InsideSources

When most people talk about mental illness, they usually talk about the same things repeatedly: Stigma. Medications. Psychiatrists. Mental hospitals. There’s plenty of talk about disorders, from anorexia to attention deficit hyperactivity to moods and anxiety. Money is always a big topic, and discussions about problems at work (or lack of work) are also frequent.

But what I am obsessed with these days is the subject of ethics in the world of mental health, partly because ethics are one of the least talked about subjects, and in my mind, it’s one of the most important.

Here’s an example. Had America’s doctors opposed the pre-existing condition clause that left millions of Americans without health insurance before the Affordable Care Act was passed in 2012 (including me), perhaps we could have changed that discriminatory law earlier. Why would they do this? Because the pre-existing condition clause was unethical, that’s why. It doesn’t mean it was illegal. That’s a different story. But it was wrong, really wrong, and people like myself were left without any kind of health insurance whatsoever. Our nation’s doctors should have taken a much stronger stance.

Here is an excerpt from the American Medical Association’s Code of Ethics addressing the issue of prejudice in the treatment of individuals.

CHAPTER 8: OPINIONS ON PHYSICIANS & THE HEALTH OF THE COMMUNITY

The medical profession has an ethical responsibility to:

(g) Help increase awareness of health care disparities.

(i) Support research that examines health care disparities, including research on the unique health needs of all genders, ethnic groups and medically disadvantaged populations, and the development of quality measures and resources to help reduce disparities.

Many people don’t realize that it wasn’t that I couldn’t get health insurance to cover my mental health issues: I couldn’t get insurance altogether. Had I been struck by cancer or any other lengthy and expensive illness, I would have been left with a lot of debt and really bad, life-long, credit scores. I lived in constant fear of the ‘big one.”

What does ethics have to do with psychiatrists? We depend on our “P-docs” a lot. Patients with mental health issues often can’t think clearly. We are very mentally vulnerable, relying often on the advice of our mental health providers of how to live our lives. We are not just regular patients.

Our decision-making process is often non-existent, we can be incredibly impulsive, and I for one take sedatives before I go to bed as part of my daily medical routine. They help my brain get adequate rest alongside the rest of my body. If I take them too late, as sometimes happens, (I’m not perfect) the next morning I can be groggy and not in the best frame of mind to make good decisions.

So I trust my psychiatrists a lot to help me think things through, to tell me if I’m overreacting to something, or whether my emotions are indeed real.

In reading the American Psychiatric Association Code of Ethics, one thing becomes clear. Sex can get in a way of what should be a perfectly good doctor-patient relationship.

Seriously?

Seriously.

It spells it out here in Section 2

“A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.”

It then goes on to say: “Further, the necessary intensity of the treatment relationship may tend to activate sexual and other needs and fantasies on the part of both patient and psychiatrist, while weakening the objectivity necessary for control. Additionally, the inherent inequality in the doctor-patient relationship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical.”

You have to wonder, why should the “inherent inequality in the doctor-patient relationship” lead to exploitation of the patient? And what’s this about a “weakening” of the doctor’s “objectivity necessary for control?” Are they trying to say that male doctors can’t control themselves sexually because they are dealing with a mentally ill patient who is vulnerable? The sad thing is, that they are addressing this issue because it is, indeed, a serious problem in the industry. That’s another story.

I think psychiatrists should sit down with their patients, on day one, and go over the code of ethics, give them a copy, have them sign it, tell them how to contact the American Psychiatric Association if they feel that their rights have been violated. An ethical, honest physician will do this.

Ethics matter.

Leonard was probably 75, in 2004, when I began really noticing his memory-loss issues. He became confused when he was driving. He wasn’t making good business decisions. And then he got so he would want the television on but he wasn’t really watching it. It was something just to look at like a picture on the wall. He didn’t want to do the things he used to do.

It was really hard. He would forget things and began asking the same question over and over, such as, “When are we going to have dinner, Jeannie?”

Sometimes I’d get angry with him because I didn’t know why he kept repeating himself. Once I looked him in the eye and said, “Look at me. I said we’re having dinner in about 10 minutes.” They didn’t know much about Alzheimer’s back then like they know now.

The doctor told me, “We think he might have Alzheimer’s. But we won’t know until we do an autopsy. Either way, there’s no point in telling him because he won’t know what it means.” And I thought that was ridiculous. I know now one of the first things caretakers should do before a loved one gets more deeply into Alzheimer’s is to talk with them about it.

There were times when we laughed. I used to buy him colorful jockey shorts: burgundy, green, black and tan. I always got the brightest colored shorts I could because he liked bright colors. One day I put a pair of my black lace panties to dry on the wide edge of our bathroom jacuzzi. The next morning I went to see why Leonard was not coming out for breakfast and there he was, struggling, trying to get my black lace panties up over his legs. … He said, “Jeannie, you’ve shrunk my shorts again.”

And I laughed, and I said, “You’re a cross dresser. I never knew that.” And he laughed too, so he knew what I meant.

One of the very hardest things for me was to realize I wasn’t just losing my husband. I was losing my lover, my friend, my mentor. I lost it all in one man as I became nurse and caregiver.

Finally my best friend and my daughter both said, “Jeannie, you’re under too much stress. You’ve got to do something about it.” So I went to the doctor and got on a treadmill. Suddenly I had the worst pain I could possibly imagine. I had a major heart attack. They admitted me in for quadruple bypass surgery early the next morning.

I was told I couldn’t take care of my husband anymore. I still get tears in my eyes when I think about that moment. It was awful. Probably the very toughest thing I ever did in my life was to find a nursing home to put him in. I must have looked at probably 10 or more facilities in Las Vegas.

I visited him every day. At first he didn’t want to stay. He tried to follow me out the door and his caregivers had to stop him. I had to crack open the door and squeeze through while they held Leonard back. Then it got to where he knew he couldn’t go with me so he wanted me to stay overnight with him, and I couldn’t do that.

Leonard didn’t always remember our relationship. One day we were talking and he asked, “Have we known each other a long time?” And I said, “Yes, a very long time.” He said to me, “Maybe we should get married.”

I said, “Yes, I think we should.” And, of course, that’s the last time it was mentioned. He then forgot all about it. It wasn’t all sad.

Mostly we’d sit in his room and have meals together. I’d sit on his lap and talk to him and we cuddled. During the last few months of his life he changed. I’d show up, but after a few minutes he’d say, “You go now. You go.”

And I’d say, “But I just got here. Can’t I just sit with you?”

“No, go.”

“How about if I just sit here next to you in this chair and hold your hand?”

“Go!”

Those were the times when I didn’t know whether I could get to my car fast enough to cry. I never cried in front of him.

Over the years I had so many people tell me that Leonard didn’t recognize me anymore. And I’d say, “Don’t count on that because it’s the brain that has Alzheimer’s; the heart doesn’t. The heart knows if you care.”

If John Carter had been involuntary committed after he overdosed on opioids, then he might still be alive. That’s what some members of his family said when they spoke in favor of a bill that would add opioid addiction to the state’s mental illness definition in order to expand the involuntary commitment criteria for admission to mental health institutions.

John, better known as Bubba, started his drug addiction at the young age of 13 years old by smoking marijuana. By 16 years old, he went to his first drug rehabilitation center. He went more than three times during a three-year period, unable to beat his addiction. At 18 years old, he started to use intravenous drugs, and two weeks before his fatal overdose, his family went to the police to get him committed. The police said their hands were tied and couldn’t do anything, his father Jack Carter told a Senate committee on Tuesday.

“We don’t have time to wait,” he said. “There’s no reason for more families to bury their kids. These are our children. Something has to get done. President [Donald] Trump called New Hampshire ground zero for the opioid crisis. It’s time to step up and do something for these families, for us, for the kids of our future.”

Senate Majority Leader Jeb Bradley introduced Senate Bill 220 in the the Senate Health and Human Services Committee. If enacted, it would expand the state’s mental illness definition to include those listed in the “Diagnostic and Statistical Manual of Mental Disorders,” which is published by the American Psychiatric Association and includes substance abuse and addiction as a mental disorder. The bill would also expand the involuntary commitment criteria for the state’s mental health services system.

In order to be committed, the bill states, “The person has ingested opioid substances such that the person’s behavior demonstrates that he or she lacks the capacity to care for his or her own welfare and that there is a likelihood of death, serious bodily injury or serious debilitation if admission is not ordered.”

Bradley said he understands that some people might oppose his bill on the grounds that treatment only works if the person is willing to seek it and that hospitals currently don’t have the space or funds to handle involuntary commitment.

“I know there are a couple of issues,” he said. “We are clearly a ‘live free or die’ state and we believe in individual responsibility,” he said. “But responsibility falls on [everyone] who sees someone who is addicted to substances, which is an illness, and needs help. And sometimes people don’t want to seek help and then it becomes our responsibility to help those people. We ought to be able to have this tool to help people who are reluctant to seek out help. I don’t think there is any disagreement about that even in our live free or die state.”

Bradley expects the bill to be retained and worked on over the following months to discuss what the new law would cost the state and improve the language to better define what the process to be uncommitted would entail. Yet, it has bipartisan support with Democratic and Republican cosponsors.

From 2014 to 2015, New Hampshire saw a 31 percent increase in deaths from drug overdose, which is the second highest in the nation, according to the Centers for Disease Control and Prevention. The Office of the Chief Medical Examiner of New Hampshire estimates 470 deaths will be attributed to drug overdoses in 2016, but the number officially stands at 385, as 85 cases are still being investigated. The chief medical examiner predicts more than 450 people will die from an overdose in 2017.

As of 2011, 38 states had some form of an involuntary substance abuse treatment law that are separate from any kind of criminal issues, according to the Partnership for Drug-Free Kids.

From the other people who testified, the overall sentiment was general support for trying to combat the opioid crisis, but they also sought more information on the specifics of the bill.

“This is a very complex issue,” said Alexander de Nesnera, interim chief medical officer at New Hampshire Hospital. “When individuals go through detox, they are usually on many medications and it could complicate the medical detox process if they’re not monitored very carefully. When you look at developing a system for individuals to be involuntary hospitalized, we need to make sure the receiving facility is linked to a hospital directly, so they can receive treatment if there are severe complications of detox that occur.”

De Nesera also cautioned lawmakers on the possible consequences of the bill.

“By changing the definition of mental illness, you would greatly expand the number of people. Currently, there are 44 patients that are waiting admission to New Hampshire Hospital,” he said.”If we were to expand the definition of mental illness, the numbers in the queue would expand greatly. We only have 168 beds, and with that limited capacity, patients are in waiting rooms to get treatment. That’s not the answer.”

He encouraged legislators to think about investing in more outpatient programs and to have a conversation with the hospitals in the state about what would work for them.

New Hampshire is poised to receive some federal assistance from the 21st Century Cures Act, but not nearly as much as lawmakers expected. When President Barack Obama signed the act into law last year, New Hampshire officials anticipated getting $10 million over the next biennium. It turned out the state is only getting $6 million. State officials thought the money would be distributed based on per-capita overdose deaths, but that’s not what happened. New Hampshire has the second highest overdose deaths per capita in the country, yet California, who has a per-capita rate that is nearly two-thirds lower than New Hampshire, will receive the most money.

“I think our members of Congress across the country have started to recognize that the heroin epidemic is a serious problem and needs more resources,” Bradley said. “I’m surprised to see the way it’s been allocated in New Hampshire. Hopefully, that can be rectified. That being said, we also have to continue what we’ve been doing in the last budget and allocate more of our resources.”

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There’s a debate brewing in the mental health community — to diagnose President Donald Trump with a personality disorder or not — and it made an appearance in New Hampshire last month.

Elizabeth Lunbeck, a professor in residence at Harvard University’s Department of the History of Science, who specializes in psychoanalysis, psychiatry and the psychotherapies, presented a psychological case study of  Trump as part of her speech, “Acting Human: The Psychopath and the Rest of Us,” on February 14 at the University of New Hampshire.

“There is value in trying to understand him,” Lunbeck said in her speech. “He’s not a policy guy, he’s all raw, unfiltered emotions.”

She guided the audience through a case study, using the Diagnostic and Statistical Manual of Mental Disorders (DSM) by the American Psychiatric Association (APA) to identify a variety of symptoms of potential personality disorders exhibited by Trump. For evidence, she used a collection of Trump’s tweets, speeches, and statements. Lunbeck said he falls into the categories of paranoid personality disorder, histrionic personality disorder, borderline personality disorder, and narcissistic personality disorder (NPD), which is the most common one Trump has been diagnosed with by several psychologists and psychiatrists.

“I think it is startling how much of this criteria fits our current president,” she said. “I suspect Trump mobilizes his own narcissism.”

Lunbeck, who also has training as a psychologist, isn’t alone in her thinking. Just take a look at these articles from The Atlantic, Vanity Fair, New York Magazine, or on Twitter, where mental health experts weighed in. Yet, others have went a step further stating he doesn’t have the mental capacity to be president, sparking criticism within the health community on whether they should be making their opinions known without a proper medical diagnosis to determine if Trump has a personality disorder.

Thirty-five U.S. psychiatrists, psychologists, and social workers sent a letter to the editor of The New York Times saying Trump was mentally unfit to be president.

“We believe that the grave emotional instability indicated by Mr. Trump’s speech and actions makes him incapable of serving safely as president,” they wrote.

The group of experts said they were breaking their own ethics rules to speak saying they “fear that too much is at stake to be silent any longer.”

Historically, psychiatrists stick to a self-imposed ethics standard known as the Goldwater rule, which appeared in the APA’s code of ethics in 1973. The rule actually stemmed from a political incident involving presidential candidate Barry Goldwater. In 1964, Fact magazine polled 12,356 psychiatrists on Goldwater’s mental fitness to be president, with 1,189 of the 2,417 who responded saying he was psychologically unfit for the White House. Some of the psychiatrists characterized Goldwater as “grandiose, obsessive, paranoid, or paranoid schizophrenic.” Goldwater later won a $75,000 libel lawsuit against the magazine.

Usually around the time of an election the APA has to remind psychiatrists to not make psychological diagnoses of the presidential candidates.

“The unique atmosphere of this election cycle may lead some to want to psychoanalyze the candidates,” said APA President Maria Oquendo in a letter published in August 2016. “But to do so would not only be unethical, it would be irresponsible. A patient who sees that might lose confidence in their doctor. And would likely feel stigmatized by language painting a candidate with a mental disorder (real or perceived) as ‘unfit’ or ‘unworthy’ to assume the presidency.”

It’s important to note that psychologists do not have the same ethics rule as psychiatrists, as exhibited by a Change.org petition started by psychologist John Gartner, which has nearly 30,000 signatures, and is calling for Trump to be removed from office because he is “mentally ill.”

In response to this debate, Allen Frances, a psychiatrist who helped write the DSM, wrote a separate letter to the Times denouncing the claim that Trump is mentally unfit for the presidency.

“Most amateur diagnosticians have mislabeled President Trump with the diagnosis of narcissistic personality disorder,” he said. “I wrote the criteria that define this disorder, and Mr. Trump doesn’t meet them. He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder.”

John Mayer, professor of psychology with a focus on personality at UNH, said it’s time to get rid of the Goldwater rule because mental health professionals can offer diagnoses from a distance. He and his colleague researched the ethics of professional commentary on public figures. He points out that the press, without training, often makes those assessments for themselves.

“I do believe that it’s possible to diagnose from distances, with caveats, and watch them [public figures] over time even if we don’t know them personally,” he told NH Journal. “With public figures, they often intend to project an image of themselves, which can be quite different than who they really might be, so that makes it particularly challenging, though.”

Mayer said he supports free speech and health professionals have the right to discuss diagnoses and personality traits with people.

“Psychologists, psychiatrists, and other mental health professionals are among society’s assigned experts in human behavior and mental health,” he wrote in his journal article on the topic. “Judging others can be viewed as an obligation — involving a duty to educate and a duty to warn, in the case of dangerous figures.”

Frances supports the Goldwater rule and generally believes mental illnesses are over diagnosed, but he said he worries that when signers of the petition and others call Trump mentally ill, it stigmatizes people who actually suffer from those problems. It can also be a way to shut down a political discussion and distract from the more objective criticisms one could make about his time in office.

“Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy,” Frances wrote. “He can, and should, be appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers.”

Mayer agreed and said diagnosing Trump, or other public figures, isn’t without its biases. Even if the psychologist or psychiatrist don’t know it, their own political beliefs or ideas can cloud their professional work.

“With political public figures, we have to be careful and remember that there are many reasons we judge people that have little to do with personality and more to do with political loyalties or opinions,” he said. “With President Trump, we may overlook character flaws and if we are opposed, we may be very judgmental of what his personality is actually like.”

Mayer also defended the use of diagnosing Trump and other public figures as a case study for education, like what Lunbeck did with the UNH students in February. He even does a similar exercise in his own lab where students identify public figures and look at their “healthy” personalities.

Lunbeck stood by her depiction of Trump in an interview with NH Journal a couple weeks after her talk. She added, though, that looking at Trump’s rise isn’t going to be solved by just psychoanalyzing him.

“We need economic explanations, social explanations, legal explanations, et cetera,” she said. “I think looking at the psychology can be helpful, but I don’t think we have a full understanding yet. The question still is how this man, who displayed these narcissistic behaviors became president. It’s hard to explain that, and we need many tools to explain that.”

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