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Shrink Rap by Dinah - 11M ago



When Clinkshrink, Roy, and I started Shrink Rap in April of 2006, I had no idea of the places that blogging would lead me.  We started blogging, and I became a tad obsessed.  We all loved the blog, the people we met, and the stimulating discussions and interactions we had with people from all over the world about mental health issues.  My thoughts were constantly bombarded with "I have to write a blog post about that!" And write, I did.

ClinkShrink was a little more hesitant.  "You're going to get me fired!"she insisted.  Roy worried, too, and in fact, he called himself Deep Cover Roy and swore us to secrecy about his identity.  

We blogged and we blogged.  Then Roy insisted we needed a podcast, and 70 episodes of My Three Shrinks went up on iTunes (they are still there).  There was chili and beer and guests who came to be interviewed at our dining room tables.  

One night, I was at a psychiatric society dinner, and Roy proudly told someone sitting at our table, "I have a blog!"  His secret was out.  ClinkShrink decided that it couldn't really be a secret when we were presenting at the American Psychiatric Society's annual meeting.  No one got fired.

We wrote two books, Shrink Rap: Three Psychiatrists Explain Their Work, and Committed: The Battle Over Involuntary Psychiatric Care, winner of the APA's Carol Davis ethics award this year. We were on national and local radio, we've been grand rounds and CME speakers for psychiatric societies around the countries, and we've given a course on how to blog, podcast and write books.  As a direct result of Shrink Rap, we've become columnists for Clinical Psychiatry News and members of their editorial board.  We've blogged on Psychology Today, and you know, it's all been good.

The writing has been wonderful, but the people have been the absolute best. We met people who became our real life friends, and we shared in the virtual lives of so many wonderful people, both mental health professionals and tremendous human beings who happened to suffer from psychiatric disorders.

As the years passed, Anne (aka Clink) became busy with so many other projects, and with running the forensic fellowship program for the University of Maryland.  Steve (Roy) has changed lives a number of times and now works for SAMHSA.  He lost his password to the blog, and while we still get together for crabcakes at Koko's Pub or to hang out in one of our backyards,  I've been the only one who has posted on Shrink Rap for quite a long time now.  Still, we hold on to our identities as Shrink Rappers, and my friends don't know it yet, but I've reserved us three adjacent rooms  (entry set for May, 2053) at a very nice nursing home where they'll let Roy bring his homemade sangria. 

I've held on to Shrink Rap.  For the longest time it was my forum to express my frustrations with the bureaucracy of medicine, with the inconsistencies and unfairness of a constantly changing world that seemed to create mindless hurdles for both psychiatrists and patients.  Sometimes I shared the fiction I wrote, other times I just shared whatever I was thinking about, psychiatry or not.   And Shrink Rap opened my mind to all sorts of other viewpoints about psychiatric issues.  It became a gateway to discussing controversies and it was a reason to keep current with  the mental health advocacy world.  My relationship with blogger Pete Earley blossomed into a sweet friendship.  TigerMom also remains a friend and my Philly resource.  And just last night, Anne and I went to the movies with our beloved (and now retired) book editor, Jackie Wehmueller.  There are so many more people who have touched my life in such meaningful ways that I can't even begin to create a list. And there were the selfless people I met here who gave so much of their stories so we could write Committed, and the many other people who contributed to all we learned about the good and bad of involuntary treatments. 

Over the last couple of years, I've also been spread a bit thinner, and I've had more places to express my thoughts.  Instead of feeling like I couldn't wait to get home to write a Shrink Rap post, it's become something I tell myself I should do once a month or so.   When I do post, the comment section remains quiet, and it was probably time to say good bye long ago. 

Psychiatry can be an isolating career.  My career has not been isolated or lonely and the connection that came with Shrink Rap has truly been a gift. It's been a fabulous experience, and to all our friends and adversaries, colleagues, advocates, commenters, readers, and all the amazing souls I've been so blessed to share this wonderful journey with, I can't thank you enough. 

----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.
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https://www.cnn.com/videos/us/2018/06/24/finding-hope-suicide-special-report-full-show.cnn

If you are someone with suicidal impulses, please do watch Finding Hope, it was an excellent show.  The host, Anderson Cooper, as well as many of the guests, have lost a family member to suicide. 
----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.
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Today seems like a good day to talk about assessing suicide risk.

As psychiatrists, we see many people who think about suicide -- suicidal ideation is a common symptom of clinical depression.  In fact, it's very difficult to get a depressed patient into the hospital if they are not thinking about suicidal. Insurers are generally only willing to pay for inpatient care for people with life-threatening psychiatric illnesses; it's a standard no other medical specialty is held to.  Even when someone is dangerous, and when their insurance is willing to authorize an admission, there is still the very difficult issue of finding a bed.  Do check out  Suicidal: Be Prepared to Wait for Care by Dr. Nathanial Morris, a psychiatry resident at Stanford. 

That said, I wanted to introduce you to the the new podcast over on the Clinical Psychiatry News website. The MD Edge psychcast is being hosted by Dr. Lorenzo Norris of George Washington University.  I found the interview with Dr. Igor Galynker on assessing imminent suicide risk fascinating.  Dr. Galynker notes that people who go on to end their own lives often do not say they are thinking of suicide.  And yet that is the standard we use to get people into the hospital! It's an excellent interview, and I can't do it justice in a recap, so I'll ask you to invest 25 minutes of your time and listen here: https://www.mdedge.com/psychiatry/article/165827/depression/approach-assesses-imminent-suicide-risk

Finally, ClinkShrink and I were interviewed by Dr. Norris when we were in New York for the annual meeting of the American Psychiatric Association.  If you'd like to hear our interview on involuntary treatment, it can be found here:
https://www.mdedge.com/psychiatry/article/166427/mixed-topics/dr-dinah-miller-dr-annette-hanson-involuntary-psychiatric


----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.
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In the New York Times, Benjamin Weiser has a beautiful and moving story about Nakesha Williams, a lovely and vibrant woman who graduated from Williams College and then became ill with a psychotic disorder. She lived for years on the street in New York City.  Please do surf over to Mr. Weiser's story, "A 'Bright Light' Dimmed in the Shadows of Homelessness." 

The story is a tragic one about a promising woman whose future, and ultimately her life, are lost to mental illness.  Despite so many people who loved and cared about her, and so many who tried to get her help, Ms. Williams dies alone on the street. She is young, and she dies of a treatable disease, a pulmonary embolism.  Mr. Weiser does a commendable job of re-creating her story and tracking down the people who knew her in the years before and during her psychiatric decline.  To his credit, he just tells the story;  he doesn't turn it into a plea for laws that make it easier to involuntarily treat people, and he doesn't go on about how this was a life that could have been so much different if only she had been forced to have psychiatric care.  I found the story to be a richer one told simply as it was without the moralizing.

So having said that, I am now going to invoke my role as an expert on involuntary treatment to talk about the plight of the "homeless mentally ill."  Why the quotation marks?  Well, first I'd like to differentiate those who are homeless from those I prefer to call 'street people.'  You are homeless if you are an adult without a stable residence, and most people who are homeless are not sleeping on the streets.  They may be in shelters, in motels or the single room occupancies, or staying in the guestroom or on the couch of a friend or relative.  Those who are actually sleeping on the streets are our society's sickest and most disenfranchised members.  The quotations also serve to remind me that "the mentally ill" is not a term I like to use: these are people with psychiatric disorders, not to be defined by those disorders.  While many like to talk about the plight of the homeless mentally ill, I'd like to suggest that as a society, we should invest our resources in helping all of our countrymen who sleep on the streets, whether they are mentally ill, addicted, or simply indigent.  

In a wealthy country such as we are, the fact that there are people who spend their nights on the street should be a source of shame to all of us.  Logically, this can't be about money: there is nothing cheap about leaving people on the street-- to start with, they have high medical expenses, and high incarceration rates.  One way or another, they cost us all money.  Personally, I don't believe it should be legal to sleep in public places, and as a society, we should feel obligated to provide sick and destitute people with  more than a nighttime cot in a room with other people where they may not be safe.  

If you've followed my Shrink Rap posts, or read our book, Committed: The Battle Over Involuntary Psychiatric Care, then you know that the issues of involuntary treatment are nuanced and complex, and that I think it should be avoided when possible as there is the risk that involuntary care leaves some people feeling  traumatized and angry, and because we all cherish the right to make our own medical decisions.  You also may know that I'm not much for invoking "anosognosia" as a reason to force people to have treatment, and do see my post on this over on Psychology Today.  But you may also know that I believe there are times when there really seems to be no choice but to force treatment, and when it is simply the right thing to do to keep everyone safe.  A traumatized patient is better than a dead patient.  

So what about Nakesha Williams, and others like her who are "dying with their rights on."  I messaged Mr. Weiser, the NY Times journalist, and asked him if she had ever been treated.  In the article he talks with friends who have tried to get her help, and with case workers from a mental health agency who tried to engage her, all of which she refused.  Mr. Weiser thought Nakesha had been in treatment briefly when she was younger--he didn't know for sure if she had ever taken medications-- but it does not appear that she had any treatment in the years she lived on the streets of New York City.  Her family had long before lost contact with her.

So Mr. Weiser didn't say it, but I will: if people suffering from psychosis are living on the streets, unprotected from the elements, at risk of illness or of being prey to criminals, and they are so ill that they are refusing offers of housing, healthcare, and help getting financial entitlements, then they should be hospitalized and treated against their will.  As traumatic as forced care can be, I believe it is preferable to the obvious risks people on living on the streets face each and every day, and would offer them a chance at a safer and more productive, less tormented existence.  Ms. Williams was certainly a risk to herself, and her story is one of society's shame. 

So do we need new laws to get Ms. Williams and those in her situation care?  I don't believe we do: she was a risk, as can be seen by her untimely death, and as I've said above, I don't think it is a person's right (or it shouldn't be) to live in public places.   Would treatment -- and in this case, I specifically mean antipsychotic medications-- have changed her life?  I don't know, but I would hope so.  

There, I said it.  Now please let me add a plug for Housing First options that place people in housing without first requiring them to be free from drugs or alcohol, or to accept psychiatric care, as a condition of housing. 
----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.
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