Measure twice, cut once

So after consulting with my supervisor about a patient, he recommended administering the Criminogenic Thinking Profile, and he emailed me the test. Naturally, after printing the test, I took it myself and put my results in my Gmail status (40th percentile overall, if you care or if it means anything to you).

Because Gmail does not allow you to annotate emails, I often reply to myself and include relevant comments. Because the email from my supervisor only said CTP, and not the full name of the test, I posted my Gmail status message with the test's full name into a new reply to send to myself, so it would be included in the conversation and I could search for it in the future. Of course, as you'd so intuitively gathered by now, I sent my results to my supervisor. Lucky for me he's got a sense of humor and a natural curiosity. His response- "Not too bad. Any high [subscale] scores?"

More psychosis in the news

See my original post on psychosis here.

I've been following the sad story that unfolded July 29th on a Greyhound bus traveling in western Canada. Without any apparent provocation, Vince Weiguang Li calmly and repeatedly stabbed Tim McLean to death before decapitating him, displaying his head to other passengers (who had fled the bus), and eating parts of his body.

When arrested on the bus, Mr. Li said "I have to stay on the bus forever." Since his arrest, Mr. Li has declined to speak; aside from acknowledging his guilt, he only spoke when asked by the judge if he wanted a lawyer. Mr. Li shook his head and quietly said, "please kill me." Mr. Li was ordered to undergo a psychiatric evaluation and has since been admitted to a secure forensic psychiatric ward. Though he declines legal assistance, Legal Aid Manitoba stepped up to represent Mr. Li.

Following the case, I've encountered many comments on blogs and news sites condemning Mr. Li's actions and calling for Canada to reinstate the death penalty in his case. Many are dismissive of "this mental illness BS" and point to the fact that Mr. Li knew what he was doing. (Of course he knew what he was doing, but he was not doing it in the reality we experience- he acted according to the demands of another world entirely.) They think he should be thrown in a hole or deported back to China after revoking his Canadian citizenship. There are also those who recognize that Mr. Li cannot be considered fully (or at least criminally) responsible for his actions and that we should reserve judgment until more facts come to light.

In my last post on this topic, I expressed sadness at the horrors that can befall the mentally ill, their families, and bystanders. This time around, I'm saddened by the intolerance and misunderstanding still prevalent in many people's perceptions of mental illness.

On the Velocipede (or, with apologies, Zen and the Art of Bicycle Maintenance)

So I bought a used bike on Craigslist. My last bike was stolen when I was in 11th grade and I've been wanting a new one more and more in recent years. I could use the exercise, and I could use the activity to help with the doldrums of an isolated summer at home trying to make progress on my Master's thesis (more on that another time, maybe).

When I want to buy something, I research it to death. On Craigslist, my options are more limited, but I ended up buying a really good used hybrid bike I wouldn't otherwise be able to afford new. Of course, I also had to research to death a helmet, multi-tool set, mirror, bell, kickstand, lock, cyclometer, etc.

There's a hole-in-the-wall bike shop down the street from me where I went to pick up some parts. My experience corroborated the refutation of the fallacy of of of of of... HELP! I'M MIXING UP ACADEMIA AND MY BLOG!

Well, what I was trying to say was that some people believe that abundant options are an indicator of happiness, or freedom, or fresh breath or something. We talk about "Freedom of Choice" and about not being constrained by limited options. In America, one can choose to do or be anything they want! In actuality, people are easily overwhelmend by an abundance of choice, it causes anxiety, panic, and uncertainty (a source of anxiety).

So I realized that though Amazon might make available 218 types of bike lubricant, I can be much happier and at ease deciding between the two brands in my local bike shop (LBS). What's more, I can be out on my way that much sooner.

Using the awesome videos at bicycletutor.com (including one on "How to Choose the Right Lubricants" - I guess that guy would be the Lube Guru, helping anxious, confused, unhappy people make the right choice), I quickly learned my way around the morphology (uh-oh, it's happening again!) and maintenance of my bike. I got my hands dirty and felt like a real bike mechanic. So, I was ready to ride. Today, after the thunderstorms cleared up, I climbed in the saddle and took off to the Hudson River Greenway. Here's the round-trip route I took:

Now, early on I came to realize what starting off a ride in Washington Heights means- you better be sure your brakes work for the initial steep downhills, and that your knees and thighs don't give out on the return's uphills. Here's an elevation map of my trip:

I'm proud of myself, but also realized I have a lot yet to re-learn about biking.
Any suggestions for saddle-soreness? I'm hurtin!

Thoughts on psychosis

Some details have been changed to protect the confidentiality of protected patient information (Thanks Ariel for the consult).

Leaving the hospital right after my session with a remarkably insightful young man who some time ago, in a psychotic and drug-intoxicated state, shot and wounded several police officers, I heard a report on the radio about the developing case of Khiel Coppin. I'm sure news reports will be more comprehensive by the time you read this, but for now you can check out the story here (be sure to read the transcript of the 911 call) and here.

Basically, Khiel, an 18-year-old living in Brooklyn, was killed in a confrontation with police. He had stopped taking his anti-psychotic meds and decompensated. His mother called 911 because of his threatening behavior. He can be heard in the background saying he had a gun. The police responded and Kyle ignored their orders to stand down and surrender. He threatened them with a knife and then brandished something from under his shirt. It was a hairbrush.

People will blame the police for firing 20 shots at him (10 hit their mark). I don't blame the police. I don't blame Khiel. I don't blame his mother. It's just so sad when this happens. No one is directly responsible. There are only victims: the ill, the police, or in the case of other patients on my ward, a father perceived to be a robot sent by the CIA, a great-aunt who was believed to be turning into a witch.

I work with people who've committed horrific, violent crimes with incomprehensible intensity and purpose. Were these people not psychotic, they would be tried, vilified, and incarcerated. Thankfully, the law recognizes their impairments and commits them (usually) under Article 330.20 of the Criminal Procedure Law (CPL), otherwise known as "not responsible by reason of mental disease or defect."

In the short time I've served on my externship, I've come to understand two major concepts:

First, when you encounter in the news someone who is arrested after committing or attempting an exceptionally violent act (like this recent case), you can usually count on reading the words "motive unknown." You can also expect that person to fade from the media's eyes. But he (or she, though usually he) doesn't disappear. He gets swept under the rug. I work at that rug. They appear on the news radar when their actions are salient and shocking, but they often get better with medication and therapy. I often encounter incredulity when I relate the story of a given patient who committed any given -cide, who is doing really well and is heading towards discharge.

Which leads me to my second discovery. These are regular people, though ill. They are not hell-spawn or terrorists and they are not sociopaths (usually, though some of our patients are). They see and hear and experience as real things we only encounter in horror movies, and worse. When psychotic, they can feel terrified, entirely overwhelmed, with no one to turn to, and especially, no one to trust. If I were seeing demons all around me, my grandmother were the devil and angels were telling me to kill her to save my life and the world, why wouldn't I follow through?

When they are treated and come out from within the delusions and hallucinations, they can realize what they've done and they express a remorse that can be existential and eternal. One patient is reconciling with his mother for killing her mother. He is working to stay healthy and lead a productive and fulfilling life in the community. He says, "I realize what I've done. I'm horrified at what I did, I'm angry at myself, and I pray for her soul everyday. I have two choices- I can kill myself or try to move forward with my life. I choose to live. I don't want that ever to happen again and I'll never go off my meds." And he means it.

When talking about the kind of people I work with, I'm often asked
whether we rehabilitate them to the point that they can then begin serving the appropriate jail time. That would be a terrible thing. The law recognizes that their crimes were not committed with an intact mind and thankfully does not punish them for being sick; it tries to ensure they are helped to heal and to cease being a danger to themselves and others. When a person like that becomes well, he is not the same person who committed the crime and doesn't deserve to suffer the criminal consequences of the act.

It is important to know that a very small percentage of people with psychosis are violent or act violently, but when I work with these cases or hear about them on the news (and I feel like I've been hearing more and more of them), it makes me so sad.

UPDATE: A follow up post on another tragic case.

לא תקלל חרש ולפני עור, לא תתן מכשל

Last semester, I took a course in Cultural Diversity as it relates to psychological and clinical practice. It was enlightening, though remarkably biased. You see, the instructor is black and virtually all the case studies presented were of black people who had achieved great success despite backgrounds of poverty, abuse, neglect, and/or discrimination. These were all great and inspirational stories, but the curriculum seems to have gotten swept up in the mistaken notion that diversity=minority. (If you think this is racist, get an education, see the world, and have a neurologist check out that knee-jerk.)

Anyway, we had a guest speaker one day, a hearing psychologist who had worked for many years in the deaf community. The presentation was fascinating and enlightening, but I learned one thing that greatly disturbed me.

Because they cannot hear, deaf people often miss out on a lot of background information. Think about it; how much useful information do you collect every day by overhearing (not eavesdropping)? Because of this information deficit that leaves them out of the loop, deaf culture tries to glean the information directly and places a great value on information. The consequence of that is that deaf people are very self-disclosing and will ask very personal, intimate, and private questions (e.g., "How much do you make?" "Were you always overweight?" and the like). When communicating with a deaf person, it is considered an affront to deny them information; it says you don't trust them.

The guest speaker related a conversation she had with a supervisor about how to respond to these probing inquiries if disclosing the information made her uncomfortable. Her supervisor told her that there is a practice that has arisen among interlocutors of the deaf. The solution is to simply lie. That way you're not disclosing and not insulting.

Personally, I find that even more insulting and disrespectful. I learned growing up and in my professional, clinical development that the way to demonstrate your respect for someone (and indeed, to actually respect them) is to be honest with them. Sometimes the truth is scary, painful, or inconvenient. You don't have to deliver it with a sledgehammer, but you don't sugarcoat it, beat around the bush, or lie about it. The truth with compassion is the ideal.

This earth is blessed with myriad overlapping cultures. It is inevitable that many of them will clash. The mature, productive reaction should be to address the clash and reconcile differences; it doesn't mean everyone will walk away happy, but they should feel respected. Shirking away from this responsibility by misleading or misinforming the deaf, in this case, is a twisted, selfish, and cowardly response to personal discomfort.

Now that I've expressed my criticism, what solution do I have, what would I do? I would consider the nature of the question asked of me. I may find that though I am unaccustomed to disclosing the requested information, I may not really take that much issue with it and wouldn't really mind that much answering the question.

If I truly don't want to reveal the information, I would tell the deaf person that I understand their culture's value of self-disclosure and that while they are not lacking for my trust, my cultural background makes me uncomfortable answering the question. If the deaf person is sufficiently mature and culturally responsible, he or she would endeavor to understand or at least respect my culture (which Randy Cohen failed to do) while accepting that I am not being insulting.

This may not occur, and the deaf person may adopt a view that hearing/male/Jewish/etc. people are culturally obtuse and offensive. That would be sad, but at least I would have met my responsibilities.

Distasteful

Today I had to do something I feel is wrong.

In my clinical training, I perform psychological assessments. I was finishing up one such assessment process today, and met with the examinee for a feedback session to discuss the results. The assessment report can be very technical and difficult to interpret (or interpret correctly) for the lay-public (hence the feedback session to explain in everyday language).

Of course, at this point it's entirely appropriate to reference Simspons episode 9F09 (Homer's Triple Bypass):
Dr. Hibbert: Homer, I'm afraid you'll have to undergo a coronary bypass operation.
Homer: Say it in English, Doc.
Hibbert: You're going to need open heart surgery.
Homer: Spare me your medical mumbo jumbo.
Hibbert: We're going to cut you open, and tinker with your ticker.
Homer: Could you dumb it down a shade?

For this reason, my supervisor does not like to give examinees their reports after testing and, when requested, sends the report to the proper audience (e.g. a school or other doctor). When asked for a report during a feedback session, he tells the examinee that it's not "his policy" to release the report. If they continue to ask for it, he gives it to them. After all, they have a right to it- he just doesn't like to give it to them. This is not a unversal practice (even within our clinic, other supervisors don't subscribe to this policy), but it's his, and I think it's pretty deceptive.

As his supervisee, I am expected to practice this habit. Today, after doing a good job explaining to my examinee what I'd found, she asked for the report. I told her, "It's our policy not to release the report." I told her we would send it wherever she needed it sent. She asked if there was any way to get the report for her records, to facilitate sending the report in the future, to have it for her records. All I could do was repeat, "It's out policy not to release the report."

It went on, but I feel dirty enough already. I need a shower.

Update (3/15/07): The clinic's policy is, in fact, to release reports to patients, but to make them jump through minor hurdles to get it (submitting a written request and signing consent to release their report to.. themselves- huh?). So, this examinee will get her report. I feel better now, but it's yet another strike against my supervisor, with whom we already have some major issues.
At times like this, it's important to remember advice my old alte-supervisor gave me when I left work before returning to school to start my graduate studies- "תזהר מחמור נושא ספרים" (Beware of donkeys carrying books)

Update to the update: My aforementioned alte-supervisor is a secular Israeli with contempt for the practice of religious Jews (a tradition in which he was raised; in his youth, he attended an elite yeshiva, possibly qualifying him as an authentic apikores. His advice to me suddenly takes on new meaning.