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Adventures In The Mental Health Industry, Part Deux And A Half

November 30, 2010


A veritable library of paperwork had been generated about Mr. Jones over the years. He had not one chart, but about a dozen 3-inch thick three-ring binders packed with records, going back for many decades. Fortunately they were organized in sections and I could pretty easily pull out all the “assessments and evaluations”,  and after reading those, cross-check that information with the medication records.

Imagine my surprise when I found our Mr. Jones had repeatedly and consistently  been diagnosed as having chronic paranoid schizophrenia by a variety of psychiatrists and psychologists for over forty years. He’d had seven long stays, totalling 15 years, in the State Hospital. In fact, because of his “dual diagnosis” (mentally retarded  and also mentally ill) he had been  bounced back and forth between facilities and programs designed to treat one group or the other,  depending on which diagnosis was considered the most important one at the moment. He had been institutionalized since childhood.  I felt more compassion than ever, reviewing the record of years of treatment with very limited effectiveness. He’d shown some improvement when on certain psychiatric drugs.  His poorly controlled seizure disorder meant he had experienced countless grand mal seizures over his lifetime with a cumulative impact on his brain function.  Seizures lead to falls and further brain damage over the years, as well as  leaving his face scarred like an old boxer’s.  Amazingly,  after all that, his I.Q. scores barely qualified him as mildly mentally  retarded.

My next discovery was of the most  recent entries in his log by four different attending  physicians, saying the same thing. Within the past month, all four doctors–one retiring  primary care physician,  the PCP who replaced him, the  (now-fired) psychiatrist, and the neurologist. Each entry was substantially the same, with only minor differences in wording:

“This man’s violent and combative behavior makes him an immediate danger to himself and others. I do not believe he can be adequately treated  nor safety assured in this facility.I strongly recommend he be transferred to a  more secure facility. I have communicated these recommendations to the staff here in the clearest possible language. I will not be responsible for the consequences if my recommendations are not followed.” [/s/]

That’s as plain language as anyone can imagine. I made reference to this fact in my written narrative, after reviewing his mental health history, response to various interventions and medications,  and concluding that he was correctly diagnosed as having chronic paranoid schizophrenia, in acute exacerbation. I whipped out that review, report,  diagnostic conclusion, and recommendations  they had demanded as concisely and quickly as possible and presented it to them. They professed shock that I’d noticed the history of schizophrenia and quoted the doctor’s notes.

“Oh, but you’re not licensed to diagnose, are you?”

“I do it every day at the mental health center,”  I replied. “You said you wanted  a diagnostic work-up with treatment  recommendations from me.”

“But, but you’re not a doctor, are you?”

“No, you know that.  I do work under the supervision of both a  board-certified psychiatrist and a licensed clinical psychologist. I’d be happy to have them review my work and to  bring them in for consultation…” I offered,  knowing they’d back me up–and be a lot less patient with them than I was being!

“Uh, no, that won’t be necessary. But look here! We didn’t expect you to plagiarise in your report!”


“Yes! Quoting what doctors wrote in his chart! Isn’t that plagiarizing?”

“You wanted a report based on his documented assessments, records,  treatment history, and recommendations..” I replied. Not an original work of imaginative fiction.

They sighed loudly and announced they’d study my report, hold a meeting, and then get back to me.

I stressed the urgency of making a decision quickly–we need to move on this.

The next day I heard the cry, “Get the nurse! Vickie’s seizing!  In the  break room! Hurry!”  Vickie, a CNA about 27, had absorbed a heavy punch to the side of her head, a hard right cross,  from Mr. Jones the day before.  She had no prior history of seizure activity, but she was having a classic  grand mal seizure on the floor of the employee’s break room. The administration was still “considering” what action, if any, was warranted regarding Mr. Jones.

I described this and other incidents to my superiors at the Mental Health Center and said I didn’t know how much longer I could stand  be a part of this. Once again, they  vetoed any action that would put them in conflict with the ICF/MR Administrators. they encouraged me to continue to try to “educate” the Administrators.

Bear in mind this was a 24/7 residential facility, and I was only present 20 of the 168 hours in each  week,  on parts of three  days, so I was  absent when  many dramatic events occurred. The staff  always had news when I came in. One day, for example, I learned  Mr. Jones tore a hunk of his roommate’s hair out. anotehr time he threatened another resident with a heavy mop handle.

“We need you to design a Behavior Training Program for Mr. Jones, as quickly as possible,” the  Administration told me next. “Perhaps with a token economy. You do know how to do that, don’t you?”

“A behavior mod program?!”

Behavior Modification and Behavior Training Programs are just glorified versions of what many parents and teachers do when they create a behavior chart, rewarding good behavior with gold stars.  The children can earn tokens of some sort to later exchange for prizes or rewards of some kind.  Of course, the ones designed by behavioral psychologists are more complex, more sophisticated, with a detailed outline breaking down goals into limited and measurable objectives, and supposedly statistically objective and valid outcome measures. But underneath it’s the same old idea. And much easier to think up than to implement on a 24/7 basis by a rotating shift of  multiple caregivers,  all of whom have to be pretty much on the same page  and consistent with what every other caregiver is doing for it to work.  Of course,  it should be explained to the person who’s the target of this program and his or her cooperation and agreement secured.  Hint: it doesn’t work with deranged  people who are in a florid psychotic state.

“I can do that, but I don’t think that’s going to stop his  delusions, his aggressions, his disordered thought processes. This man is in the grip of a major mental illness.”

“We don’t believe in mental illness.  Say rather, he is  engaging in inappropriate behavior and needs social skills training so he will learn more socially appropriate behavior.”

“By all reports, he is usually very high-functioning! He has good social skills when he’s not in the  grip of a psychosis. He’s not unskilled or ignorant, he’s crazy!  There’s a difference!”

“We also explained we don’t believe in chemical restraints to control behavior….”

“Would you cut him off his Dilantin that controls  his seizure disorder?  That would make just as much sense!   Do you think grand mal seizures are just bad behavior that a person can learn to control? Through behavior mod programs? That’s contrary to fact, horribly inhumane and malpractice, in my opinion! Mr. Jones can no more control his psychosis than he can control his seizures.  Think about that, please!”

They said they’d mull it over and hold another meeting.

Soon an incident took it out of all our hands.  I heard, the next day, that after I had left,  Mr. Jones, whiel combatting invisible enemies in mortal combat,  fell and split his head that night.  He had to be taken to the ER. . The ER doctor  called the colleague of mine who was the on-call emergency clinician from the mental health center. He or the doctor signed an M-I, a 72-hour involuntary mental health hold that directed his immediate  transfer to the State Hospital.

Frankly, I was relieved.  The State Hospital is certainly no place of magic cures, but his physical and mental health problems would  get serious attention there.  More extensive examinations, medical tests, work-ups, and trials on medications in  a safe setting could be performed.  I faxed my report and summarized history to them for their consideration. I didn’t even mind there was muttering among the administrators of the ICF/MR that it was my fault he had to be sent to the  State Hospital. After all, the line went, if I had trained the overnight shift of the 24-hour staff better on how to implement the Behavior Training Program, and  followed the Director’s recommendation to use dominos as tokens in the token economy portion,  Mr. Jones’  “inappropriate behaviors” could have been resolved within the facility.  He could’ve been cashing in dominos he’d earned for self-restraint for candy bars. and turned tame and content. Shame they couldn’t get decent help from mental health professionals who were supposed to be experts, for whose services they were paying  the lordly sum of $15 an hour (of which I acutally got  about $9.50 gross, before taxes and other deductions. But this was 1988).

Well, that’s the story. I won’t bore you with an account of the time they wanted me to do psychological testing on a  man who’d been comatose for a week.  (“So, don’t want to  do your job, huh?)

Or the multiple times a primary physician asked, “How’s my patient doing on those new meds I prescribed last month?” only to be told, “Oh, we haven’t been giving them to her.”

“What?  I ordered that over a month ago….”

“Oh, we [the non-medical staff] had a meeting and decided she didn’t need those meds. I guess somebody was supposed to tell you. Maybe they didn’t. Why, is that a problem? [i.e.,  if you want argument, I’m ready.]

Needless to say, they had a fair amount of turnover, among physicians as well as among the facility staff. They had no clue about issues  of professional responsibiliy , liability, and ethics.  “Attitude’ substituted for knowledge, understanding, ethics, and skills. “We’re the boss, so reality is whatever we proclaim that it is. People who don’t agree are trouble makers.”

I actually wrote a satirical one-act play about these events and called it Team Player.  I’m sad it’s never been produced on stage.

Once again, it’s not the clients that make work int he mental health industry difficult, exasperating, and sometimes crazy-making.

And finally remember this all happened under the aegis of an  organization that trumpets itself as  Standard-Setting Leader in Quality Treatment, a pillar of integrity and the highest professional standards,  a pioneer in cutting-edge top qualty treatment,  that the  rest of us erratic, untrustworthy,and  dubious  individuals not fully under their control,  can only hope to aspire to. It’s so hard to get good help these days!
















































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