March 11, 2008

Suicidal Patients' Access To Their Psychiatrist

In the tradition of Robert Kagan and the folks at Policy Review, Robert Simon, MD defines foreign policy for the next century.

Robert Simon, MD is one of the big forensic psychiatrists in the country, along with Park Dietz, Robert Sadoff, etc.  In many ways, he sets standards of forensic practice.  He frames the debates: he (and others) decide what words we'll use, what principles are in vogue, how clinical data are applied in a legal context.

Which is why his latest article, "Suicidal Patients' Access To Their Psychiatrists" is-- no other way to say it-- a disaster for psychiatry.

His article can be summarized by the large red font excerpt in the middle of the page:

Standard of care requires that psychiatrists or their designees be accessible to suicidal patients and that they respond within a reasonable time.
He gives examples of what he feels constitutes standard of care practice:

In solo practice, the psychiatrist or covering clinician must be accessible 24 hours a day, 7 days a week, by cell phone, pager...Twenty-four hour coverage for patient emergencies is an established... standard of care.

First, I'll go on record and say that I think he is wrong.

On a simple level, the problem with the article is that he does not distinguish between "standard of care" and "best care."

Standard of care is defined in many ways, but here are two good ones: "customary practice" or "reasonably prudent similar health care provider."   They're not the same.  "Reasonably prudent" is not based on number of docs doing it.  Even if 99% of docs are doing X, it could still be substandard care.   Which is, in effect, what he is saying: whether or not most psychiatrists do this is irrelevant-- they should do it.

So the trick is this: in the guild system (yes, like a thieves' guild) of medicine, who decides what the standard is?  What a "reasonably prudent" doctor would do?  In some cases, it's obvious (e.g. no sleeping with patients no matter how hot they are) but ultimately the answer is there is no answer:  it's decided in court, in a duel between experts.  And academic articles are the ammunition. 

So while I disagree with him on what is standard of care, the real problem with the article is more serious:  by writing this article, Simon isn't merely reporting the standard of care, he is causing this to be the standard of care.


II.

Believe it or not, I am not completely without empathy for other people.

I recognize the feeling of crisis, of vertigo-- nausea-- that some have when their bodies and their minds tell them they have to GO NOW-- or, for others, that it's simply better and easier (just) to go...

That is a structural problem, a logistic problem, for psychiatry: how can we deliver effective and efficient care to those who, almost by definition, need us when we are not available?  This can be solved with outcome studies, with data, with debate.

But the issue right here is that this discussion has been effectively commandeered by Simon, and others-- others, BTW, who do not actually treat any patients in crisis. No one asked a regular psychiatrist; no one did a survey of the exiting practices.  He just said it.

He may be right that this should be standard of care, but he should have to defend his position. (For example: Is it true that the suicide rate is lower when there is 24 hour access?)

But by writing this, he's not asked to defend why he's right-- he just established the default position. The onus is now on everyone else to explain why he might be wrong.  The analogy is, well, Iraq: what happens when others in government-- who have never seen a war, let alone fought one-- tell you how and when to conduct a war? 

You're nodding?  Don't, because here's the answer: they get voted back into office, again.    Policy is always set by those with little direct investment in it; because those who have most to gain or lose have so little time, and so little access to the debate itself, that inertia takes over.

III.

I don't blame Simon, and no, I don't blame Bush either.  It's not exactly their fault.  They are repeatedly given mandates to decide policy, and so they decide based on their principles (yes, Bush, too.)  They believe they're right-- and no one is around to tell them they're not.

Simon thinks he's right; and, for support, he offers the "top" psychiatrists-- academics.  Who, of course, don't have to deal with 24 hour coverage, either.

You can't tell Dr. Simon that 24 hour coverage is physically impossible.  For a solo practitioner with 100 patients, if 1% have a crisis, he's dealing with 1 phone call.   In a city, community mental health clinics treat 3000-10000 patients.  If 1% have a crisis, that clinic closes.   In states like Idaho, where there is one psychiatrist for a gigantic area-- sometimes even one NP who travels-- it's impossible.

But much more importantly, you would be scared to tell him he's wrong.  You can write a letter to the Psychiatric Times and say, yo playa, you're wrong-- but what's the point?  His article is in pubmed, yours isn't.  But you sure as hell wouldn't dare to tell him that within a mile of a courthouse.  "Dr. Simon is wrong, no community clinic in the Inland Empire does that."   Oh?   You just abandon your suicidal patients to the night and city streets?  Let the drug dealers and roaches care for them in a crisis?  Maybe the care in the Inland Empire isn't very good?  According to Dr. Simon, it's standard practice everywhere else.  Perhaps you should stop torturing your patients with your incompetence?

So you nod your head in assent in public, but stay quiet, hoping no one will ever scrutinize your practice.

IV.

Simon's logorrhea has a side effect: he's changing social policy.  I know he doesn't mean to, I know he would deny it, but it's true.

This is how it goes: the Law looks to Psychiatry to shed light on behavior.  Society watches this interaction and adapts.

Simon makes a specific point that leaving a "if this is an emergency, go to your nearest ER" outgoing message is not acceptable.  But then why is it for primary care?  If you have a heart attack at 2am, can you sue your doctor because he wasn't available and you didn't know you had to go to an ER?  Society hears him, and it says, "oh, people with psychiatric disorders are out of control.  They need 24 hour coverage." 

Forensic psychiatrists have massive power, they decide how psychiatry is applied to the law, to the public.  They make things true, not least because no one checks their work (except possibly the other expert.)  And Society has little reason not to accept it.

So Society infers: psych patients can't think clearly. They cannot be responsible for themselves, even when they're doing fine, because they might suddenly not be fine-- so  someone has to be there around the clock to catch them. 

And another steel I-beam is riveted to the infrastructure of a custodial society.

 








Comments

You're an evil cunt and a p... (Below threshold)

March 12, 2008 8:32 AM | Posted by Bill: | Reply

You're an evil cunt and a pseudoscientist responsible for countless lives ending early, and lives lived in misery and fear. You built your fucking house on fear sold as 'disease' without any fucking credible science. You're an indoctrinated autocratic meddler, of the worst order, and the world would be better off had you chosen a real vocation, not that of a pretender. I hope that one day you can see the harm you've caused.

Alone's response: Awesome. Confirmation that I suck. And now, to the rum.

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I noticed recently that a p... (Below threshold)

March 12, 2008 9:57 AM | Posted by Christian: | Reply

I noticed recently that a psychiatrist my family once used had changed her out-of-hours voice mail message from:

"If you are having an emergency, hang up and dial 911 ..."

to:

"If you are having an emergency, use this system to page me by ..."

When suicidal to the point of needing help, isn't 911 the way to go? Or one of the hot lines?

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Yo, yo, yo, brutha, you be ... (Below threshold)

March 12, 2008 12:31 PM | Posted by Paul: | Reply

Yo, yo, yo, brutha, you be preachin' the troof! Love the blog, it be one of my main sites i be readin on a regular basis....keep on, keeping on, Mayor! word

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yeah. we're fucked. I'm not... (Below threshold)

March 12, 2008 7:52 PM | Posted by Anonymous: | Reply

yeah. we're fucked. I'm not changing my voice mail and I'll be sleeping through the night anyway.

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In my part of the country, ... (Below threshold)

March 12, 2008 10:16 PM | Posted by stresssed out: | Reply

In my part of the country, almost all psychiatrists and psychotherapists in solo practice have a message on their machine instructing patients to call the local crisis service.

I have been carrying a beeper 24 hours a day, 7 days a week for 10 years. and I am sick of it! I am about to go on a trip, I have arranged coverage but I feel like I am imposing on my colleague (he's on call at the hospital) so I will be checking my voicemail twice a day. I don't feel virtuous, I feel like a neurotic goody goody rule follower because I no longer do it to be of service to my patients but rather this was the rule I learned as a medical student, that a physician is always available or has coverage

For a solo physician to carry a beeper 24 hours a day, seven days a week means to carry a beeper when you go to the pool, to the movie, to a concert, when you're with other clients, when you are at the dentist, at the gynecologist! (I put it on vibrate and check it when I get out). I can never have more than two drinks in an evening. I actually answered my beeper while undergoing chemotherapy.

I rarely get beeped for clinical emergencies, perhaps once a month. most of my beeps are protocol, I have a consult assigment, my patient showed up late, etc. The lack of crisis in the beeps make it more onerous to carry the beeper because it doesn't seem truly clinically important.

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I a former psyche patient w... (Below threshold)

March 13, 2008 1:04 AM | Posted by Diane Abus: | Reply

I a former psyche patient want only to be left alone unless I ask.I am fine,I choose whether and to what to degree I medicate and I look forward to a free! future.A custodial attitude to me -repugnant thought.I think you rock too0)

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I have been clinically seve... (Below threshold)

March 13, 2008 6:20 AM | Posted by Heather J: | Reply

I have been clinically severely depressed for ten years, diagnosed as bipolar or borderline personality disordered, and have had psychotic episodes. Living in the UK, I have never in all that time had 24 access to my doctor or psychiatrist. I beleive having it would have been unhealthy, dissuading me from using my own coping skills in a crisis, and causing me to depend on one or two people who would have tired of me, rather than having the benefit fo being seen by clinicians at Casualty who could approach my presentation without the prejudice of knowing me and having been called at 3 a.m. from a peaceful sleep.

I think 24 access is ludicrous, and any patient I personally know of who has that has only really lapsed into a state of dependency and lack of progress. Why deal with the pain of your emotions and mental ill health, when you can page your doctor and try to make them deliver you of it?

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Can someone explain to me h... (Below threshold)

March 13, 2008 8:28 AM | Posted by Larry Smith: | Reply

Can someone explain to me how somebody can "feel suicidal" (you need to define this) and, at the same time, take steps to prevent his/her suicide, like dial 911 or go to an ER? A lot of people can be more or less illogical (hence CBT and what not), but this sounds like an extreme case of cognitive dissonance: "OMG, I'm going to kill myself, but I DON'T want to die".

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If you want the power to co... (Below threshold)

March 13, 2008 9:33 AM | Posted by mark p.s.: | Reply

If you want the power to commit/jail people for being "mentally ill", you got to pay the price of responsibility. Otherwise don't take the job.

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i have to say yeah, if you ... (Below threshold)

March 14, 2008 1:27 AM | Posted by Stephany: | Reply

i have to say yeah, if you don't want responsibility a pager for patients you care for, then go get a new job. why ppl call 911 or go to ER's? or hit speed dial on the psych ? because maybe, just maybe they think someone is really there when you need them to be like they say they will be what the hell is the point of having 800 -suicide call centers? they SAVE LIVES. OK so let's say there are no more hotlines, or directives to redirect a person's thoughts. maybe we cut all of it out as a trial to see if suicide rates increase. maybe like a placebo effect vs. antidepressants? i don't know but i've had 2 ppl in my life take action and call for help and they aren't dead now. never underestimate a suicide call, and never underestimate the power of an encouraging word, telling someone they are important enough to live on this earth. it's a real comfort to know doctors hate pagers. then don't have one!

Alone's response: Just to be clear, my point in this article wasn't that having a system of 24 hour coverage was good or bad, rather that this decision should be made the same way we decide to use a certain medicine for diabetes-- study. But here, a single forensic psychiatrist has unilaterally decided policy. It's no different than if he wrote an article saying, "not giving lithium to a suicidal patient is below the standard of care." And so now I have to document in the chart why I don't choose lithium.

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You make some very good poi... (Below threshold)

March 14, 2008 7:46 AM | Posted by Kelly: | Reply

You make some very good points. The whole purpose of emergency rooms and ambulance service is to deal with sudden health crises at three in the morning, so I see nothing wrong with telling patients to dial 911 in that circumstance.

I dislike the implication that psychiatrists should be available 24/7 both in empathy for the doctors and as a patient. What happens to a doctor's own emotional health when he or she never gets a break? I've seen the stress on my mom (as a director of nursing) when she can't even get a weekend away with my dad without getting someone else to be on-call for her--which they always resent. And the stress on her must be less than what it must be for a doc, because they're the ones she ends up calling when there's a severe problem.

More selfishly, as a patient, I also don't want my doctor half-conscious when I'm explaining to her how my meds are working, because she got six calls in the middle of the night. Aren't a huge majority of medical errors made by doctors who are sleep-deprived? Granted, being on-call 24/7 doesn't automatically equal sleep deprivation, but it certainly helps. There's also the more subtle stress of never truly being able to relax. Sure, no one called you on this particular night, but you didn't quite sleep soundly because what if the phone rang and you didn't hear it?

Also as a patient, I resent the implication that, somehow, I'm not responsible for my own choices and need a 24/7 baby-sitter.

I can see how that perception can not only lead to patients becoming more dependent and less able to deal with their own problems, but also to people with mental health issues choosing not to get help. Better to fight your own demons than to have yourself labeled as helpless.

So, for those who know how to behave like adults and take responsibility for their own choices, that adds another barrier to dealing with mental health problems. For those with no sense of responsibility, on the other hand, a diagnosis becomes a Get Out of Jail Free card--one more reason to avoid taking responsibility for their own choices.

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I'm boarded and have practi... (Below threshold)

March 14, 2008 10:15 AM | Posted by Brad S: | Reply

I'm boarded and have practiced in both primary care and psychiatry. Worked in small towns and large, practiced privately and for lots of agencies. What I've observed is a completely different attitude towards after hours coverage. Expected and delivered routinely by medical specialties, rarely provided and (unfortunately) unexpected by mental health providers. The difference is stark and frankly confusing.

Personally, I'm persuaded by the primary care model for many reasons and have come to believe my mental health colleagues' practice results from their own personal motives wrapped in a mantle of 'local standard of care' and 'professional differences' rather than any consensus or evidence-based practice. In my more cynical moments, I see it as frankly lazy.

RE: Dr. Simon, Last, your points are well taken. As a guild we should have wrestled with this issue long ago. We need to get the data we can, discuss this amongst ourselves, with our clients and with our medical colleagues to agree on what works best before we 'dictate' standards of care. We have not to our discredit. Like sheep we follow 'expertise' rather than consider and debate. Is there hope to wrest this process back from the 'experts' and the lawyers? I hope SO...any ideas on how to get it going?

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Great post and you're exact... (Below threshold)

March 14, 2008 11:54 AM | Posted by Steve : | Reply

Great post and you're exactly right on. But I just will take issue with your assertion that forensic psychiatrists have "massive power." As an expert myself, I often think experts overestimate their power. There's no better indication of this than in criminal cases. Was it really the case that Park Dietz was the deciding factor in Yates' first trial? Or was it simply the culture of Texas in relation to punishment?

Sure, Robert Simon may be setting policy, but there will always be someone to push back on that policy. Whether that's simple economics of supply and demand (there's already a shortage of psychiatrists, and this policy may further that trend) or regulation, eventually there will be a push against Simon and others who formulate policies such as these without having to undertake the burden.

By the way: a good way to push back against this particular policy to publish a legal analysis in a law review and invoke precedent on your side. The law loves precedent even if the precedent is all wrong.

Alone's reposne: yes to everything you said, except one part: "there is always someone to push back against Simon." Well, in court, yes; but Simon wrote an article _saying_ this is the standard of care. It would require another, similarly statured forensic psychiatrist to write another article in a comparable periodical saying "no, it isn't," in order to negate his effect. There isn't such an article. dditionally, law review would be good for lawyers, but I think forensic psychiatrists have more influence over our cultural attitudes.

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Hey Doc,If everyon... (Below threshold)

March 17, 2008 3:51 PM | Posted by Mary: | Reply

Hey Doc,

If everyone's on antidepressants, why hasn't the suicide rate fallen?

Alone's response: that's the real question of psychiatry (if meds exist, why aren't people _as a whole_ better off?) and the answer is simply, obviously, and incontrovertibly: you cannot alter the will with a pill. You can influence it, nudge it, but you cannot reverse behavior on autopilot. So in the single specific case of suicide: unless the person has "learned" other ways of living and dealing with their pain, you can't prevent them from killing themselves with Prozac any more than you can prevent them from watching Lipstick Jungle (which I really wish you could), a sad movie about Lucy Lui as a woman battling anorexia as she studies for the priesthood; Kim Cattrall as a transgendered individual looking for love in all the wrong places (e.g. France), and a supporting cast of unknown and neutered men who exist only so the women can have someone to cheat on and then feel conflicted about. Hey, you asked.

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Agreed that it would need t... (Below threshold)

March 18, 2008 11:16 AM | Posted by Stan Stammers: | Reply

Agreed that it would need to be proven that 24x7 care indeed reduces suicide rates, however one psychologist could never be expected to do this. What are you suppose to do if two suicidal patients of yours both call at the same time? Do you attempt to juggle both phone calls at once? Are you still responsible if one of them manages to kill themselves within a 3 minute time frame you are helping another through some crisis?

And what is there to say about those that abuse the privilege of being able to call anytime with their problems, under the guise that they are going to kill themselves over something minute? How can you dismiss them, and what if you do dismiss their problem as not of a suicidal tendency and then out of this rejection they go and kill themselves.

I think that issues such as this are best left to things such as
1-800-SUICIDE 1-800-273-TALK
http://suicidehotlines.com/national.html

Once more I think the important factor in not killing oneself is that there is _someone_ there to talk to. I don't believe that person necessarily has to be your psychologist. I think that any patient could talk about what their psychiatrist said during some session to the people at a free hotline (or even at the ER) and manage to work through their crisis. If its a big enough emergency its up to one of the above agencies to contact you, but that should almost never happen or the hotline/help system would appear to be inadequate in the first-place. I would think the only responsibility a psychiatrist should have is to provide instructions for what to do during an emergency/crisis to their suicidal patients. Bureaucracy would have you & the patient sign a paper proving that you informed them. The additional paperwork might prove to the patient that you don't personally care, but it seems necessary to protect oneself legally if thats the direction things are going in, and you can always say it proves that you have 24x7 concern for them and might even help in treatment.

Of course, a dead man can't sue you, but their families might try to blame you for the death. I think the person who committed the murder is at fault regardless, and its somewhat strange to have to protect yourself if you were only trying to help.

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I almost succeeded in killi... (Below threshold)

March 20, 2008 12:37 PM | Posted by phoenix: | Reply

I almost succeeded in killing myself when I was just thirteen. I remember my state of mind clearly. I was far gone into a fantasy world where the heroin had to die and my emotions had shut down. I literally felt nothing as I "acted out"; I was trapped in a dream.

About ten years ago I had a major crisis with events of the present directly linked to incidents of severe trauma in childhood, buried but never forgotten. My anxiety level soared and pushed me into therapy - several months later, in relentless severe psychic pain that seem to last an eternity, I was repeatedly assailed by fantasies of jumping in the lake, slicing my wrists, etc. I hesitatingly talked a bit about these fantasies in therapy one day (I think I was legitimately afraid of being hospitalized), and mentioned that in one particularly paroxysmal moment I had thought about calling him to see if he could stop them somehow. He asked me why I hadn't called and even seemed a bit surprised that I hadn't. I'm not totally sure, but I think I hadn't called because 1) I knew that no one else could help, not even the most well meaning person on earth, not even "my" therapist, and perhaps more importantly 2) I knew on some level that as long as I could feel this bad, I would not act.
I'm no expert, but I think if you are really going to kill yourself you have passed into a sphere beyond communication and even beyond misery. Therapists on call for their patients can certainly help reduce their suffering, but - and it might be awful of me to say this - being on call is probably not going to change the suicide rate in the world.

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Who decides the standard of... (Below threshold)

March 25, 2008 9:26 PM | Posted by Chip: | Reply

Who decides the standard of care? Dr. Simon has made tremendous and prodigal contributions to psychiatry, but on suicide risk assessment he has gone too far. I resent his audacity at opining on "the standard of care" when I know his opinion does not reflect my practice or the practice of ANY psychiatrists I know.

Perhaps, he makes me feel inadequate, but I think of my practice as consistently meeting or surpassing the so-called standard of care. One point in particular he made during a lecture I attended was that it is MALPRACTICE not to conduct a suicide risk assessment at the time of a patient's discharge from the hospital.

Who does that each and every time? Who? I challenge you to find a psychiatrist who always does it. Sure, it makes perfect sense to RECOMMEND performing a suicide risk assessment upon discharge, but it is by no possible meaning of the term, "THE standard of care." I cringed from hearing from a man I respect that I have been committing malpractice for years. Was all that I had done somehow deficient? And my colleagues (who I know to perform far fewer suicide risk assessments than I), were they negligent too?

But I have Dr. Simon to thank for improving my practice. At that time, I almost never performed a suicide risk assessment upon discharge. Since then, I have done it some, albeit infrequently. Still, I believe he has made wise recommendations that do not constitute "the standard of care."

So as I listened to his lecture on suicide prevention (and, yes, I own his blue and black covered book on suicide risk assessment) I was struck that, for all his experience and expertise, Dr. Simon is far removed from the realities of the psychiatric world I know

As a leading forensic psychiatrist, Dr. Simon has no excuse not to know how the standard of care is actually determined. In court "the standard of care" is supposed to represent what a similarly situated provider would have done in the same situation. It may very well be that most providers would do what is less than ideal or even what is clearly wrong. Sorry, but that's the standard. Has Dr. Simon polled a representative sample of psychiatrists to determine "the standard of care"? I assure you he has not, but I wish he would. This would be closer to a standard of care better than some decree from on high.

But even a superbly-conducted poll might prove insufficient at establishing, once-and-for-all, a suicide standard of care. There is a tremendous "hindsight bias" (Monday morning quarterbacking) when someone completes suicide. This bias doesn't just occur in the jury box, but affects psychiatrists as well.

One study illustrates this nicely. Hypothetical patient cases were presented to reviewing psychiatrists, who were then asked to assess the risk for suicide from the information received. Cases were paired such that two different cases did not differ with one exception. The cases were identical except in one case, the patient was presented as having committed suicide. Well, surprise, surprise! The psychiatrists rated the deceased hypothetical patient as having had higher risk for suicide. So, when an expert opines in a suicide malpractice case, is that risk assessment is biased? Is it fair to have an expert opine, in hindsight, that the patient had a greater risk of suicide than the psychiatrist at the time appreciated?

On an unrelated issue, I object to the blogger's depiction that nobody checks the work of forensic psychiatrists. This blog is proof of the opposite. In fact, forensic psychiatrists are subject to an incredible amount of scrutiny. It is not for the thin-skinned. The adversarial judicial system we all enjoy ensures that any opinion of import is criticized thoroughly. The Latin root of the word "forensic" means public.

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An Open Letter to "The L... (Below threshold)

March 27, 2008 10:38 PM | Posted by Anonymous from ALT.SUICIDE.HOLIDAY: | Reply

An Open Letter to "The Last Psychiatrist" ...

Alone's response: Your comment was a particularly good one, and very important, so I've taken it and used it as a post (sorry) but thanks as well.

http://thelastpsychiatrist.com/2008/03/but_i_wanna_kill_myself.html

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In Seattle in February of 0... (Below threshold)

May 12, 2009 6:54 PM | Posted by Patient Abandonment : | Reply

In Seattle in February of 09 a local psychiatrist lost a patient to a suicide (she OD while driving and died after a car accident of a heart arrhythmia) The Psychiatrist P.S. then left a voice mail message in which she refused to continue to see another actively suicidal sexual assault victim as she "felt that she couldn't provide the level of care that she needed) and refused to return her clients repeated calls and voice mail messages. Even though the patient has the providers cell phone number she never called it despite being in acute distress for almost a month.

Two weeks later P.S. sent the patient her records along with a referral to a clinic that didn't take any insurance (the patient had used up 1/2 her visits with the p-doc and had been seeing her for the prior 9 months). The patient continued to try and contact her P-doc to at least see her while she looked for a new provider, but was unable to get in to see anyone she could afford. She ended up not seeing or talking to anyone other then a short phone call to an on-call resident at the UW for the next 6 weeks.

The client then made a serious suicide attempt but apparently didn't disclose that to either the EMS nor her doctors who treated her. About a month ago she came to me.

I am just a Bachelors level case manager working on my Masters degree at a local training clinic and am now trying to help this woman. She no longer trusts therapists thanks to the lack of access to her prior psychiatrist, the abrupt discontinuation of care and her months long attempt find someone to see her. 24/7 care is nothing compared to the ongoing practice of only treating people who don't really need the services of a psychiatrist.

I have to admit that I share her belief that the sicker you are with a mental health problem the less likely you are to receive high quality care as most psychiatrist treat the healthy wealthy worried and the people who are the most disabled end up with bachelors level case managers like me.

So lets take about how this is the only profession where you get to pick and chose your patients and drop the ones you don't like.

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I'd like to echo Heather J,... (Below threshold)

June 14, 2009 9:17 PM | Posted by Christina MacKinnon: | Reply

I'd like to echo Heather J, and remind posters that there are miles and miles between the suicide attempt, and the seriously wanting to die final act. Perhaps the former would benefit from someone on call and familiar with their case, but the latter would do fine just with a caring person trained to listen (hotline staff), if they make a call at all.

I'd also prefer that psychiatrists get protected time completely off work for their own sanity. Hoping they can lead the rest of us in that direction with a little more authority once they've had a rest themselves.

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I'm a stickler for high sta... (Below threshold)

March 9, 2012 6:19 PM | Posted by Anonymous: | Reply

I'm a stickler for high standards, because I've been a patient, but even I think it is wrong to expect psychiatrists to be available 24/7. Actually, I think a normal 40 hour work week like everyone else tries to have is fine. Or maybe even a 36-hour, 3 day work week.
I'm not sure why we would expect a psychiatrist to behave in such an unhealthy, workaholic way when they are supposed to model good healthy behavior to their patient. Also, if psychiatrists are struggling now---to meet or exceed all kinds of professional obligations---I can't imagine how much worse it will get when they have to be available 24/7.
Resentment will be the not-uncommon result, and the patient will pick it up and read it as rejection, potentially---which could ultimately be more damaging to the patient.
ER is fine. People in crisis can go to ER. If there is no ER reasonably close, then arrangements can be made to maybe get a live answering service to sum up what needs to be done and whether the doctor needs to be called or something. Or, maybe the patient can call the police. Or an ambulance.
If mentally ill people get too used to ridiculous, inhuman levels of service (like 24/7 care) it does them a disservice. And they need to maintain somewhat realistic expectations of what to expect from at least some of the people in their life, shrinks could be ideal for introducing that concept.
It would also be healthy for mentally ill people, or any other kind of people, to recognize that other people, shrinks included, need a life, too.
Also, I live in Chicago and I've gotten a ton of good care here, and for the most part, if I have a crisis after hours then the path I've been led to expect (even from the big name hospitals here) is ER, more or less. I know I *could* in a pinch, torture a shrink especially if s/he is a resident, but that has never been set up by my shrinks as any idea of an ideal support system. And I have a history of serious suicide attempts (10+ of them). Still I say this.

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Clarification: the standard... (Below threshold)

March 9, 2012 6:36 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Clarification: the standard, applicable to all patients, would have to of course be explained upon beginning treatment, and periodically reiterated so the patient was set up with realistic expectations in the first place. But of course everyone knows that. I wanted to clarify because of the possibility of some...doofus....doing the wrong thing with what I said. (You never know).

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My psychiatrist of 6+ years... (Below threshold)

May 9, 2013 3:07 PM | Posted by NeverTrustAgain: | Reply

My psychiatrist of 6+ years, 3 x's a week pro-Bono with whom I made amazing progress with out of the 23 years and 19 other Mental Health Professionals I worked with and/or was forced to consult. My MD and I were incredibly close, with a doctor-patient relationship that exceeding Transference. It was the first and last time I have ever felt safety and hope. But when his MD wife discovered the nature of his therapy with me, the length it had been going on, and, in particular that his work with me was proBono. She threatened me, mistreated me, attempted to intimidate me to the point of willfully giving up my treatment with her husband. Most importantly - as she was substituting for his practice due to a family emergency he was having - refused to provide my regular prescription, stating that she hoped that when I *had* to go to an ER for treatment she would "make sure that (I) never left" implying forcible involuntary institutionalization. The next day my psychiatrist - her husband - sent me a brief, kurt, spontaneous letter of termination. He did nothing to ensure my safety, continued treatment during the transition, and in fact has now placed false information on any Records Check. I have lost my job, my insurance, my access to medications - which were not only for a historically documented Mental Health need(s) of approx. 23 years, but which were supported by the former 19 other psychiatrists I had worked with - never making the type of progress I did with my MD before the incident with his wife. At this point a non-mental health related condition which my MD was fully aware of prior to the initiation of the 2000+ sessions with me but which is terminal without medication. I AM NOW FACING DEATH AS A RESULT OF MY PSYCHIATRIST'S ABANDONMENT/TERMINATION DESPITE THE MANY ATTEMPTS BY LAWYERS, MEDICAL PROFESSIONALS, OTHER PSYCHIATRISTS, AND RELATIVE ORGANIZATIONS & ADVOCATES MAING PLEAS OR COMMUNICATION ATTEMPTS WITH HIM. HE IS AWARE THAT HE WILL SOON FACE A WRONGFUL DEATH SUIT NOW SPONSORED BY REPRESENTATIVES WITH UNLIMITED FUNDS AND HISTORICAL SUCESS. NONETHELESS HE REMAINS SILENT, UNCARING, SUPPORTIVE OF HIS WIFE, AND CONTINUES TO ACT WITH SIMILAR MEASURES. I AM BROKEN, DESTROYED, UNABLE TO EVEN GET OUT OF BED. IN AN IRONIC TWIST OF FAITH THE INTELLECTUAL INTIMATE NATURE OF OUR WORK AND HIS SUDDEN ABANDONMENT AND APATHY HAVE IN FACT ASSISTED ME IN A WAY I NEVER THOUGHT POSSIBLE. IN A WORLD WHERE INJUSTICE SUCH AS THIS NOT ONLY GOES UNPUNISHED BUT IGNORED, I WELCOME DEATH. I suppose your belief is that no one whom you care for could ever find themselves in such a position. I have a PhD in BioEthical Global Reform specific to International Social Welfare, now made irrelevant due to the restrictions placed upon me via my psychiatrist's statements to my official records. I spent my life trying to help others, and I will now die alone. To anyone with trauma that you apparently have never been the victim of, commentaries such as this are in essence not merely the epitome of injustice, but the beginnings of what will eventually become an accepted practice of death for those with Mental Health issues. You undermine your own point. I assume you come from an Upper Middle class family which was without abuse and any trauma you may have been exposed to has been repressed or merely forgotten - an excellent way to further change for the better, similar to social ideals held in Fascism, or atrocities committed world wide, Better to forget and or deny then remember and seek justice for at the very least an attempt to make sure this type of crime and end results does not reoccur. Oh, also, you're welcome to come to my funeral.

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Where has that post gone?</... (Below threshold)

April 20, 2014 5:25 PM | Posted, in reply to Anonymous from ALT.SUICIDE.HOLIDAY's comment, by johnnycoconut: | Reply

Where has that post gone?

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<a href="https://web.archiv... (Below threshold) Thank you! I now see why th... (Below threshold)

April 21, 2014 1:18 PM | Posted by johnnycoconut: | Reply

Thank you! I now see why that post was taken down--people posted that they were going to kill themselves. Here's the latest capture from web.archive.org before the post was taken down (am I supposed to put a trigger warning here?):

https://web.archive.org/web/20080928124951/http://thelastpsychiatrist.com/2008/03/but_i_wanna_kill_myself.html

There were many thoughtful replies agreeing and disagreeing with what Alone said on the topic of suicide and its causes. Many of these thoughtful replies were very, very heated, and I can see why. I have strong feelings on this issue myself.

I just hope I don't open up another can of worms with this comment.

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