The One with the Problem

Carroll’s Second Law of Psychiatry: The patient is the one with the problem.

I was at one end of a table in one of the best addiction treatment programs in the country, and at the other end was one of my counselors. For those unfamiliar with the addiction treatment system, addictions counselors are the footsoldiers of righteousness in an ongoing battle against the darkest evil of the human heart. It’s mainly a bachelor’s level job, filled by young idealistic people on the way somewhere else or more experienced people who are often on a mission; and armed with that four-year degree and accompanying inadequate salary they stand in the gap between redemption and some of the worst human depravity you will never hear. This also provides them with some absolutely bitchin’ happy hour stories.

My kind of people.

This particular counselor was a young fellow, whip-smart; quiet and calm and dedicated. We were discussing a patient who, while so far testing negative for drugs, was floundering – not showing up to groups, missing counseling sessions. Not often, but consequences were piling up. Consequences that could eventually lead to the patient exiting the program. Which meant almost certain relapse.

I asked my counselor what was going wrong. He told me a story of how he had messed up the case. He hadn’t paid close enough attention, he had missed a couple of opportunities to remind the patient of groups, he hadn’t appreciated how frustrated the patient was getting with how regimented and unyielding the place was.

There were a lot of people in the room, but this story was being told to an audience of one. In the scales balancing justice and mercy, I was the linchpin. I was either going to tell my counselor to drop the hammer on the patient and require him to do more groups, show up for his counseling and so forth;  or cut him some slack and give him some room to get himself together before he lost the one thing that was holding him together.

I’ll be honest with you (that’s a later post): This is not the least bit paraphrased nor edited. I said:

“Smart Quiet Passionate Counselor I Really Like (not his real name), you have been manipulated.”

A minor digression (you’ll see that to which I am up soon): In disorders of learned behavior, the patient, to one degree or another, wants to do something that is bad for him. That’s not to say he doesn’t want to stop it, by the way. You can want your cake and hate your waistline. Conflicting goals and desires is the human condition. For most of us, thankfully, it’s just chocolate cake – not crack cocaine. Judging by the line at The Cheesecake Factory, it’s a good thing, too. We could have a full-on Walking Dead situation.

So you are dealing with this fundamental glitch in human nature – that immediate, reliable, transient jolt of yeah, baby can take over a human life and steal a human soul. Little decisions to do some little thing over and over again, until your life organizes itself around that little thing; raising the pipe to the lips, the powder to the nose, the cigarette from the pack. Reducing a human life to a bad EDM set on endless repeat.

So that little thing starts taking up more and more life space – time, money, attention. That means other things get slowly crowded out – like responsibilities, family. Slowly, insidiously, decision by decision, cop-out by cop-out, lies and manipulation creep in. Again, that’s not to say somebody starts out wanting to be a liar or a manipulator.

People early in recovery have to manage such a load of self-loathing it’s hard for others to fathom. Imagine coming out of a haze one day, looking around, and realizing that not even your parents are willing to put a roof over your head in winter because they can’t trust you in their house.

Then imagine that you know they are absolutely right.

It is a monstrous thing to acknowledge you sold your soul ten bucks at a time for two decades, and it’s going to cost a hell of a lot more than money to get it back. The folks who manage that, who come back from that, are a fascinating bunch. They have probably taught me more about the good in human nature than anybody else. They are the reason I’ve stayed in the addictions world for so long.

That early blast of shame and remorse, though, comes just from seeing the things you know you’ve been trained by the drug to do. Yet more insidious is the ice under the water. All the little things that you do that serve your addiction, that you don’t even know serve your addiction.

Back to my counselor.

I started asking questions about our patient.He was a likeable, pleasant guy. He had put together several stints of abstinence, maybe six months at a time. Early in these periods he would be a model citizen; uncomplaining, reliable, enthusiastic at whatever occupation he found himself. Then stuff started to go wrong. Once people liked him and he was doing everything right, he started to slide. At which point all these people found ways to fill in for his minor, completely understandable mistakes. Until the occasional mistake turned into the continuous lateness, missed commitments, and then relapse. After which he became an unreliable cloud of lies and excuses, and left all those people sick of his bull@#^* and unwilling to lift a finger for him. Cut to scene of gaunt, ill, haunted looking guy with nobody and nothing, ducking into a boarded up house in West Baltimore.

Now here in front of me I have my counselor. The counselor of a pleasant, reliable patient who’s doing the right thing, mostly. A counselor who just keeps forgetting little things like reminding that patient about the group he missed last week, or to be on time to those appointments. 

Addiction is a vicious, sneaky bastard. Sure it will magnify your weaknesses. Its true evil, however, is in its capacity to turn your virtues into vices. It twisted our poor patient into spending all the goodwill he obtained early in his recovery to have other people cover for him while he relapses. In the process, it cost him every single one of those people.

What might happen, one wonders, if somebody who cared about him were to redefine the situation for him? To not accept the role of the one who helps him by bailing him out; and instead to ask how did he get me to act just like his old boss, his mother, his sister? How did he turn me into the guy begging for mercy on his behalf while he gets closer to a relapse?

What if, in fact, that is his relapse? Relapses, you see, happen well before the money and the pills change hands. They are a departure from the behavior pattern of recovery, and a slow return to the behavior pattern of using.

It’s a lesson hard learned. Doctors, counselors, therapists, the lot of us want to help. Patients, mostly, want help; at least the ones who keep showing up. The addiction, though, it wants to come back. It wants to turn you against each other. It wants to twist your head around into thinking that giving it room to sink its hooks into him deeper is helping him out. It wants to convince him that asking for a hand up from that nice counselor is a way to get back on track, instead of a way to go further down the wrong road.

Anthropomorphizing much, doc?

Yeah, I am. I’m an obstreperous cuss. It’s my job to see what’s happening. One way I can do that is to decide to be an opponent, not a pawn. I hate to get beaten. It keeps my eyes clear.

He’s been playing the game by the enemy’s rules for too long. That’s why he has me. It’s my job to show him that. It’s only when we’re both playing the right game that we can be on the same side.

The first question we want to ask is, “How can I help you?” It probably should be second.

The first is, “How is this your problem?”

Blindingly obvious, yet somehow newsworthy.

When you give sick people intensive wraparound treatment they do better!!!

Yeah, stunning.

I was listening to NPR a couple of days ago discussing the results from the RAISE trial.

The title on their website is:

Study Suggests Talk Therapy Eases Symptoms Of Schizophrenia.

Which is not what the study does at all. Though talk therapy does help with schizophrenia; that’s not at all what this was about. If you get right down to the nitty gritty, the outcomes for many of the core symptoms of schizophrenia, like hallucinations and delusions, didn’t differ much, if at all. What changed mainly was overall quality of life and some things related to mood and organization.

Another bit that struck me, which doesn’t come across very well in print, was this:

Until now, the standard prescription was powerful drugs, which sometimes have intense side effects. Now researchers recommend a range of interventions, including low dosage drugs, talk therapy, family involvement and supported employment or education.

What doesn’t come out in print was the verbal emphasis on powerful drugs and intense side effects.

Strangely, this is simultaneously not news and all wrong.

  1. These patients were still using antipsychotic medicines (you know, those “powerful drugs” with “intense side effects”). Hopefully they got away with lower doses, but that isn’t reported in the study at all, so you couldn’t conclude that. The symptoms that antipsychotic medicines are best at treating didn’t really differ between groups, and neither did hospitalizations.
  2. It’s no secret at all that talk therapy helps schizophrenia.
  3. This was a comparison of intensive, team-based, multidisciplinary treatment with “community care.” It wasn’t a comparison of talk therapy vs. high dose powerful medicines with intense side effects.
  4. We know these kinds of comprehensive treatment models work better. There have been several trials with similar results, and plenty of clinical programs involving such interventions that clearly work. In this neck of the woods, we have Chesapeake Connections and Creative Alternatives. These models even go one step further and involve integrating the payment model into the treatment system; and they probably look after sicker patients than those in the RAISE trial.

I have a sneaking suspicion. The sneaking suspicion is that under all this is a set of biases that medicines are dangerous and talk therapy is some kinder, gentler, all-natural, GMO-free, organic alternative. So when there is a study that involves both, there is some ingrained tendency to find a way that it is either/or.

Antipsychotic medicines aren’t lots of fun, for certain. Neither is psychosis. Between the two, antipsychotic medicines are probably better, particularly for people with full-blown chronic schizophrenia. Getting the same results with lower doses would be a laudable goal.

Psychotherapy, real psychotherapy, is no damn joke, though. It takes lots of time. You have to talk a lot about things that are really uncomfortable. Folks with severe psychoses can be quite overwhelmed with such interactions, and they often have major trouble communicating. It requires a lot of conscious effort, and homework. Progress tends to be slow and incremental, over many months. Sometimes it actually makes people worse, and it is very, very operator dependent.

This study is a really, really big deal. It is not a really big deal because it showed that lower doses of medicines to get the same result is better. It didn’t, but we knew that already.

It is not a really big deal because it showed that a comprehensive approach to treatment works better than the 15-minute-med-check model of psychiatry that our system presses us into. Everybody knows that.

Why it’s a big deal is that they implemented it in multiple community-based sites; and that there was continued evidence that catching people earlier may prevent deterioration.

That last part, really, was the most important one. I am afraid that point is lost in the overall squickiness people feel about treating psychiatric symptoms with medicines. That is particularly sad.

So long as everything about psychiatry is reported with an implicit dichotomization of “scary psychiatry” vs. “gentle, healing psychiatry” the reality of the thing is lost. It’s really just psychiatry, which really is just medicine. There’s what works, and what doesn’t work. For what works, there’s how much it works, and the risks. Then there’s the cost.

We’re starting to see that getting to people early with a comprehensive strategy for patient care, rather than just symptom mitigation, could save people from years of disability and deterioration.

It would be nice if the media figured that out. Powerful medicines vs. psychotherapy was, and is, settled. The solution is you substitute & for vs.  Is it any wonder the public is so weirded out by psychiatry, when the media is still talking about the psychiatry of 1959?

Them that shows up

The Fundamental Law of Prognosis: Them that shows up gets better.

I have this one patient I saw that.

[Nonmedical people: I am not, in fact, clairvoyant. It’s just that “I have this one patient…” begins a certain kind of story; a story of very bad things happening. Such stories cause reflexive wincing in medical people. I’m just messing with them. No need to clear your browser history. Keep reading.]

This is not one of those stories, medical people. Promise.

I have this one patient who I will call Sylvia and I am going to alter all kinds of other things about her except the point of this story.

Sylvia is sick as hell. Sylvia has bipolar disorder (or, archaic but more accurate, manic-depressive illness). She was reasonably stable until she had to stop this one medicine. After which everything went to hell. Severe depression, psychosis, catatonia, the whole nine. Hospitalized several times per year, constant medication changes, none of which worked. After one of those med changes, she had a protracted mania and did a lot of stuff that really effed up her life. She came under the care of a really good doc, who got the mania under control and sent her to me. The scene is set.

I am about to rant. I will mark this out with the following symbol: ******.

******RANT*******

It is almost impossible to understand how bad psychiatric diseases are unless you’ve been through it. One thing that makes that even harder is that people use words with two meanings, but think they only have one.  For most people, “depression” is the feeling of getting a crappy performance review at work; or how you feel the first month or two after a breakup.

And then there’s depression, or melancholia as Hippocrates called it. Which is like being attacked by a horde of dementors except the dementors don’t even have the basic decency to exist and attack you because you just feel that way for no damn reason at all and there ain’t no patronuses to be found.

Care to add a little more torture? Well, manic-depressive illness can do that for ya! Try catatonia! You can’t even talk, move, or feed yourself. Or mania! Imagine having boatloads of energy, not having to sleep for days on end, doing a thousand things, and feeling ten feet tall and bulletproof. Good deal right? Until you crash back into that depression thing, and realize all that time you were feeling ten feet tall and bulletproof you did a lot of really stupid stuff that you would never, ever do; and as a bonus you spent yourself broke on weird online scams and lottery tickets.

So when people who haven’t been through it talk about “being a little bipolar” it’s like saying “I’m having a malignant melanoma moment now,” or perhaps “I’m feeling a tad stroke-y.”

Then there’s the “everybody gets depressed” line. People need to toughen up and get through it, right? Why is everybody trying to medicate away normal feelings with “happy pills?” Well, if you’re in the middle of a major depressive episode, you’re probably longing to feel as good as you did on a normal bad day. And happy pills, my ass. I have yet to see anybody melting down their Prozac (little R-in-circle thing) and shooting up in the doctor’s office for that SSRI rush. So there’s that.

I think we need to find some new words for these things. Something so polysyllabic in a language so long-dead that nobody will mistake it for any normal experience. “Malignant Melancholic Syndrome,” maybe.

The points of that rant were:

  1. Psychiatric diseases are entirely abnormal.
  2. Lots of psychiatric diseases are really, really bad.
  3. The people who have them often get treated like they’re punks who can’t get over a bad day or two by people who have no clue whatsoever how badly they are suffering.
  4. The people who have them who try to get treated for it catch even more crap, as if they are in cahoots with a conspiracy to drug away all normal emotion.

*********RANT OVER*********

Sylvia’s prognosis, right on its face, sucks. She’s got every risk factor for a chronic, severe, treatment refractory course; and, let’s just say it out loud, death.

I do my thing. I dig through a mountain of records and plug stuff into my handy compulsive freak’s timeline making software. I find out one good thing – there’s one medicine that clearly prevents her manias. Then I find out one other thing. Sylvia’s been on close to a dozen antidepressants, and she’s only had a single adequate trial of one antidepressant in 5 long years.

How can this be, you ask?

All of the medicines take bloody forever to work. With antidepressants, it takes four to six weeks to be sure it’s a failure; and that assumes you’re at the right dose. Getting there can take weeks, too. The side effects, though – the side effects you get right up front. Antidepressants are a lot better now, but still you’re going to have all the bad effects while waiting around for any benefit. About a third of the time, that benefit never shows up, and you’re a couple of  months down the road and back at square 1.

Now, when you go into the hospital and you’re sick as hell, people try to help. They do that by changing stuff. Even if that stuff had been started less than a month ago. Even if the doses weren’t maxed out. Hell, the insurance companies practically force you to do it.

Reviewer: “Have you made any med changes in the last ten minutes?”

Doc: “Ummmm… No. We just started it and it takes four to six weeks to work. I guess I could use some bulls@!# line about how I’m ‘considering adding something’ to make you happy…? “

Reviewer: “Nah. That won’t be necessary. We’ll come up with some other reason to deny care anyway. I mean, he doesn’t have a knife to his throat right this minute, and the policy is written so I can deny if he’s not ‘acutely suicidal,’ which itself is completely impossible to objectively define. So, you don’t have a leg to stand on. Have a good day.”

This constant pressure from patients, payors, and your own perfectionism is one of the reasons (prepare for terrible revelation) that heartless algorithms can sometimes outperform doctors. While the doctors are busily individualizing treatment; and the insurers are looking with a baleful eye and asking “why aren’t you doing something?”, the heartless algorithm says, “Screw the side effects and inadequate response! Sucks to your ass-mar! You haven’t had an adequate trial of this medicine so suck it up and stick with it.”

[I will personally award 3 cool points to the first person who gets the “sucks to your ass-mar” reference.]

Sylvia now has one good prognostic factor. Instead of having severe, treatment refractory manic-depressive illness; she now merely has severe untreated manic depressive illness.

If that’s good news, you’re pretty starved for good news.

There is one prognostic factor that you can’t find in any epidemiologic study, though. One I don’t know she had for several weeks. One I have started to think may be the only one that really matters.

You see, there are patients who don’t show up. There are patients who are pretty good about showing up. There are patients who show up. Then, there is Sylvia.

Sylvia shows the f#&** up. Sylvia shows up the way Cal Ripken, Jr. played baseball. Sylvia shows up like Georgia O’Keefe painted flowers. Sylvia shows up like Bruce Banner gets road rage. She is the tenth-level black belt grandmaster of showing up.

She showed up for weeks when we tried the first antidepressant, ever so slowly and carefully to watch for that mania. Then she developed an allergy. Back to square one. She still showed up.

Partial responses to several medicines. Months of instability, grinding improvement but constant setbacks. Now, she is officially treatment refractory. So much for that prognostic factor. Yet still, she was in my waiting room, no less than five minutes early, every @&&*ing time. I check her blood levels, and they are always exactly the same. She barely misses a single dose.

Time to get fancy. Combinations, high dose trials. Weeks and months more. Then, one month, one entire month, the depression goes away. During which time I am sitting on my hands, waiting for the disease to snatch this hard-won victory back, and for the mania to happen. It never does.

There is a lot more. The year or two to get the first job, which she still has, because even though she had minor episodes, still she kept showing up.

A couple of years of trying to find a way into life when everybody her age had advanced in their jobs, gotten married, and started having children. One day a week, every week, every one of those years, she was in my waiting room. On average, ten minutes early.

I have been looking after her for close to  a decade now. There was the one relapse that scared the hell out of me, but with the help of a really good inpatient doc, she actually came through better than ever.

Now she’s employed, in a solid relationship with a guy who is good for her, and about to be a stepmother. You wouldn’t know her from anybody else. Me, I have the singular honor of knowing she is a real life no – sh#t superhero. She spat in the devil’s eye, and in her quiet, pleasant, implacable, unrelentingly badass way kicked his ass right up the block.

She is not the only one. There was the young guy whose symptoms were so complicated there wasn’t even a category for him in DSM-IV. He told me the story about how he had to bury his face in a pillow at night so his wailing would not bother the neighbors.  Never missed a single appointment. He didn’t get well. I’m not that good. I don’t think any of us are that good, yet. He did get better, though.

The one who was in a wheelchair in the day hospital? Showed up every day for months, and walked out on his own hind legs.

If I had what Sylvia has, I might well be dead. Many people are. I have never correctly finished a single course of antibiotics in my life, and I’m a bloody doctor. I know better, and my wife still had to drag my obstinate ass in to the doctor when I was coughing my guts out and had a fever of 104. It was a pneumonia, of course. I figured it would pass.

I suck as a patient. I’m a better doctor. I’m not the best in the world, or for that matter the best in the building. I do show up, though.

Careful readers (or compulsive freaks like your esteemed author) might have noticed that algorithm thing had more dropouts than usual care. Maybe I’m romanticizing things, but I suspect there’s some other part of doctoring that matters besides sticking to the protocol. Algorithms don’t listen. They don’t give a damn. They don’t cheer and high five when you get that first date or that first job after you’ve been on the DL so long you don’t know if you can ever get off the bench again. 

I think the people who show up need somebody to show up for. So I show up, for them. Also, of course, it’s the only way to get better. I want to get better. I want to get better for all of them. I’m no superhero, but I know a few, and I would hate to let one of them down.

The Point, If There Is One.

Carroll’s 22nd Law of Psychiatry: If you can’t talk about psychiatry, you’re boring.

I’m blogging.

This is not a thing I expected to write. Ever, really.

Which then leads to the eternal, dangerous, and often useless question of why am I doing this?

By way of introduction, about the title: Carroll’s Laws of Psychiatry are a set of rules of thumb I started writing down lo these many years ago. I can’t remember when, exactly; but it was long, long before I had any right to think I should be writing anything about psychiatry, or anything else, and calling it a “Law.” I was like that, back then.

I’m better now, but I still have a high estimation of my own abilities and a propensity to self-reliance. That would be the polite way to phrase it, others might throw about words like “stubborn, ” “oppositional,” “perfectionistic,” and “pedantic.” (The latter I have to thank a dear nurse for.) I attribute that to the fact that I can be stubborn, oppositional, perfectionistic, and pedantic. I have, happily, had a heavy dose of humility and gratitude beaten into me over the years, mainly by my patients and my wife; these being the people who have far and away taught me the most in my adult life.

So these things are not laws. What they are, first and most importantly, are jokes. That’s one part of the why. I like cracking wise about this stuff.

What we do in psychiatry, and all the related caring professions, is hard work. We often are grappling with some of the nastiest diseases and most pernicious problems available to human beings. We have to do this while laboring under a lack of evidence, or even conceptual clarity, that a lot of medical fields have put behind them (though fewer than you might think). Psychiatry’s portrayal in common culture is… unflattering. The two movie psychiatrist types are the guy in the white coat who comes in to inject your brain with green glowing fluid; or the idiot who diagnoses the hero as delusional when he’s really been right all along, you fools! Soylent Green is people!

OK, there was no psychiatrist in Soylent Green. I think you get the point.

Our patients – with whom we share the most soul-baring sorts of conversations and care about immensely – are blamed or ostracized or both. Sometimes, they want to do stuff that’s bad for them and we have to put ourselves in conflict with them for their own good, which is a hard spot to be in.

In with all that, we have to grapple with level of self-examination that most people don’t have to employ. The best of us are asking a whole slew of questions constantly: “How is what I’m thinking affecting whether I’m doing the right thing for this patient?” “What’s his responsibility and what’s mine?” “Do I have some kind of bias that’s shifting how I deal with this patient?” It’s tricky to keep this from degenerating into self doubt.

There are a lot of moving parts to this.

It is also tremendous amounts of fun. Partly because it is, and partly because it has to be.

It is because the s–t that we see and hear and say is really, really hilarious. Case in point: The homeless guy griping to me about how hard his hospital bed is. Of course, the fight wasn’t about a hospital bed. The fight is never about what the fight is about. That’s another post.

I have said things like “Please put down the feces” with a straight face. I have seen the face of someone who was about to inflict grievous bodily harm on another person he though stole from him, only to realize he had spent the money and didn’t remember a blessed thing from the last week. I have walked into hospital rooms and been challenged to a dance-off. That last one would have you changing your underwear if you knew me better.

So we see some really funny stuff.

It also has to be funny, because if we weren’t laughing we’d be in rough shape. The guy griping about the bed was craving heroin and finding some excuse to sign himself out of the hospital. The guy who didn’t remember spending his check did so in an alcoholic blackout.

If we took this stuff as seriously as it is all the time we would be no use to anyone. Which by the way also means just because I’m joking about it, doesn’t mean I’m not taking it seriously. It just means I’m not being serious about it. It’s the kind of balancing act we do all the time.

That gets to the other part of the why. I see very little of what it is like to do psychiatry out there. There are authoritative outlets for psychiatric knowledge. That’s not the same thing as what it’s like to be in a room with somebody who is deliberately picking a fight with you over a mattress when he was sleeping in an abandoned house 24 hours ago. Then realizing that he’s relapsing to a condition that may put him in a box by midnight. Then realizing that the conversation you are about to have could be all that is between him and that box. Then realizing that the odds are against you, and you very well may have to move on to the next one and hope you see this guy above ground again one day to give it another shot. Then finding a way to laugh about it so you can go on to the next one.

So it’s funny, and it’s fun, and it’s difficult, and it’s as serious as life and death; occasionally more so. I don’t see anybody conveying all that. I don’t think I can either, really. But it’s what interests me.

I’m not doing this as any kind of authority. I do have some hard earned expertise, but I am not going to be referencing my every word and providing reasoned arguments for my opinion here.

I’m not doing this as the voice of any institution. I’ve been associated with some good ones, but anything I write here is entirely my own. If I reference any of those who went before me, it’s my interpretation and not their thoughts I’m talking about. You want to know what they think, ask ’em.

Feel free to assume any patient references I make are heavily altered, composites, and/or remote in time. This is one time when assumptions will be rewarded.

I curse. A lot. I will make efforts to censor myself using the universal symbolic code for unprofessional language (#%^@#), but stuff could come out.

Back to the reasons: I just feel like it. One of my English teachers once told me that “writing clarifies thinking.” I like clarifying my thinking (rf that perfectionistic, pedantic thing). And walking down the halls of a psychiatric unit mumbling to yourself looks bad on a psychiatrist.

So here, dear reader, if you exist, are my hall mumblings. Feel free to listen, the people in the walls are.

(Yeah, that was a joke.)