Turn Your Head and Scoff

2006-09-13T15:35:00.000-07:00

If you're wondering why no new posts, it's because I'm now HERE. You should be re-directed in 10 seconds. It's a long story, but it has to do with Blogger-BETA. I was blocked from this site for 2 weeks, so I moved everything. Same content, different setting. Hope to see you!

Are We Clear? Crystal.

2006-08-30T15:08:00.000-07:00

My first patient had me thinking of a number of things at once. The first thought was of one of my first clinical instructors, who described his process of differential diagnosis: "I ask questions, and I keep asking questions until I have a crystal clear image in my mind of what might be wrong with this patient." I also thought of the "clinical tales" of Dr. Irvin Yalom, where he initiates the assessment with the simple words, "What ails?" Questioning. "What brings you here today?" "How can I help you?" And, of course, the ever-poular, "So, what's up?" Now, be sure to read Dinah's interesting take on what people talk about in therapy (before she thinks I have again stolen from her): "I've taken to giving patients fairly specific instructions about what I want to hear, what I think will be helpful to them." This, I believe (and feel free to correct my presumption, ShrinkRap), presumes you have already determined what is wrong; what needs to be "helped."

This patient presents with the textbook affect of major depression: sad face, slow shuffling walk, eyes averted, shoulders hunched. He has a fundamental lack of animation, absent range of emotion, soft and pressured speech. Yet, when he speaks, his vocabulary, thought process, and general "fund of information" suggests that he is quite intelligent. But like a prepared witness, he offers no more than what I specifically ask. Sleep & appetite disturbance, lack of motivation, doesn't seem to enjoy much of anything; about two years ago, when he was especially depressed, he admits to hearing voices. The voices have continued, and now he "sees shadows or ghosts" in his peripheral vision; "When I turn to look, they're gone." "Why are you here to see me?" "I need to re-apply for Social Security Disability." Disability? This is an anomoly among these patients, generally, because to qualify, you must have an actual history of work, "on the books," and have actually paid taxes & FICA. This is only the second request in as many years.

It turns out he has an AA degree, was going to night school to get his BA, and had a "niche" job in a major technology company because he had training in an unique specialization. Until the "accident." "How did you get on disability?" "I got in an accident at work and was injured." "What happened?" Nothing. Silence. He is looking at the floor and remains unresponsive. I wait a reasonable moment and gently say, "Can you tell me about the accident?" Tears begin rolling down his face, but he makes no eye-contact, nor provides a response. He has now dropped his head in his arms onto the table. Again, I wait a reasonable moment and gently say, "In order for me to help you, you have to help me understand." Another silence, and finally, "I'm sorry. I just can't talk about it." Wow. OK.

As I consider the next course of action, I offer him some water, and finally ask if he believes he can continue. Factually, if he is filing for SSDI for a physical disability, I really don't need a psych work-up, and I also realize that under these circumstances, I shouldn't be seeing him in the first place. This fact is made more prominent when he tells me that he has a $50,000 brokerage account and a trust for his children. But equally factual is that applying for disability doesn't take a lot of time or effort, and there is no harm in helping him. He signs the forms, I ask the minimal questions, and we're done.

Lastly, I ask, "What is your controlling case?" (i.e. the crime that brought you to prison). Without a hesitation and with direct eye-contact he casually says, "Forced oral copulation of a minor with violence, and possession of a controlled substance." WTF! I am shocked at the bluntness of his statement; like he had just told me the Padre's score. After he leaves I get his chart: First-time offender. Depression NOS, Mirtazapine 45 mg. q hs. Axis III, "lower back pain." Report of radiology consult of the lower back: no evidence of trauma or derangement, inconclusive. Absolutely no reference, not one, to any accident.

"You can't handle the truth!"

My Friend Sophia: About Pride & Joy

2006-08-28T16:14:00.000-07:00

Today, my friend Sophia, a Deputy District Attorney, spoke to my team about prison gangs, at my invitation. Her presentation (yes, PowerPointed) was exceptional, and staff told me that it was among, if not the single best presentation in the 2 previous years. To be honest, I was hardly surprised, because you have to know Sophia.

Sophia comes from an unique family: her father is a second-career teacher (after computer support of medical software), and body-surfs in the Pacific every day of the year; her mother is a second-career Public Health Nurse, investigating infectious disease; her brother, now "retired," is a world-champion surfer, whose unique pose adorns many a surf shop in CA (When I worked with adolescents, I had a signed poster, and kids would say, "You know Paul!!!" Yup); one sister received her doctorate in Literature and teaches in the UC system; and her younger sister is a gifted poet and artist.

Sophia graduated from high school and immediately wanted to get married. Her parents were not pleased, but eventually supported her. Her husband came with 2 very young daughters in his custody. Her husband turned out to be a "drugado" and a jerk. Sophia booted him to hell out and divorced. But there was the matter of these 2 young girls. Her ex-husband was nowhere to be found; the natural mother had lost custody because of her drug use; and the only options were keeping them or placing them in foster-care. For Sophia, there was no choice, and she became their foster-mother. They lived on ADFC & the foster-care stipend - the father was ordered to pay child support, but obviously did not. Sophia struggled, worked, and went to college at night. Given the circumstances, and undoubtedly the genetics, Sophia's daughters posed many behavioural and emotional problems; problems that led some to gossip, and others to outright suggest that she "bail" - "They're not your kids." This was the wrong thing to say to Sophia, and only strengthened her resolve to do what was right: she was the only parent they had known.

Sophia tested, applied, and was accepted into a prestigious law school, and everything was upward from there. Upon graduation, she was immediately hired by the District Attorney's Office, then passed the CA Bar Examination on her first attempt. She began with arraignments, moved to prosecuting domestic violence, headed the Task Force prosecuting gangs (in a corridor where most drugs are moved from Mexico, through San Diego, and on to LA), and now she prosecutes some of the most notorious and publicly-scrutinized cases in the County. More importantly, both of Sophia's daughters graduated from high school, and live lives beyond what anyone could have imagined - except Sophia. In my mind, they will always be a tribute to her love for her daughters.

And so, I hope the extent of my pride, admiration, and respect over a "presentation" is obvious. I have felt honored all day by my friend Sophia.

On Innocence

2006-08-23T17:46:00.000-07:00

I called out the name of the next patient into a room of approximately 50, lined up on benches facing each other. A young man stood up at the farthest end, dressed in orange, blond hair that exposed and inch or so of black roots, He leaned over and hugged the man next to him, then literally bounded across the room with a smile on his face. I said, "Good morning," and he extended a limp hand, which I reluctantly shook.

I have a general rule about not touching patients. Perhaps I was unduly impressed by a lecture that focused on touching as "manipulation" (e.g. giving the message of "Please like me; don't hurt me"), perhaps I am overly-sensitive to professional "boundaries," and it certainly flies in the face of "auscultation, percussion, and palpation." Likewise, many of my colleagues emphasize that prisons, in general, are "filthy places," and the alcohol-gel hand cleaner is as common to them as a whistle. All of which is humorously ironic when a delusional patients says the same thing; one man told me he makes a "paste" of liquid handsoap & toothpaste, convinces the CO's to give him a pair of surgical gloves every Sunday evening, and by coating his hands for an hour he is "protected" from prison contamination for the week. Some colleagues use the "technique" of always having a pen or paper in hand, thereby discouraging touch. I emphasize that I am never rude - if a hand is extended, I will generally shake - but I am always cognizant of the level of violence & danger. But this is a post about innocence.

My young patient took a seat across from me, and the first thing I noticed were the long scars of self-mutilation on the top of his arms; easily a dozen on each arm. He had large doe-eyes that were locked on me, but he had little range of affect. He had fixed delusions, mainly of a judgmental. religious nature. Voices tormented him with deprecation of his past "evil life," which included his father who was murdered on the streets by gang members over drugs. A father with whom he learned to get high at age 14. Now, his father's voice scolded him as a "loser."

The first thing he said to me upon being seated was that he was not going to accept the disability "discount" the county gives for a monthly transit pass, because he was not "grateful enough" for being saved from death. He was so concrete that I found it necessary to be careful what I said, but when I asked what activities or hobbies he enjoyed, he said, "I love to fish, feed the birds, go to the mall," and very pointedly, I love girls." I spontaneously laughed, and for a moment his face was blank, wide-eyed, but just as spontaneously, he too began to laugh and extended his hand in a sort of "high-5" motion saying, "dude." Now, in prison inmates tap fists in greeting or dismissal, but staff never engage in the same manner with them. One CO even complained to me that a group of CO's had seen one of our staff exchanging "fists" with a patient. "What is he? One of their buddies?"

With a pen in my hand, I gently returned the hand motion. Why? In my heart, he was so sick, so disabled, so helpless, that he was an innocent. And as it turned out, he was a non-violent thief; stealing things from stores to sell for drug money, stealing from his family. I did not know this at the time. When we finished, walking him back to the CO's, he was grateful for my help, but he did not attempt to shake hands. But he did wait until I had gotten the next patient, and as I passed he waved good-bye.

This has only happened to me on one other occasion, and it was in the hospital at San Quentin. A man in his late-50's, who had served 24 years of a life-sentence for murder, much of it spent in the hospital, was now about to parole. He too was very ill, very gentle, very child-like. In fact, he could think of no positive reason to be leaving: his day was structured & predictable; he had his own cell with a window he could open to both see & experience the bay through bars; and he could feed the birds. His only concession was that he did want to see his elderly parents before they died, but he would gladly come back. As is typical, I interviewed him in a room barely large enough for the two chairs we sat upon. When we finished, we stood up, he thanked me, and suddenly and unexpectedly, he hugged me. It happened so fast that I didn't have time to feel either threatened or shocked. He then turned and went out the door. When I got into the hall, I told a female CO what had happened, and she literally gasped: "Oh. my God, are you OK?" When I got back to the office, my colleagues responded in exactly the same way, "You could have been killed." But he was an innocent.

This is the daily dilemma of working with the gravely impaired, dangerous, and violent. Walking a maze of professional behaviour, providing a level of care that approximates the community, acutely aware of your own safety, and the demands of your humanity. It's a bitch.

Do You Solemnly Swear?

2006-08-22T21:26:00.000-07:00

A member of our clinical team did an assessment of an inmate two years ago, whose diagnosis was Major Depression. A year latter, apparently after using PCP and marijuana, he he got in a morning dispute, shot one man to death and injured another. By noon he was in a second dispute, killing another man and injuring the man's brother. By afternoon, he had killed another man and injured another. By the time the police caught up with him, he had terrorized two more people with an empty gun, the fact of which they were unaware. He was reported as shouting "I am the devil" as he was shooting. He was charged with 3 murders and 4 attempted murders, and in CA, the circumstance of multiple-murders qualifies you for the death penalty. He refused to allow his attorney to raise the issues of drug use or his psychiatric history. He was convicted after 4 hours of jury deliberation. The sentencing phase began today, and my colleague was subpoenaed by the defense for this coming Monday, as it attempts to convince a jury to spare his life. In my mind, this is a clinician's nightmare.

As I read the clinical note, it basically described a man who had been in jail a majority of the past 20 years, apparently had a difficult time on the streets, and reported that he occasionally, purposely, committed a crime in order to "get a roof over my head." While he reported feeling "a little depressed," he was taking medication which he indicated as "helpful." There was no evidence of frank delusion, thought disorder, psychosis, anxiety, or cyclical pattern of depression; in other words, he met the diagnosis for Major Depressive Disorder. He was diagnosed as Antisocial Personality Disorder - and I am usually cautious with this diagnosis, in that some who are "difficult" forensic patients are given this diagnosis without a corroborating psychiatric & criminal history. But in this case, the suggestive criminal history was present.

In hindsight he made two comments, that my colleague quoted in the note, that are suggestive. When asked if had thoughts of harming or killing anyone, he denied them. I have had numerous patients tell me sarcastically, "I'm in a maximum security prison; I have them [thoughts] every day." But do you have a plan? This patient stated, "I have gotten mad enough where I could have killed someone." When asked of his future plans he said, "When you have nothing, you have nothing to lose." In and of themselves, these two comments are certainly not predictive, but they are undoubtedly open to interpretation. My colleague is being asked to provide context to these comments.

A small group of us sat around this afternoon discussing this situation. As you might expect, my colleague is anxious. I suspect that too many movies and too much Law and Order has her believing she will be "torn apart" by an attorney. Factually, she did not diagnose or provide him with any form of treatment. Apart from her case note, she vaguely recalls this patient and her single interaction with him. We "Googled" the case to get the details, of which we are now intimately familiar. We don't belong in court. We work in a forensic environment, but we are not forensic experts.

I have been thinking this evening that if a defense team (and I suspect an underfunded court-appointed defense team) feels compelled to utilize the testimony and single-page case note of a one-time interaction with a truly peripheral clinician to aid in a Death Penalty defense, "justice" is an extraordinarily loose concept. In fact, I find it too pitiful to imagine.

Put Your Hands, Put Your Hands in the Air

2006-08-19T21:59:00.000-07:00

After reading that NeoNurseChic received her passport and eagerly awaits a trip, I recalled that, for whatever reason, I have difficulty traveling. Well, to be honest, whatever reason isn't exactly accurate.

I have previously alluded to my generalized scruffiness, an issue over which I am not particularly apologetic. I have yet to have a convicted murderer tell me that I was inappropriately dressed for the setting. This generalization, unfortunately, has made its way beyond my mere persona, and invaded my documents: my passport. Anyone who has seen my passport photo comes to the conclusion that I "look like a terrorist." It's a combination of the tan (SoCal - walking the yard), hair (too much & too mangey), black t-shirt & dungaree jacket (with up-turned collar), and gross profiling. I have been heartily "examined" by customs agents in foreign countries, and every single time I have returned from Canada, I have been pointed to the "Secondary Inspection" and my car has been searched. But I also add that in order to be admitted to a CA Sate Prison, I have been "background checked" by the US & CA Depts. of Justice, fingerprinted twice, and photographed & background checked yearly. This leads to a description of a visit to Mexico.

It is simple to cross the border into Tijuana (and notice the spelling - it's generally pronounced TIA-wana, when, in fact, it is pronounced ti-WANA). You walk through a tall turnstile, like leaving the NYC subway, where you can enter but not return. About 25 yards and a marker on the ground delineates the actual border. Keep walking and you come upon an office posted with a, generally, young man in a uniform with a large automatic weapon. Oddly, on the right is a traffic (people?) signal, mounted at about eye-level on the wall. It is never lit, and I have yet to determine its purpose. Within walking distance of the border are large plazas with more pharmacies than you have ever seen in one place in your life: "Lowest prices in Tijuana!" Intermixed are jewelry, leather, and liquor stores; dentists, especially the very notable Dental Felix (amazingly in Google Images!); doctors, known for just providing "prescriptions" (some medications are controlled in Mexico); and many restaurants and clubs.

My purpose on this particular day was to have lunch with a friend. It was "June gloom," the time of the year when overcast skies rules. I had a sweatshirt on, but as the day progressed, I removed the shirt and tied it around my waist. With the increased security at the border (except for the Arellano Felix family, who apparently could get anyone & anything across the border with no difficulty), the auto traffic wait is horrendous, and now even the walking wait was equally horrendous and can take more than an hour. The sign says, "busiest entry point in the world." WTF, I've been to Motor Vehicles in NY. Cue up.

Now, I interact with law enforcement frequently, but I mysteriously experience anxiety around local police and "La Migra," the Border Agents, INS. I immediately begin to feel guilt and I have no insight. Anyway, the first odd thing to happen was that I was approached by an officer leading a drug dog, in this case, it was a small Springer Spaniel; not exactly my idea of a "border protector," but the officer was kind enough to explain their sniffing ability. I learned something.

To enter the US from Mexico, you must first pass the INS; generally, show your driver's license, they may or may not ask where you were born, and keep moving. There are computers available at every INS agent station, but I have never even seen them turned on. Whatever... Next, if you have anything to declare, US Customs officers are waiting with x-ray scanners. I had brought nothing back, but as I passed by, an officer called out and asked me to approach. He asked me, "Sir, what is that in your waistband?" I started to say, "It's just my sweatshirt tied.." and as I reached to raise my t-shirt, he screamed, "PUT YOUR HANDS IN THE AIR!" I didn't even have time to panic. "I will check your waistband." As he checked, I weakly said, "It's just my sweatshirt." When he finished, I asked if this really had been necessary. "It was for our protection. You're free to go." As I walked away I heard him say to another officer, "You have to be very observant about things like that."

When I get a haircut, I usually begin the negotiation with, "I am not in the military," this being a big military town and all. But maybe in 6 months when I go for a haircut, I shall reconsider. My passport expires in December.

How Different is Dangerous

2006-08-18T17:18:00.000-07:00

I saw a transgendered inmate today, and it caused me to inquire how she fared in an all-male prison. She said, "I'm really harassed by the Neo-Nazis, but I have a group of people who watch out for me, and I draw strength from them." Hmm. Yea, I kind of feel the same way about the Neo-Nazis. But what was most disturbing was her discussion of how she is treated by staff, given the circumstance of the Plata decision that placed the CDC medical system in receivership. This patient has chronic hepatitis B and hepatitis C, leading to cirrhotic asceties and esophageal varicies from Portal hypertension (This was of notable interest to me after a recent seminar on HCV/HCC/HIV that I recently attended - who would have thought...). He was vomiting blood one night, and no staff would believe anything was seriously wrong. He bled for several hours before his cellmate "acted the fool" to draw attention and they took her to an outside hospital. This reminded me of the story of Jennifer Sutton.

I attended safety training ("Block Training") at a prison that is a medical facility. It is always a mixed group of employees - from physicians to gardener's - and you sit through discussion that have no application to your duties (you may know how fond I am of such occasions), such as 2 hours of "Weapons and the Use of Deadly Force." Whatever... At some point in my wilting afternoon, a person from HR came in to do a presentation regarding sexual harassment. Now, for an environment known for the harassment of women, this was a truly lame presentation (and God bless all female CO's and Clinkshrink). Lame enough that some support staff broke into a discussion of transgendered inmates: "If one talks to me, could that be considered sexual harassment?" Yikes! This quickly evolved into hostility, religious belief, and discrimination. I suffered this as long as possible before, in a polite & professional manner (and you know I am), discussed the conflict with these "opinions" and California law. Yea, there are definitely some conflicts. The HR person stood there without comment. I left the training watching my back.

I cannot say I conceptually grasp the developmental transgender, or for that matter, gender assignment and sexual orientation. Is it genetically influenced, bio-psych-social-environmental as is evidenced-based medicine? On the single occasion a patient came to me for therapy, required for gender re-assignment, as is living as the other gender and receiving hormones, I had to honestly say that I was unqualified to provide what I believed to be and appropriate treatment, and made a referral. I will not end this without commenting on the issue of countertransference & prejudice. Since this is an unconscious process, it would seem incumbent upon a clinician to become aware of their operation and influence. Further, I recall once asking Dr. Otto Kernberg why I had felt increasing anger as I evaluated an abused woman, given that countertransference is classically thought to be based in personal experience (and I've never abused a woman - thought I'd throw that in), he described the phenomenon of projective identification, whereby an individual will "project" a feeling, thoughts, or beliefs onto another, and the other will feel or act as if they share the feeling or thought. As with countertransference, projective identification is an unconscious process..

All of this is to say that the difference between countertransference and prejudice is that, while the former is unconscious and the latter is conscious, both are equally capable of destroying therapeutic relationships. Likewise, the former is discoverable & correctable, and the latter is ignorant and ugly.

You Started Somewhere

2006-08-16T16:15:00.000-07:00

You too were young once & started somewhere. Axis Deviation has good Karma and makes it worth while to remember. And he's from SoCal.

My Lucky Damn Day

2006-08-16T13:31:00.000-07:00

Having just received this e-mail, spam-filtered through a major research university, this is to advize you that I will no longer be posting from "America's Finest City," but rather from my as-yet-to-be-determined tropical retreat. When the cheque clears. Please, share in my joy:

Dear Winner

FROM: THE DESK OF THE PROMOTIONS MANAGER, INTERNATIONAL PROMOTIONS / PRIZE AWARD DEPARTMENT, UK NATIONAL LOTTO PROMOTION, HEADQUARTERS: 10 NORTHUMBERLAND AVENUE, LONDON WC2N 5BX, THE UNITED KINGDOM.

REF NO.: UK/61230235017/06
BATCH NO.: 82/00613/PUK

RE- WINNING NOTIFICATION / FINAL NOTICE

We happily announce to you the draw number 620 of UK NATIONAL LOTTO PROMOTION, UNITED KINGDOM / INTERNATIONAL, PROGRAMS which held on the 7th of August 2006.

This result is today released to you and your e-mail address is attached to ticket number: 014-026-433-162, with serial number 3217-22 drew the lucky numbers 80-62-14-53-11-70, which subsequently won you the lottery in the 2nd category.

It is our pleasure to inform you that you have emerged as a Category "B" winner of the UK NATIONAL LOTTO PROMOTION.

You have therefore been approved to claim a total sum of One Million, Five Hundred Thousand-America Dollars ($US1, 500,000) in cash credited to the file REF NO. UK/61230235017/06. This is from a total cash prize of Twenty Five Million, Five Hundred Thousand-American Dollars ($US25, 500,000), shared amongst the first seventeen- (17) lucky winners in this category “B". Please note that your lucky winning number falls within our European booklet representative office in Europe as indicated in your coupon.

In view of this, the Certified Bank Check of your One Million, Five Hundred Thousand-American Dollars ($US1, 500,000) would be released to you by our finance firm in London, U.K. They will immediately commence the process to facilitate the release of your funds as soon as you contact them.

As a category "B" winner, all participants for the free online lotto version were selected randomly from World Wide Web site through the computer draw system and extracted from over 100,000 names / companies from Africa, Australia, New Zealand, America, Europe, North America and Asia as Part of International Promotions of the new year Program, which is Conducted quarterly. After the computer ballot of our International Promotions Program, only first seventeen- (17) lucky winners were emerged in this category and therefore both are to receive payouts of One Million, Five Hundred Thousand-American Dollars ($US1, 500,000) from a total cash prize of Twenty Five Million, Five Hundred Thousand-American Dollars ($US25, 500,000), for this category’s winners.

This lottery program was organized by the philanthropist group of computer software’s manufacturers here in U.K. while it was promoted and sponsored by the eminent personalities like, Bill Gates of Microsoft Inc, Carly Fiorina of Hewlett Packard, the sultan of Brunei, Multi Choice Company and other corporate Organizations. This lottery program was organized to improving the use of computer software and for the benefit of every Computer user.

Due to the mix up of some numbers and names, and for security reasons of the winners’ won prize, you are advised to keep your winning information confidential till your claims is being processed and your Certified Bank Cheque is being received by you.

This is part of our security protocol to avoid double claiming and unwarranted abuse of this program by some unscrupulous elements, so be warned.

Moreover, it should be noted that the below contact information is our Category "B" fiduciary agent who is your claims agent whom you will contact for the claiming of your won prize.

MR. MAXWELL WESLEY FOREIGN SERVICE MANAGER, VINTAGE INVESTMENT SERVICES PLC.
Email: maxwellwesley@openforyou.com
Email: maxwellwesley@mailpersonal.com

And to file your claim, you should send to our aforementioned Category "B" fiduciary agent who is your claim agent, the needed information as requested below for the processing of your won prize. And for the prompt / due processing of your won prize, you are advised to send to your claim agent the correct information in accordance with the required information as stated below.
YOUR FULL NAME:
YOUR AGE:
YOUR SEX:
YOUR OCCUPATION:
YOUR TITLE OR POSITION:
YOUR BATCH NUMBER:
YOUR REFERENCE NUMBER:
YOUR COUNTRY OF ORIGIN:
YOUR TELEPHONE NUMBER:
YOUR FAX NUMBER:
YOUR FULL ADDRESS FOR THE POSTAGE OF YOUR WON PRIZE:

However, it should be also noted that all winners should state clearly to us the MODE/OPTION of their choice with which they will want their won prize’s Certified Bank Check to be received by them, either they will prefer to go to our cash payment office in Spain for the personal collection of their won prize or they will want the Certified Bank Cheque of their won prize to be couriered to them in their Country, as this will be in form of an agreement to be made between us and winners concerning the mode of receiving their won prize.

Hence your full contact address (home or office address) is compulsory to be forwarded to us for the postal delivery of your Certified Bank Chequed if you will want the Certified Bank Cheque of your won prize to be couriered to you in your Country, while you need not to forward your address to us again if you will prefer to our cash payment office in Spain for the cash collection of your won prize.

Besides, any winner who is willing to go to our cash payment office in Spain for the personal collection of his or her won prize must not only compulsorily have a valid working permit attached to his or her traveling visa for the evidence of the said winner being eligible under the act of the Spanish Monetary policy to receive such huge amount in cash from Spain, but the said winner must also have to be in Spain at least 5 working days before the expiration of the given deadline, if the said winner really want his/her won prize to be personally collected by him or her in our office there in Spain, this is due to the fact that some necessary documentation must be processed and signed by the said winner for the processing of the won prize’s personal collection, instead of our Attorney who would have signed for the said winner on his/her behalf, should the Certified Bank Cheque of the won prize will be Couriered to the said winner in his or her Country of location.

With this information properly given to the aforesaid fiduciary agent, we will then go ahead and process your won prize, while your winnings Certificate and all other relevant documents for your payment accreditation including your won prize will be prepared and sent to you after proper verification and authentication of your claims information.

Finally, it should be noted that all won prize must be claimed not later than 5th of September 2006, while any claim not made before the aforesaid date will be returned back to the UK NATIONAL LOTTO PROMOTION as unclaimed won prize.

NOTE: In order to avoid unnecessary delays and Complications, endeavour to always quote correctly your REFERENCE and BATCH numbers in your correspondences with your claim agent exactly as stated above on this very message

Furthermore, should there be any Change of your address, do also inform our fiduciary agent who is your claims agent as prompt as possible.

NOTICE: Be informed that only ENGLISH RESPONSES will be attended to / treated by us since English remain our general language while any response with another language will be automatically disqualified the said winner from this promo.

Congratulations to you once again from all our staff for being lucky to be part of our promotional lottery program, and it is our hope that apart of your won prize, you will participate in our middle of the year high stakes of US$75.5Million International Lottery.
Sincerely,

MRS. JESSICA HARRISON The Promotions Manager,
UK NATIONAL LOTTO PROMOTION, UNITED KINGDOM.

N.B. Any winner below age of twenty (20) is automatically disqualify from this promo while any breach of confidentiality on the part of the winners will also result to disqualification.

Now, I could just stay put, perhaps send you all a drink coupon (Cheers!), buy some meds for the elderly, feed and clothe the poor, or rescue some damsel. But to be honest, I much too greedy for that. And apologies to SHP for robbing her national coffers. By God, I'm giddy.

SHIT! Did I just breach confidentiality?

NEXT: My Nigerian betrothal...

Comment and See What Happens

2006-08-15T19:29:00.000-07:00

If you have not seen the blog of the President of Iran, Mahoud Ahmadinejad, it is available in four languages. To this Great Satan, it's a bit of a bore, all in all, but, hey, it's a new concept.

Death Be Not Proud, Part 2

2006-08-15T07:19:00.000-07:00

Dante wote of the 4th Division of the 9th Circle of hell, a place where "I did not die, and I alive remained not." A placed reserved for Brutus, Cassius, and the greatest betrayer, the one who suffers the most pain, Judas Iscariot. In Dante's vision, the misery of hell went no further than this, and from this point forward, one can only ascend. In California, this place is the Adjustment Center.

The Adjustment Center is visible immediately upon entering the prison proper. White, quiet, with a hand-drawn sign above the entrance. A well maintained lawn with trees and bushes lie before it; a lawn from which Larry King recently conducted two evenings of "softball" interviews with lifers, who all happened to know nothing about drugs, sex, or abuse in San Quentin. Both its name and appearence would suggest the banal or the benign, but in fact, it holds approximately 90 of the "worst of the worst" of condemned men: Richard Allen Davis, the murderer of 12 year-old Polly Klass, and blamed by all CA inmates for the "3 Strike Law"; Richard Ramirez, the "NightStalker" who hailed Satan at his sentencing; Paul "Roscoe" Tuilaepa, considered the most dangerous man in San Quentin, who plotted to take over the Adjustment Center, not to escape, but to "kill as many CO's as possible"; and George Jackson, Soledad Brother & Black Panther who used a smuggled gun in an escape attempt, and murdered 5 before he himself was killed. Gang leaders, those segregated for safety, those violent in North & East Blocks, and those who assualt staff on Death Row appear here. There is AdSeg, SHU, and SuperMax, then there is the AC.

To get inside The AC, it was necessary to enter a small watch building approximately 50-yards from the entrance. Your ID is inspected and your business is determined before the CO places a call into the AC to announce you. S/he then walks you the 50-yards to a small caged entranceway, unlocks the gate by hand, and locks you in. Through an intercom mounted on the wall, you buzz, and again identify yourself and your purpose. The anxiety I felt reminded me of Dorothy at the Gates of the Land of Oz, having no idea what to expect. The door opens manually, is locked behind you, where another gate is manually opened, and you are in.

The differences between East-Block and the AC are marked. First and foremost is the quiet; footsteps, muffled conversation by CO's, and the occasional raised voice as a CO spoke to someone in a cell. The facility is immaculately clean as if sterile. The cell block is SuperMax, single-cell isolation, and it appeared that a lot of noise would have to be made to be heard. Recreation, for those allowed, is an hour per day, 3x per week, alone in what is basically a dog pen, like at the kennel, for men. I was immediately struck by the CO's themselves: enormous, muscular men with green jumpsuits, pant-cuffs tucked into their black boots; full bullet-proof/stab-proof vests and helmets with flip-down faceshields; and surgical gloves. Attached to them was a body alarm, baton, massive cell and gate door keys, handcuffs, and a large pepper-spray canister strapped to their legs. If the point was to be both imposing & intimidating, it certainly worked on me. As I was signing the log book, and acutely aware of my own anxiety, I stupidly mentioned to a CO, "My back hurts today. I could use a little adjustment myself." He slowly looked up at me, "Don't even joke about this place. You can't go lower than this." Yes, sir.

Again, I am here to see the mentally ill, non-condemned, who were violent, assaultive, or unmanageable elsewhere. To interview a patient, you stand in front of what is essentially a "bay window" made of cell bars. A CO pulls down a massive wooden lever in the wall, a metal door slides open, your patient steps forward, and the metal door slides closed behind him, leaving an area of approximately 3 feet by 4 feet in which he stands. And everything is accomplished standing. I was surprised to find the AC patients significantly less psychotic, but not surprised to find them markedly more aggressive, more angry, more agitated. How do they get here? One young man was diagnosed with Bipolar I Disorder (most recent manic), and during the course of anxiety-reducing "self-pleasure," he was interrupted by a CO. The patient insisted the activity was symptomatic of his mania, the CO insisted he cuff up, he "accidently" struck the officer, and here he has resided since.

Imagine our mentally ill patients, held, not only in isolative conditions, but among psychopathic serial murderers, sexual preditors and murders of children, and gang members and leaders who have murdered and ordered the murders of others, paroled from Death Row directly to the street. What have they become, and what will they become from this experience?

I oppose capital punishment. The logic begins with the ethics, continues with the lack of demonstrated cost effectiveness , and concludes with a lack of demonstrated deterrence. This seems simple and stratightforward. Until I hear of a particularly heinous, particularly senseless crime. Then, for the moment, the logic gives way to outrage, vulnerability, helplessness, and a demand for justice. If you have not read Clinkshrink on the senseless murder of a corrections officer in Maryland, you should. Nevertheless, it is absolutely clear to me that the need for justice that I feel is, rather, the need for revenge. And when I become aware of this feeling, I can again resume my ethics and logic. But this is not a post about capital punishment, but about walking on Death Row.

Death Be Not Proud, Part 1

2006-08-13T18:29:00.000-07:00

I was at San Quentin State Prison doing my usual business. It was an interesting several days that included being forced to see patients in an extraordinarily cold x-ray room because no other space was available. I joked with the patients that I had to "ask a bunch of question, take your picture, and we're done." "What?" "I'm kidding, dude." I moved to to a secure unit to conduct assessments in a claustrophobic, windowless room with an elementary school-sized table and two ancient wooden chairs. The lieutenant informed me that 5 patients from "E-Block" could not be escorted over, and offered to take me to them. As we left, we passed an open "emergency equipment" locker that, among gas masks and batons, contained about 25 of the biggest rubber mallets I have ever seen. They reminded me of the county fair "test of strength"; use the giant hammer to ring the bell. I did not ask how these mallets were utilized.

The lieutenant led the way through hundreds of men waiting to get to the dining hall. "Make a path, men! Coming through!" Shoulder and elbow banging with inmates for 50-yards or so is, at best, nerve-wracking. Pointing, he instructed me, "Go through that gate, turn left, and go straight ahead to the door. Pick up the phone & they'll let you in." When I had turned left, I was facing an odd, lime colored wall and matching colored metal door. Above the door was a handwritten sign, "Condemned - East Block." Condemned? This is Death Row.

As it turns out, CA has three death rows: North Block, East Block, and the Adjustment Center, each with an increasing level of security. Oddly enough, San Quentin is not a maximum security prison, the majority of inmates at San Quentin are Level II security in a IV security level system. But 639 men are currently held between the three AdSeg, maximum-security Death Row units. North Block holds 70 inmates and is the original condemned facility, built in the late 1930's. North Block is a "prime location" in that admittance is by petition to the classification committee only. It is a relatively relaxed, generally non-violent housing unit, a significant distance from the main facility. Donald Beardslee, however, who lived in North Block for 21 years, was executed in 2005 despite clemency pleas to the governor emphasizing his model behaviour on the North Block. The vast majority of Death Row inmates are held in the East Block.

Upon entering East Block, there are two further gates at which your ID is checked and you sign the log indicating your presence. E-Block is an enormous building, with a massive cell block sitting in the middle of the building. As you stand facing the block, the Yard Side is to your left, and the Bay Side to your right, 54 cells long and 5 tiers high. Each side has a separate gate for access. Catwalks run atop the cell block, and gunners, who only shoot to kill, walk silently to observe from above. The amount of razor-wire contained in this building is astonishing.

I don't know exactly why, but I somehow presumed Death Row to be a contemplative place; condemned men living "exemplary" lives in contrition, attempting to demonstrate either their innocence or their rehabilitation as their appeals wind through the courts. I was wrong. E-Block is deafeningly noisy: hundreds of "conversations" being yelled at once; the usual pointless screams, yells, and animal noises; a virtually unintelligible PA system, giving constant orders or information, it is unknown; and an unrelenting hum/buzz combination that may be lights, electronics, or electricity. My first thought was that, for me, daily subjection to this level of noise would be unbearable, without even considering other factors. The air is damp, mainly from the bay, but pipes on the walls of the buildings leak, streaking rust down the sides of the white walls. And with 450 or so men with limited shower privileges and a dank old structure, the smell is awful. Since the passing of Proposition 7 in 1978 to restore capital punishment in CA, 14 men have been executed. They averaged nearly 19 years on Death Row before execution. I happened to at San Quentin while the sentencing phase of the Scott Peterson murder trial was happening. I looked around E-Block and thought, what hell on earth could be worse than this? Could dying be this awful?

You might wonder why, when I deal with pre-parole inmates with a mental health designation, I would find myself on Death Row. It is because some of the most violent, seriously mentally ill inmates, unmanageable in a Level II prison, are housed on the ground tier of Death Row. The only "saving" aspect to this classification of housing is that, for the most part, they are oblivious to their location. Many of their cells can be immediately identified because a large clear plexiglas screen stands in front of their cell to prevent "gassing," the throwing of any fluid, though it is nearly always bodily, onto custody staff. A CO pointedly described an inmate who held urine, feces, or a combination of the two, in his mouth and spit it on the CO who brought his breakfast.

On the Bay Side lower tier are physician offices, and it is here that these violent, grossly mentally ill inmates become "patients." They are double-escorted by 2-3 officers wearing stab-proof vests, helmets with faceguards, and surgical gloves. Patients themselves wear bright yellow jumpsuits held together by three ties in the front, and are handcuffed with their hands behind them, and many are outfitted with spit bags. They are locked into the cages seen across from the physician offices, and one by one, they are led into the dimly-lit office and locked into a similar cage. Approximately half are then uncuffed through a port, and sit on the built-in seat. A one-piece classroom desk was placed a distance from the cage, and the CO suggested, "for your own safety," that I not move closer.

By this point, I definitely felt out of my element. The patients, to a man, were floridly psychotic, disoriented, paranoid, angry, even hostile, and in one case, barely capable of maintaining a conversation. In each case I attempted the formal MMSE, but it was pointless. One man continuously paced in a small circle, and one man repeatedly asked, "When am I going home?" When I had "completed" an assessment, I walked out of the office and searched for a CO to remove the caged patient and transfer another. At one point, as I walked out the door, under the tier, I felt fluid drip onto my head. Was it a pipe? Was it running off the tier? Inmates are known to "flood" by plugging their sink or toilet and letting the water run until it fills their cell and runs under their cell door. At that point, their was nothing to do but tolerate it.

"Gassing" and "flooding" are both citable violations, but how to do you punish a man already on death row?

NEXT: The Adjustment Center

Your Secret is Safe with Me... (unless)

2006-08-12T15:02:00.000-07:00

This is a riff of Shrinkrap's Undisclosed Locations, regarding the duty to inform, and Dr. A.'s discussion of Online Drugs, about getting to the truth, and the consequences of not doing so. In the last two years, I have had cause to question my "duty to inform" patients of my requirement, by law, to report such things as child abuse, domestic violence, direct plans to do great bodily harm or kill another, and to intervene in case of substantial impairment such as suicide. In California, it is quite specific. In a private setting, I always discuss with a patient the boundries of confidentiality in the initial session. But how is this applied in a prison setting? The question is not whether I must report, but rather, am I obligated to inform the patient that I am obligated to report.

There is no specific law I can find in CA that obligates me to inform a patient of the existing law that is in force; that I have no legal responsibility to warn as to the consequence of possible disclosures. I would appreciate any information to the contrary. Nevertheless, It seems to me, that there are issues of logic and obviousness in operation here. I have seen signs prominently displayed in prison psychiatrists' offices detailing the exceptions to patient confidentiality. If I tell you I am required to report child abuse, how likely are you, then, to tell me you committed child abuse? But again, how badly do you want me to know? I have learned only by experience, for example, that unless you specifically inquire about matters of, say, sexual abuse, most people won't offer the information. When a corrections patient asks, "Do you want me to tell you the truth?" I must admit that there are occasions when it flashes through my mind, "No! Don't tell me!"

Further, this issue has been dismissed by other providers with the argument that inmates know their phone calls are monitored; know their mail (incoming & outgoing) is read; know that custody staff is present and listening during visitations. Therefore, they should have no presumption of confidentiality. Any contractor coming into prison from the outside is considered staff, and inmates are presumed to know that what you tell staff can be used against you. I want to be clear, however, that information of an historical nature (e.g. you confess to me a murder that law enforcement is unaware you committed), remains confidential. But if I am provided with future planning (again, say, to murder someone), I am obligated to report.

The American Academy of Psychiatry and the Law (AAPL) has offerred ethical guidelines that "supplement the Annotations Specifically Applicable to Psychiatry of the American Psychiatric Association to the Principles of Medical Ethics of the American Medical Association." Quite a mouthful. These ethical guidelines are specific to forensics in that "a forensic evaluation requires notice to the evaluee and collateral sources of reasonably anticipated limitations of confidentiality," and makes a clear distinction that an evaluator must use continuous caution to prevent that "an evaluee may develop the belief that there is a treatment relationship." And to those who would take on a forensic role for a patient they are treating, be aware (duh) that "this may adversely affect the therapeutic relationship." Several important points: these guidelines do not expand upon reasonable anticipation; I am not a forensic expert (I just happen to work in a prison as a contractor); while I refer to those I see as "patients," I am not providing direct treatment; and I do not report my findings to law enforcement or the courts. My findings are reported to a receiving parole physician. I am only required to report to law enforcement as noted above, PLUS, issues that are the necessary for the safe operation of the Department of Corrections (e.g. plans to escape, possession of contraband). You may have read of my previous dilemma.

Finally, there is the obvious conflict with law enforcement. I cannot and would not discuss a patient's condition or symptoms with custody staff unless I needed assistance - suicide immediately comes to mind. In the above mentioned case, custody staff was not pleased that I did not pursue the location of the weapon. I am more interested in the fact that my inclination was to stop the discussion. Would I have told the CO's the location of the weapon had the patient told me? Certainly. It is the legal and ethical response. But I do not like feeling like law enforcement: ordering patients to the ground, issuing violations, "forcing" the illusion of respect, reporting things like missing paper clips and pens. It feels against my nature, against my ethics, and against my profession to "betray" confidence.

In my head, I know it is the correct thing to do, but my heart is resistant.

It's In the Bag

2006-08-11T22:47:00.000-07:00

This cautionary tale began with a brief interaction with a new staff member in our staff lunchroom/ kitchen. A young Korean woman who, in my estimation, neither spoke nor understood the nuances of the English language enough to be working with dangerous, violent prisoners, asked me, "Do you work here?" I said I did, and after a pause she said, "You look homeless," an apparent acknowledgment of my "scruffiness." I openly admit that for me, a major perk of this job is that nobody cares how you dress. The only restriction in prison is wearing blue or orange, (and the issue of my hair, which is fodder for another post). My response to her: "You aren't the first to point this out. You should speak to my mother." This young woman shared with us at lunch that she had two rabbits at home , one as a pet, and one to eat. And she finalized her nomination for Miss Congeniality by painstakingly explaining to me the difference between Chinese, Japanese, and Korean women, and I how I "deserve" a Korean woman. The significance of this particular lunchtime discussion became more apparent on the Monday she didn't appear at the staff meeting, and we were unceremoniuosly informed that she had been, unfortunately, released by the university because she had a "problem with her visa." All of this, I might add, was and remains a rich source of amusement for my colleagues.

So, I usually carry all my daily "stuff" (e.g. my camera, iPod, keys, journals, articles, water, etc.) in a plastic bag. I'm generally not particular as to the brand of bag, though I lean toward the Gap and Old Navy when I need a sturdy container. But, believe me, a grocery store bag will suffice in an emergency. As you might imagine, carrying my things this way contributes to my colleague's continuing portrayal of me as "scruffy" and "homeless." My office roommate decided recently that I should cease my plasticity and get a Man Purse, and that the shopping should begin post haste.

Now, my brother, who has many more important things to carry than me, has a beautiful aged-leather bag, and I would add that he can afford such a fine accessory. Don't get me wrong, my brother is as scruffy as me, but in "designer scruff," while I would say Macy's is a significant leap for me. In fact, my mother marks significant life events with a Macy's gift card, which I end up carrying it forever because I can't find anything I want. Like the Clinkshrink, I'll throw on a scrub shirt to wear under the stab-proof vest, and all is well. So, buying an appropriate bag has been a week-long ordeal with which I have struggled.

I treked from store to store, eliminating briefcases, computer & camera bags; leather and nylon; cheap and expensive. God only knows if they make a Kevlar bag, but I'll bet somebody does. Each day I left the store empty-handed and dejected. So I was out tonight and decided it was to be found in Target, or nowhere. Surprisingly, they had a large selection, but leaning toward the briefcase/computer bag models. I picked up an "intermediate" nylon black computer bag thing, and it's done. But as I'm leaving the department, I come upon this. I read the specs and, hey, it's perfect. Downside? Pink or baby-blue. I compare it to the black computer bag. There is no choice here. I'm going with what I need, baby-blue, whatever. And the divine confirmation, the sign I had done the right thing: as I'm paying, for the very first time, a former prison patient is in a red vest and mopping in front of the restrooms! Schizoaffective and stable on meds. A tiny flash of annoyance that I spent a considerable time with his SSI application, but, hey, taxpayers will be pleased at his contirbution to our society. At least for tonight, it is he who has served me. He apparently did not recognize me.

My house roommate looks at my purchase and immediately says, "that is not masculine." I say to her, "They did have a G.I. Joe backpack. Would that have been more appropriate?" I strongly suspect this portends the reaction on Monday, but for now I am satisfied. Though I have yet to unpackage it. And I can always return it...

Stories of Personal Growth, Part 2

2006-08-11T11:40:00.000-07:00

The second day of the mandatory conference, again, sucked, but true to the organizer's word, completed at 11:00 am. Oorah.

The festivities began with a "speaker" (whom I had observed snoozing yesterday) who was the director of health services for another county, and did not really speak. She instead showed an edited DVD presentation on "Accountability and Government" prepared for their local county Board of Supervisors, who themselves were not present at the presentation. The DVD opened with a geek dude introducing himself to an empty Board chamber. What did I get from this presentation? Well, with the help of the iPod: Nirvana, Babyshambles, a full 10 minutes of Miles Davis & John Coltrane, Rage Against the Machine, Mahalia Jackson (where did that come from?), Nellie, Wu-Tang (x2), and it was over. Which leads me to say that I count the creation of the iPod as an event close to the discovery of fire. Turn it low, and it takes the "edge" off of most anything. Except a CA prison, where they are not allowed. As a sergeant told me, "the men in here might be able to turn it into a communication device." Hey, lady, you heard of the ROKR? Apple and Motorola can't give it away. Enough said. I take interludes when I can get them.

There was a nice (because of the people presenting), but very basic presentation on AIDS/HIV medication adherence in mentally ill parolees. Blame this again on collateral disciplines. They were throwing candy bars to the first to match the "solution" to the side-effect: OTC Imodium, rice, apples, bread = diarrhea. I might add that in our state database, for non-psych meds, you must identify the purpose of a medication from an uneditable drop-down menu, where diarrhea is spelled six different ways. Take your pick. Hydroclorothiazide? The only available option I see is "heart," spelled three different ways. There should be a candybar for choosing the correct spelling from the multiple choices. I am not suggesting there is any chance I would win, spelling being what it is. I digress...

We ended with another silly "team building" exercise that focused on "Who are our customers?" I only mention this because of the interdisciplinary discussion. Some disciplines refer to our inmates as "customers," others suggest "clients," San Diego County referred to clinic patients as "consumers" (and even insisted that we refer to them as such). "Patient," in their minds, was pejorative and stigmatizing, unnecessarily labeling someone as "sick." Well... THEY ARE! You don't prescribe fluphenazine to enhance their complexion. If you are receiving medical care, you are a patient. "Hi, Dr. Z., I had a chance to examine your customer..."

I'm thinking if my Java class goes well, I might branch out and take a plumbing course. They seem to make a decent hourly wage, and in my experience, they generally seem happy.

Huh?

2006-08-10T20:05:00.000-07:00

Why is this here?

Stories of Personal Growth

2006-08-10T17:34:00.000-07:00

I attended a mandatory departmental "conference" today that included counterparts from another region. It met my every expectation, and them some. It sucked. Alright, there was one worthwhile presentation on predicting recidivism among the most dangerous sexual offenders (with the exception of rapists), but I had assisted by proofing and contributing to the research material and had already "previewed" the presentation. One presentation, by a state official, was directed at a specific segment of the extended department, and for 90-minutes I had no clue what they were discussing; as is typical, loaded with undefined acronyms like a foreign language, or a story that's an inside joke.

The agenda included a mixture of presentation, followed by "team building exercises." Now, I can't say I was ever fond of these scripted activities drawn from some workbook, but I'm open to new experiences... No, that was a flat-out lie. My expectation was that these "group activities" (e.g. 12 people silently attempting to build the tallest "skyscraper" from construction paper, coffee cups, tape, paper clips, and popsicle sticks) would suck. Then, it is always necessary to "process" the experience; "What did you learn from this experience?" And I delicately broach the issue of mixed team "disciplines" in such activities. There are some healthcare disciplines within this department of psychiatry that are operating from a base of untested, unvalidated, "I just read this book I got from the self-help section at Borders," pseudo-science. I love case-conferences with my colleagues, I love being video-taped and it being examined by my colleagues, I love 2-way mirroring for team observation and critique by my colleagues. What did I learn from this "team-building" exprerience? NOTHING! I learned absolutely nothing, other than I am surprizingly tolerant, not impulsive, and am able to remain appropriate. And no, my group didn't win. The prize for the best "skyscraper?" Free tuition to the department's 36th annual Summer Institute, which I can already attend for free. Does this go on in other disciplines of medicine, or is it peculiar to psychiatry?

Then I went to get coffee with a few colleagues, and out of the corner of my eye, I see a former patient. These public interactions are always awkward for me anyway - I'm out with my brother, so is it impolite not to introduce him? - but this patient had disliked me (read that as euphemism), and our relationship was me, on my second day of work there, being assigned to resolve a grievance she had filed against the clinic . I had to clean out her chart of any reports and information not generated by the clinic, and sit silently by while an attorney from a health consumer's agency reviewed the chart and tried to draw me into the conversation: "You know, when you are given this diagnosis, you often are stereotyped..." Really? I've never heard that...

My colleagues, not being aware of the situation, continue their discourse as usual; Michelle referring to me as an "idiot" (we've been there before). I'm adding things to my coffee, off to the side, and this ex-patient is shooting me glances from the line. I have a general rule about ex-patients, that I will not acknowledge unless acknowledged, and I applied it here. I also hustled my butt out the front door of the store and waited for my colleagues. I don't believe that this general discomfort happens to dentists or surgeons. Unless, I suppose, they operated on the wrong limb or actually tormented you by hitting an exposed nerve. Is this, too, peculiar to psychiatry?

My only consolation today is that, because of the anti-terrorism mess at the airport, my counterparts must leave early tomorrow in order to enjoy their weekend. For this, I salute them. A fine job, you, even if you can't build an award-winning "skyscraper."

Who, Me?

2006-08-09T20:00:00.000-07:00

Are Overweight Doctors a Problem for the Profession?

Posted 08/02/2006

Introduction

Most people would agree that excess body weight is a significant health risk, but should doctors be held to a higher standard than the general public for maintaining appropriate weight and fitness levels? We posed that question to the 4 members of our new Medscape Roundtable Discussion group.

Robert M. Centor: Physicians Are Role Models

Until recently, I had not even thought about the idea of overweight or obese physicians. But, I believe this concept should not be viewed narrowly as only about physician weight and fitness. I believe that what we are considering here is the physician as a role model.

Unlike Charles Barkley or other pop icons who can choose not to adopt exemplary lifestyles, we have the responsibility to serve as role models for our patients. How can we recommend lifestyle changes to our patients if we do not believe in those changes strongly enough to apply them to ourselves?

Now, I understand that expecting physicians to control their weight and to exercise may seem draconian. However, for those who believe that this is good advice for patients, the failure to act personally on such advice is at best hypocritical and at worst disingenuous.

If we compare this to cigarette smoking (and I know I am stretching the comparison here), then I believe physicians have the discipline for success. Although some physicians still smoke, I can count on one hand the few that I know personally -- and I probably know well over 1000 physicians.

How did we reach the point where so few physicians smoke? It represents the success of a long campaign. We police each other. We constantly discuss the damaging health effects of cigarette smoking. We make smoking inconvenient and, frankly, unacceptable.

Can we achieve the same success with weight control and exercise? I believe we can. However, we must change some fundamental aspects of training and practice. Currently, we expect our students, residents, and even ourselves to work very hard. After a long day of being a physician, many feel too depleted to exercise. We start work too early and finish too late. And yet, some of us manage to exercise regularly and control our weight. How do we make this more universal?

We probably need to start making changes in medical school. Somehow, we must make exercise a priority there. We must help future physicians develop the discipline and love of exercise during their formative training years.

Our challenge is great, but it is worthwhile. If we cannot manage this problem for physicians, then we will likely fail in helping our patients. Obesity and excess weight have become endemic in the United States, and the problem is rapidly becoming endemic throughout the world.

We can argue about why adults become overweight and then obese. But we do know how to prevent obesity and enable weight loss: portion control and energy expenditure (exercise).

Many would argue that expecting physicians to succeed in this area represents an unreasonable goal. But if we do not set high expectations, we can never reach them.

Pennie Marchetti: Fighting Anti-Fat Bias

Do doctors need to be slim and fit to be effective in the war on obesity? There's no doubt that personal appearance influences patients' perceptions of our abilities.^[1] That's why most of us dress up, not down, when we see patients. And there is some evidence that even the obese think fat people are inherently bad and lazy.^[2] So it would seem, at a cursory glance at least, that if we expect our obese patients to take our advice seriously, we ourselves should be fit and trim.

But that is an assumption that deserves a closer look. Overweight and obese people are well aware of the pervasiveness of anti-fat bias. How could they not be? Not only must they endure frequent slights from their peers, they also are hammered with almost daily condemnations in the popular press. The message is loud and clear: If you are fat, every negative health problem you experience is your own fault.

The anti-fat bias is not limited to the general public; it also exists among healthcare workers. In one study,^[3] almost a quarter of nurses admitted that they were "repulsed" by obese people. In another study,^[4] a majority of obesity specialists described obese people as "bad, lazy, stupid, and worthless." How good can a patient-physician relationship be if it's burdened by those kinds of emotions and prejudicial assumptions? Perhaps that's why obese women get fewer preventive pelvic exams than their thinner counterparts.^[5] On the other hand, heavier healthcare professionals are less likely to categorize the obese in negative terms.^[4] So, it's fair to conclude that, absent the barrier of disdain, they are able to build better relationships with obese patients.

Do you have degenerative arthritis of the knees? "Lose weight," we tell patients. Blood pressure high? "Lose weight." Plagued by indigestion? "Lose weight." Feeling tired? "Lose weight." Sometimes, doctors are even more forceful. I have had more than one patient return to me in despair and humiliation after being told by a specialist, "I won't even touch you until you've lost 50 pounds." While the recommendation to lose weight in these cases is medically sound, the blunt delivery makes the doctor's underlying bias all too clear. We may be saying "lose weight," but the obese patient hears, "Become thin. Become a better person," especially if it's a thin, fit physician uttering the admonition.

There's no evidence that obese patients are any more compliant with recommendations given by fat doctors, but they may read less implicit condemnation in that advice than they do when it comes from a thinner doctor. Empathy is a very important tool in the doctor's bag, and there's no doubt that a doctor who understands firsthand how difficult it is for some of us to maintain an ideal body weight has more empathy with his patient's struggles. That's not to say that physicians need to be fat in order to provide good care to the obese. It's just that being fit and slim does not automatically make one a better physician, any more than it makes one a better person.

Robert W. Donnell: A Personal Struggle

In a recent video editorial appearing on Medscape,^[6] a slim, svelte Michael Dansinger, MD, gently scolded the medical profession about the problem of physician obesity. When I responded with a somewhat curmudgeonly post on my own blog asking, "Are doctors the next targets of the fat police?"^[7] I left out something important: my conflict of interest disclosure. I suffer from "tight white coat syndrome" myself.

I had all the usual excuses for adding 40 pounds to my 5-foot 10-inch frame over the past 10 years, including middle age, stress eating, and too little time for exercise. Disgust with my ever increasing poundage grew over the years, but I did little about it. There were constant reminders. Among the most painful were those from former patients I hadn't seen since leaving private practice to become a hospitalist. "Better watch it there, doc," they'd say, some of them people I'd lectured about their own eating habits years ago. Clearly, as my waistline grew, so did my credibility gap.

When given the assignment to discuss physician obesity in this forum, I knew it was time for some personal changes. As I pondered how to go about it, Dr. Dansinger's suggestions seemed appealing in their simplicity: Count calories and exercise. But the exercise regimen is difficult. The Institute of Medicine recommends at least an hour a day of moderately vigorous physical activity,^[8] but for busy doctors, the benefits of exercise come at a high price. With only so many hours in the day, something has to give, and often it's sleep. Ironically, recent research has implicated sleep deprivation as a contributor to obesity.^[9-11] Thus, a compulsive schedule of exercise conceivably could produce diminishing returns if sleep deprivation counters the benefits.

Maybe it's not so simple after all. We're all different. In the real world, each of us must find a routine that matches our individual lifestyle and sleep requirements. What will work best for me? I'm not sure, but I know I'll have one thing going for me now that I've been outed: public accountability. Stay tuned for progress reports on my blog.

Roy M. Poses: Adding Insult to Injury

Primary care physicians are increasingly demoralized. They are retiring at an increasing rate, while fewer young physicians are entering primary care residencies.^[12]

The reasons are not hard to find. The compensation primary care physicians receive has not kept up with inflation, partially because reimbursement has declined. In particular, a report by the Center for Studying Health System Change^[13] showed that primary care physicians' income dropped over 10% adjusted for inflation from 1995 to 2003, while Medicare reimbursement increases lagged inflation by about 8 percentage points during the same period. Primary care physicians are subject to ever-increasing paperwork and bureaucratic demands,^[14,15] leading to decreased autonomy. Finally, they are bombarded with constant demands to do more about more problems, without being provided the funding, resources, or time to fulfill these obligations.

A clear illustration of the latter problem was provided by the analysis by Yarnall and colleagues.^[16] On the basis of guidelines from the US Preventive Services Task Force, these investigators calculated it would take 7.4 hours a day for the typical primary care practitioner to accomplish all of the preventive services that were given the strongest recommendations (A or B level) by the Task Force. Keep in mind that the Task Force's suggestions are evidence-based and generally considered conservative. Thus, a physician dedicated to performing just the preventive services that have the strongest evidence in their favor would barely have any time left to take care of patients' acute problems, address their diagnostic and prognostic questions, manage their chronic and/or complex diseases, or handle their biopsychosocial issues.

However, Dr. Michael Dansinger wants to add to these obligations; he says physicians should exercise an hour a day, not just for whatever good it may do them, but for the good of their patients.^[6] Dr. Dansinger did not suggest where we physicians should get that extra hour in the day to exercise. Should we cut some of those preventive services offered to patients, spend less time with our families, or just sleep less?

Furthermore, Dr. Dansinger begged the question of whether lifestyle change is an effective or realistic means of weight reduction, much less whether having physicians change their diet or exercise more would actually benefit their patients. Note that the systematic review by Douketis and colleagues^[17] found no evidence that any weight-reduction program has long-term effectiveness. However, maybe an expert adviser to the television show "The Biggest Loser"^[18] would find these questions awkward.

Finally, Dr. Dansinger chastised physicians for being overweight or obese. He charged not only that rotund physicians "fail to embrace lifestyle recommendations in our personal and professional lives," but that this failure leads to "a public perception that lifestyle change is ineffective or unrealistic." Worse, he alleged that physicians who "fail to heed lifestyle recommendations" also "fail to recognize and treat obesity." Thus, he suggested that physicians have in some sense "failed," are politically incorrect, or are morally at fault if they weigh too much. This is at odds with the compassionate way we should treat our patients who have not found it easy to lose weight.

Of course, I agree that primary care physicians should help their overweight or obese patients lose weight, eat well, and exercise sensibly. But blaming physicians for being too heavy will not help them help their patients in this regard.

Discussion

What do you think about this issue? You can respond to one of these positions or offer your own opinion by joining our discussion.

References

Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor's attire on the trust and confidence of patients. Am J Med. 2005;118:1279-1286. Abstract
Schwartz MB, Vartanian LR, Nosek BA, Brownell KD. The influence of one's own body weight on implicit and explicit anti-fat bias. Obesity. 2006;14:440-447. Abstract
Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001;9:788-805. Abstract
Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias among health professionals specializing in obesity. Obes Res. 2003;11:1033-1039. Abstract
Fontaine KR, Faith MS, Allison DB, Cheskin LJ. Body weight and health care among women in the general population. Arch Fam Med. 1998;7:381-384. Abstract
Dansinger M. Tight white-coat syndrome: physician heal thyself. Med Gen Med. 2006;8:42. Available at http://www.medscape.com/viewarticle/531752.
Donnell C. Tight white coat syndrome. Posted June 4, 2006. Available at http://doctorrw.blogspot.com/2006/06/tight-white-coat-syndrome.html.
Brooks GA, Butte NF, Rand WM, Flatt JP, Caballero B. Chronicle of the Institute of Medicine physical activity recommendation: how a physical activity recommendation came to be among dietary recommendations. Am J Clin Nutr. 2004;79:921S-930S. Abstract
Copinschi G. Metabolic and endocrine effects of sleep deprivation. Essent Psychopharmacol. 2006;6:341-347.
Gangwisch JE. Inadequate sleep as a risk factor for obesity: analyses of the NHANES I. Sleep. 2005;10:1289-1296.
Flier JS. A good night's sleep: future antidote to the obesity epidemic? Ann Intern Med. 2004;141:885-886.
Weinberger SE, Smith LG, Collier VU, Education Committee of the American College of Physicians. Redesigning training for internal medicine. Ann Intern Med. 2006;144:938-939. Abstract
Tu HT, Ginsburg PB. Losing ground: physician income, 1995-2003. Washington, DC: Center for Studying Health System Change, 2006. Available at http://www.hschange.org/CONTENT/851/. Accessed July 19, 2006.
Jacob JA. Practicing at warp speed. Am Med News. Nov. 20, 2000.
Chin T. Doctors' costs going up faster than revenues. Am Med News. Nov. 21, 2005.
Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635-641. Abstract
Douketis JD, Feightner JW, Attia J, Feldman WF. Periodic health examination, 1999 update: 1. Detection, prevention and treatment of obesity. Canadian Task Force on Preventive Health Care. CMAJ. 1999;160:503-506. Abstract
NBC's The Biggest Loser physician profile. Available at http://www.nbc.com/The_Biggest_Loser/about/doctor.shtml. Accessed July 19, 2006.

Robert M. Centor, MD, Professor, Department of Medicine, University of Alabama at Birmingham School of Medicine; Pennie Marchetti, MD, family physician in private practice, Stow, Ohio; Robert W. Donnell, MD, Staff Physician, Department of Medicine, St. Mary's Hospital, Rogers, Arkansas; Roy M. Poses, MD, President, Foundation for Integrity and Responsibility in Medicine (http://www.firmfound.org/), Warren, Rhode Island; general internist, Internal Medicine Health Associates, Taunton, Massachusetts

Or Trade It All for What's Behind Box #5

2006-08-05T20:36:00.000-07:00

Saturday, August 05, 2006

By John Agar

The Grand Rapids Press

GRAND RAPIDS -- E'lla Luster is convinced her brother's mental illness led to the killing of another brother.

"Without his condition, he wouldn't have done it -- it's all because of his condition," she said Friday, outside Grand Rapids District Court.

Iatonda Taylor, 35, charged in the May 6 stabbing death of Moise Taylor, 36, was found not competent Friday to stand trial, but has a "substantial likelihood" of improving with treatment to face an open murder charge, according to a report prepared by the Center for Forensic Psychiatry in Ypsilanti.

Kent County authorities are awaiting a report to determine whether Taylor -- once found not guilty by reason of insanity in an unrelated case, and sent to a state psychiatric hospital -- bears criminal responsibility for the killing.

Police say Iatonda Taylor killed his brother in the brother's home at 730 Diamond Ave. NE. Moise Taylor had allowed his brother to move into his home in February, after his release from a psychiatric hospital. The defendant, who had a history of violence, was hospitalized after he stabbed his girlfriend four years ago, carjacked a vehicle and led police on a chase before he cut his throat.

Luster would not comment on Iatonda Taylor's earlier release, or if she believed he should have been out. But she is certain Moise Taylor would be alive if it weren't for her other brother's mental-health troubles.

Moise Taylor, a father of four who worked for AT&T, was found dead in his home by his wife, Carmen.

Michigan has an interesting application of the "competency to stand trial law" which provides for trial upon the original charge if it is determined that there is a substantial likehood of the return of competency. An evaluator, in this cas the Ypsilanti facility (and you must remember the Three Christ's), apparently certifies to the Court by a Finding and Order on Competency, what the likely outcome of hospitalization and treatment might be. Interestingly, the charge must be dropped by the Court if the District attorney does not intend to pursue them, but more importantly, they must be dropped if the Court is not able to determine competency within a period of 15 months, and the DA does not apply re-file:

No order or combination of orders to continue a matter while the defendant is treated to attempt to render him competent for trial may have effect for a total in excess of 15 months or 1/3 of the maximum sentence permissible for the charged offense, whichever is lesser. The limitation on the time of treatment guards against misuse of incompetency to dispose of mentally ill defendants without a trial on the merits of substantive insanity. It also implements the constitutional right to a judicial determination of the right not to be detained without benefit of theprocess available to those subject to civil commitment.

This would seem to speak to the question of whether, despite your incompetency at the time of the offense, you are nevertheless "responsible" for the consequences of your actions should you be restored to competency. Someone is again, however, put in the unenviable position of attempting to predict the recurrence of violence.

I can only wonder if it would have been wiser that, once Itonda Taylor was again determined to be competent, he had been remanded to the custody of the Michigan Dept. of Corrections to serve his original sentence. Would the outcome have been different?

I Could Use Some Time to Myself

2006-08-03T21:56:00.000-07:00

I spent the past two days in AdSeg (ASU), where I go to the patients because they cannot come to me. In this particular unit, they cannot come to me because they have demonstrated violence - assaulting staff or another inmate - or are know gang members or violent felons. They are held in a single cell. This is what was traditionally referred to as "solitary confinement" or "the hole." Other prisons refer to such units as SHU, special or security housing units. When an entire facility is devoted to the most violent and dangerous, they are often referred to as "SuperMax," such as CA's Pelican Bay. In my case, the violent mentally ill are mixed in with the just violent.

I usually arrive when meds are being distributed, and vitals are being taken. One female CO sits to the side of the med-cart with a gadget that looks like a giant garlic press, and does nothing but crush pills - usually Wellbutrin & Seroquel - and stirs them into cups of water. Why? Both meds have major value in prison as Wellbutrin is "snorted" in the ridiculous belief that you can get a "high," and Seroquel to get a "low." I generally ask a patient the number of times they eat per day, and one man told me "twice, because I sell my lunch [a bagged lunch distributed at breakfast] for Wellbutrin." I'm waiting for drug reps to appear, giving patients pens or "sticky notes" to trade lunch for their particular medication.

The only sounds are the televisions which constitute most of the "group therapy," with up to 10 men in individual cages (about the size of an old phone booth, arranged in a semi-circle), animals noises, screaming, and from those cells close to you, muffled insults and comments: "I'm feeling suicidal, " or "my cellie just cut his wrists." This usually invokes great laughter from those cells in the area. It was pretty surreal to see a slightly-built psychologist, seated to the side of the cages, in a too-large stab-proof vest, and a clear plastic face shield.

These units are notorious for the fact that an inmate will spend all day, every day, segregated in his cell. Those with a "single escort" designation (meaning one officer brings you where you need to go within the unit) can go out to a very small yard for an hour, either alone or with a selected small group. This "yard time" is totally dependent on the availability of staff; if staff is busy, you'll stay in your cell. One patient with a "single escort" designation told me he had been in the yard 7x in a year. "Double-escort" inmates rarely get out. Neither TV's nor radios are permitted, only books are allowed. Obviously, this is of no distraction if you cannot read; unfortunately, this number is unusually significant.

I saw five AdSeg patients, and four of the five were "scrawny"; under 160 pounds and all of 5' 4" to 5' 7." What could they have done to end up here? I only asked one: "I was getting Prolixin shots at the state hospital, and the Dr. said, 'Remember, always ask for 100 mg.' When I got on Yard One and they wouldn't give it to me, I started yelling and protesting. They started [pepper] spraying me and I ended up here." Well, son, you were asking for 10x the maximum dosage, so right there you had a problem... But AdSeg?

How ironic that Social Security makes me inquire, as part of the "Daily Activity" aspect of applying for SSI, "Describe an average day." I feel quite stupid asking these men. One man said, "Well, first I get up and sharpen my knives, then I start to plot how I'll overthrow the government." But he could not stop himself from crying when he described living three continuous years on AdSeg: "You get so desperate for human discussion." What does he do? He's in the middle of reading 5 books at once; he can't read enough.

One 19 year-old patient arriving with a CO with bright, bushy red hair tied back in a ponytail. He was small and had a bit of a gait problem, and in contrast to the CO, he looked like a child. He said he was classified as developmentally disabled, but I'll bet if he was actually tested he would be Borderline Intellectual Functioning. He really didn't know anything was wrong "until two years ago when the prison gave me meds and the voices got very quiet." "Can you read and right more than your name?" "Yeah, but I don't read so good and I don't understand what I'm writing." When I asked about the average day, he just stared at me blankly for a few moments before saying, "nothing." He asked me, "But what do I do with these credits?" Credits? "Didn't you say I'd get between 850-950 credits?" "No, I said 'dollars'." He had been in a gang, only gone to school through the 8th grade. He softly cried as he said, "I really want to change my ways, sir."

The last patient was typical of the lunacy of this system. The sergeant told me ahead of time that he might have an "immigration" hold. This usually means that a Mexican National has been imprisoned, and when he paroles or completes his term, he is released to the INS for deportation. I addressed him by his last name, which he acknowledged, but immediately said, "That's not my real name." He explained that he was born at "Harbor." Harbor? Oh, Harbor-UCLA Medical Center. He is a citizen. He was in prison before and was absconding from parole when he crossed the border into Tijuana to buy drugs. He got high, and in an incident he says he vaguely recalls, came back across the border, was frightened by a "drug dog" and tried to run through the border entrance. The INS and the San Diego Police chased him, pepper sprayed him, and knocked him to the ground. "It burns your eyes, your nose, and your mouth, and I was spitting it out. They said I spit on them and told them I had AIDS."

He had originally been imprisoned under his illegal cousin's name, and that's whom he returned to prison as. He had a moderate tattoo of his real name on his left chest, and another that was basically a half-circle from hip to hip over his navel. Who knows who he really is. To be released from the INS hold, he has to prove to Immigration that he does not have AIDS, because you cannot immigrate if you have AIDS. He too began crying when he talked about never receiving any communication from his family in LA; "No Christmas card, New Year's. My birthday was 2 weeks ago. Nothing." Sometimes he cuts his arms (and he showed at least a dozen long horizontal scars on his forearms) "just so I can go to the hospital and talk to the nurses. I get so depressed. I need to talk to somebody."

We sequester men with major mental illness in SuperMax-type units, with no natural light, no access to the outdoors, and no external stimulation but the shouts and screams of other inmates. Then from here, they will be paroled directly to the street. What are we thinking?

Genetic Influences in Alcoholism

2006-08-02T20:03:00.000-07:00

The university is sponsoring a 3-day conference on addictions & corrections, and I had the opportunity to run in and hear Mark Schuckit, MD, a scholar and expert in the genetic influences in alcoholism. His PowerPoint (agh, yuck) presentation of July, 2006 is worth a look. An excellent lecturer (as always) and excellent information.

An Impression is as Good as an Estimation

2006-07-30T13:15:00.000-07:00

Roy expressed an interest in what Clinkshrink and I might offer as to the recent verdict regarding Andrea Yates. Since Clinkshrink has not bitten, I offer some preliminary thoughts.

I attempt to pattern my assessments and reports as closely as possible to Chapter 7 of Kaplan and Sadock's Synopsis of Psychiatry. I mention this only for the following:

The mental status part of the report concludes with the
psychiatrist's impressions of the patient's reliability and
capacity to report his or her situation accurately. It

includes an estimation of the psychiatrist's impression
of the patient's truthfulness or veracity. For instance, if
the patient is open about significant substance abuse
or about circumstances that the patient knows may
reflect badly (for example, trouble with the law) the
psychiatrist may estimate the patients reliability to be good.

Well, I note that the short statement above is loaded with two "impressions," and two "estimations." We rely upon the patient's "presenting complaint" and description of symptoms in order to draw a medical conclusion. Obviously, we take into consideration a patient's history, family history, treatment and medication history, etc. We can, occasionally, determine a physiological or substance-related etiology for psychiatric symptoms. We can observe the results of administering medication, or we can administer a validated scale (with its incumbent "degrees of confidence"). But the "truth" is a matter of "impression" and "estimation."

A forensic setting provides the ultimate challenge. A "crime" has been committed, and to be responsible for a crime, you must be "competent" to stand trial or plead guilty. In Yates' case, as in most cases, the prosecution and the defense proffered "experts" with "impressions" and "estimations" that were diametrically opposed. For the prosecution, Michael Welner, MD:

"In my professional opinion, Andrea Yates knew her conduct was wrong when she anticipated and then carried out the drownings on June 20, 2001."

Welner agreed that Yates suffered from psychosis and major depression as evidenced by her history of psychiatric care and two suicide attempts but he told jurors that the only person she was trying to help when she drowned them was "herself."

For the defense, Phillip Resnick, MD:

"Even though she knew it was against the law, she did what she thought was right in the world she perceived through her psychotic eyes at the time."

Now, we need the definition of psychotic, and Kaplan and Sadock's is as good as any:

inability to distinguish reality from fantasy; impaired reality testing, with the creation of a new reality (as opposed to neurosis; mental disorder in which reality testing is intact; behaviour may not violate gross social norms, but is relatively enduring or recurrent without treatment).

I can only presume that Dr. Welner could agree that Yates was psychotic, but drew an "impression" of Yates in that her behaviour was "relatively enduring or recurrent" and did not "violate gross social norms," with one notable exception. Resnick diagnosed her with Schizoaffective Disorder, and Welner said she suffered from psychosis and major depression (it is not clear from media reports if he diagnosed her with MDD, Severe, With Psychotic Features). The jury foreman stated, ""It was very clear to us all that she did have psychosis, before, during and after." Impressions and estimations.

Personally, I have made it to the jury box once in the voir dire selection process. It was a petty case where one witness would be called. The DA roundly questioned me as to my ability to remain impartial: "It so happens that my sister is a psychologist, and we argue all the time. She would more likely than not support the notion that the individual is "sick" in committing crime, while I would be more likely to presume it was just a "crime." Right. I'm sure the surprise was written all over my face. I responded, "I believe you both can be correct, depending on the situation." I was the first person dismissed.

As I've noted previously, a liver panel doesn't lie. If only it were true for patients.

The Discovery Has Landed

2006-07-29T22:07:00.000-07:00

Today, my worst fear was realized: I am a dumbass.

It started out simply enough. I was looking at various Apple and Mac sights and I came upon a nice little program, Linker, which is a free Mac utility to create the html for adding a link to your blog. I mean, sometimes the text scrolls out to where you can't see the whole line of the html code and this makes the process difficult. Cool, Very cool. I should have been satisfied, but I ventured on.

I then came upon DreamCatcher, another free utility that begins its pitch by noting how stupid and unprofessional you look when you have misspellings on your website. Hmm. I download it and turn it loose on this blog. Madonna Mia! Every single post is caught. OK. I start looking through what DreamCatcher has flagged, and for a few moments I am relieved; only words the spellchecker doesn't know. But as I move on, it slowly sinks in: you are a dumbass. While I would say in my own defense that I type with two fingers (it was some kind of reaction formation having to do with my mother) and I am mildly dyslexic (causing me to either leave out words in a sentence - or is it sentance - and double words like "the"). Some words (e.g. tattoo, incredible, etc.) I consistantly... I meant consistently, misspelled. To this day, there are certain words I must check every time I use them: is it existance or existence, roomate or roommate, signifigance or significance, etc. I have become so dependent on the "auto-correct" function of my spellchecker, that now I'm not even aware when I make errors. And the kicker: I just realized that the "abc" on the Blogger tool bar is a spellchecker!

Now if I could only get a speechchecker, I'd be a genius.

We Found No Body, But We Found the Black Box

2006-07-28T18:36:00.000-07:00

This was an exceptionally odd, exceptionally exhausting week. It is grossly hot in San Diego, at the border with Mexico. Enough said.

I walk into the office, and as I am going down the hall I notice, like birthday presents, a red box is on everyone's desk. When I arrive at mine, I find the red box contains a black box that is intended to be a "portable desk." On the front is a clip to hold paper, the top lifts to reveal a pull-up easel-stand to hold papers, and all-in-all, it is intended to store papers. The point? Somebody thought this would make us HIPPA-compliant in carrying records. I am betting that no one even investigated if you are allowed to take this thing into a prison (you can't, for example, carry a backpack). Secondly, isn't a briefcase or zippered binder HIPPA-compliant? I'll bet they got a good deal on the purchase, and I'll bet they try to force me to use it. "What's in the black box, man?"

Wednesday, I am working in AdSeg with the cuffed and caged. It has been so incredibly hot here that, with inmates taking showers in four locations (single unit stalls with bars into which they are locked), it was like a sauna. Making it worse, they were out of the light-weight, stab-proof vest, and only had the thick bullet-proof/stab-proof vests. I was about to see my 4th patient when the CO's asked me to back up against the wall while they brought another man to a cage. I ended up backed into a corner as they passed, and when the patient began to struggle and fight, WHOOSH, and we all got pepper sprayed. I would note (as I have previously) that CO's don't carry the little hand-sized cans that you can purchase as a "civilian," but rather in a size more likened to a small fire extinguisher. And more than just an aerosol, it is in the form of a bright orange-colored gel. I have been told, and recently seen demonstrated, that some individuals do not react to pepper spray; rather, they are not subdued. I am not one of those individuals. My eyes were immediately burning and I began to cough. A CO pulled me out to the front door, and as a group they were highly amused. Being asthmatic, I always carry albuterol and I hit it hard, washed my face, and got out. On the way home, I bought and drank 2 liters of Gatorade. Chili, my ass.

Today I did a lot of walking; "protective custody," reception, AdSeg, and the Psych Unit. I can't adequately describe what an experience it is to be on the "yard," walking from building to building. There are several hundred men outside, and, at most 20 CO's, standing in small groups talking. A man I've seen before was in the center of the yard, dancing in a wide circle, shaking a plastic bottle filled with some stones, and repeatedly singing into a paper towel roll, "Your battle!" It also struck me that numerous men (obviously enough for me to notice) walked the circle of the yard with a single crutch. Were they sharing or was CDC out of canes? I have no idea. I also was reminded of the beach: men who ordinarily would not be seen without a shirt, or if they were so bold, would appear objectional, walked among the tan, tattooed, and fit. Pasty white skin, seriously out of shape, shirtless in the heat. The joggers are every conceivable age and body shape; sunglasses, cd players, tape players, breathing heavily and soaked with sweat. The saddest sights were the elderly, never together, some walking very slowly on their own, some struggling behind wheelchairs. White hair and beards, bent over, limping, undoubtedly much younger than they appeared. How hard it must be to spend your life surrounded by young, violent thugs who care about no one. As I left the yard of the psych unit, it struck me for the first time amidst a basically desolate yard, at the gate was a large, well-maintained sign on the ground made of grass letters surrounded by hose that said, "Facility One." Apparently, someone took great pride in maintaining this perfectly green space.

Murderers, the violent, sex offenders, those who torture, robbers, pimps, drug dealers, burglars, gangsters. I even sat with a colleague today who charted on a man caught having sex with a dead body he had found in a dumpster. It always amazes me that it isn't until I leave that I, again, become aware of where I have been, what I have seen, and who I have been with. As I sit in the car, I feel the tension in my neck and shoulders. I also never lose the sense of sadness that comes from observing the worst than can become a human being.

Who snitched?

2006-07-25T13:38:00.000-07:00

I sat for 2 hours this morning attempting to decipher the scrawled case notes of someone who obviously did not believe they would ever be read by another human being. I kept going to colleagues, "What do you think this says?" At the peak of frustration, the cell phone rings (if you're interested, the ringtone is the opening 30-seconds of Stevie Ray Vaughn's Crossfire, created and transferred by Bluetooth on the PowerBook G4). I look at the caller-ID: SAN DIEGO BLOODBANK! C'est impossible! I made the decision to answer. It turns out they were just calling to thank me for donating yesterday. I sheepishly responded, "My pleasure. Please call again when I'm eligible."

Now I have to figure out who turned me in...

It was a bloody mess

2006-07-24T16:04:00.000-07:00

I have come to the realization that giving blood is like inviting the telemarketers. Give once, and your are deluged with letters, flyers, e-mail, and phone calls. Why do I bring this up now? I am approximately 2 hours away from a scheduled appointment to "help save a life."

I will confess that I have memorized the phone number of the local Red Cross affiliate, but I do not answer it when it pops up on the caller ID. I take it as a reminder - I must be eligible again - and I go to the website and look for a reasonably distanced location and make an appointment. But I resent the continuous struggle with my last name and the canned speech: "Your blood type (that would be O+, and I revealingly post this without challenging Dinah to post her BMI) is dangerously low in San Diego County..." Yeah, yeah, how many died because they couldn't find O+? Hit the med school students & residents, for heaven's sake. Each is good for a pint. I got 2 reminder e-mails, a reminder phone message (which I didn't answer), and then, on the same day, another message (which I also didn't answer), reminding me that I was eligible to donate, and I was needed to "help save a life." The right hand, apparently, knew not of the left. Nevertheless, both ended with, "and have a great day." Is that a "blood" 'thang or a California 'thang?

I am not complaining, really. I know blood solicitation is serious and a necessity, and donation is a noble act. I'll let the nurse turn her head while I confidentially affix the sticker saying, "Yes," you can use my blood (though I wonder why, if the answer is "No," I'd be there in the first place, or then allow you to place that big-bore needle); I'll drink the juice and take the cookies (in San Diego they were giving out a t-shirt that said, "Do it for the doughnut," though they never had doughnuts - or they were gone before I got there); and I just might take you up on your suggestion that I sign up now for the big Fall blood drive when the San Diego Chargers will be present (you can't stop the bleeding). Damn it, I'll even wear the "Be kind to me, I gave blood today!" (at least for the walk to the car). But please, one phone message and I'm there.

I conclude by noting that the Crips never call, but I probably wouldn't answer.

ADDENUM: Just in... The iPod, Rage Against the Machine, 40 minutes and I'm home. They gave a tall, cool glass of orange juice; a coupon for a free admission for one to the Del Mar Racetrack Clubhouse; a free oil change (by appointment only, but 17 locations to choose from); a coupon for a free 6-inch Subway sandwich; and last, but surely not least, a Red Cross t-shirt that says, "Fearless." Hey, if they threw in the lower bunk (for my prison friends!), it would be as close to a birthday as one gets!

I Will Not Be Going Out for Sushi

2006-07-21T13:11:00.000-07:00

Today I was reminded of an episode of the TV series MASH - well, not exactly the storyline - but the fact that each scene was punctuated by a guy playing the guitar and singing about Tokyo. It was not a humorous episode, and while bad things happened, each scene was puctuated by this guy playing the guitar.

It was already big-time hot at 8:30 am as I waited to get through the gate into Yard 1. They were sliding the big gate open in order to allow about 10 inmates to push massive carts of trash out. In the heat, the smell was horrendous. As I turned the corner toward the psych unit, a tall young man was standing near the medication window playing an acoustic guitar. It didn't seem to be any song I could tell, but nice, calming, "folksy," 7th kind of chords. He had a blank expression on his face as I passed him, and he looked at me but didn't appear to be seeking acknowledgement. The yard was active with runners, gamers, talkers, laughter, business as usual. But it was damn hot.

With one foot in the door, I'm pounced upon: "This guy's doc wants you to see him now. He's paroling tomorrow." Now, you say. "And two of your people are in crisis beds in CTC (the hospital) and they want you to go see them ASAP." ASAP, you say. OK. I'm going to see the first guy, and I'll catch the hospital on the way back. I pack up my stuff, leave the air conditioned psych unit and head for Yard 2. I pass the expressionless guitar player.

Yard 2 is a considerable walk - did I mention it was hot - and outside the gate was the repository for all that trash. I am nauseated too easily by such things, and am quick to get past it. This yard is absolutely desolate. Dirt and some some burned weeds. It would seem appropriate for tumbleweeds to roll by. As I walk to the back of the yard, I see on a building a wooden sign into which is burned the word "Handicrafts." The glass is cracked, filthy, and the room is full of trash. Like walking past "good intentions." The front door to Building 9 is open and I enter the steaming tunnel that leads to a gate. CO's are yelling to the gunner, "Staff coming in." He takes his time closing the front door so he can open the gate for me. The patient is pretty stinky and covered, head-to-toe, with tattoos. I ask him to sit down with me, and he has food on his face and chest. All said, he was very grateful that I had come to re-iterate instructions and wish him the customary, "I never want to see you again."

I stop at CTC and it appears as any hospital, but the nursing station is posted by nurses and CO's, and some CO's who are nurses. The doors to the patient rooms, however, are the full-metal cell door's. The chief CO says, "Get the f*** 'outta here. They're all liars and want free money from my taxes." Not a bad platform to run on, I suppose. I enter the crisis unit and am told both patients are currently "heavily sedated." It, apparently, was a bad morning. No problem; they're certainly not going anywhere.

Back to Yard 1, passing the guitar player. It's been an hour. "Your 10:00 is in AdSeg. They're waiting for you." What? Yard 2, Building 6. I was just 3 doors away! Back passed the guitarist - now into some serious barre chords with a 9th bent - passed the steaming trash, into Yard 2, up to building 6, "ASU." Warning signs on the door: "All entering are subject to identification." Why am I wearing this ID? Why would anyone in their right mind want to get in here? Through the tunnel, through the gate, and now having to put on the heavy vest. Deafening "hurricane" fans compete with animal sounds; behind the cell doors, you know they are yelling at you by what you're wearing: "Hey, you checker shirted faggot motherfucker!" I was wearing a "herringbone" Polo (purchased at an outlet store). Thanks for the fashion statement. Ignore, is always the word of the day. My patient has a "MUST have double-escort" sign on his cell door, and I wait as two giant CO's deliver a 5' 6" late adolescent with acne to a cage. He is a truly sad, abused, molested, young man, who struggles to make eye-contact with me as I gather a history. Discharged from the Marines under "less than honourable conditions," where he'd gone to "straighten out my life." He answered every one of my questions with, Yes, sir, " or "No, sir." "Dude, I'll do what I can for you, but please, please, stay out of here." I turn in the vest and I'm soaking wet, like someone poured a bucket of water over me.

Back to Yard 1 and, yup, passed the guitarist. "Where've you been?" "AdSeg." "Well, two patients left because they got tired of waiting." I can hear the CO in the CTC: "Tired of waiting for free money! You see!" Next! Gentleman, very paranoid, comes in and says, "I don't need your help. I got SSI." "But you've been down for 18 months. You can only re-instate within 12. I'll help you with a new application." "You're wrong. I don't need your help." Cool. "Let me give you the (800) number for SSI re-instatement." He looks at me, stands up and walks out.

Last customer of the day. Bright orange suit: reception center garb. Back on a violation. "I only used a tiny bit of meth twice; gave her dirty urines; and the bitch (i.e. Parole Agent) slammed me." Absolutely relentless complaints. Then, "they arbitrarily stopped my Seroquel. I haven't slept in 3 nights." I have him stand with the CO's while I get his chart. "There is no order to stop any med you're taking." "They do it on the sly. They can get away with it. I'm desperate! I'm going crazy! You leave me no alternative but to cut my wrists, to kill myself!" Oh, Lord. "Are you telling me you have a plan to harm yourself?" Deep stare. "I know what you're up to. I am not going in that cage for 6 hours! I didn't say anything. I want to see my doctor!" I seat him with CO's and explain that I need him under observation. I call the supervizing psychiatrist on his yard, and he says, "have custody bring him here and I'll take care of it." The patient has sort of snuck up on me while I'm on the phone: "Please, can we just forget this. Just let me go home and we'll forget it ever happened." "I need you to take a seat. Custody will return you to your yard and you can see your doctor." "CUSTODY! You screwed me! You're a blah, blah, blah." "I need you to take the seat as I directed you." "You blah, blah, blah. You are ruining my life!" Custody says, "Let's go." No cuffs, just an escort home. I chart, copy files, and pack up. I am soaked and exhausted.

I walk out to find the guitarist. Apparently four uninterrupted hours of music. As I went by, I smiled and asked, "Do you know Tokyo?"

And Nothing but the Truth

2006-07-20T22:28:00.000-07:00

A patient recently told me that his "problems" began in 1978 with his witnessing the spectacular crash of Pacific Southwest Airline Flight 182 in the North Park section of San Diego. Worse, "half my family was aboard that flight." He reports recurrent nightmares of "bodies covering me," of "my brother dying in my arms." Contributing information: he has spent 23 of the last 25 years in one prison or another; he is the meth addict's meth addict; and he pelts me with "treatment jargon," speculating as to what he believes an examiner wishes to hear. He is diagnosed with Psychotic Disorder NOS (and apparently CA prisons are one of the few places you can maintain an NOS for 11 years) with fixed delusions, and Antisocial Personality Disorder (which he reeks of like a cheap aftershave lotion). All right, delusions must include the element of possibility, but what is the probability of this tale being true?

Second case. A man appears at the public clinic late in the day while I'm on call. He identifies himself as a former patient, as the staff moves to the basement to find his records. Examining his chart, I ask him if recalls his medication history. He offers a relatively benign list of tricyclics. I turn the page to find copies of prescriptions, basically several year's worth of haloperidol and fluphenazine decanoate. I ask him and he angrily states he never took the meds. "But wasn't [doctor] your doctor?" "Yes, he was great." "But he wrote you all these prescriptions," and I show him the chart. "I DID NOT TAKE THOSE MEDICATIONS." OK. Let's change direction. I ask, "What brings you here now?" He goes on to tell me that he was working at the corporate headquarters of a major hotel chain in a neighboring county, when he was informed that his sister died in the collapse of the North Tower of the World Trade Center. The corporation graciously granted him a leave of absence and he came to San Diego. "Where are you living?" "On the street." "So you took a leave of absence from a major corporation to live on the streets in San Diego?" "You know, I have better things to do. I'm leaving." "Please wait. I'm just trying to understand the situation so I can offer you services." He leaves, and the next morning, under my provider number, the hit list says he went to the county's Emergency Psychiatric Unit, told the same story, assaulted a doctor and was arrested. Again, his story is possible, but how probable?

Third case. I sit in a silent prison housing unit on lockdown, and the control officer/gunner calls the patient's name over the PA and automatically opens the cell door. It is dark inside, with no apparent movement. She calls him again, and then again. From the cell emerges a train-wreck of a human being, seated in one of the world's oldest wheel-chairs, a rag tied on his head and askew, disheveled, no teeth, and appearing to be in significant pain. He finally rolls up to the table, greetings, and we get down to business. 3 separate times I inquire as to his disability, and 3 times he doesn't answer: "I was in Viet Nam," "I had 2 strokes in prison," "I was hit in the head with a bat." Are any the source of his disability? I don't know. Next, I spend too long listening to a lecture on "bulk laxatives, because when you're in a wheel-chair..." He declines every service I offer. "Where will you live?" "I own an apartment building?" What? "I got a multi-million dollar settlement with the city, so I bought an apartment building." "How far did you go in school?" "I have a degree in engineering and work for an engineering firm." I examine his medical chart. Neurological reports and reports of 3 MRI's: "No discernible signs of CVA." Neurologist writes, "I asked him to get out of the wheel-chair and sit in a regular chair in my examination room. He immediately complied." Discharge order from the doc at the prison from where he transferred: "This inmate is absolutely, under no circumstance, allowed to have access to a wheel-chair, walker. crutches, or a cane. He has no disability" I'm holding my breath as I turn to the psych notes. Diagnosis: Factitious Disorder. Now how often do you see that? I'm speaking with a Bulgarian colleague with a known psychoanalytic bent: hysterical neuroses, he muses. Hmm. A month later, I look on the computer for the Out-Patient notes following parole: His psychiatrist has confirmed that he won a multi-million dollar settlement, lives in an apartment building he owns, has a degree in engineering, and even spoke directly with his employer who confirmed his employment.

Apparently, there can be a fine line between veracity, delusion, probability, and personality disorder. Documented liver functions won't make you crazy; it's indisputable evidence. Truth, however, does not necessarily set you free.

One Father Too Many

2006-07-17T22:15:00.000-07:00

Apparently someone didn't watch the "New Asylums." This just should not be a daily occurrence. It simply should not.

Pick Up the Receiver

2006-07-17T16:16:00.000-07:00

I received a copy of the Receiver's First Monthly Report filed with the US District Court for Northern California. The background is that an inmate named Marciano Plata brought a class action suit against the California Department of Corrections & Rehabilitation (CDCR), claiming the medical system was inadequate and even harmful. Upon a lengthy investigation, the Court determined Plata's claim was true, and ordered the entire medical delivery system into receivership.

The Receiver, Robert Sillen, verifies the Court's findings, but "unfortunately, he has well concluded that the situation in California's prisons is, perhaps, worse" than the situation as already known to the Court. After visiting prisons, speaking with everyone from officials, employees, to inmates, he reports:

The medical services provided by the CDCR are without question "broken beyond
repair," as found by the Court in the Findings of Fact and Conclusions of Law. Almost
every necessary element of a working medical care system either does not exist,
or functions in a state of abject disrepair, including but not limited to the following:
medical records, pharmacy, information technology, peer review, training, chronic
disease care, and specialty services. Similar to the conditions reported to the Court,
the Receiver has observed cases where inmate/patients did not receive adequate
care because of their inability to access care; also, and perhaps more disturbing, he
has reviewed cases where inmate/patients did not receive adequate care even after
accessing the CDCR medical care system.

Well, it strikes me that the Receiver is a bit naive in finding things "worse" than already reported; he should have been shocked to find something changed or better than reported. While the Receiver suggests numerous causes for the "broken beyond repair" system, both from within and without the system (and you can read a poor scan of the entire document as filed with the Court here), it seems to miss something blatantly obvious: our "inmate/patients" are some of the most loathsome, despicable, despised, and dangerous members of humanity. We have warehoused them (in CA at 200% over designed capacity) precisely, and in most cases justifiably, for this reason: they don't belong among us.

Nevertheless, this inextricable mindset of "inmate/patient" is more than an adjective. Only with the emphasis on "inmate" can a medical delivery system become "broken beyond repair"; broken to the point where union members speak of literally carrying on their person specific instructions that, should they be hurt or injured on the job, they refuse medical "treatment " provided by the facility. These patients are removed from society, yet they retain their humanity. It is not a job for everyone; how many times, and how many ways can it be said? But for those who choose it, it seems incumbent to set a standard as high as those practicing outside the walls. CA CDCR is a scandal against humanity.

A Royal Flush - All of a One Suit

2006-07-11T07:45:00.000-07:00

I happened to drive past the Family Court yesterday, and noticed the usual line waiting to pass through the metal detector, and the street lined with (mainly) men in varying degree of quality suits, some on cell phones, some smoking, all pulling totes with boxes of papers. Having worked directly across from the Family Court, it was not unusual that the legal "business" spilled out onto the street, immediately prior to or immediately following the dispensing of justice. More times than I wish to recall, sheriff's deputies stepped in, asking us to lock our doors, as someone was "dissatisfied" with their outcome and walking the streets, aggressively expressing their displeasure. Once captured, all was clear.

One morning it was particularly quiet in our office, and I was upstairs charting with the window opening. It was, unfortunately, not unusual to hear screaming or arguing coming from across the street, but today it was of a markedly more dire character. A woman was screaming, "Look what you did to me! Why'd you do this to me?" I walked to our conference room windows that faced the street and saw a car pulled up on the sidewalk in front of our building. A woman sat in the driver's seat, face bloodied, and blood had soaked the front of her yellow t-shirt. A very thin man in a running suit was speaking to her through the passenger window. I couldn't hear what he was saying - he appeared quite nonchalant - but she was continuing to scream, "Look what you did to me?" I picked up the phone and called 911, and I couldn't help but notice the usual gathering of suits across the street, cell phones, smoking, totes, all watching. The police arrived in moments (which I can't say was true about violence calls from within our clinic), and the man in the running suit was on the ground, while paramedics attended to the bleeding woman.

The following morning, I received a call from a detective who said she was very surprised to find that my call came from the mental health clinic; she presumed it was from a lawyer standing in front of the Family Court. As it turned out, mine was the only call to 911. She asked for my description of events, and concluded, "You took down a very bad guy, with a long rap sheet and a list of warrants as long as your arm. Thank you for calling." My pleasure. I felt like John Walsh. Several days, I was called from a therapy group to be served a subpoena, and when I arrived home, the same subpoena was taped to my front door. The day before I was to appear, the DA's office called to say the man had pled out (a second "strike") and my presence was not needed.

As I was driving home I thought, "You just don't look that good in a suit."

Go Play in the Yard

2006-07-07T13:21:00.000-07:00

Many believe in premonitions and signs. I tend to only appreciate them post-fact, where I can ascribe them meaning in my own particular framework. I should learn. It's Friday.

As I make the turn down the 3-mile dead end road (lined with prominent signs indicating you may neither stop, wait, nor park) that leads to the county jail and state prison, my eye catches a glint of orange in the field off to the right. I approach what appears to be a 70's-era VW van parked about 50-feet off the road. Next to it, a man in bright orange running shorts is balanced solely on his head, arms out parallel to the ground, and legs spread-eagle above him. A woman in an ankle-lengthed flowered skirt stood nearby, chin in her hands, observing. It did not cross my mind, "What could this possibly mean?"

Another half-mile and the local news on NPR announces that, overnight, a 63-year-old serial rapist (of young men, on the highway, at gunpoint) had been released from a state hospital to a trailer on the grounds of the prison I was now entering. At the crest of a small hill, a satellite truck and a TV camera came into view on my left, focused on, in my estimation, on an exceptionally small trailer in the middle of acres of nothing but dried brush to my right. The trailer was surrounded by fencing, with overhead lights at the four corners. Said serial rapist was being provided 10 hours of "home healthcare" per day (your guess is as good as mine), was wearing a GPS bracelet that reported his location at all times, and he was said to have access to "public transportation." Judging by the location, I could only imagine this referred to a mule. As to what the TV camera was recording (his morning constitution?) will not be know until 6:00 pm. This was the first and only time I've seen someone actually posted at the outer-entrance to check ID's; as I was later told, "to keep the press out."

Inside, it was pretty much uneventful, considering that as I passed the med line a patient unknown to me said, "Dr. Starbuck." I was unsure as to whether this was a step up or down from "Starfish." My colleagues, by secret ballot, preferred "Starfish." One patient shocked me by stating, "I don't want SSI 'cause it will make me lazy and unmotivated, and I need to get a career and stay out of jail." When my final patient was 20-minutes late (and I was prepared to charge him, Dinah), the CO's said they would call his house, and I stepped out into the hot yard under a cloudless sky. Then all hell broke loose.

The full-yard alarms went off, buzzers, flashing lights, alternating public address system commands of, "The yard is down! Everybody down!" and "Alarm in Unit One!" I was standing about 50-yards from the entrance to Unit One, and officers raced past me from everywhere, puctuated by the metallic "snap" of nightsticks. Blaring, blaring, blaring. A side security door was locked and a group of CO's were screaming for the control officer to unlock it so they could get in. Then it stopped. Out the front door the sergeant led a man in boxer shorts and high-top sneakers who, from 50-yards, appeared to be covered with blood, a stream running from the center of his forehead. As he got closer, he was bleeding from his forehead, but as my eyes started to sting and I started to cough, I realized he was covered with orange pepper spray gel. And as he passed by with an expression-less glance, I realized he was the same young man who several weeks ago had stood next to me with the identical expression-less glance, covered with blood because he had made two slashes to his throat. The bleeding from his head today was the result of his banging his head against the edge of the cell door.

They caged him and he was floridly psychotic. He was experiencing auditory and visual hallucinations, falling to his knees screaming, "I am in hell!" Officers arrived and took him out to the yard, and with two garden hoses, "decontaminated" him. A nurse with a syringe held behind his back quickly and quietly nailed him during the shower; an action I don't think he even noticed. He stopped yelling, cursing, and growling. Two inmate therapy groups ended, and as they passed by I heard several say, "Oh, it's [him]. That dude's messed up, man. He needs help." The orange was gone, but the red, burning irritation that was his skin remained.

As I drove out, the sun was peaked and the field and the little trailer shimmered from the intense heat. Just minutes from the border with Mexico, it had to be close to 100 degrees. The windows of the trailer were rolled open, suggesting there was no air conditioning. There was no discernible movement. I had to wonder how the serial rapist was spending his first day of "freedom."

Culture Wars

2006-07-06T21:51:00.000-07:00

I met with a kid today ("kid," meaning 22 years old - young for big-league prison) who was pleasant but presented as somehow, "simple." Judging by his vocabulary, he was poorly educated and had a "basic fund of information" that seemed less than what one would expect. There was an incongruence to him: young, healthy Hispanic male, beautiful gang tattoos, but timid and anxious. He couldn't be a gangster. Mental status exam was poor for orientation, memory, and following basic directions. A printed picture of a clock indicating 10:10, he described as "two o'clock."

"Why are you in the mental health program?" "I had no problems until 1998 when we were fighting and a guy hit me in the head with a baseball bat." (Displays indentation and scar). "Ever since then I get dizzy, paranoid, and I'm clumsy." Sounds vaguely neurological, but there is no evidence of formal testing. I went to the usual questions of , "Does your mind ever play tricks on you," and he didn't want to answer. "Why?" "Are we alone?" "Of course." "Look, I hear voices. "What kind of voices?" "Mostly gibberish. I can't understand them. Especially this one little girl who has a mean tone of voice, but I don't know what's she's saying." "Have they ever told you to do anything?" "One single time that I could understand the little girl, she told me to hurt my girlfriend, but I stopped because I knew God didn't want me to be that kind of person."

When I look at his current orders, four months after his arrival, all psych meds have been discontinued (Risperidone in a healthy dose and Sertraline), and he had discontinued all contact with his psychiatrist. "Why did you stop taking your medications." "Are you 'gonna tell anybody?" "I'm going to tell your out-patient doctor." "Nobody in here?" "Not if you don't want me to speak with anyone." "I really need the meds. I've been feeling so crazy. I can't sleep. I'm so afraid." "Why did you stop?" "Gang members don't allow you take meds or see psychs. If you're crazy they'll kick your ass or kill you." So here is his Catch-22: he won't take meds because he's on a general population yard with gang members who intimidate others into refusing meds, and he can't be transferred to a psych yard where he'll be safe because he won't take meds. "I used to go to group therapy, which I really liked, but they yelled and laughed at me and I got too afraid to cross the yard to go for group." "You never told this to your doctor?" "NO!" "And you don't want me to tell her?" "NO!" Paranoid, paranoid delusion, or both?

24 days to the gate. He will live with his father and older brother who will take care of him, insisting and assisting him in taking his medications. Making sure he showers, shaves, and cuts his hair. Driving him to his appointments because, "Once I took the bus and got so lost, I didn't know where I was. I was so relieved when the bus driver told me I was back in my neighborhood." I find out he is now classified DD2 (developmentally disabled to the point where he needs strong prompts to function normally), describing him as "poor at social relationships, easily intimidated, and vulnerable to being victimized." He is diagnosed as Schizophrenic, Paranoid Type. Nobody thought to protect him.

"Is it crazy to be scared all the time." "No, man. You're in a dangerous place and it's appropriate to be careful. We're all afraid sometimes. " "OK." "You promise me you're going to take the meds when you get out?" "My appointment with the doctor is the same day I get out." "Cool, you be safe. I don't want to see you again." "You won't see me again!" Smile.

Please, I don't want to ever see you again.

That's Your Opinion

2006-06-27T21:11:00.000-07:00

I was writing elsewhere about pointing out to a patient who stinks that he, in fact, stinks. Reality testing. Stating the obvious. Providing the patient, who because of a psychotic state, does not have the appropriate information to form an opinion. A basic, but necessary, professional duty.

The stinkiest human being I ever encountered looked disheveled, but, at least from a distance, did not appear to smell the way he did. As he closed in on me, seated at my "on call" post, I was overcome. He reeked. It was the middle of summer, our air conditioning struggled, and I literally gagged. He was wearing khakis, a knit Izod-type shirt, and a cap from a marina. As he sat down across from me, the totally blank affect and lack of orientation said schizophrenia. He was referred by the Homeless Outreach Team because he "lost" his meds (who knows when), and was at the point of losing his residence in a board-and-care facility. After getting some initial information, the receptionist turned on a small fan and left the room. A few more minutes, and she returned with air freshener. I, then, pointed the receptionist's small fan directly at the patient and told him, "You smell very badly. So bad that I am struggling to continue." He said, "That's your opinion." I said, "Correct. But right now, mine is the only opinion that matters. If you want to be admitted as an out-patient, you're going to have to go down the street to the clubhouse to shower and wash your clothes." It was Wednesday.

The county had a system whereby every provider is issued a provider number, and all patients are registered and tracked under their provider's specific number. Should a registered patient of county services visit or be admitted to any county ER or hospital, the provider is notified by an on-line "hit list," and expected to attempt to contact the patient and get them in as quickly as possible. Monday morning, bright and early, my bad smelling patient is on the "hit list" as having been admitted to the university hospital via the ER, transported by the police. I call for the record and it is immediately faxed to me. The university tactfully referred to him as "grossly malodorous," incoherent, and catatonic upon arrival on the in-patient unit from the ER. He was said to have a "waxy flexibility," but they were able to "dispose" of his clothing, shower him, and get him into a bed. He was catatonic for three days before, like the Tin Man, he loosened up. At this point I certainly had enough information about the incident, but I kept reading: "Was taken into custody by the police who found him wandering in traffic carrying a basket of laundry." Oh, my!

A week later, he returned for his appointment with me, shot full of fluphenazine, sheveled(?), and markedly non-malodorous. "Why were you admitted to the hospital?" "I'm not sure." "I read that you were taken to the ER by the police because you were in bad shape." "That's your opinion." "But Dr. J. described you as completely disorganized, disoriented, and you couldn't even speak." "That's his opinion." "Let me read you part of the description given by the Medical Center." I do. Providing the patient, who because of a psychotic state, does not have the appropriate information to form an opinion. He says, "That's their opinion." OK. "Why did you come back here?" "I need to get off these meds. I don't need them."

That's your opinion.

We are (apparently) shocked

2006-06-27T21:07:00.000-07:00

AT: I have C. here who is taking Bupropion SR 150 BID, Quetiapine 300 q hs, and Gabapentin 300 mg q hs. He says he's having "liver pains." He wants to know which one of his meds is processed through his liver.

Me: They all are. Ask him to point out where the pain is.

AT: Doesn't appear to be near his liver.

Me: I'm shocked.

AT: He's been drinking since he was 8, and has been a really heavy drinker since. He's 40 now.

Me: I'm shocked. He shouldn't be concerned about those meds and his liver. Tell him if he has liver problems, they are from alcohol, and he risks having a big time seizure with the Bupropion if he drinks.

AT: He also says he has HCV (hepatitis C) from shooting meth.

Me: I'm shocked.

AT: He said when the liver pains started, he got so angry that he flushed the Bupropion down the toilet. He has now reconsidered and he wants his prescription replaced. Our team said no. Do you agree?

Me: hahahahahaha

AT: I'm shocked.

Me: Was he pissed?

AT: Quite.

Me: I'm shocked.

A Beautiful, Broken Friday

2006-06-17T15:32:00.000-07:00

Friday was an astonishingly beautiful day. Cloudless, warm, breezy. Everybody seemed to be in a good mood. The ordinarily grumpy CO (though I think it's an act) who opens the gate to Yard 1 and the psych unit was joking about how, at high noon, he was going to jump in the lawn sprinkler. The psych unit was quiet, cool, air conditioning humming, and a bit dark, business as usual. As always, the office doors have a sign that order they remain closed so as not to damage the air conditioning units. The large front doors of the building, however, are always wide open. I saw one patient, missing upper and lower front teeth, and quite prone to smiling; "I pretty much been in and out of prison for the past 20 years," he said with a grin. Likewise, he knew the routine: "I'm learning to love myself," "I'm learning to forgive myself," "I'm learning to blah, blah, blah myself." 8 separate terms in state prison and he's trying to convince me (himself?) that this time it will be different. He rejects the offer of a referral to chemical dependency treatment. "I haven't used in 8 years." "But you've been in here." "I know, but I could have used, and I didn't." "Your central file says you had 2 violations for manufacturing and consuming "pruno" (a god-awful smelling prison concoction, usually made in garbage bags, with any kind of fruit they can get, juice or water, and the natural process of fermentation). "Well, those were special occasions." Right. He is so well defended that I don't say what should be said: "You, sir, are full of shit. If you knew how to stop using on your own, you would have done so by now. You have lost the ability to live drug and alcohol free." Instead, I propose that his assessment of his own needs are "short-sighted," and I'll be recommending alcoholism treatment to his parole agent. I know he's not happy, but he nevertheless flashes that big toothless grin. As he leaves, over-thanking me for my hospitality (and who am I to argue?), he asks, "So will Medical help me get some teeth?" Oorah, buddy. Following him, a young man rushes in, and all he needs is the phone number to re-instate SSI. My pleasure. He stands up to leave and says, "Can you get me a shot of Haldol?" You're joking. On such a beautiful day? Haloperidol is a first-generation antipsychotic with enough side-effects to sicken an elephant (although, ironically, it is quite effective). "Ask the CO's for the doctor on call." The next 4 patients are "no shows." No shows are not necessarily unusual, but 4 in row is unusual. "Not in their house(s)," the CO's say. I walk outside into the yard and I am immediately aware of why I have no shows. I'll bet the sidewalk around the yard is more than a half-mile, and men are walking or running; shirts off, headphones on, tanning. The baseball in-field and out-field are full of men wearing mitts, shirtless, laughing, yelling, joking with each other. One man pitches softballs, and hitters are lined up, each taking 5 hits before politely allowing the next batter. Every concrete table and bench is filled and surrounded, some playing cards, many playing chess on the board painted on the table. 6 or 8 men are playing handball on the courts provided. I find myself smiling, occasionally laughing at the comments I overhear. My eyes moving from one tattooed man to the next. Extraordinary art. Then the inevitable alarm. Blue lights like K-Mart are flashing on poles on the wall. The horns are blasting, reminding me of the war movies: "Dive, dive, dive!" Everyone is pretty much down before the speakers blare, "Everybody down! The yard is down!" Just as quickly, the horns and lights are gone, and the yard awakens from stop-action as if nothing happened. But my attention is now drawn to the fact that there are "gunners," men and women with automatic weapons overseeing the "fun." How odd. While I was imagining carefree kids in the park, I am reminded that I was observing murderers, burglars, robbers, perpetrators of violence, tormentors. Finally, the recall comes and hundreds of men make their way back to the 4 massive buildings in which they are held. "You people, next to the wall, move it. Let's go. Everybody Home." I wouldn't have kept my appointment either.

Toujour et Tout-Jour Vendredi

2006-06-15T07:08:00.000-07:00

I was warned Thursday that two African-American inmates got into a fight, and one "cut the other one's throat." He died in the infirmary before he could be transported out. Hmm. CO's "rumor" is that once in the infirmary, the mortally wounded inmate fought off his helpers, tearing out IV lines and thwarting any attempt to save him. I'm thinking, what physician wouldn't have immediately sedated a severely injured patient in order to stabilized him? I suppose stranger things have happened. But it did lead to an absurd discussion over lunch. One colleague suggested that the stabber's attorney will say he was only guilty of "attempted murder," and the dude actually contributed to his own death (25%?). Yikes! I set off today anticipating it would be a slow day because of one sort of "lockdown" or another. The first young man I saw was so psychotic it was both breathtaking and unnerving. He didn't answer one question without a 30 second or more delay; often I repeated the question or he (eventually) asked me to repeat the question. The sequence was familiar: question, stare, looks away, stares, either answers or ask for a repeat of the question, and all the while talking to "somebody." And of course, an alarm. I open the door and tell him to step out, he stands next to me, and I have to "order" him to get down before the screaming CO's arrive. Interestingly, the only odd thing he said was, "I don't eat vegetables because I really can't taste them, 'cause we loose taste buds as we get older." He was 25. We ended with me asking if he had questions, he stared and left. I asked the CO's for the next patient and they were laughing and commenting about how "cute" he looked; "You'll recognize him with orange eye- shadow today," they all laughed. Deep breath. Walk away from them. Keep thinking, "If I'm ever in trouble, they'll be the ones to save me..." I call out the name and a kid, and by that I mean a 20 year old who looks 15, approaches. His hair is spiked everywhere except the front, where it's glued down, giving him an Alfalfa-of-the-Little-Rascals look. His pants are cut to (I don't know how else to describe it) "capri-length" and he's wearing the black, state-issued hi-top sneakers, loosely based on Converse, but an exceptionally cheap model. He is wearing a standard blue scrub-resembling shirt over a white longsleeved T-shirt. When he sat down in the office, I noticed he had tattoos that formed side-burns on his face, and a tatoo tear falling from the far corner of each eye. The neckline of his T-shirt was low, revealing a beautiful, dark blue tattoo, and tattoos ended at the tops of his hands that obviously began under his long sleeves. At one point when I asked his current weight and his answer seemed improbably high, he pulled up his shirt (why do they always feel compelled to pull up their shirts?) and I was struck by the fact that he was pretty much covered with tatoos. As we spoke, his voice had the tonality of a 15-year old, and it was tremendously disconcerting to imagine him in with these tough speaking, hardcore criminals. We talked about his ability to function, his work history, his education, and then we got to the issue of his family. He said that he was "on my own for a long time," and he had no contact with his family. I asked if the lack of contact was by choice (meaning, some people don't want anyone to know they're in prison), or by circumstance (meaning, there are "issues"). He said, "I was really badly abused," and began crying; and then crying to the point of not being able to catch his breath. He finally said, "I don't like to talk about this." I helped him as best I could with a little "self-soothing," but then we got to the issue of living arrangements. "I don't want to go back to the streets. I had a horrible time on the streets," and he began to cry again; "I just can't trust anybody." At least here I was able to assure him that because of his mental health designation, he could not be homeless on parole by law. Prison was the first time he had been in therapy, and he found it helpful. I urged & urged (and urged) him to continue taking his meds and avail himself of therapy in the out-patient clinic. He broke my heart today. Amidst so many truly disordered and needy, this young man broke my heart. I was exhausted. As I went to return medical charts before leaving, I heard someone calling "Dr, Starfish," and only after it repeated a few times, I looked over to see my patient with the severe head trauma, who had been shot twice, and who set me on a 2 week chase to find his correct Social Security number. "Starfish" is a loose (very loose) mnemonic of my last name - the kind of odd "suggestion" you sometimes get from a spell-checker - and I forget that I had scheduled him. As we walked to the office he said that he was worried "you were like everybody else around here" and had forgotten him. I gave him the letter I had prepared for him with his actual number. When he saw it, he laughed very hard: "How did I come up with the one I gave you?" The 2 weren't even close. "Man, you really went of your way for me. You didn't need to do that. I really appreciate it." He put out his hand and I shook it. "I don't want to see your face in here again." "You won't man. I mean it." Friday.

The Sweeny Todd of Sacramento

2006-06-15T07:07:00.000-07:00

A parole social worker emailed me from near Sacramento saying "I am seeing a patient next week who did time for possessing 157 lbs. of human remains (e.g. a head, a chest cavity, a cache of Pap smear slides). Any suggestions as to what I should ask him?" His actual crimes were "receiving stolen property" (which I presume to mean the remains, after they were weighed) and possession of methamphetamine. He was an "autopsy assistant" who, apparently, took his work home with him. His son told the police that his dad had, at one point, brought home & dissected a fetus. He had an RN but never worked as a nurse. He reported a "measured" IQ of 140, and refused medications for Bipolar I Disorder (an often maddening mood swinging from mania to depression) because it lowered his IQ by 60 points. Under California law, he was prescribed medical marijuana. I offered a bunch of suggestions, then spent some of the afternoon discussing this with colleagues. Our learned opinion: better you than us. My further opinion: he couldn't have done enough time to be going the street.

Her worst fear: "I killed him."

2006-06-05T22:40:00.000-07:00

Michelle and I were seeing patients in the "S" clinic, when she had a no-show for an anticipated SSI evaluation. I was talking with the control officer when she approached and requested he phone the patient's house to find out where he was. The officer phoned and said, "He's dead." Michelle said, "Come on, where is he? I don't have time for this. "No, I mean it. They took him to a community hospital because of his diabetes and he died." We looked at each for a brief moment, smiled, and she called the next patient from a group waiting in a locked area. The patient said to me, "I want to see you; I don't want to see her." Everyone laughed.

It reminded of Richard Pryor relating that his father died in flagrante delicto with a prostitute. "Nobody would touch that woman for six months." [Note: I cleaned up his quote. Use your imagination].

You'll be in jail for Christmas (if only in my dreams)

2006-06-04T13:33:00.000-07:00

Completing discharge summaries reminded me of the old "discharge parties" we had at a downtown clinic. Sixty days of no contact with the doctor (which obviously meant you weren't taking your meds) and the County wanted you officially discharged. With a case-load of 150+ patients each, it wasn't unusual to get behind in discharging the MIA's; MIA's in the sense that they were never really "gone," just gone for a while. In fact, sometimes the most effective way to get someone to return was to send them a discharge letter; and hopefully they would come in during a 180-day grace period where they could just be "re-opened" rather than going through the new admission process. We would gather at the conference room table, stacked with charts, and discharge for several hours. There are other circumstances for discharge (the obvious violence in any form, transfer to a new clinic, etc.), but quite often it was for missing appointments without notification. Three times and you're gone. We had a system where each clinician served one morning and one afternoon per week as the "on call" for walk-ins and emergencies. It so happened, by coincidence, that one young woman had missed three appointments without notification through me because I happened to be on call. It was also by coincidence that at a discharge party, I happened to have actually discharged her, though she was not my patient. This was August. For whatever reason, our clinic was open for a half-day on both Christmas & New Year's eve. I drew "on call" for Christmas eve. For you Easterners, let me just say that it was a sunny, cloudless day, but you did need a light jacket outside to be comfortable. An uneventful morning was closing when I hear the angry voice of the young woman I had discharged in August repeatedly mispronouncing my name to the receptionist (at first glance it may appear "difficult," but divided into 2 syllables, a child - at least me - could pronounce it correctly). I asked the support staff to get me her chart, and with it I proceeded to the window to speak with her. She was there with her mother, and my immediate impression was that she was as high as a kite. From the first word, she was yelling and cursing - a not altogether unusual occurrence in our little operation - and I modeled the calm, expected behaviour: "Lower your voice. I can hear you. I can't help you if you're yelling at me." "If I'm not crazy why do I have these?" She throws a half-empty prescription bottle at me. Depakote 1200 mg per day, no refills, last filled in July. "You are obviously not taking these meds if you have half a bottle since July. That's why I discharged you." She's escalating and getting louder, she is now standing and yelling. "If you are not able to calm yourself, young lady, I have no choice but to call the police." "Go ahead, CALL THE POLICE!" Unleashed was a Joycean stream of consciousness and tears repeatedly punctuated with "you faggot motherfucker." Hmm. I turn to the receptionist, who is already a step ahead of me on the phone, "Call 911." The mother attempts to calmly intervene, occasionally turning around to tell her daughter to shut up. I calmly began to explain to the mother our process, which only escalated the daughter. I finally said, "You had better get her out of here before the police arrive. You don't want your daughter in jail for Christmas." The young woman is totally out of control, and her mother pushes her out of the reception area into the entrance foyer, the door locking behind them. The young woman is pounding on the receptionist's large window, thankfully Plexiglas, with both fists; the frame is shaking so hard that the receptionist leaves thinking it might crash in on her. I say, "Young lady, you are trespassing and I order you out of this building. You're going to spend Christmas in Los Colinas (the women's county jail." The mother is defeated and helpless, and I keep telling her, "Get her out of here before the police get here." They are a half a block away when the police roll up on them. We closed up, everyone exchanging holiday greetings, and I went outside and sat on the front steps, waiting for my roommate to pick me up. Directly across the street is the Family Court, another source of daily chaos, dark and silent. As a matter of fact, the streets are basically empty, void of the usually heavy traffic headed downtown. It's noon and I hear church bells from various sources in the downtown. The surrounding blocks are fundamentally void of any decorations suggesting a holiday. I sat really, really hoping the police cut her loose. I never heard from her again.

A Day Without African Americans

2006-06-03T13:15:00.000-07:00

Walking to the psych unit, I notice the yard is basically empty. Only in the Dept. of Corrections could you hear such a thing: "No Black patients can come out today, only Whites and Mexicans." What? "There were problems yesterday and Black inmates are locked down." No one ever explained what the "problems" were exactly. My African American colleague advised me that "it was Black 'thang." This knocks out half my patients for today. "You can go to their house after they're done feeding and interview them there." Translation: After breakfast is finished, I can go to their housing unit, stand there on the tier wearing a stab-proof vest, yelling out their personal business while everyone else is at their own door, staring at me through their window, listening to everything. "I'll make new appointments." As I leave the unit after seeing only Whites, I notice an Asian inmate walking, basically alone on the yard. I imagined the dialog: "How do you fit into this?" "It's a Zen thing."

An AdSeg Kind of Day

2006-06-03T13:05:00.000-07:00

I took a trainee into AdSeg with me today, and he got to experience the sickest of the sick AND the baddest of the bad. It was so noisy and agitated today (yelling, animal sounds, people kicking - or hitting their heads - on metal doors, obscenities galore) on top of it being hot and altogether distempered. You have to picture a VERY large room with "stations" of approximately ten cages, each bolted to the floor in a semi-circle. Everybody, including us, are vested, and many have the disposable face shields you now see in surgery, in the ER, and even at the dentist's. I would also note that the correction's officers seem to be in exceptional physical shape, for obvious reasons.

They refused to bring out our first guest, stating that he had been violent with staff within the past 24-hours, and a note had been placed on his door indicating that he needed 24 to chill. "I don't won't to be cement bouncing anybody today, so he stays put." No problem. We'll catch him again, because one thing is certain, he isn't going anywhere.

Our second guest was a bit more gracious and immediately cuffed up for the officer - turning around and placing his hands through the food port of his cell so the officer could easily place the cuffs on him. The CO then called for the control officer to electronically open the cell door, and he quietly lead him to a cage. He was locked in, and uncuffed as the process was reversed. As he was being led to the cage, he was bugged-eyed wild. The trainee said to me, "He looks crazed!" Once he's safely locked in, he can be Satan himself for all I care. What was immediately noticeable to me was that his fingernails were at least over an inch long (to the point of bending over), sharply filed to points, his white jumpsuit was dirty with body fluids, and he smelled badly. His goatee was shaved so that it was only on the left side of his face. Take all this as you will.

All in all, he was friendly enough; from the outset, he stated that he was honest with people who were honest with him, and I seemed to fit the bill. I told him I would explain the reason behind my questioning, and he seemed satisfied. One odd thing he did do was suddenly jump up from the seat in cage, addressing the trainee with, "And who the fuck are you?" The trainee was so stunned, that I had to answer for him. The inmate then said, "OK, I just need to know who I'm talking to" (I had actually made the introduction previously). When it came to suicide, he was open that he had both contemplated and attempted such at the instigation of command-type hallucinations. When asked if he ever thought of harming someone else, he indicated he had, but when asked if he had a specific plan, he said, "We'll just say no one is in harm's way for the moment."

He had the typical paranoia - he believed people looked at him, talked about him, and plotted against him. They could also read his thoughts, so it was essential that he clear his mind to prevent this. He was what is referred to as "tangential" in his thought process, meaning he jumped from idea to idea without any perceivable connection. For example: because he is caged, I am reluctant to call a CO so I can give him a pen to sign forms, lest he refuse to give it back. A CO won't hesitate to first threaten, then actually pepper spray a caged man to get a pen back; and this isn't one of those little "personal" hand-held deals you see sold in stores. Pepper spray in prison is more like a small fire extinguisher. So I ask, "would you like me to get a CO and you can sign these forms, or will you authorize me to sign them for you?" "Well, this lady got on the computer and was calculating my time served..." He is totally off track and needs to be continually "redirected," brought back to the point. Secondly, he "talked past the point," meaning, while he eventually got there, he talked of anything and everything before directly answering the question. This, when done consistently, is unnerving, if not crazy making.

In the end, I got the information I needed, he was grateful and thankful for my time, making a special point to indicate that I was "very patient, and most people aren't with me because I'm crazy." While I rarely make a point of shaking hands in prison, he stuck his hand through an opening in the cage and I shook his hand. He did likewise for the trainee. We unvested and got the hell out. I believe the trainee was thinking, "just what kind of job did I sign up for?" Me, I'm loving the intensity of the environment and the level of illness. I love these patients!

Bottom of the Aryan Ninth

2006-06-03T12:59:00.000-07:00

Prison gangs. Many 'gangstas from the outside join the OG's on the inside. Some sign up to, as they say, "protect 'yo neck"; gangs got your back. Likewise, there are "benefits" (e.g. sex, tobacco, drugs, influence on the outside). Every variation and derivation of Crip, Blood, Latin King, Skinhead, Aryan Brotherhood, and more have a seat at the table. "Can't we all just get along?" Most do. They basically stay away from one another. Then there's the yard. There is a complex "matrix" of who can be out with whom, and when. No Crips with Bloods, no African-American & Latino gangs, etc. Then there's the issue of "known enemies" (e.g. people you owe money, "rats," those "ratted out"). Further, you have to add to the mix the celebrity (this can range from Tommy Lee, to Scott Peterson, to John Gotti - anybody who would give a rep to the one who clocked them), pretty much any sexual offender (and God help a sexual perpetrator of children), and anybody vulnerable (i.e. subject to predators: developmentally disabled, mentally ill, "victims"). Some try to drop out of a gang, others are reasonably or unreasonably afraid, and the only way to survive is AdSeg; 23 of 24 hours in a cell. Yard by yourself, escorted, or with other vulnerable inmates. But it's always in the back of your mind: Who can I trust? You can torture and murder a store owner, his wife, and his parents during a robbery, for absolutely no discernible reason, and people will leave you alone; you may even have a perverted form of respect. But if it's found out you sexually abused a child, and you're in the general population, you are not long for this world. I got scammed once by an African-American patient who led me to a table on one side of the housing unit in order for me to interview him. About 5 minutes into the interview, everyone came back from the yard. This inmate kept looking around, looking behind his back, constantly losing focus. I finally said, "What is the problem here?" He said, "We're sitting at a white boy's table - brothers sit over there [pointing]. But it's OK 'cause you're white." It was then I noticed the same group of white faces cross my line of vision as they circled by. I stood up and said to the group of white inmates, "If you cross my line of vision again while I'm doing my job, I'm going to write you a violation." They were angry, but they moved away. I wrote up the black inmate for manipulation. He and his partners were amused. Today, when I entered the AdSeg yard 4, I went to sign in at the administrative office and there were two handcuffed white gang members (and I discerned this by the swastika and spiderweb tatoos - a tip-off), one with a bleeding slash from his left ear to front of his chin, and the other with an eye nearly swollen shut and obvious punch or kick marks all over his body. They were seated on the ground, surrounded by CO's, waiting to be transported for medical attention. When I returned to sign out, another cuffed man with the shaved head and swastika tatoos was also seated on the ground, red from punches, and a large section of the left side of his nose was missing. Since it was not a clean cut, I presumed it had been bitten off. All in all, it was a bad day for the Aryans. 3 to 0 at 12:30 pm. I suspect this is to even out in the end.

The winter of my emotions

2006-06-03T12:53:00.000-07:00

At the end of my day, I sat at a brushed steel table-chair combination bolted to the floor in an empty housing unit. Everyone was locked in so apart from some muffled music behind cell doors, it was quiet and cool. Two CO's escorted the patient, a tall, thin, light-skinned black man down the tier, his hands cuffed behind him. He wore the customary boxers, white t-shirt, white socks, and shower slippers. The odd thing about about him was that he wore a second t-shirt like a headdress; the neckline formed a headband, and the remainder was draped over his left shoulder. He sat down, and with a short, salt-and-pepper beard and soft voice, he reminded me of Bin-Laden. The officers returned to their office, leaving us alone.

He was so quiet, polite, and articulate that his entire presentation was hypnotic. But the discussion was punctuated by a fly; one that, in a very large room, finds you and refuses to leave. It landed on me and I swatted it away. Again, it landed and I swatted it away. Relentless. It changed tactics and landed on this patient. Being cuffed, he could only twist, shrug, and shake his head. At certain points, he simply didn't bother, and I watched the fly walk on his face. I suppressed my urge to help. What goes through my head at times like this is extraordinarily complex, and extraordinarily fast: if I help him, he will perceive me as vulnerable; if a CO sees me help, he'll think I'm stupid and a "sucker"; I am aware of a natural urge as a "helper." I ignore what I see, and he doesn't act as he ever expected me to assist.

"Why are you in the mental health program?" He tells me about his older brother: "He's nothing like me. He's a responsible man. A working man." His brother managed to buy himself a small house in Oakland and lived with his three children. He had sole custody because his ex-wife was a street addict and missing for several years. "He was a good father and provider. He was a very responsible man." Silently, a single tear rolls down his cheek. He tries to reach it with his shoulder, but he cannot. I suppressed the urge to get a tissue from my bag, and to redirect him away from the details of this story, to a discussion of his symptoms, but it is hypnotic.

This patient described his brother's neighborhood as Asian, and home to numerous gangs. It was not unusual to hear fighting and gunfire, to the point where no one bothered to call the police just because of gunfire. He said his brother awoke to what seemed to be a fight in his backyard, so he open the window and yelled. He was shot in the forehead and crashed to the floor, awakening his children who called for help. His brother did not survive. This patient was not allowed to attend the funeral. He began a descent into depression, hallucinating that his brother was calling for help and chastizing him for being in jail, and finally he attempted suicide Tears openly rolled down his cheeks and he made no effort to hide them. I didn't move.

Our discussion concluded with his desire to "get those babies when I get out and raise them as my own." I stupidly babbled on about him having a reason to stay out of jail, blah, blah, blah. We stood up and he turned around and extended a cuffed hand. I shook it, and he mildly returned the handshake. He said, "I need the appointment letter your were going to give me." I was embarrassed at forgetting that he never expected a "connection" with me, just the letter. But as he left, I couldn't help but put my hand on his shoulder: "You hang in there, man." "Thanks, man, I appreciate it." Whether he was sincere, and whether I was simply assuaging my fear of my own "coldness" will never be settled.

I presented this case in supervisory group, and sat back silently, listening to the detached clinical music of counter-transference, veracity, professional boundary, and "decompressing" emotional experiences. I got up and walked out, headed for the bathroom and vomited. Let's discuss the psychodynamics of that.

I Wouldn't Do It with His Hands

2006-05-25T20:48:00.000-07:00

I sat just inside the door of the Mental Health Unit waiting for patients to arrive - it was cold & rainy (in San Diego!) - and it was generally grim. There are no windows to the outside and the facility has a warehouse feel to it, high ceilings with silver wrapped ventilation pipes. There is absolutely no sense of time. Every inmate who enters immediately turns his back and raises his arms parallel to the floor so he can be frisked. Bad enough that everyone was wet, but in walked a very tall, morbidly obese man, arms out, waiting to be frisked. No one wanted to do it. The corrections officers were saying, "No way," "Not me," and "Give me a break, I ain't had my coffee," and walked past him. He was wearing a yellow rain slicker, white tee-shirt, and standard issue blue pants with "CDC Prisoner" prominently printed on the legs. With his arms out and his slicker open, it was impossible not to notice that he had large breasts, and it went through my mind that it would be somehow obscene to "pat him down." Suddenly an alarm went off; you wear a "panic button," about as large as a garage door opener, and if you're in danger, the button sets off a full-unit alarm. CO's immediately start yelling, "Get Down!" meaning all prisoners must lie on the ground. Through the front door, CO's start pouring in, yard-long nightsticks in hand. It turned out to be a false alarm. The obese man asked for assistance and was met with the same indifference as when he entered. With a sort of roll and boost from a desk, he finally made it to his feet again. Having seen enough, I moved on to begin my business. I still don't know who the lucky CO was that had to do the deed.

Tales from the Backside

2006-05-25T20:47:00.002-07:00

Jessica told the story of working in the hospital at San Quentin this week, interviewing a man through the "food port" of the cell door (a padlocked port through which an inmate can put his hands out to be handcuffed before the cell door is opened - food & other things can be passed in as well). Obviously, there is little privacy and everyone can hear your voice (and believe me everyone wants to). A woman's voice in an all male prison draws particular attention. A voice down the hall kept calling, "Nurse!" and Jessica ignored it. Then the voice called, "Nurse, there are worms in my bootie-hole." Medically speaking, it certainly is a possibility, but we're talking about a psych unit. Jessica was then quick to yell out, "I am not the nurse." End of callings.

I was once waiting for a patient at Salinas Valley, when everyone returned from the yard and back to their cells. An officer was quick to place a young man, who was very agitated, into a cage near the entrance door. I heard the CO saying, "Chill out, man. It'll be OK." I recognized the young man's voice as "one of mine," and the CO asked if I would speak to him to and try to calm him down. When I asked him the problem, he told me, "My psychologist accused me of being 'punked' by my cellie, and he said I could be charged with a crime." "Punked" means to be on the receiving end of sex with your cellmate. It was obvious that he was manic psychotic, wildly pacing, squatting, pacing, swinging his arms, and speaking to internal voices. Suddenly, he dropped his pants and yelled at me, "Check my ass! No DNA evidence!" Yikes! The CO's watching were greatly amused.

Bad Karma

2006-05-25T20:47:00.001-07:00

Doing the endless paperwork and came across a patient that was one of the sickest I'd ever seen in a prison. The Medical Facility - home to the aged, the infirm, the elderly, transexual, HIV/AIDS, and the very mentally ill. He was 36, tall, not a bad looking man from a distance. Severely diabetic, in renal (kidney) failure & on dialysis 3x per week. Lost sight in his left eye because of the diabetes and elected to have surgery on his failing right eye, which resulted in blindness. Taking enough meds to kill a large dog. Calcium level too high, potassium level too low, always one step from disaster. Total meth addict; needle tracks like maps over his arms. He was brought to me by a porter, wearing a bright orange vest that said "Visually Impaired" on the back. It was obvious he didn't know how to use the white cane he had in his hands. Once seated, the initial observation: "meth mouth." Methamphetamine inhibits proper salivation and the mouth becomes continually dry, damaging your teeth. Actually, they rot and fall out. Breathing in my face. After short introductions, he began a tirade of complaints and demands: out of the dorm into a private cell; call my girlfriend and have her bring me...; I want Ativan (a central nervous system depressant like Klonopin, Valium, Xanax, etc.) and my doctor won't give it to me; etc., etc., etc. Sample dialog:

Me: "I don't work for this facility, and I don't have the authority to authorize the changes."

Him (in slow, deliberate voice like he is speaking to a dumb waitress): "Do you mean to tell me you can't walk down the hall and knock on my psychiatrist's door and get these things done?"

Me (knowing damn well why his Dr. won't respond to his continuous demands): "It would be inappropriate for me to do that."

Him (after a long silence): "You are totally fucking worthless to me."

Me: "Point taken."

I find out he is PC 290, registered sex offender, convicted of "intentional cruelty to children," and has a briefcase of domestic violence charges. He hurts people just for the hell of it. I thought to myself, "Karma has caught up with your ass, but fast. I suspect you'll comes back as a Norwegian Brown Rat." Sometimes, no matter how hard you try, you can't even buy compassion.

...and Then the BBQ

2006-05-25T20:46:00.000-07:00

Some inmates need "escorts." This means they are generally cuffed and led by an officer or officers (depending on their perceived level of violence) to wherever they are going. The CO's yell out, "Escort," and at San Quentin, for example, any inmate they are passing has to turn and face the wall. I suspect the rationale is that someone might try to clock a handcuffed man; sometimes retaliators actually wait for the opportunity. At Donovan, it seems people just get out of the way. Anyway, I'm waiting for a CO to call a patient's "house" because he didn't appear on his own, and the call, "Escort!" begins. Everybody backs up as two handcuffed lads are led in by CO's and immediately locked in cages. The receiving officer says, "Wha'd they do?" The escorts say, "barbecuing in their cell." They apparently were cellmates. It is unclear to me if they were actually "cooking," attempting to cook each other, or harm themselves independently. Whatever, they were now caged in psych, and neither appeared happy about it.

In the drab, colorless world of corrections facilities (some yards are so barren you'd expect sagebrush to blow by), I came across an inmate watering an area in front of a building with a beautiful garden I had never really noticed. Cactus, small palms, azaleas, flowers. And the amazing thing was the number of birds in the garden - it literally sounded like an aviary. Since any number of people walked past me as I stood there, I wondered if anyone paid attention to this with the exception of the man assigned to provide water.

Of Dry Feet

2006-05-25T20:45:00.000-07:00

I've been meaning to mention that upon examining the medical files of hundreds of California inmates, I have found what I believe to be an inordinate number of them "prescribed" moisturizer for their feet. Eucerin seems to be the most popular brand. Now, Eucerin claims they are "the brand dermatologists trust." I wouldn't know. Note that this an anecdotal report, as I have not done the research. Please, this is not an endorsement, but if your feet are "sensitive and dry," it probably wouldn't kill you to consider the satisfaction of California inmates with a similar condition.

You Might Be Awake When they Kill You

2006-05-25T20:44:00.000-07:00

The Lancet - Volume 366, Issue 9491 , 24 September 2005-30 September 2005, Page 1073

When asked by editors of The Lancet to assess for publication ÂInadequate anaesthesia in lethal injection for executionÂ by Leonidas Koniaris and colleagues (Apr 16, p 1412),1 I expressed strong support for the article because it contained the largest series of post-mortem lethal injection thiopental concentrations published to date. Furthermore, the finding that many inmates had low serum thiopental concentrations, and were possibly awake during execution, was new and vital information that could profoundly affect the public discourse on lethal injection.

However, after more research, I became concerned that the statement that Â21 (43%) [inmates] had [thiopental] concentrations consistent with consciousnessÂ may be erroneous because of a lack of equipoise in the study. In their zeal to ÂproveÂ that thiopental concentrations during execution were low, Koniaris and colleagues may have erred in their reporting of the crucial measurement of the elapsed time between the moment of death and the retrieval of blood samples, stating that the samples were collected the Âsame day or next dayÂ. In fact, a graph provided to reviewers, but not included in the paper, suggests that most samples were obtained 12 or more hours after death. This graph clusters nine samples exactly 1 day after death, and 15 or more at about 0Â·5 days, suggesting that these times were rounded off. Most importantly, only two samples seem to have been obtained within a few hours of execution.

The elapsed time is critical because thiopentalÂa lipid-soluble and ultra-short-acting anaesthetic agentÂredistributes into fat and muscle, even after death. In addition, a lethal injection is a unique clinical event, in that death occurs within a few minutes of injection of a large bolus of this drug, therefore a steady-state is not present. Under these circumstances, post-mortem serum concentrations are not reliable if a substantial amount of time has elapsed, because the high concentration of drug in the blood rapidly diffuses across a concentration gradient into the surrounding tissues after death. To state that Âthiopental concentrations did not fall with increased time between execution and blood sample collectionÂ consistent with data showing that thiopental is quite stable in stored human plasmaÂ is erroneous since few samples were taken within the first few hours after death. Furthermore, there is a huge difference between the behaviour of thiopental in a corpse (where it diffuses out of the blood and into tissues in the body) and in a test tube of serum (where it has nowhere else to go). Other studies, not cited by Koniaris and colleagues, suggest that post-mortem serum thiopental concentrations in thiopental-caused deaths are lower in blood than in tissue 2 and 3 and could be unreliable.4

Although Koniaris and colleagues' conclusion that lethal injection has Âled to the unnecessary suffering of at least some of those executedÂ is probably true, it is not supported by the data presented. Clearly, public review of lethal injection is warranted for several reasons, but so is more careful scrutiny of how and when post-mortem blood samples are obtained.

At the Border(line)

2006-05-25T20:43:00.001-07:00

A friend, who left the University Hospital and became a staff psychiatrist at a state hospital, is working with incarcerated women who have Borderline Personality Disorder. The disorder is characterized by "fluid" personal boundaries, emotional lability (extreme expression of emotions - quite often in a varying range), difficulty with intimate relationships, and just being all-around manipulative and difficult.

This discussion reminded me of a patient I had who was truly a 5-star borderline and who I saw twice a week. Since she was "boundary-less," it was necessary to establish some boundaries immediately: you have a scheduled appointment, and if you're late, the session won't last longer; 20 minutes late and the appointment is cancelled; 1 phone call per week, and it must be a true emergency, and it is limited to 10 minutes (I will hang up); after she touched my leg during a session, there was a rule of no touching; etc., etc.

There was a constant testing of boundaries every single session: "Are you gay? It's OK. It doesn't bother me." (I'm not) "Oh, you're Jewish, so you wouldn't know about Christmas." (I'm not). "Well you can afford a new car (I can't) so you don't know it's like to worry about your car breaking down (I certainly do). After she touched my leg she said, "Relax! I didn't mean anything by it, I wasn't going to jump in your lap. But hasn't everyone fanticized about having an affair with their shrink." Yikes!

One day she told me about a dream and I asked her what she had done that day. Shopped for shoes, had dinner, and watched TV. I asked what she had watched on TV. "Oh, you're good! You know what to ask. As a gift, I ordered the Playboy Channel. I like to watch women with women. At about 2:00 am I got on a lesbian website and posted my profile. In the morning, seeing that I got several responses, I freaked and wrote the Webmaster and asked to be removed because someone had played a joke and profiled me, and I'm not gay." When she arrived for the next session, I could tell she was angry, and in a rage she said told me she was furious about me having "coerced" sexual information from her. I said, "I only asked you what you watched on TV."

As time passed, I realized that every single session was devoted to a crisis: her mother, unemployment, eviction notices, etc. She would being by saying, "What are we going to do about this..." As I increasingly emphasized, "What are your options," she burst out with, "WHERE ARE YOUR FUCKING CLINICAL SKILLS? Do you even know what you're doing?" I had such ambivalent feelings toward this woman: I emphathized and felt sad for her miserable life, but the continual testing was maddening. While there is no medication for personality disorders, sometimes medications for, say, depression can actually lessen the Borderline symptoms. 3 times, with 3 different med, she would take a prescription, but she would never fill it.

Finally, after a year, it all came to head when I pointed out that she was in a "double-bind" with her mother: she had a briefcase of unresolved issues (including child abuse), but she depended on her mother to pay for her existence. She created crisis to focus on in therapy to avoid the real issues. She came in the next week and said, "I don't know why I come to this rathole. You don't know what your doing and you're not helping me. I'm done here and I'm not coming back." As she was leaving, I told her that I would keep her appointments open. She yelled back from the end of the hallway, "Fuck you, you idiot." And so it goes...

A Whack to Friday

2006-05-25T20:41:00.000-07:00

Yeah, I know everybody's Friday is whack, nothing out of the ordinary. My day began walking to the psychiatry unit through the yard where a 100 or so prisoners were walking, sitting at tables playing chess or cards, etc. But in the middle of the baseball diamond was a man with a cardboard paper towel roll, playing it like a musical instrument, then singing insanely loud, dancing all around the infield. Apparently, no one else was interested, concerned, or were accustomed. I found it plenty bizarre.

The first man I saw claimed to have been adopted by two CIA agents in Berlin, but this was concealed, and his birth certificate says he was born in Washington, DC. It was there that he worked with Presidents Reagan, Bush I, and Bush II, but apparently his drinking caught up with him in the form of a cirrhotic liver, "hard as a stone." His chauffeur ran off with his limousine, and he was pretty much left destitute. What does that say about the generosity of our Republican presidents? Drinking, "run-ins with the cops," absconding parole for Ensenada, Mexico all contributed to his facin' it up with me. His parole plans were, "fuck the medications and my Parole Agent; I'm less than a mile from the border crossin', I get $200 cash gate money, and I'm getting me a few cold Coronas and watch the ladies getting on the trolley at San Ysidro from other side of the border." Well, I sure as hell have no intention of chasing him. Good luck pal, and remember to take your meds before the Coronas.

The last man I saw was Vietnamese, which is unusual; Hispanic, African-American, Caucasian (in that order) usually cover it, before others. This man was dressed all in orange because he was from the Reception Center, which serves as a diagnostic unit for people just coming into the system and who will be sent elsewhere, or as a short-term unit for people who were returned by the judge for a violation of parole. All in all, I found out nothing from this man except that he was floridly psychotic, responding to internal stimuli (i.e. interacting with voices he hears), and basically incapable of focusing or participating in a real conversation. I say, "What are the voices saying?" His face goes completely blank and he stares at me for what, in my estimation, was an uncomfortably long period of time. He then turns his head to the left and begins giggling. He said: "They're saying I should tell you to shut up before I have to fuck you up." Lovely. All I found out was that he was recruited into the US Air Force "as a baby," and his job is to drop bombs all over the world. He says, "I am paid extraordinarily well to do my job." I say, "You can only have $1,500 in the bank as a burial fund or you don't qualify for assistance. Approximately how much do you have?" He repeats the blank stare, the consultation to his left, the giggling turns into laughter, and he says "34 billion dollars!" I don't know what crime he committed, but he's out on 04/24/06. And so it goes...

2006-05-25T20:40:00.000-07:00

Having seen so many photos of cats on Buzznet, I am reminded of a complex discussion of Obsessive-compulsive disorder (OCD) and Obsessive-compulsive personality disorder (OCPD) that occurred in a seminar on psychopathology. OCD/OCPD is generally characterized by obsessive behavior(s) such as counting, cleaning, checking, or hoarding. Someone asked if the people who are found to have many, if not hundreds, of cats in their home could be considered OCD, "hoarding type." An intern friend whispered a phrase to me that became an obsessive phrase for the year: "It's always cats." If you think about it, you don't usually hear of the police going into some old lady's home and finding hundreds of dogs; hundreds of birds; hundreds of minx; or hundreds of rhesus macaque (M. mulatta) monkeys. I believe this to be a worthy truism.

Distinguishing the Nuts from the Merely High

2006-05-25T20:39:00.000-07:00

My roommate told me of a walk-in patient she saw yesterday who was totally whack. She said the woman was extremely thin, dilated pupils, and tangential in her thought process. "She had these delusions that cars were swerving on the highway trying to hit her [OK], that the CIA & FBI were watching her [OK, sigh], and raccoons were driving a car that passed on the highway [WTF]." Delusion must have a basis in reality; it must have even an outside chance of possibility. Raccoons driving a car is outside the realm of possibly, as near as I can tell. "Did you get a urine on her?" "No, I'm really not accustomed to working with this kind of patient." I'm thinking tweaker (methamphetamine) with substance-induced psychosis.

I was reminded of a woman I saw who was in a battle with Child Protective Services to regain her children, who had written on her intake that she had quit drinking five years ago. I asked, "Why did you quit drinking?" "Because my mother didn't like it, so I prayed to God to send me a terrible hangover. The next day I was so hungover and sick, I never drank again." Hmm. "What would I find if I took a urine sample right now." "You white motherfucker! As soon as I saw you I knew! I knew you would try and stop me from getting my babies back." "What would I find in your urine?" "I smoked a joint before coming here this morning because of my nerves." "Do you see anything odd about coming to this assessment when you're high?" Silence and a cold stare. "Is it possible for you not to get high tonight and come back tomorrow?" "Yes." "OK, I'm ending this interview because I won't interview anyone whose drunk or high." As she leaves she is heard to say, "that motherfucker." She returned the next morning, I asked her in the hall if she had used and she said no. "OK, wait here and I'll get the nurse to collect your urine." "I don't need to give you a urine! I already told you what I used." "Then you can leave." "You white motherfucker! I'll do it, but I want to see somebody else." My pleasure.

If this strikes as uncompassionate or too hardass, my first lesson in dealing with hardcore "drugados" happened to be a woman with children who was living in a welfare hotel, awaiting sentencing for drug possession. The judge referred her to me as part of the pre-sentencing investigation. An hour before her appointment, she called me in distress, crying and telling me, "I can't find anybody to watch my babies. What am I supposed to do?" Chill. "I'll give you another appointment in two days, no problem." "Oh, thank you SO much." An hour before the second appointment, she calls again with the same situation. I tell her I'd have to speak with my supervisor before I could give her another appointment. I go and tell my supervisor the story. She picks up the call, hears the woman's story and says, "Where were you're babies while you were on the street 'coppin dope? You better have your ass in here on time," and hangs up on her. The woman showed up on time. Prince said, "If I were your girlfriend..."

On Ambivalence, and Such

2006-05-25T20:38:00.000-07:00

I interviewed a man with Major Depressive Disorder, Severe, with Psychotic Features (meaning he gets so depressed that he hallucinates, in this case, he hears voices). He is also diagnosed with Dementia Relate to AIDS, Polysubstance dependence, AIDS, and Antisocial Personality Disorder. This is a large briefcase of blues. "When did your psychiatric symptoms first start?" "1997, when my brother was murdered." [4 out of 5 of his siblings are also in prison]. Wow. "When were you diagnosed with HIV?" "1995." Wow. "What do the voices say to you?" "They tell me I am no good and that I should kill myself," i.e. command-type hallucinations. Wow. "Have you ever harmed yourself or tried to commit suicide?" "In 2004 I cut my throat, and in 2003 I hung myself [You mean hanged]." Wow. "Do you know your T4 helper cell count?" "Well, they said it was below 200 [i.e. very low], but they put me on some meds [2 anti-retrovirals] and it's better now." Wow. "What's your controlling case?" "Felon in possession of a gun and robbery." Wow.

When I think about this, I am confronted with facts: 1) We had known how to prevent HIV infection more than 10 years before he was infected. 2) He is relatively stable when he takes his psych meds, but when he gets out (he's finishing his 4th term), he stops and gets high. 3) Dementia means he is loosing and will probably continue to lose his sense of orientation to date, time, place, & person. 4) When he stops his meds, he becomes suicidal as demonstrated by 2 serious attempts. 5) Why, exactly, was he in possession of a gun? I would say he is "train wreck," but his situation is not unusual in a forensic setting.

This said, I am an individual who takes this all in. I am a helping professional, and I stress professional. It's my job to be objective. But some people are objectionable, stupid, and dangerous; felon in possession of a gun. Do I have compassion for this man? Absolutely. He is a desolate, rejected, despised human being. Am I pissed off at this man? Absolutely. While he says one thing, his history says, should he live so long, he'll be back. What is it I am doing? Bringing light to a darkened individual, if only for the time we are together? I would hope and be satisfied with this outcome. Do I believe he will recall anything I've said after he is released? No. I am ambivalent.

Termination

2006-05-25T20:36:00.000-07:00

Termination has many definitions, but in psychotherapy, it is the process of ending the clinical relationship with the patient. This means that you set a date, for (hopefully) weeks away, and you prepare the patient for the end. This can come about because the therapy is completed in a positive way, or it can be in a negative way; most often the patient just stops coming and doesn't return calls. Sometimes, they just leave a message, knowing you can't answer the phone, and thanking you for your help, but... And sometimes it comes about simply because you are leaving.

One of worst days of my life came on my last day on the Child & Adolescent Psychiatry Unit. On that day, everybody cried, and especially me. A 5 year-old girl, whom I had transitioned to the Chief Psychiatrist of the unit by taking her to him several times so she would be familiar with him, walked down the hall with me holding my hand. Her mother was a nurse at the medical center, and her father was a junkie who abandoned her. As we reached the reception desk, she suddenly hugged my leg and said, "I want you to be my Daddy!" I was hugging her and she was crying, and I was dropping tears down onto her head. It is sometimes helpful to give a "transitional object," and since she loved puppies, I bought her the softest, cutest stuffed dog I could find and told her when she was lonely or afraid at night, she could hold the dog.

An 11 year-old boy with Aspberger's Disorder (an autism-spectrum disorder) was with me for a year. Aspberger's Disorder children are very functional, intelligent, and can be obsessively focused on the things they find interesting; this young man knew all the details regarding Navy ships. They have a very poor social skills, make friends with great difficulty, and are often picked on by other kids because they seem "different." I called the doctor who was prescribing his meds, and occasionally progress checked in with him. When I would tell this doc about my relationship with this patient, he was cynical and discouraging. I quit calling him. This young man loved to play the card game, "Go Fish," and every time he beat me, he would go, "WooHoo!" He also loved to sit in my chair while I sat on the couch. One day he came in with 2 bottles of soda and gave me one. His mother said later, "He insisted on getting it for you, and paid for it with his own money!" On the last day, he too broke my heart; he cried and hugged me, saying, "You are my only friend." I gave him a deck of cards that had the emblems of various ships on the back of the deck.

A 14 year-old girl had been brought to me by her mother (who was in the Navy, and a wonderful mother) after a 20 year-old had coerced her into sexual activity with him. I was obligated to report this to Child Protective Services, and support this young lady in not regretting giving this dog up. She would insist, "He pressured me, but I chose to do it." It took a long time to convince her that a 14 year-old cannot "consent" to have sex with an adult because it's not a "relationship" but intimidation. I so much enjoyed watching her and her mother sitting on my couch, holding hands and leaning against each other. On the last day, she was so sad and kept crying and saying, "But I can tell you anything." I had my supervisor come in and meet her, hoping they would connect. This young lady loved music, so I gave her a guitar pick I got from Eric Clapton after a concert that I had put on a chain.

Children are astonishingly resilient. I couldn't get over this for weeks.

Bathroom Issues

2006-05-25T20:35:00.000-07:00

I was in the San Jose Airport last week, switched to an earlier flight home, and I went into the bathroom to change out of my "prison clothes" and into regular clothes. I went into a stall - I was the only one in the bathroom - and a man entered, went into another stall and began vomiting. And not just vomiting, WRETCHING, moaning, WRETCHING. In the middle of the epic yak, his cell phone rings, he answers, "Yeah, can I call you back?" and returns to WRETCHING. Again his phone rings, again, "Let me call you back," and again back to the yak. Bad sushi, or what?

I had forgotten to take my Corrections ID (and whistle) from around my neck, and when I got to the gate, an airline person came up to me and whispered, "Are you flying armed today?" WTF! Are you out of your mind! Who in there right mind would issue a gun to me?

I'll Tarasoff Your Ass

2006-05-25T20:34:00.000-07:00

Every department in a hospital has a sacred rite to air their dirty laundry of astonishingly stupid acts that have resulted in harm or death to a patient. This is universally referred to as a "Morbidity & Mortality" conference, or M&M. The beauty of M&M is that it is a closed, confidential, and best of all, unsubpoenable conference. Discuss and move on. Now as you can imagine, psychiatry M&M is much unlike, say, surgery or internal medicine. Breaking legally protected patient confidentiality or not reporting child abuse is no small matter, but it rarely results in death. Then there is the matter of Tarasoff.

Tarasoff was an unfortunate woman who was murdered by a man who had informed his therapist of his intent. The therapist, relying upon the prevailing law at the time, maintained his patient's confidentiality and did nothing. Obviously, this resulted in the forging and later refinement of a law that mandates the reporting of a substantial threat of harm or murder, first to the police, then to the intended victim, and CHART what you did. If you do not properly chart such and similar events, when you get to court, it never happened. This particular "Tarasoff-related M&M" brought up several issues for me.

It is a wise clinician who, under any cirumstance of contact with a patient, inquires: "Do you have any thoughts of harming or killing yourself?" followed by, "Do you have any thoughts of harming or killing someone else?" Trust me, you can get used to people admitting to thoughts of suicide. The follow-up to a positive response to either question is, "Do you have a plan?" Again, it is not unusual that someone admits to a plan for suicide, and you immediately enter a mode of protecting them. But I must say, nothing has ever prepared me for a positive response to the second question. It is one of my top ten chilling moments.

I will often expand the question to "have you ever had thoughts of harming or killing someone?" for the sake of determining history and level of violence. My thought would be, who would honestly admit to such a thing? One man very casually said to me, "Three months ago a man insulted me in front of other people & I decided I needed to kill him." Did you have a plan? "Yeah, I bought a shank and I was 'gonna cut that motherfucker's throat." What happened? "I was waiting to catch him playing cards with his back to me, but a door I needed to go through was locked." Do you still intend to kill him? "Nah, a week later he apologized and we cool." Are there Tarasoff issues here? I'm told no, because this is a past event. If you tell me you intend to kill someone, the law obligates me to report. But if you told you have already killed someone, I am bound to protect your right to confidentiality.

My opinion: W to the izzacky, S to the izzhit.

Free Lunch

2006-05-25T20:33:00.000-07:00

Free Lunch?

Kevin P. Hill, M.D.

"Dr. Hill, are we changing my medicine because they gave you a pen?"

Iwas moments away from offering an explanation of drug half-lives when my patient’s eyes brightened and she asked the question that jolted me. This 47-year-old psychopharmacology clinic patient at times seemed slow to follow the logic of our treatment plan, but this question about her antianxiety medication came swiftly. My cheeks and forehead were suddenly awash with warmth as I looked down and saw my pen did indeed announce the availability of a popular benzodiazepine in a new formulation. At that moment I felt bought and paid for.

My stance on the influence of drug lunches changed over the course of my psychiatry residency. At the beginning, I thought I could slide a pen into my pocket or grab a few slices of pizza without my behavior being affected. So did most of my colleagues, who eagerly engaged in small talk with drug representatives ("reps") in order to claim another mug or pocket pharmacopoeia. We wondered when the reps who brought the tasty pad thai would be back, joking that we could not recall the company for which they worked. However, some of my fellow residents refused to eat the free drug company lunch right from the start. I scoffed at them, for I thought I could save a few bucks on lunch and still choose medications for my patients in an unbiased manner.

A wealth of research has shown my initial response to the free lunches was typical for many doctors. I drew a flexible line between reasonable gifts—pens, simple lunches of sandwiches or pizza—and those gifts I thought too extravagant to accept—dinners at the most expensive restaurants in town. I was amazed at the number of brightly colored invitations to listen to an expert extol the merits of new drugs over dinner at restaurants I could not afford on my resident’s salary. While it was difficult to pass up five-star dinners, I was comfortable with my self-imposed standard for the first 3 years of my residency. I did notice, however, that each time events were held at a fancy French restaurant written up in the paper, the lectures seemed especially pertinent to me.

My position on drug companies and their gifts continued to evolve during my fourth year of residency. I recalled the uncomfortable feelings caused by patients like my psychopharmacology clinic attendee, and with a little more free time on my hands in my final year of training, I decided to read about the pharmaceutical industry’s influence on medicine. Even gifts of negligible value can alter the behavior of doctors in ways we are not always aware. And while peer-reviewed research studies can make a strong impact upon the way we as doctors practice medicine, and drug companies have collaborated with psychiatric investigators on some important studies, implementing a study’s findings is a matter of choice. Although listening to descriptions of recent studies while sipping hot coffee brought into the clinic by drug representatives is more convenient than reading journals on your own, one consequence may be that too large a fraction of one’s knowledge of new research and its application to practice is heavily filtered and arguably biased.

With my residency training at Brigham and Women’s Hospital now completed, I reflect upon the array of topics I have learned, from psychodynamic psychotherapy to opioid detoxification. Few, however, are as complex as the issue of drug company influence on training and practice. As a result of my experiences, my pens are no longer emblazoned with the latest medications, and I bring my lunch from home.

But my eyes still do linger on the pad thai.

American Journal of Psychiatry 2006 163: 569-570

'Goin to the End of the Line

2006-05-25T20:32:00.000-07:00

A few years ago I was introduced to a young couple by my mother who, to my great consternation, told them my business. Their relationship was forged, in my estimation, under one of the of the worst possible circumstances: the met in a drug rehab and left AMA without completing treatment. They were married shortly thereafter. He was a big, over-muscular man who I suspect benefited from anabolic steroids. A. was very petite and liked meth & alcohol. He had just gotten out of jail for sale of cocaine, and she had just allowed her sister (who had basically raised her nephew) to adopt her son. They always wanted to speak to me about some problem they were having, and I continually referred them to someone I believed could help them. He remained extremely wealthy without much evidence of employment, and they lived very well. Then they had a daughter, and I didn't hear about them for a while.

I then ran into A. in a social situation where she very dramatically rushed up to hug me too tightly, holding my head to kiss my cheek, too loudly. She smelled of alcohol. Someone told me she was living separately from her husband, and their daughter was with the father. A.'s husband continued to support her. A few months later, he filed for divorce & sole custody, and she was found out. She was denied visitation until, again, returning to complete rehab, and demonstrating sobriety to the court. She came out, took care of business, remained sober, and though she continued to be supported by her now ex-husband (who was having a new baby with his daughter's babysitter), she got a job. Finally, she was granted supervized visitation with her daughter, then week-ends, and then joint custody. She was so excited at each step of the process. She was in a new relationship and married a man who seemed very nice, very stable, and himself had two young children. I didn't hear about them for awhile.

Last Saturday, in another social situation, she appeared accompanied by her children. Again she delivered the dramatic hug & kiss, and I smelled the alcohol. She looked awful, old, worn out. I was shocked at her appearance, but she quickly moved on to greet others. I told my friend Sophia, the deputy district attorney, the situation: A. was intoxicated, she had driven here with 3 children, and she obviously intended to drive home. Sophia emphatically stated, "She is not driving home." I told A.'s best friend the situation and she burst into tears, "A. just got out of rehab." A. was nowhere to be found, and I went outside to look for her; maybe she was using, maybe passed out, maybe... I looked in all the parked cars in the area, walked around the block, she was nowhere. I returned to find the children asleep, watched over by Sophia & A.'s best friend. "These kids are not going with her, I guarantee it."

A.'s mother was alcoholic and probably schizophrenic, leaving her with a significant genetic vulnerability; she began using at a young age and experienced significant life consequences very rapidly and in a great abundance. Likewise the neuro-derangement from the chronic use of meth does not always resolve, and certainly not quickly. And despite treatment and periods of sobriety, she returns to using. I juxtapose this with seeing her sitting on a couch with her daughter, who clung to her as A. stroked her hair, even as she reeked of alcohol. I felt equally saddened and sickened. How long can she live like this? She didn't reappear, the children were safe, and I excused myself and went home. I have not called anyone to find out the outcome.

Is Lying Perjury?

2006-05-25T20:29:00.000-07:00

I counted up 16 separate patient applications for Supplemental Security Income (SSI) I did this month. This is a federal social security benefit for low income pensioners and for the disabled. For those qualified, it is a legitimate, if not life-saving benefit to maintain independence. Mental illness qualifies as a disability, and you can apply for SSI 30-days before parole, hoping you will be already approved when you step out the gate with your $200 in gate money. It is a painstaking, tedious, repetitive process of interviewing liars and filling out forms. The vast majority (even those who are actually qualified) are denied on the first go-round. The yellow pages here are filled with adds from contingency fee lawyers, one more dramatic than the next ("I will FIGHT for your rights, and you will pay NOTHING if I don't win"), who do nothing but SSI appeals. I do not mean to deprecate those who are truly needy, even in a prison setting, but many a man's pants have caught fire right in my presence. "Describe for me a typical day." The lie: "I get up, shower, eat breakfast, go to the park, read the Bible/Koran, watch some TV and go to bed."The truth: "I get up, smoke a cigarette, get high, go the park, and molest children, and get high." "How many hours a night do you sleep?"The lie: "I can only sleep two [many say four because it is prison tradition] hours a night." The truth: Anytime I have to go a housing unit to see someone, 70% of the time they are fast asleep, regardless of the time of day. Not that I blame them, particularly; what else do they have to do? "What prevents you from working?" The lie: "I hear voices that tell me to hurt people, and I see things like blood running down the wall." The truth: There are no observable signs of psychosis, and since nobody believes them, they are not receiving meds that support such a diagnosis. Fact: The overwhelming number of applicants have used or are using enough street drugs per day to drop a race horse in its tracks. In what service am I complicit? The provision of approximately $850 per month. The truly qualified will seek out supportive living or a board-and-care facility. They will take their medication as prescribed and avail themselves of the services of the Parole Out-Patient Clinic. The others? They will, perhaps, get one check, get high, run out of money about the 15th of the month and, best case scenario, panhandle; worst case scenario, snatch an elderly woman's purse or stick a gun in your chest and take your wallet. Thus, having re-offended, they will eventually live to see me again, in due time, to start the soul-saving process all over again. I, of course, remain objective.

Crime Don't Pay, Except for the Criminals (the bahstahds)

2006-05-25T20:27:00.000-07:00

I went out tonight and bought a flash drive, Woody Allen's "Manhattan," and dutifully locked everything in the trunk of the car. Then I went into a Vietnamese restaurant for a bowl of soup. All of this was in a very nice area of Mission Valley. When I returned and entered the car, the contents of the glove box was strewn on the floor and the passenger seat. I opened the center armrest and my iPod and charger were gone. I opened the ash tray and $20 in quarters was gone. Then I opened the trunk, and of course the stuff I had just purchased was gone. As I'm driving home, I remembered that my Nikon SLR was in a compartment in the trunk. I got home and opened the trunk, and of course the Nikon was gone as well. At first I thought I must have forgotten to lock and set the alarm, but when I checked the driver's door, the lock had been broken, probably with a screwdriver.

It is ironic that I deal with these people every day, tolerating their fundamental lack of remorse or their inability to identify with the feeling of violation they have perpetrated. Except if someone steals their cigarettes, then, as one man so casually told me, "I'm 'gonna cut his 'motherfuckin throat." Today, Mexico decriminalized the possession of marijuana, cocaine, and heroin in amounts deemed "for personal use," thereby allowing the police to focus on "major traffickers" (or more likely start dealing "personal use" amounts of drugs themselves). I suspect someone was taking up Mr. Fox's offer by selling my shit.

Shall I lose any sense of compassion or even propriety when I return to the prison? Nah. The gates always opens and always closes; they go, they come back, they go again, and they come back again. And many times, they will have to deal with me. I will do what I always do for them. It's just shit, you know?

Are Sex Offenders Treatable?

2006-05-25T20:25:00.000-07:00

Are Sex Offenders Treatable? Research Overview (Psychiatr Serv 50:349-361, March 1999)

Although some forms of treatment for sex offenders appear promising, little is known definitively about which treatments are most effective, or for which offenders, over what time span, or in what combinations. What emerges from the literature is a strong suggestion that a comprehensive cognitive-behavioral program should involve components that reduce deviant arousal while increasing appropriate arousal and should include cognitive restructuring, social skills training, victim empathy awareness, and relapse prevention. In addition, patients should be considered for antiandrogen medication if they are at high risk of reoffending.

In general, results from biological and cognitive-behavioral treatment programs strongly suggest that treatment decreases recidivism of sexual crimes. In evaluating whether the amelioration produced by treatment is clinically significant, Hall's meta-analysis (96) suggested that antiandrogen and cognitive-behavioral treatment lead to a decrease in recidivism from a baseline rate of 27 percent in untreated individuals to a rate of 19 percent in patients who receive treatment. Hall summarized these findings as an outcome of eight fewer sex offenders per 100.

However, the results of his meta-analysis may be viewed in another way: from a baseline recidivism rate of 27 percent, a decrease in recidivism among treated patients to a level of 19 percent amounts to a 30 percent remission rate as a result of treatment. When viewed from this perspective, the analysis suggests an outcome of 30 fewer sex offenders per 100, and it reflects a follow-up period of nearly seven years. This outcome is not a negligible impact from the standpoint of clinical treatment.

By comparison, lithium prophylaxis of bipolar disorder—a standard treatment for a well-established psychiatric illness—was found in a recent five-year prospective study to be associated with complete remission in approximately 38 percent of patients still taking lithium (98). Because a number of other patients dropped out of this study due to perceived lack of efficacy of lithium, this percentage may actually overestimate lithium's medical effectiveness.

Zonana (3) has suggested, however, that the consequences of recidivism in sex offenders are so detrimental to society that a recidivism rate of zero is the only acceptable risk level. Such an assumption could lead to the conclusion that indefinite confinement is the only conceivable effective intervention with or without medical treatment. But the demonstrated reduction in recidivism that emerged in the meta-analysis of research on treatment of sex offenders is a robust finding and suggests that treatment for patients in this population improves outcome and may protect potential sexual assault victims.

Recent legislation in an increasing number of states focusing on the preventive detention of sexually violent persons has stimulated vigorous legal and policy discussion and debate (1,2, 3). This newer legislation may have significant impact on public mental health systems because the proceedings involve civil commitment rather than criminal prosecution and are associated with mandates for medical evaluation and treatment. Clinicians have not traditionally regarded sex offenders as falling within the target population of severely and persistently mentally ill persons considered appropriate for civil commitment.

Yet although it may be true that, in general, public mental health programs have little to offer by way of a service line tailored to this population, it is far less clear that individuals exhibiting chronic, repeated sexually aggressive behaviors do not suffer from mental illnesses. Nor is it clear that psychiatric treatment is without benefit for this patient population, despite frequent anecdotal references to the lack of effective treatments. To the contrary, research provides evidence of a robust treatment effect that has the potential to reduce sexually aggressive behavior.

Although the conclusion that sex offenders are untreatable is unwarranted, caution must be exercised in unfolding the implications of the positive treatment findings in the literature. It is worth underscoring the finding of Hall's meta-analysis (96) that treatment of outpatients was associated with a larger treatment effect than treatment of institutionalized individuals. Further, in the discriminant analysis of Bench and colleagues (9), failure to complete treatment was a weak predictor of sex-offense-specific recidivism in comparison with the extent of the felony conviction record.

These findings appear to suggest, unfortunately, that the more a sex offender needs confinement, the less confident we can be that treatment will have lasting benefits. Paradoxically, however, it is precisely the more dangerous subset of patients that psychiatry is being called to treat based on the new legislation. Civil commitment of sex offenders is based on the problem of perceived persistent dangerousness.

Precautions must be taken to ensure that treatment environments are appropriate for the risk level presented by these patients. Psychiatrists, other mental health professionals, and public administrators are concerned about the potential for predatory behavior by sex offenders who are mixed with the currently defined population of patients with serious and persistent mental illness. Criteria must be developed to determine which sex offenders are more appropriate for outpatient programs and to provide a rational basis for transitioning patients from institutional to outpatient care. Civil commitment to outpatient treatment may provide a more appropriate level of care for many patients than psychiatric hospitalization in traditional general inpatient settings.

Finally, from a scientific standpoint, there remain significant problems with the available data from sex offender treatment studies. An optimistic perspective must be entertained cautiously and accompanied by a commitment to the advancement of scientific knowledge in the field. This perspective is not new to psychiatry, where gains in knowledge about treatment of chronic illnesses such as schizophrenia have been gradual and hard earned. Yet as Bradford (66) recently pointed out, support for the scientific study of deviant sexual behavior has not kept pace with the apparent—or at least official—public sentiment about the management of sexual aggressors. It would be informative for such research to include a focus on sex offenders from additional populations, such as women and adolescents.

Treatments for sex offenders do exist, and the outcome data are not uniformly discouraging. They are, however, complex, difficult to interpret, and cause for cautious optimism at best. If mental health professionals and society at large are to accept the challenge of promoting treatment for sex offenders, vigorous ongoing research efforts are mandatory. Psychiatr Serv 50:349-361, March 1999

Walking with Murderers

2006-05-25T20:23:00.000-07:00

It is odd to say that I am comfortable being with murderers. Or, by experience, while exerting every necessary caution, I am not frightened by them. Or, I've grown accustomed to murderers. Or most likely, just by repeatedly being with them, I am now emotionally defended against them and just do my job. It is customary that they do not know that I am aware of their crime. At times, they even lie, or better put, "withhold" the information. Some try to sell the "I was just defending myself" story, but the central file always says otherwise. Others are charged with manslaughter, or negligent homicide, but this often turns out to be a plea bargain, meaning they are just murderers. The whole "cold blooded" thing is difficult to appreciate or describe; you must witness it. Plenty of people murder and it is extremely rare that they ever murder again; it was born of rage, fear, "heat of the moment," "passion." Psychopathic murders feel nothing for their victims; they do not possess the ability to empathize or feel remorse for anything.

I was told today that a new parolee was received into the Parole Out-Patient Clinic who was a nurse. Her mother was an OBGYN, and her grandmother was 90 and on her way out. The grandmother died from an overdose of morphine when she was not prescribed morphine. The mother/daughter were rumored to be complicit, but the daughter accepted responsibility and did the time. She may feel no remorse because she feels "justified" in that it was, in her mind, a selfless act in service to humanity. The court, however, disagreed.

We execute criminals; we assist with suicide in certain states; we openly kill in war and measure success with body counts; and we allow justifiable deadly force in self-defense, by ourselves, or by those sworn to uphold the law. When I am here, now, away from murderers, I contemplate the overwhelming enormity of taking a human life. I have been asked, "Would I kill someone in self-defense or in defense of your family?" In this theoretical framework, WTF, yea, I suppose. But I always am then forced to think, "How would I feel afterward?" Would I feel "justified" or even "exonerated" or "vindicated" under the law? What would it feel like to be among the murderers, as one of them? Sitting before someone like myself, answering the questions, detailing the circumstances, walking back into society? Justified?

I came across the chart of a man who had "accidentally" slammed his infant son's head into a doorway, likely killing him immediately by the extent of the head trauma. There was a specific psychiatry note that the issue was not to be discussed with him, that he could not bear it. He requested administrative segregation. He never left his cell. He never spoke with anyone. I cannot image; for the life of me, I cannot imagine.

Are You Familiar with ASPD?

2006-05-25T20:21:00.000-07:00

I met with a patient today who is serving his 6th prison term. He was the fairly typical no eye-contact, "I really can't be around other people," & "I hear voices telling me to harm myself" ("and/or you") sort of fellow. Judging by his vocabulary, he presented as quite intelligent and articulate. He described, "grabbing a guy who was in my face by his chin and smashing his head into the wall again, and again, and again." hmm. He asks, "Are you familiar with antisocial personality disorder?" I mumble, "Yup," as I'm writing. The only thing worse than a prison "psychiatrist" is a prison "lawyer."

Antisocial is often interpreted to be isolative, unfriendly, difficult, or nasty. In psychiatry, it has much different meaning. Anstisocial Personality Disorder (ASPD), like all personality disorders, seems to involve a derangement or traumatic influence during personality development. In this patient's case, he reported being sexually abused for six years by his step-father, and his mother & brother did not believe him until his mother inadvertently walked in on it. Generally speaking, there aren't medications or typical therapy for personality disorders, though some new methods are emerging.

ASPD, or its worst manifestation, psychopathy (they are sometimes referred to "psychopaths" or "sociopaths), is an extraordinarily complex disorder. Dr. Robert Hare is an expert in psychopathy and provides the following "symptoms":

Superficial charm; grandiose sense of self-worth; need for stimulation & proneness to boredom; pathological lying; conning/manipulation (even of family and closest friends); lack of remorse or guilt; unable to experience emotions; callous & lacking empathy; parasitic lifestyle; (relying on others for financial support); poor behavioural controls (aggressive); promiscuous sexual behaviour; early behavioural problems (e.g. Conduct Disorder as a child); a lack of realistic long-term goals; impulsivity; irresponsibility (money, work, family); failure to take responsibility fore their actions; unstable personal relationships; and many "short-term" relationships or marriages.

I know, anybody can and does have a few, some, or even a majority of these characteristics at one time or another - and don't use this list to "diagnose"- but the issue is "pervasiveness" and that they are "in agreement" (systonic) with the personality (i.e. if there is a sense something is "wrong" or this behaviour is personally disturbing, then it is "dystonic," not related to their personality). An example:

An 88 year old woman took $400 out of an ATM, which was the max amount she could take in a 24-hour period. She got back into her car and found a young man in the passenger seat. He took the money and told her to go back and get more. She tried to explain that she was maxed for 24-hours. He made her drive around San Diego for 2 hours, stopping at different bank ATM's, where she repeatedly (and obviously) could not withdraw more money. After 2 hours, the robber finally figured it out. At this point, our diagnosis is simply, "dumb-ass punk-ass punk." He then made her drive him to another part of town (probably his own) and made her get out of the car and open the door for him. He walked off with her money. He obviously was impulsive, parasitic, manipulative, callous and unremoseful, risk taking, and took great pleasure in humiliating his victim. He is beyond just being a robber, and thankfully wasn't violent.

To fully appreciate this pathological state, it is necessary to actually observe it; I can describe and explain it in the best clinical terms, but being in its actual presence, feeling the lack of remorse & empathy, the callousness, and the inability to appreciate actions is one of the creepiest, most disturbing experiences I've ever had.

Yea, pal, I've heard of ASPD. And having said that, my prediction is that it won't be long before you're back serving your 7th term, and all the bbetter for society.

When the TV Talks to You

2006-05-25T20:20:00.000-07:00

Two out of the four patients I saw today experienced something called "ideas of reference." This is a paranoid delusion of schizophrenia where someone believes that things said by strangers, or in these cases on TV, are intended for them; i.e. when they watch TV, they believe that the people reporting the news, acting in a sit-com, or in a movie are speaking directly to them. Likewise, they often can hear the message from a stranger as the stranger thinks them, rather than actually verbalizes them. This can be overt or covert. This is distinguished from "thought broadcasting," which is a paranoid delusion that people can hear your thoughts. One young man gave the example of having just come from his psychologist's office yesterday, where they had discussed issues that were very painful to him. When he returned to his cell, his cellmate had the TV on. He explained that a character on a show "told me everything was going to be all right, and not to be worried." He could not recall the exact dialog, but he could summarize the message. In this example, the "idea of reference" was comforting to him. Also, he reported to receiving instructions to "speak" with non-human & inanimate objects (he used the examples of dogs & trees). When I asked his hobbies or activities that he does for fun, he said "I go to the 24-hour internet cafe," where he searches websites at the non-verbal direction of strangers, "mostly sites about what's happening in the world." I asked if it was ever frightening or if he found these messages intrusive, and he said "absolutely not." Likewise, he denied "hearing voices" in the traditional way individuals with schizophrenia generally report (or malingerers lie about): derogatory, invasive, and often command-type hallucinations that instruct suicide, self-mutilation, or doing harm to others. The second man said that he was "paranoid," and when I asked him to define it, he basically described the textbook symptoms: an inordinate amount of suspicion and fear that others are speaking about him, looking at him, and have some intention to harm him. He too received messages from TV, radio, and strangers, but in his case they were not positive in the least. What was most fascinating about him was the fact that he recognized the symptoms from an early age, but never spoke about them because he feared he was especially sick, or nobody would believe him. He said that in 1990, a psychiatrist explained his problem to him in detail, put him on antipsychotic meds, and it turned out to be a dramatic revelation to him; now he could talk about it. Why, you might reasonably ask, having discovered the source and "cure" for his illness, was he in jail? The short answer, alcohol. When he begins to drink, he quits taking his meds, starts to believe his paranoid delusions, "and I go off the edge." He is going to an alcoholism treatment program for "dual-diagnosis" patients upon parole, and hopefully he will stay on his meds & not drink. Finally, I shall mention in passing the last man I saw today. He didn't need my help as he was already set up with necessary services when he paroles. He came, I believe, just to speak with another human being who would considerately listen to his madness, at least for a few moments. The defining event in his life, as he described in brutal detail, was possessing a small cannon. One evening, in an unremarkable drunken state, he set it up on the back of a pickup truck, loaded it with gunpowder and two bullets, and then set it off. His "mistake" was not getting out of the line of fire, and he described how the ring finger on his left hand "vaporized" in front of his eyes (and at this point he dutifully & dramatically displays his hand), and continues to report how one of the bullets struck him in the groin. Trust that he arose with every intention of displaying the entry point, which I would not allow. After I asked (in so many words) what this had to do with anything, he responded that he was in the midst of "legal cases," suing the State of CA, the governor, the Dept. of Corrections, etc, etc. etc. for not supplying him the proper psychological support in dealing with this trauma. "I really need the money." What could I say? "I don't work for the State. I can't be of any help to you," and I'm thinking, "Couldn't we all use the money." With that, "Good night and good luck," and he even said, "God bless you for your work." I responded, "and you as well." Call it another Friday.

The Trouble with Honesty

2006-05-25T20:18:00.000-07:00

I saw a young man today who was respectful, open, honest, and trusting. It was a disaster of an interview. He is "five weeks to the gate," to parole.

The background: His father left the family early, abandoning three sons. This patient had psychiatric problems and had been taking medication since the age of seven. Most of his special education came via the Juvenile Hall (county jail for juvenile offenders). At age 18, he came home to find blood everywhere, and his mother dead on the floor, having been shot twice in the head and five times in the back. He called 911, the police arrived, put him in cuffs and held him in custody until they figured out and arrested the real murderer. The real murderer got a life sentence. The patient said, "If he showed up here, I'd kill him myself." While I certainly couldn't condone murder, I could appreciate the sentiment.

This was a fairly straightforward interview of someone who had a thought disorder and whose primary symptoms were persecutory paranoid delusions. He emphasized that he didn't routinely trust anyone but his grandmother. He was traumatized several weeks ago by being in the area when an inmate was slashed across the throat by another inmate. He then complained that "they put me in a cell with an old man who disrespects me." He kept saying that it took everything in his power not to "beat the hell out of the old man." Thus said, we entered a discussion of anger management, etc. But he continued, "I'll be honest with you, I hear voices sometimes that tell me to cut his throat." Hmm. We have taken a turn that has to be rapidly assessed: "Do you have an actual plan?" "No." OK

It is ironic that in supervision this week, we mainly discussed techniques of establishing trust and encouraging honesty in order to get the most reliable and accurate information from an interview. He continued, "We've been locked down since the stabbing [you may have read the previous, A Day Without African- Americans], and being locked up in that cell is claustrophobic and increases my paranoia. And I'll tell you honestly, I am afraid of what might happen when I go to the streets, being so paranoid." "Are you afraid for your life?" "I'll be honest with you, I got a weapon, and if anyone comes at me, I'll kill them." SHIT! Why did you have to tell me that? "You know I'm obligated to report that you are in possession of a weapon?" Silence. "Well, I didn't really mean I had a weapon. I meant I had access to a weapon." "Same difference. I have to report you." I told the sergeant, I told the chief psychiatrist, and I charted the event. The lieutenant called me from his housing unit and said the inmate had admitted everything to him, but denied possessing or having access to weapon. They were going to strip his cell when I was leaving.

What I did was the right thing to do. Why do I feel so badly about turning him in? His history, his openness, his honesty? Possession of a weapon is a felony; he would undoubtedly get a new, much longer sentence. Five weeks to the gate. I also think to myself, what if he actually cut his cellie's throat or stabbed an officer? Would I be able to walk in and admit that he had reported possessing a weapon to me? Could I live with someone being harmed just because I wanted to be liked and appreciated by this man? What I did was the right thing to do, and sometimes, this time, honesty had a high price for him and for me.

As I left, I again heard what seemed to be an aviary of birds. This time I looked up to find at least 150 nests woven together with mud and twigs under the eaves of what used to be a gym. They looked like sparrows, flying in and out and singing their hearts out. The world is an irrational place.

How Newz Travels FAST

2006-05-25T20:04:00.000-07:00

The first patient I saw yesterday called out to me as I passed through the long line of men sitting on facing benches waiting to see someone or other, "Aren't I supposed to see you?" I asked his name, and sure enough, he was scheduled to see me. Now the interesting thing about this interaction was that he had never seen me before.

This is a phenomenon that occurs in prison frequently. Inmates find out who you are and what you do, and the information spreads like a wave. People used to ask: "Are you the DA?" "Are you the public defender?" "Are you the teacher?" No more. The down side to this phenomenon is that when information is known, it can be dangerous, if not deadly. It is well known that sexual predators of children do not fare well in the general population. Somehow, information gets out; maybe it's an inmate secretary who has access to information, maybe it's staff, but it gets out. Imagine you have absolutely nothing to do, 24 hours a day, seven days a week, for years on end. If I find out something about you, your crime, your gang affiliation, I've got all the time in the world to observe your patterns, learn where you live, where you go, what you do, who your friends are. It can be months, or it can be years, but if I want you, and you are not scrupulously vigilant, you're clocked. I was seeing patients in administrative segregation (adseg), when the CO's told me that one inmate refused to come out of his cell. I put on the vest and the eye protection and went down to see him at the cell door. As I approached his cell, about 5 different voices were heard to yell things like, "Come on out, you fucking diddler." "Be a man and come out you pussy boy." Hmm. Whatever happens in prison, in any prison in the state for that matter, is immediately known.

The upside of this phenomenon is that criminals are stupid, and just can't seem to keep their mouths shut, even in their own best interest. How many dumb-asses have you heard about who were caught, both outside and inside prison, because they just couldn't contain what they did or were planning to do? But apparently this fact doesn't seep into the mind of a dumb-ass. OR, they revel in the rep. Men tell me about attacking someone in the county jail so their rep proceeds them to prison. One man told me that because he was short and lean, his first time in the chow line he took a food tray and beat the hell out of someone "thought" to be a sexual predator of children. "I wanted people to think, 'He's crazy. Stay away from him." He did his six months in adseg, will always be considered "high control" (very dangerous), which is another rep, and people will probably leave him alone. If the rep wears off, he'll clock somebody again and do his adseg time.

I laugh when I hear about this "age of 24-hour access to news," as if it were something new and unique. You haven't been in prison, pal, where all the news, fit or unfit, travels fast.

City of Hope

2006-05-25T20:02:00.000-07:00

He sort of lumbered, shuffled, a big man dressed in prison blues, and basically fell into the chair. Unlike most, his hair was whitening, and he told me he had been "down," incarcerated, for the past 11 years. I didn't ask why. His speech was a bit slurred and his hands trembled. "Schizophrenia, Paranoid Type, Chronic," the chart said, but it also stated he had "significant Axis III issues," meaning medical conditions that contribute to his mental disorder.

He told me the story of how he came out of a neighborhood convenience store and was "knocked in the head" by persons "unknown" and for reasons "unknown." He indicated that he was shot in the chest and shoulder, and he dutifully displayed the entry wound scars, as they always do (how do they get their shirts up so fast?). Then he leaned forward and displayed the measured scar of an obvious craniotomy winding around his scalp. The chart indicated, "head trauma with loss of consciousness, coma for three weeks" and "resulting seizures."

As I took a history, I also found that he is DD2 (developmentally disabled to the point where he "needs active prompts to maintain the activities of everyday life"). This basically means, he cannot maintain his hygiene, keep his cell clean, nor do basic "chores" (e.g. shopping with the few dollars he receives monthly at the canteen). Nor will he be able to do this on the outside, worsened by the fact that when you're homeless, there is no one to "prompt" you. After 11 years, few family members are alive or in the area, he doesn't know if his "friends" (the few he trusted because of his paranoia) are alive, and he is headed to downtown LA. He wants to live in a board-and-care, a structured home environment where meals are served, hygiene is monitored, and medication is dispensed.

I gathered the information necessary for an SSI application, got the forms signed by him, and copied the medical records. As customary, I had taken his Social Security number from the database. I always ask a patient to first tell me their number to cross-reference with what I have, then I read it back to them to verify again. The application asks for a 3rd party besides his doctor to verify his condition. He has a sister but he can't recall her name, address, or phone number. "I keep it in my house," his cell. I tell him I will request him next time I'm there so he can bring the information to me. "Write it down, please, because I won't remember. I can't read, but I'll hang it up so my cellie can remind me." "Any questions for me? "Someone told me if you get out on a weekend, you can have trouble getting your meds?" [By law, an inmate is issued "discharge meds," a 30-day supply until they get to out-patient psychiatrist]. "That's just talk." "But what If I don't get my meds and I have a seizure?" "Don't worry. You'll get your meds," I hope.

I begin to complete and sign all the paperwork back in my office. I fax a pre-parole referral for an expedited decision from Social Security. A day later, they call to say I have sent the wrong Social Security number; they can't find his name with the number I provided from Corrections and "verified" by the patient. Did he, at some point, lie about his number - perhaps to avoid identification - and has now forgotten? Did Corrections rely on his memory-poor report of the number?

11 years in jail with the result of head trauma, seizures, auditory hallucinations, illiterate, and a developmental disability, heading to the streets. "I need the structure and assistance, or I'll be back here or in the state hospital." I am overwhelmed with sadness and discouragement; 11 years of "keeping to my cell because I'm too suspicious of people," and I can only turn him over to a parole system that, at best, seems to randomly provide real assistance.

There are so many like him, and so little I can do to help. Sometimes I forget why I am doing this work.

Wednesday

2006-05-25T20:01:00.000-07:00

I experienced the disturbing consequences of methamphetamine today. It started with me holding his photo ID card and calling out his name from the group lining the benches. He stared at me for a moment and said, "How did you know it was me?" "I have your ID," as I showed him. Again a stare, then, "Oh." Such was the entire assessment. Sort of like living near Qualcomm stadium with the door open, hearing the fireworks of the National Anthem and the roar of the F-18's in real-time, only to hear the echo 5 seconds later on ESPN. "Have you ever been married?" Eyes staring, jaw tightens and untightens, blink, blink. "Have you ever been married?" "No." "Have you worked in the last 15 years?" Eyes staring, jaw tightens and untightens, blink, blink. "What?" "Have you worked in the last 15 years?" "No." He reached forward to sign a form and I saw the beginnings of tracks. He showed me his arms: scar-covered from needles, abcesses, scratching infected sores, from "skin picking." But also the wide horizontal cuts at each wrist, and thinner horizontal cuts on the tops of his arms: the former because he felt too much, and the latter because he could feel nothing at all. His brain, robbed of dopamine by meth, is metabolically deranged. He is "dull," with a fundamental lack of emotions; there, but not there. Anhedonia, or some call it "hypophoric," lacking "euphoria." Lacking pleasure, lacking joy. "What hobbies or activities do you do for fun?" "None." "Do you belong to any churches, support groups, AA/NA?" "No." "do you have any difficulties interacting with friends or family?" "I don't have friends, and I don't know where my family is." "Do you have thoughts of harming yourself, or killing yourself?" "Everyday."

The second man was older, sadder, a loner. Covered in prison blues - the long navy blue dungaree coat with the big square pockets, worn by old railroad workers, young 'gangstas, and the CA incarcerated. Though buttoned to the throat, one of those black/gray beautifully scripted tatoos that only gang members have was obvious on his neck. Then one on his left hand, then one on the knuckles of his right hand. Thin, precise script, art, nearly unimaginably accomplished with a needle and ink. He is pessimistic about his chances on the outside: "This my 4th term. The longest I been out since '95 was one week." "What happens?" "I don't know, man, I'm just a fuck up. My kids are so mad at me. My daughter called my wife and said my little gandson woke up in the middle of the night calling for me. She said to my wife, 'He fucked up my life, now he's fucking up the lives of my children.'" But this is the first time he decided to come into the treatment program. "These meds give me a new way of thinking. I don't always want to fight. I can ignore the voices telling me to hurt myself, to go hurt somebody else. I just started in the group [therapy] and I forced myself to talk. It's eally hard." I talk about stability, I talk about having support on the outside, I talk about the Parole Out-Patient Clinic, and I talk about hope.

I talk shit.

A Man in Whom There is no Guile

2006-05-25T19:58:00.000-07:00

The man walked in, and you would swear he was the late Vincent Shavelli, Fredrickson of One Flew Over the CooCoo's Nest; tall, gaunt, pale, long drooping face, the slow shuffle, wild out-of-control hair, the dull affect of schizophrenia, the wild eyes when listening, . "Why are you here?" "Well, on a violation [of parole] for burglary, but technically, I just took the screen off the window, then went and told the police. Now the time before that, it was actual burglary. I did it. I won't lie." "Why are you in the mental health program?" "I don't know, really. One woman told me we just couldn't understand each other. We didn't make no sense to each other. So she gave me this medication and it's much better. Yeah, I'm here because of communication." "Does your mind ever play tricks on you? Do you ever hear things other people can't hear, or see things others can't see?" "Oh no [he laughs], nothing like that! I'm just happy!"

"Look, I don't have your Social Security number; it doesn't come up in the database. Do you happen to remember it?" "Oh, my... let me see..." He says one, corrects it, then corrects it again. "Ok, look, let me get some other information so they can be sure to identify you. What was your mother's name?" "Lucille." "What was her maiden name, before she married your father?" "Ball. Lucille Ball." Hmm. "What was your grandmother's name? Your mother's mother?" "Oh, it was A.E. F. [spells out last name]." "So your mother's maiden name was F.?" "No, her name was Lucille Ball." OK. "What was your father's name?" "I know it's 'gonna sound strange and all, but it was Elvis Presley. I know he's a celebrity and all, but Mamma always told me he was my Daddy." "Did you ever meet your father?" "Oh no, it was just Mamma and me, but she told me stories, told me how much he loved me."

The questions are monotonous, repetitive, like Social Security is trying to catch you in a lie: Aha! You answered this differently on page 10! He was tired, and quickly losing interest; "I already answered that as much as I can." "Describe an average day. "You know, if you boil it all down, I just want to be happy. If I wasn't hungry, I wouldn't break into to nowhere. Ok, I'll take the pills because they want me to; I'll go see the doctor and my parole agent because I have to; but I just want to ride my bike, go see things, talk to people, and be happy. That's all. I love to go see things and talk to people" "How long have you been down?" "I came back in 2003. I was on 'summary parole' [unsupervized], but now I'm back to 3 years of regular parole." 3 years down and three years parole. People do less for armed robbery or domestic violence.

Customarily: "Good luck to you. Just do what you have to do. I don't want to see you again." "[Happily], Oh, you won't sir! I'm 'gonna be easy going and take care of business. I won't be back! Thank you for your time, sir! You be happy, sir!"

If only, pal. Yeah, if only.