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Adventures In The Mental Health Industry, Part Deux

November 30, 2010

[If you haven’t already read “Adventures in the Mental Health Industry, Part One”, dated Nov. 11, please do so before reading this second installment.  Or at least read the first two paragraphs that establish the setting,  the context.]

A new crisis soon arose at the Intermediate Care Facility for the Mentally Retarded, or “ICF/MR” for short, that  distracted all of us from the issue of inventing fake Medicaid records.

One resident, a man in his  late fifties or early sixties, was becoming intermittently disoriented and combative., according to the administrators.  He had punched one staff member and tried to choke another resident. Normally one of the highest-functioning residents , with a broad vocabulary and who sometimes showed a remarkably sly wit, his recent behavior, erratic and unpredictable, puzzled the staff.  By their report, he was sometimes sullen and withdrawn, mumbling to himself, other times shouting defiance at voices only he could hear, punching an invisible army of “Turkish attackers” who had come to torment him. He would scream and cry, snarl and punch, wild-eyed and extremely agitated, before losing the thread again and lapsing into a semi-conscious state.  When I quizzed them, they were  baffled as to the origin of this fairly sudden behavior change.

“Any changes in his physical health recently?”

“No. He just had a physical and blood work done. Nothing noteworthy or new was found.”

“No recent medication changes?” I asked. No, I was told. He does have a seizure disorder controlled by medications but there have been  no  changes in many months.  He just had an exam by the neurologist who presribes his anticonvulsant  meds.

“Any recent changes in his routine?”


“No contacts with any Turkish people in his history that you know of? No traumatic memories that might be the basis of this persecutory belief?”


“Any changes in relationships?  Conflicts with another resident? Loss of a friendship?  A  relative ceasing to visit? Departure of a favorite staff member?” No, no. no, no, they said.

I met with the resident–let’s call him Mr. Jones. At that time,  he was fairly calm and superficially cooperative,  but could not tell me his name or where he was, or guess the season. In short, he was not oriented to person, place, or time.  His level of alertness seemed to fluctuate.  He displayed no awareness of his recent behavior. Speech was rambling and slurred. Thought processes appeared confused and disorganized;  thought content involved bizarre, paranoid , delusions a bout the Turkish Army coming after him. He could not elaborate on that theme. He appeared to be responding to “internal stimulation” as they say, meaning he was hearing voices and seeing things that were of internal origin as if they were external phenomena.

“What psychiatric meds is he on now?”  I asked.

“None! We fired that quack psychiatrist months ago.”

“Another psychiatrist of your choice, then. He definitely  needs to be evaluated for psychiatric meds. If he becomes anymore combative he may need to be transferred to a psychiatric hospital and I’d like to avoid that if possible.””

“We need to know what kind of test battery you intend to perform on him. Like Rorshach,  MMPI, Stanford-Binet….”

“You cannot test someone in the middle of a florid psychotic break. It’s impractical and unethical.  In the state he’s in, he cannot sit down for pencil-and-paper tests and the results wouldn’t be valid anyway. You see….”

Once again they acted like “Why did we hire this guy if he’s not going to do what we tell him? He’s not a team player.”

“At a minimum then, ” they said. “We need a new I.Q. score.”

“What on earth would that tell you? How  would that be useful information?”

“It’s the state law.”

“No, it’s not. And in any case, he’s not testable in his  present state of mind. Look, the purpose of testing is to get certain information. Since we cannot get it by testing, we need to back up and ask ourselves what information we need and then find some other way to get it.”

“Well, we need to know what’s  going on with him….”

“He’s having a psychotic episode, characterized by disorientation, agitation, paranoia, disorganized thought processes, hallucinations and delusions….”

“You can’t say that! You don’t know he’s hallucinating.”

“Technically, you’re right. There are no lab tests or blood work or that sort of test that comes back positive or negative, to determine whether someone is hallucinating or not.  I can say he gives evidence, he  appears to be hearing voices and seeing things. “

“That’s just your opinion!”

“Which is what you just asked me for.  You are paying me for my professional opinions as part of my job. He looks schizophrenic to me.”

“Well, we’ll need you to do a comprehensive review of all his records, past behavior problems, treatment interventions, his response to them, what psychiatric medications he’s been tried on, and his response to each of those. Finally,  a diagnostic assessment with treatment recommendations. We will need that ASAP because we cannot make any decision until we have that from you.”

“Very well. I’ll do  a prompt chart review.  But we can’t waste time. If he’s not put on anti-psychotic medications very soon,  he may soon have to be sent to the State Hospital, the only place I know that would take him.  This man is dangerous in his current state. Dangerous to himself, to the other residents and to the staff, because of his mental illness. And we have a n obligation to ensure the safety  of everyone around here.”

But no matter how kindly and cooperatively I expressed it, they appeared “offended” that a lowly flunky like me should dare remind  them about their  professional, legal, ethical, or practical obligations.

“We don’t believe in chemical restraints,” they snapped.

“Chemical…? Oh, you mean psychiatric drugs.  Look, I’m no pill-pusher but  psychiatric meds have their place. It’s simply not true they are nothing but chemical restraints on behavior. That’s wildly inaccurate.  And  in any case, it’s quickly coming down to a choice between chemical restraints versus  physical restraints! Is the latter more humane?  And you are not licensed or prepared for that, are you? How many alternatives do you have?”

Exhausting, exasperating. I consulted with My Real Boss at Mental Health but he felt since it was their facility, it was their decision how to handle this crisis. We would only advise and recommend.

[Whew! This is a longer story than I envisioned it would be . I will have to continue it tomorrow with “Part Deux  and 1/2”]





















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