Category: Psychiatry

Categories
Empathy General Mental Health Narrative Psychiatry

From Her Mind to Mine

By Jessica D Simon

Walking down the familiar dead-end hall of Psych 2, I nearly walked right past the thin woman almost drowning in her hospital gown as she calmly allowed the nurse to take her vitals. I stopped to confirm her identity and introduce myself. “Oh hello, how are you?” came the polite response. Stories of Betty had wafted down from the consult-liaison team for the past week with a macabre fascination. Her image was contradictory; it seemed implausible that the frail, proper lady sitting in front of me, hair pulled neatly back into a graying ponytail, had just a few days prior made the desperate decision to violently shoot herself in the chest with the intention of ending her life.

I held my breath in anticipation, unable to deny my excitement at being assigned to this case followed immediately by the familiar sensation of guilt. How can I be fascinated by someone’s dark tragedy? I would soon learn that this dissonance, walking the line between compassion and self-gratification, lies at the heart of providing effective psychiatric care.

We exchanged pleasantries as together we made our way to the optimistically named “comfort room,” home to one large battered upholstered chair, a modest wooden table, and a window with an AC unit, culminating in a poor excuse for a respite on Psych 2. Betty shuffled slowly, still healing physically from her wounds, until finally making it to the red armchair where she would spend much of her time over the coming weeks. She looked at us expectantly with a hollow stare. She had a defeated yet pleasant energy about her, and the gentle wrinkles surrounding her dead-set gaze told me that I was sitting in front of a woman whose life I knew nothing about.

Betty met her husband Steve in high school, forming an immediate infatuation that continued to blossom into 45 years of loving marriage. They had no children and spent their days attending church, going for long walks with their dogs, and volunteering together in the community. Their lives were filled with a beautiful simplicity that bestowed long-lasting contentment, a sentiment for which many spend their whole lives searching. When Steve was diagnosed with an aggressive glioblastoma on September 1, 2021, Betty’s life quickly evolved into an endless cycle of hospital appointments, research, and clinical trial investigation. Yet she helplessly watched as Steve’s condition steadily worsened, his movements slowing and memory fading. In May 2022, when Steve failed multiple clinical trials, Betty fell into a deep despair that ultimately pushed her past the precarious edge of desperation.

Betty’s hopelessness was palpable, leaving an icy chill hanging in the room. I was alarmed to find myself feeling her agony to the extent that I almost wished for her sake that she had fulfilled her wish to die. I knew I could not promise this woman that she would have a happy future, devoid of the comfort and love that she had shared with a now dying man for the greater portion of her life. I took a deep breath. Working with Betty, I would slowly realize the therapeutic power of carrying the hope that individuals have lost in the flooding sea of mental illness until they again emerge and attempt to swim.

On Monday, Betty’s third day of admission, we received news that Steve had passed away in hospice earlier that morning. I hesitantly approached her for our usual session, preparing myself for an explosive encounter. I was shocked to find her eerily calm, her tone level, her response rational, her composure unscathed. She stared at me with the same dead eyes and motionless face that seem to challenge me, now what?

Betty guarded her true emotions with years of protective layers built from privacy and stoicism, speaking slowly with stiff unmoving facial features. I spent hours sitting across from her, watching her sip her two vanilla ensures that she ordered for lunch and racking my brain for how to engage her in a therapeutic relationship. A two-hour session with her felt equivalent to about twenty minutes of meaningful conversation, and for days it felt like we were getting nowhere. One day she said, “No one actually cares. You come and talk to me, but you don’t think about me once you go home.” Remembering the numerous times I had neurotically checked Epic late at night, my immediate unfiltered reply came, “actually I do think about you when I go home.” I saw her face soften ever so slightly, yet immediately regretted responding with my own emotional response rather than creating a space for self-reflection.

This moment brought me face-to-face with my own humanity and its effect on my patients. My response had centered myself in her healing, needing her to see my goodness and selfishly wanting our relationship to be special to her. The real question was why had she made that statement in the first place? The grief of losing her husband had clearly left her in the depths of an extreme loneliness, and this statement had unveiled a desperate longing to be held. An opportunity to guide her towards conscious awareness of her deepest desires became instead a chance for me to prove my compassion, a band-aid for her depression. I began questioning my habit of spending two hours daily speaking with her. What expectations was I setting? Was I doing it for her or for me? Doctors of course are all human, affected by the accumulation of past life experiences with flaws and strengths alike. I now realized the extreme importance of having self-awareness and acknowledging my own emotional needs as a future psychiatrist.

Betty thanked me politely after each session, maintaining her image of a proper, well-brought up woman despite her circumstances. As we approached more difficult questions, her eyes would close tight with a wide grimace that displayed all her teeth, the veins in her face tensing with discomfort – a look as if she was about to break-down into heaving sobs. Yet I never saw her shed a tear. Over time, I slowly began to see changes in her as she learned to label her emotions, reflect on her self-isolating nature, and even display a forward-thinking attitude about what her future life may look like. Eventually, she entrusted me with the information that her suicide attempt had been a “joint act” with her husband, in a Romeo and Juliet moment where they had felt that life was not worth living without one another.

It is hard to know how to react to such information, and my mind swarmed with questions and wonder upon this disclosure. The juxtaposition of romance and violence was truly something out of a movie. I was struck by the commitment of their love, yet deeply saddened by the decision to which it had led. Is love dangerous? Is grief inescapable? Are parts of life worse than death? Betty’s story was a reminder to withhold assumptions, and in the world of psychiatry it is often better to ask questions than it is to demand answers.

On her day of discharge, I stared at the familiar phrase in Epic that I had copy and pasted many times: “Betty Wolff* is a 64-year-old female who presents after a self-inflicted gunshot wound to the chest s/p pulmonary wedge resection.” The brief summary evoked alarming images of the well-intentioned, loyal woman I had gotten to know intimately over the past couple of weeks. As I watched her walk out the door that day, neatly dressed in the button down and tennis shoes that her brother had brought, a wild mix of emotions swelled inside me. I felt proud to have played a role in her recovery process yet fearful of how she would respond to her new reality.

Psychiatry is wrought with uncertainty, with mistakes potentially resulting in devastating consequences that can keep you up at night. Yet I found solace in knowing that we had given Betty the potential to reclaim her life after unimaginable tragedy had left her in the dark sea of hopelessness. Everyone deserves that chance. I left my rotation with a deep appreciation for the complex nature of psychiatry with an increased comfort in relinquishing control over the unknown, acknowledgement of our shared humanity and limitations as clinicians, and an acceptance of the unpredictability of life and fellow humans.

And when Betty returned to the unit two days after her discharge having asked her brother to kill her, I learned to see this not as a failure but as a small stepping-stone in the complex journey to recovery.

* all names and identifiable information have been altered for patient privacy

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Categories
Clinical Emotion Empathy General Humanistic Psychology Narrative Palliative Care Poetry Psychiatry Psychology Reflection Spirituality

The Dying Man

The Dying Man
Written by Janie Cao
Edited by Mary Abramczuk
A few years ago, I spent half my day with a dying man. I remember these things about him: his name, his past profession, and that he was dying alone.

I never saw his résumé, the size of his house, or how much money was left in his bank account. I was not curious to know, either. But I bet they seemed significant once upon a time, at a dinner party, maybe. He worked as an engineer.

On that day—the day he died—no one who had cared about those things was there.
I was a stranger, yet I saw his last breaths. It was a curious day.

This world teaches us to do many things. To set goals (S.M.A.R.T ones, in fact) and to meet them. To maximize profit and minimize loss, and to use other people, to our advantage. We learn to build storage houses and efficiently fill them with glorified trash; to talk like we matter, and live like it, too.

Someday, we will all be that dying man. Not fully here, and not quite there; mere wisps of breath. When that day comes, will this world be at your bedside? 
Sometimes, I wonder.




-----
Dedicated to a friend: May you find what you are searching for.
Photo credit: Jörg Lange
Categories
Emotion Empathy General Humanistic Psychology Literature Opinion Patient-Centered Care Psychiatry Psychology Public Health Reflection

Book Review: Loose Girl by Kerry Cohen

Hi MSPress Blog Readers!
……
We didn’t have a blog post scheduled for this week, so here’s a book review instead 🙂 I read this book last week for my Adolescent Sexual Health MPH course and enjoyed it.There’s a lot of interesting tidbits on sexual health issues. I mention two.
Even if you don’t agree with everything the author says, I think memoirs can be helpful in showing you unique life perspectives based on true experiences that you may never have experienced yourself. Furthermore, reading memoirs can get you acquainted with potential resources to help others. Ever heard of bibliotherapy, anyone? 🙂
……
Your Blog Associate Editor,
Janie Cao

Categories
General Healthcare Cost Humour Lifestyle Opinion Pharmacology Psychiatry Psychology Public Health Reflection

Well, Well, Well: Products and services compete for shelf space in trendy wellness market, but are they worth your money?

When a friend recently asked me to join them for a class at Inscape, a New York-based meditation studio that New York Magazine described as the “SoulCycle of meditation”, I was skeptical. On the one hand, I usually meditate at home for free, so paying almost $30 for a meditation class seemed a bit silly. On the other hand, my meditation practice had dropped off considerably since the beginning of the year. Maybe an expensive luxury meditation class was just what I needed to get me back into my regular practice. Stepping off bustling 21st Street into the clean modern space, I heard the sounds of, well…nothing. It was incredibly quiet. Before getting to the actual meditation studios, I had to pass through Inscape’s retail space. The minimalistic shelves hold a variety of supplements, tinctures, and powders that include unique ingredients like Reishi medicinal mushrooms and cannabidiol extract. Many contain adaptogens, herbal compounds that purport to increase one’s resistance to stress, though their efficacy has never been quantitatively proven.[1] These products’ promises run the gamut from shiny hair and stress relief to aura cleansing. I may be a super-skeptic, but even I am not immune to the lures of top-notch marketing. With great consideration, I purchased one of the many magical powders for sale labeled as ‘edible intelligence.’

Since wellness has become trendy, a considerable space in the retail market has opened for associated products dedicated to helping people live their best lives. As Amy Larocca pointed out in her June 2017 article The Wellness Epidemic, “[In the wellness world] a loaf of bread may be considered toxic, but a willingness to plunge into the largely unregulated world of vitamins and supplements is a given.” Even a recent episode of Modern Family poked fun at the wellness trend when Haley Dunphy applied for an ultra-competitive job with fictional wellness guru Nicole Rosemary Page. During her interview at Page’s Nerp company headquarters, Page laments, “People say that Nerp is nothing more than a con-job, a cash grab vanity project from a kooky actress. I want to turn Nerp into the next Disney-Facebook-Tesla-Botox. It’s a world changer.” Though Page is a fictional character, I can’t help but wonder whether the character was inspired by the very real Amanda Chantal Bacon, the founder of Moon Juice, which bills itself as an adaptogenic beauty and wellness brand. Bacon’s Moon Dusts retail for $38 a jar and come in varieties such as Spirit, Beauty, and Dream.

The bottom line is that a sense of well-being needn’t come at the price of thirty-plus dollars an ounce. In fairness to those who choose to spend lavishly, I believe that plunking down a chunk of cash might create an intention to use and derive value from a product, thus positively influencing one’s perception of how well the product works. Rest assured, however, that living with intention and gratitude can be just as easily accomplished without spending any money at all. Carving out time in the day to create a small ritual for yourself can be as simple as spending a few minutes in the morning listening to jazz as you drink your first cup of coffee or allowing yourself to become immersed in a good book before drifting off to sleep. These simple acts allow us to bestow kindness upon ourselves that is especially important in our stressful and busy lives as medical students. My suspicion is that by performing such rituals with intention, we derive much of the same benefit whether our mug is filled with the trendy mushroom coffee or just plain old Folgers.

I’m always thinking about ways I can improve my own well-being, but as graduation approaches I also find myself thinking about how these practices might help my patients as well. One of my fundamental goals as a future psychiatrist will be to help my patients see the value in themselves and in their own lives. I predict that for many of my patients, achieving this goal will depend perhaps on medications but also on the deployment of simple wellness tactics such as I described. I’m not going to lie…I’m still intrigued by many of the wellness products that can be found in places like Inscape, Whole Foods, and the Vitamin Shoppe, especially when I think about the potential benefits they might have for my future patients. I figure that if these products do even half of what they promise to, some of them might even be worth the money. So what happened when I added a sachet of intelligence powder to my usual morning smoothies? Pretty much nothing. At one point, I got excited when I began to feel my fingers getting tingly. Then I realized I had been leaning on my ulnar nerve. Not so brainy after all.

[1] Reflection Paper on the Adaptogenic Concept, Committee on Herbal Medicine Products of the European Medicines Agency, May 2008.

 

Photo credit: Open Grid Scheduler / Grid Engine

Categories
Clinical Patient-Centered Care Psychiatry Public Health

If you don’t ask, you’ll never know

On the first day of my first rotation as a medical student, my preceptor shared this bit of wisdom: if you don’t ask, you’ll never know.  In the nearly 18 months that have followed, I think about those words on a daily basis. To my mind, asking questions does more than just help us gather data. Asking questions establishes the type of relationship we are going to have with our patients. There are so many questions I wish I would never have to ask, whose affirmative answers are often indicative of the cruelty of this world. But when I ask about things like whether a patient has been the victim of abuse, I hope it sends the message that the relationship we are about to embark upon is one that can withstand such unpleasantness.

Not only can it be excruciatingly frustrating when other practitioners don’t share this point of view, it potentially has grave consequences. Unfortunately, patients with mental illness often seem to be the victims of physician “brush-off.” As someone who plans to devote her life to working with the mentally ill, I can only hypothesize as to why the same patients I find so much joy in working with are often given sub-par medical care as compared to their non-mentally ill peers. Perhaps physicians feel uncomfortable providing care for patients who come across as different than the norm, or perhaps their medical problems are too frequently attributed to psychiatric causes.

I recently cared for a patient who was two weeks post-partum from the birth of her first child. Though she was being seen for psychiatric admission, multiple aspects of her health were addressed during our initial evaluation.  When asked about her post-partum health, she denied having been scheduled for a post-partum visit with her obstetrician. Casually, she mentioned that she was having some malodorous green discharge since giving birth. It doesn’t take a medical degree to know that green, foul-smelling discharge is not a good sign, let alone when it occurs in the immediate post-partum time period. We were able to secure a next-day appointment with our hospital’s obstetrical practice, and with the patient’s permission, called ahead to the clinic to alert them of her complaints.

The next day, the care team gathered around to read the note from the obstetrician who had seen our patient. The note comprised all of five lines.  There were no pending labs. There was no mention of a physical exam.

There was no mention of the discharge at all.

The American Congress of Obstetricians and Gynecologists (ACOG) states, “It is recommended that all women undergo a comprehensive postpartum visit within the first 6 weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being.”[1] The issue here, though, isn’t really about post-partum care. The issue here is about how we as health care providers need to provide equal care for unequal bodies and minds, and how we need to protect and advocate for our patients.

Patients with mental illness undeniably have poorer overall health. The average lifespan for an American adult with mental illness is a striking 30% shorter than for a non-mentally ill individual.[2]  While it is known that mental illness itself creates difficulty in accessing the healthcare system, for mentally-ill patients who do access healthcare, their quality of care is demonstrably lower than it is for those without mental illness. Literature consistently demonstrates that patients with psychiatric diagnoses receive fewer preventative health measures and have overall poorer quality healthcare than patients without psychiatric diagnoses.[3],[4] No matter what field of medicine you are in, you will see patients with mental illness. For these patients who sometimes cannot speak for themselves, the role of the physician in patient advocacy becomes even more crucial.

I will never know exactly what transpired during that appointment between my patient and the obstetrician, but I do know that obstetrician did not ask the questions that needed to be asked, and therefore did not ascertain the information necessary to appropriately care for the patient. At our request, a different practitioner saw the patient again. This time, the appropriate questions were asked, the appropriate testing was completed, and ultimately the patient was diagnosed with a sexually transmitted infection. Left untreated by the first obstetrician, this infection could have caused my patient systemic symptoms and permanent infertility.

As future physicians, it’s important for us to keep asking questions. So often, I have been surprised by the information I find when I ask a question about which I almost kept silent. Equally as important as asking the questions, however, is doing something with the information that you receive. The good doctor isn’t necessarily the one that stops the green discharge; they’re the one the identifies the problem in the first place and advocates on behalf of the patient to get the best people for the job.

[1] https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care

[2] http://europepmc.org/abstract/med/19570498

[3] http://journals.lww.com/lww-medicalcare/Abstract/2002/02000/Quality_of_Preventive_Medical_Care_for_Patients.7.aspx

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951586/

Photo credit: airpix

Categories
General Psychiatry Psychology

The Case Against Global Mental Health

‘We have become not a melting pot but a beautiful mosaic. Different people, different beliefs, different yearnings, different hopes, different dreams.’
– Jimmy Carter

Western culture is taking over the world; from supermodels on television screens, to fashion accessories in shopping outlets around the world, to the movies made in Hollywood and disseminated worldwide online. Globalization has opened new doors. It has allowed us to build new relationships and learn about new cultures. It has opened our eyes to the worlds beyond our borders – to different languages, religions and beliefs. It has had an impact on every aspect of our lives, including medicine and healthcare.

The pathophysiology of most disease is similar throughout the globe. The diagnosis of a myocardial infarction will have similarities across different continents; an ECG that is normal in the UK will likely be deemed normal in the USA. But when it comes to our inner thoughts and our minds, a similar comparison cannot be made. The Western model of mental illness, of the divisions of neurosis, psychosis and personality disorders yields more than just mere categories. It also produces a set of values and beliefs – namely, that these thoughts and behaviours are outside the remit of social norms. Does a person with a diagnosis of Major Depressive Disorder in the USA show the same symptoms as someone in South Africa? Does this diagnosis hold the same meaning on the other side of the continent? My answer: no, it does not.

Mental health problems go beyond human anatomy and pathophysiology, and treating them like they do not leads to inappropriate therapies. Culture and mental health have close ties that are not addressed when treatment involves only the prescription of a drug. Our mental health colors how we view the world around us; how we view ourselves, our failures and our successes. It defines our identity. In the West our society is based upon science and rational thought. Such a focus has placed a large emphasis on the ‘biomedical model,’ i.e. that symptoms can be clustered together into categories, leading to a diagnosis and a form of treatment. Yet in other countries the idea of being labeled with a ‘disease’ seems bizarre. In many cultures, mental distress is explained through a spiritual lens, based upon the power of one’s ancestors or a curse placed upon one’s family. Who are we to step into this other world and banish such beliefs in the name of the ‘superior’ Western thought?

It can be argued that by placing people within a scientific category, one is filtering out a person’s lived experiences. Sure, a diagnosis may be appropriate in certain circumstances, allowing appropriate support and treatment to be offered to those who are in distress, but we must remember that the diagnoses written in the textbooks do not always correlate with the chaos that is human life.

What is it that makes someone ‘mentally unwell?’ More than anything else, it is a social judgment; it is based upon the idea that everyone over this line is unwell, while those of us who are able to follow the norms of our society are deemed ‘sane.’ Every society is different, and every society has its own ideas of what an illness is and is not. We can often be so determined to get out there and ‘save lives’, that it can be easy for us to forget that when it comes to mental health, it is they (the patients) who have the far superior knowledge of what they are going through. They are the ones who know what emotions they are feeling, what thoughts skip through their mind, what fears drench their hearts. They are the masters of their lives. What is needed is not a rush to produce pills, to prescribe, to diagnose and to medicalize – no, what is needed is humility. The appreciation of our own ignorance in a culture that is different from our own – an understanding that human beings are different. Only then can we begin to take that step to alleviate the distress of mental health problems worldwide.

If we were to take out our Diagnostic Statistical Manuals and set about drawing boxes in other countries, we would find that such a rigid classification system does not translate well to other cultures; a person who fits the criteria for Major Depressive Disorder in London, UK does not necessarily experience the same illness as someone in New Delhi, India. We need to go beyond the symptoms and think about the person’s suffering and pain; what is it that has led them to feel such despair? For some it may be the loss of a job, or status, or wealth. For others, it may be a fall within their social circle, the death of a spouse, or the belief that they are being cursed or punished. We need to be able to understand another person’s suffering if we want to help them. A setback within someone’s life needs to be seen within its context. This involves sitting with people, attempting to understand their lives, eating their food, conversing in their language and understanding what it means to be a citizen in their country. It is not a process that can be ticked through in a few minutes based on a checklist of symptoms. Such arbitrary methods do not capture the emotional and spiritual parts of mental distress, nor do they take into account the vastly different cultural contexts in which patients may live.

Remember that the labels we put on our patients are often value-laden. These criteria we use from our diagnostic manuals are often drawn from the concept of right and wrong – what each society chooses to accept and reject as the norm. When it comes to mental health, what is most important is not the structure of the neurons, nor the actions of their neurotransmitters; it is the effect on the individual, the person within, the person who breathes and feels and cries and laughs.

All of these issues can be illustrated with the worldwide response to the Tsunami in 2005. Following the disaster, many NGOs provided ‘mental health assistance’ by using the Western psychological models of distress, particularly to describe the response to trauma. Most of the workers were ignorant of the local cultural beliefs and traditions, which resulted in a set goals that were more in line with the charities than the victims.

“We are fishermen and we need space in our houses – not only to live but also to store our fishing equipment. After the tsunami we have been living in this camp, which is 12 kilometers away from the coast and in this place for reconstruction. When the international agency came and started building a housing scheme, we realized that they are building flats, which is not suitable to us. But when we try to explain this to the foreigners who are building this scheme, they looked at us as if we were aliens from another planet. What are we supposed to do?”
[..] We have lost our families, now we are having our homes stolen too.”
– Action Aid International 2006 (8)

Such interventions have raised questions as to whether this ‘external mental health aid’ is actually harmful, leading to a division between the ‘superior’ external workers with their Western knowledge, and the locals who have been left helpless and vulnerable.

I am not suggesting that we place a hold on Global Mental Health. I am not suggesting that we stop giving aid. What I am suggesting is that when it comes to mental health, we acknowledge the diversity of the human race. We accept that to be mentally unwell means more than to have an imbalance of chemicals. And by accepting that mental illness affects not just a brain but a person, an identity, a family and a society, we are able to put on our boots and trudge deep into the mud alongside those who we are hoping to help, and perhaps we may even help ourselves along the way.

References

  1. Gilbert, J. 1999. Responding to mental distress: Cultural imperialism or the struggle for synthesis? Development in practice. 9:287-295
  2. Aggarwal, N.K. 2013. From DSM-IV to DSM-5 an interim report from a cultural psychiatry perspective. British Journal of Psychiatry. 37:171-174
  3. Alarcon, R.D. 2009. Culture, cultural factors and psychiatric diagnosis: review and projections. World Psychiatry. 8:131-139
  4. Canino, G., Alegria, M. 2008. Psychiatric diagnosis – is it universal or relative to culture? The Journal of Child Psychology and Psychiatry. 49: 237-250
  5. Harpham, T. 1994. Urbanization and mental health in developing countries: A research role for social scientists, public health professionals and social psychiatrists. Social Science & Medicine. 39:233-245
  6. Kirmayer, L.J. 1989. Cultural variations in the response to psychiatric disorders and emotional distress. Social Science & Medicine. 29: 327-339
  7. Thakker, J., Ward, T., Strongman, K.T. 1999. Mental disorder and cross-cultural psychology: A constructivist perspective. Clinical Psychology Review. 19: 843-874
  8. Gilbert, J. 2007. Mental Health: Culture, Language and Power. Global Health Watch 2.
  9. Gilbert, J. 2007. What is it to be human? Finding meaning in a cultural context.
  10. Gilbert, J. Cultural imperialism revisisted. Counselling and globalization. Critical Psychology.
  11. Gilbert, J. 2006. Cultural imperialism revisited: Counselling and Globalisation. International Journal of Critical Psychology, Special Issue: Critical Psychology in Africa. 17:10-28
  12. Gilbert, J. 2000. Crossing the Cultural Divide? The Health Exchange. April 15-16

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Mental Health Conditions by amenclinicsphotos ac