Shrink Rap

Continued coverage of the American Academy of Psychiatry and Law (AAPL) conference. For Part 2, click 

The first talk of the day was a discussion of SB1070, the Arizona law which required police officers to verify the citizenship status of anyone suspected of being an illegal alien. I learned that there were several parts to the law and that some parts were under injunction and were working their way through legal challenges. An immigration attorney talked about the ambiguity of the law and how it could be misapplied. For example, one provision barred anyone from picking up day laborers. In theory, it could be used against emergency medical personnel who transported illegal aliens. He also talked about the problems faced by mentally ill illegals who were deported to Mexico where they had no family support or access to mental health services.

I was planning to go the session about fMRI's in court, but I ended up getting invited on a trip to 

. Very cool little place with nice shops. Incidentally, Tupac is just past the Titan Missile Museum. I didn't go tour the museum because it creeped me out a bit but you can see a short video of the place 

I got back for the afternoon sessions. Dr. Ezra Griffith gave the Isaac Ray lecture entitled "Identity, Representation, and Oral Performance in Forensic Psychiary." I could never give it justice in a short summary. Fortunately you can read the full text of his talk 

, because AAPL continues to be one of the few organizations that still keeps it's articles open to the public for free. Griffith talked about the role of perfomance in expert testimony. While most people would think of this solely in terms of communication skills, he put testimony in the context of the performing arts or literary narrative. The telling of the crime "story" is like drama, with behavioral elements and a physical context (the court room). The expert's purpose is to develop the facts as one would a character, so that the listener can hear the facts in a coherent way and is able to infer a line of understanding about the case. The jury then chooses between two competing narratives, the defense and the prosecution. Read the paper, Ezra explains it much better than I can.

The last session was about privacy in forensic psychiatry. I tweeted the highlights until my data coverage gave out.

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Continued coverage of the American Academy of Psychiatry and Law (AAPL) conference.

What I Learned at the AAPL Conference: Part 3

There's this funny thing about humor: it's not funny to everyone. I tend to like the unexpected, what's dry or witty or sarcastic. ClinkShrink, bless her Midwestern soul, likes puns. And Roy, well he still likes potty humor.

Jokes are often made at the expense of a group, and I don't understand a lot of ethnic, racial, put-down humor. That said, the other day I went to put up a post, and since I've recently written about how to find a psychiatrist, and what makes mental illness bad---both serious posts that took me a while---I thought I'd opt out and just went to youtube and searched for "psychiatry humor." Lazy, you say. Yup! But I listened to the audio of 

 and I laughed out loud. Even though I hesitated for a moment, I posted it.

Two readers and Roy pointed out that this YouTube makes fun of people with mental illnesses. Does it? I had trouble seeing this as the same phenomena as your usual make-fun-of-a-group in a hurtful way type joke. For one thing, the "if you're a nymphomanic press...." was the part I laughed out loud at, and nymphomania is not a psychiatric diagnosis. Hypersexuality is a symptom of some disorders, but if I can't laugh at a nymphomania joke, maybe I should go home and learn to like bad puns. If you're co-dependent, have someone help you press 5. Ah, co-dependence is not a psychiatric diagnosis either, but a lay designation used to describe a constellation of behaviors in a way that some people find to be meaningful and helpful. The rest of the tape....okay, I admit, it pokes fun of people with illnesses. Somehow, I couldn't come to terms with this as being bad. I still own a Prozac mug and my friends comment when I serve them coffee in it---- is that bad? It certainly gets more of a reaction than a Lamisil mug would get.

Here is the thing though, something invaluable that I learned from Dr. Fox who taught us family therapy behind a one-way mirror : Insults and offenses are defined by those who are insulted or offended. If someone is injured, that's what counts and the offending party is left to recant. The reality isn't in "Oh, but you should find this funny" or "It's not offensive." The reality is that someone is offended and those feelings are valid. With that, I should take the post down. However-- and do forgive me, Dr. Fox--but it is hard to negotiate life (much less a blog with a duck mascot) if one tiptoes through afraid of insulting or offending any one of the 2,500 weekly unique visitors.

 to read the rest of this post and vote in Dinah’s poll.

There's this funny thing about humor: it's not funny to everyone. 

Funny: At the Expense of Whom? Please Vote

The following originally appeared on our network site 

So why is it that some people have a psychiatric disorder and they bounce back and it's not a big deal, while others struggle terribly? For the unlucky ones, mental illness defines them.

Here are some factors that affect how much impact psychiatric illness has in a person's life:

(Note to Roy: did I get the effect/affect thing right here?)

Any way you dice it, mild-to-moderate anxiety can often be hidden and isn't as disruptive as an episode of psychosis with hallucinations and paranoid delusions.

So a chronic depression or severe obsessive compulsive disorder may be more disabling than a brief episode of psychosis.

Some symptoms are intrinsically more public than others, or more difficult to bounce back from. In terms of "

Can I be a doctor if I have bipolar disorder?

," one episode of walking around the hospital naked may be all it takes to get sent home.

Form and severity of symptoms, and the duration of the episodes, are likely to be intrinsic to the disease and not something the individual controls.

4) How responsive the illness is to treatments.

Some people have very severe symptoms that are very responsive to treatment.

5) External support systems: access to good care, chicken soup, and TLC. Job flexibility may enable some people to quietly take time off when the going gets rough. Understanding friends & family-- these are all good things.

6) Individual personality features that support good coping. This is vague and I just made it up, but it's the best I can do--- maybe 'resilience' is another term for it.

Why is it that some people have a psychiatric disorder and they bounce back and it's not a big deal, while others struggle terribly? 

What Makes Mental Illness Bad?

	Seems like a simple enough questions: How do you find a shrink?

	It's not that easy to answer. There are all sorts of shrinks who do all sorts of things (therapy, not therapy, specific forms of therapy like psychoanalysis or CBT), and then there's the overriding insurance question. Not to mention location, location, location.

We've talked before about insurance, and if you haven't read 

, please do. It's a good place to start. In areas where shrinks are in short supply, often, they do take insurances and they only see patients for medication management. In areas where there are more docs and people have treatment options, they may split between those who do and don't take insurance. You should be aware that if a shrink doesn't take your insurance, you will likely still get reimbursed, but there may be a higher deductible, you'll need to mail in the form yourself, and there will be a long wait (and assorted hassles) for the money to come back. Some people are reimbursed very well, others or not. If your insurance is an HMO or has no out-of-network benefits, then a non-insurance doc will costs you the entire fee.

	--Does it matter if the shrink is in your insurance network?

	If it does, and you live in an area where many shrinks don't participate with insurance, then call the insurance company and get names and numbers and do hope they aren't all dead or not-accepting patients.

	--What kind of shrink? If the patient is under age 16-18, your best best is a child & adolescent psychiatrist. Be aware that many psychiatrists at academic centers run research projects and teach, and don't see many outpatients. That's not to say never---and most have a few patients, but they are often a bit harder to reach, especially when they are presenting at conferences or have grants dues, and may have difficult parking. So child, general adult, or is there some specialty need which may be very restrictive---for example treatment of sexual or eating disorders or psychoanalysis? For ClinkShrink, I will throw in that if you are looking for evaluation for a matter pertaining to the legal system, you may want to look specifically for a forensic psychiatrist.

	--Finally: does it matter to you if the shrink does psychotherapy or are you fine seeing one person for therapy (if necessary) and another for meds? If it matters, you need to clarify this upfront.

	Now you've got the big three questions. There are other obvious ones: parking is always a biggy, the setting may be a concern (is your ex-lover working in the same practice?), how difficult is it to get an appointment? How long do appointments last? If the first evaluation is routinely scheduled for under 50 minutes and you have a choice as to where you go: then go somewhere else. In an institution---jails, a substance abuse clinic, the medical unit of a hospital, an emergency room--- evaluations may be very brief, but in these settings your records may be available for review and the evaluation may have a very specific and limited purpose. But for a thoughtful, comprehensive evaluation before beginning on-going treatment, the usual is a minimum of 50 minutes and often 90-120 minutes. Some psychiatrists do their evaluation over several sessions.

	If you have no insurance and no money, your options are limited. The traditional place for treatment in this case is a local Community Mental Health Center or CMHC and the standard has been to have one per geographic catchment area. These clinics usually offer split care, there may be a wait, and you don't get to choose your shrink. They take Medicare and Medicaid, and they sometimes don't take private insurance. How do you find your CMHC (or OMHC)...I'm not really sure. Try Google, and then call any clinic in your area and have a heart-to-heart with the receptionist. He may be able to give you the number of the clinic that serves you.

	There are other agencies that over care for the indigent. In Baltimore, HealthCare for the Homeless offers psychiatric treatment, and The Pro Bono Counseling Project will give referrals for free or discounted care from professionals in the community who have agreed to volunteer their time. Again, there's no choice in which shrink you get.

	If you have insurance and want to stay in network: Call your insurance company for a list of names.

	Aside from money concerns, here are the best ways to find a good shrink:

See what advice patients are being given to find you and your fellow psychiatrists.

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