary and therefore unfair. In the same circumstance, one judge would release a person who another would rule for forced drugs or forced hospitalization. One family would favor hospitalization and another would favor discharge. One crisis worker would see clear evidence of dangerousness and another would not.
I am fortunate to work in a state that leans heavily towards the protection of civil liberties. Court hearings for civil commitment in Vermont take hours. They took 20 minutes in Pennsylvania. Economic forces favor freedom – hospitals and jails are expensive. Some may argue that managed care compromises human rights; in my experience economics have been a huge factor in pushing doctors to discharge people from hospitals or choose to not admit them.
I am fortunate to work in a state that values, builds, and funds non-hospital alternatives.
I try to keep my sense of humanity and fairness foremost in my mind. What would I do if this were my child, my mother, me? I understand that families are not perfect but even in families with strain and rupture, there are parents who deeply love their children and their worry for their safety is deep and genuine.
I have had the conversation with parents and children of individuals who died by suicide; in some instances, I was the clinician who discharged that person from the hospital. I have had the conversation with the parent who is exhausted from being awake night after night but who will not ask his child to leave his home. I have had the conversation with the parent whose child has disappeared. I have had the conversation with the child who ran away from persecution – it may be some combination of real and misperceived. I ask, “Can you call home just to let them know you are alive?” and many times the answer is no. But I also talk frequently with people who are angry that they were forced into hospitals and are forced to accept treatment that they do not consider treatment. I know this is ultimately a failure on our part to connect and understand. But I also work with these people for years and try to forge some sort of mutual underrstanding and collaboration even in the midst of our disagreement.
This is the most serious thing I do. These decisions are hard but I say that not to ask for forgiveness or pity or sympathy. I chose this job although when I found that I had this deep pull towards this work I honestly did not think carefully about this part of the job. I did not do this to have the chance to force people into taking drugs or being in the hospital. It came with the job and I have tried to face this with the seriousness it deserves.
Robert Whitaker has taken psychiatry to task for its lack of intellectual honesty. I believe it is dishonest – or at least an error of omission – to talk about some of my work but not all of it. I do not pretend to have the answers. At least I will be honest. What do we do for the person who is wielding the knife or dismantling the electric wiring in his apartment or walking outside at night in a t-shirt and bare feet when the temperature is below freezing? If someone is screaming obscenities all night at his voices is it better that he get jailed for disorderly conduct or put into a psychiatric hospital? We try to engage, join, understand; but when we are not successful in that moment, when that person still wants to walk away, what is to be done?
Anatomy of a Psychiatrist: Dr. Steingard chronicles how she is integrating information from Anatomy of an Epidemic into her community mental health practice. She also discusses changes in Vermont’s mental health system and the influence of pharmaceutical advertising on clinical practice.