Tag Archives: mental health

Mar 4 2015

Your character sees a psychiatrist

Let’s suppose you don’t want to have you character hospitalized but he needs to see a shrink of some sort. How do you handle this?

First off you need to decide what sort of shrink. Does your character need meds? Let’s say you’ve got a tough guy who can’t see the point of talking about stuff, but his stress level is causing problems on the job. So, he goes to his primary care doc who says: “I don’t prescribe psych meds, but I can send you to a psychiatrist.” Now, if the primary care doc is part of a group, he can make some entries into his computer and the referral is sent. If the doc is on his own, he can make some suggestions. Or Mr. Tough can call his insurance company and see what their procedures are.

So, now Mr. Tough arrives at the psychiatrist’s office. This could easily be quite a while later since demand is high in a lot of places while supply of psychiatrists is low. Nice set-up for some conflict there. “Yes, boss. I’ve got an appointment but the soonest they had was six weeks from now.” What’s a good boss to do?? J.

Mr. Tough finally gets in to see the psychiatrist and checks in with the receptionist who takes insurance cards and has him fill out paperwork, including stuff about privacy. (You don’t really want a discussion about HIPAA, do you? Didn’t think so.) The waiting room is likely to have one or two other people there, or maybe not. Anyway, it’s probably pretty plane with the obligatory magazines scattered on the tables.

Eventually, the psychiatrist comes out and conducts Mr. Tough to the office. Please, do not expect a couch! There will likely be a desk with a couple chairs arranged in front. On the wall, Mr. Tough will likely see the psychiatrist’s diploma. The furnishings are likely to be bland. You never know what someone might find offensive or upsetting. Do not expect Mr. Tough to be sitting in some gorgeous, high-end office. They exist, I’m sure, but in today’s managed care environment, most of us see a doc with rather utilitarian offices. You can add setting details like books and photos. The doc may or may not have a computer on his or her desk. Maybe on a credenza behind the desk.

The initial appointment may last 45 minutes. This allows the doc to get some background and an idea of what’s going on with Mr. Tough. The focus will mostly be on signs and symptoms and any history of mental health problems. This history will include any family history of mental illness since a number of illnesses have strong genetic components. The psychiatrist will then write out a prescription (or several) and suggest that they get together again in a few weeks. Hopefully this will be only a couple weeks so the psychiatrist can check on side effects and well as the impact of the meds on the problem.

Please be aware that many psychotropic meds take a while to “kick in”. This is true particularly of antidepressants.

So, Mr. Tough is given a prescription for antidepressants even though he insists the problem is anger. That happens a lot. The reasoning is that what’s underlying the anger is unhappiness and stress and these meds have been shown to be effective. He may also be given a prescription for something to help him sleep. I’ll discuss some medication issue at a later date since side effects can really give your client some problems to deal with.

When Mr. Tough comes back, the appointment will only be for about 15 minutes and focused on how the meds are doing and any side effects noted. The psychiatrist will, hopefully, be supportive and allow some discussion about the problems in Mr. Tough’s life, but this will be limited. I can’t tell you how many times I’ve had clients come to me, complaining about their psychiatrist’s failure to talk to them about anything other than the meds. It’s just the way things are nowadays in the US. The doctor may or may not change medications around. He’s not likely to refer to a psychologist or social worker.

So, that’s essentially outpatient treatment with a psychiatrist in the US. In a later post I’ll talk about seeing a psychologist on an outpatient basis. As usual, please leave any questions or comments below.

Feb 25 2015

Insanity, Schizophrenia, PTSD, and Eddie Ray Routh

Just some thoughts on the trial and verdict regarding Eddie Ray Routh. Last night (2/24/15) Routh was found guilty of murdering Chris Kyle and Chad Littlefield. The defense had contended that Routh was insane at the time of the murders, but the jury clearly rejected this. I have no information regarding why the jury did so, but likely did feel that Routh “knew right from wrong” when he killed those two men. That is the standard or “test” in Texas and it does seem he knew that at least some of society would determine that what he did was wrong. Routh apparently tried to evade police in the aftermath. He ran.

It was clear (at least to me) that Routh was mentally ill. He reportedly had been diagnosed as schizophrenic by the VA. The reports of hallucinations and delusions back this up. As I will discuss in a later post(s) on PTSD, these are not, I repeat not, symptoms of PTSD. He may have suffered from PTSD as well as schizophrenia. Unfortunately, when his mother reached out to Mr. Kyle for help, she only made note of PTSD and not the schizophrenia. For a long time, the media focused on the reports of PTSD. It’s become somewhat of a fad, I’m sad to say, particularly when dealing with veterans who deployed either to Afghanistan or Iraq. It seems like Americans have become quick to label veterans of the War On Terror who have mental health problems as all suffering from PTSD and likely to become violent. It’s just not true.

Could Routh’s schizophrenia have been triggered by his deployment? Possibly, though not very likely. Could it have been a coincidence that his schizophrenia emerged during this time frame? Yes. Schizophrenia often emerges during a person’s 20s.

What’s the take-away here? I think there are a couple. First, different jurisdictions have different “tests” for calling a person “insane”. As writers, you’ll need to check the test for the state your characters are in. Second, a person can be crazy but still not be insane. This can give you a lot of tension and conflict for your story. Third, be careful when labeling your nut case. Familiarize yourself with the signs and symptoms of the various mental health diagnoses. I’ll do my best to help you with this.

Feb 18 2015

Psychology and Writers: Schizophrenia (Part 1)

Schizophrenia. Yes, it does translate to “split mind”, but that doesn’t mean that we’re dealing with multiple personalities here. Instead the “split” is with reality.

The National Institute of Mental Health (NIMH) has published a nice, concise discussion on schizophrenia here: http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml. It’s a good place to start. For information on rates of schizophrenia, see the CDC: http://www.cdc.gov/mentalhealth/basics/burden.htm.

Okay, so you’re now armed with gobs of information about schizophrenia. What does that mean for your characters? A lot of mystery writers have as their perpetrator someone with schizophrenia or at least claiming to have schizophrenia. Certainly, some criminals have had schizophrenia. However, it is far more likely that a schizophrenic will be the victim of a crime rather than being the perpetrator. Schizophrenics are also much more likely to attempt suicide than they are to murder. Sure, the delusion that people are trying to kill you can lead a schizophrenic to murder. It’s just not very common at all. So, you can use your schizophrenic as victim, witness or perpetrator.

Now that you’ve decided to have a schizophrenic character, how do you portray him or her? Getting into the pov of such a character will be hard to do convincingly (at least to shrinks like me! J). Your character is likely to be hearing at least one voice that’s saying some pretty nasty things about him or her. The patients I’ve worked with never actually told me what the voices were saying, but did say that the voices were horrible in their comments about the patient. And they couldn’t turn it off!

How untreated schizophrenics think, I just don’t know. None of my patients have ever told me. My guess is that their thinking is jumbled and illogical. According to the NIMH, they have trouble with short-term or working memory. They have trouble using information to make decisions and control their behavior, so they’re likely to act impulsively. They are likely to be fearful if their delusions are of the paranoid sort*.

A few other symptoms are likely to be apparent. One of these is “flat affect”. This means that the individual shows little, if any, emotional response to the things going on around them. Be aware that the medications used to treat schizophrenia can also make the person “flat.” Conversation is likely to be limited and the patient has difficulty following through on plans.

Some patients, rather than being “flat”, do exhibit irritability. I recall one individual, who was not being treated by our clinic, who hung around the smoking area at the hospital where I worked. He appeared angry and quite intimidating. He usually tried to bum cigarettes. While I didn’t give him any (I only brought out one for myself), but I made a point to treat him politely. And he did respond to that, calming a bit and responding nicely. I think, with absolutely no proof, that his irritability was based more on what was going on in his mind. Perhaps he was angry about the voices he heard.

I’m going to end this here with the promise to write more about schizophrenia at a later time. If you have any questions or requests or comments, please let me know.

PS:

I’d like to make a couple comments about the current murder trial of Eddie Ray Routh, accused of killing “American Sniper” Chris Kyle and his friend. The family is claiming two things: that Routh was “crazy” and that he had PTSD. People with PTSD don’t have delusions about demons. They may have flashbacks in which they think they are back in a traumatic situation. Back when I was in the Air Force in the late ‘80’s, an individual came into the ER with a rifle. He believed he was in Viet Nam and that it was 1968. He was disarmed and taken to a mental health unit. This was a flashback, not a delusion. I know it’s hard to make the distinction, but it’s important. So, what’s going on with Routh? I’m not sure. It may be that there are more than one illness going on here. Or maybe just (!) schizophrenia that happened to emerge during or shortly after his deployment. He was the right age.

*“Paranoid” is not being worried or anxious or simply fearful. It’s the belief that someone(s) are plotting against you, trying to harm you.

Feb 8 2015

Psychology and writing: Is my character insane?

Insanity is a term used widely, and most often incorrectly. We’ve all seen the interviews with bystanders saying some criminal had to be “insane.” We may even have had one of our characters say of another, “She’s insane!” What a layperson means is that the other person’s behavior doesn’t make sense or that the other person is mentally ill. Some people may even believe it’s a term that is used in mental health circles. They’d be wrong. The term “insane” is not a mental health term, but a legal one.

I am not a lawyer and you might want to talk with one if you plan on using the term in your work. Do realize that different states (and countries) have different definitions of insanity. Essentially, the accused is claiming that because of some mental illness or defect he or she shouldn’t be held legally responsible for his or her actions. The insanity defense is rarely used in the US and even more rarely does it result in a ruling of “not guilty by reason of insanity.” Usually it’s the defense that has to show that the defendant meets the standards for such a decision by the jury. In other words, the “burden of proof” lies with the defense.

It’s not enough to show that the defendant is mentally ill. In the early 1970s, Herbert Mullin killed 13 people. He said that voices told him that he could prevent an earthquake in California if he killed. It’s not surprising that his defense initially was “not guilty by reason of insanity.” He was hearing voices; he was clearly mentally ill. But…the jury didn’t buy that defense, primarily because he’d tried to cover his tracks and showed some sign of premeditation in some of his kills. He was found guilty instead and sent to prison. He’ll be eligible for parole in 2021, when he’s 74.

Personally, I don’t think premeditation, by itself, negates an insanity defense. I do think it is possible for a mentally ill person to plan out a crime and carry it through while still meeting the standards or “tests” for a decision of insanity. This might be a good source of some conflict for your story and an interesting cross examination of a psychologist on the stand. Attempts to cover up the crime is more problematic since it suggests that the killer knows that what he or she did was wrong.

Be sure that you don’t have your psychologist or psychiatrist making the determination that your character was insane. That’s something the jury must do.

BTW: an insanity defense is not the same as competency to stand trial. This is a separate determination and looks at whether or not a defendant understands that he or she is being tried for a crime, who’s involved, and if the defendant can assist his attorney(s) in his or her defense. It relates to the time of the trial and not to the time of the crime. You can have your defendant completely psychotic at the time of the crime, but because he’s now on his meds, he’s able to understand the trial and assist his attorneys.

A good resource regarding these issues would certainly be a lawyer. You might also want to get in touch with a forensic psychologist or psychiatrist. These individuals are often called in to develop an opinion regarding both competency and insanity.

So, how do you use this information in your story? Let’s say to have a character, Sam, who goes on a killing spree. It’s Saturday morning and Sam leaves the house carrying the shotgun he’d bought a week ago and a fanny-pack full of cartridges. Let’s say you decide to write this scene from Sam’s point of view. He’s hearing voices that tell him he must kill or he will die. The voices are screaming at him. He shoots his next door neighbor who’s mowing the lawn. He walks further down the road and shoots a passing motorist. Now the voices are encouraging him to kill more, more. Perhaps the people he passes look like some sort of demon to Sam. His own thoughts are barely coherent. Eventually the police stop him and by some miracle Sam survives. Of course to Sam, he doesn’t die because he’d carried out what the voices demanded. Perhaps Sam even surrenders. Great!

You can have the neighbors saying Sam is insane. Particularly if Sam has a history of mental health problems. Maybe the neighbors get into an argument about whether or not Sam’s crazy or just an evil monster. People do this.

You follow up with the evaluations and hearings and trial. You get Sam put on meds and within a few days, the voices have backed off and Sam realizes what’s going on. So you have a shrink determine that he’s competent to stand trial. Now for the wrangle over whether or not Sam was insane at the time of the killing spree. The defense points to a prior diagnosis of paranoid schizophrenia (more about diagnoses in following posts!) and evidence that he’d stopped his medications a few weeks previously. The prosecutor points out that Sam had the foresight to buy a shotgun and cartridges and even a fanny-pack to hold all the cartridges.

Feel free to contact me if you have questions or comments. I’m happy to help.

Update (2/13/15)

The current trial of Eddie Ray Routh, accused in the murder of “American Sniper” Chris Kyle, highlights some of the issues related to legal insanity versus being mentally ill. Kyle apparently texted that Routh was “straight-up nuts.” But police have recounted Routh’s fleeing from the scene and leading them on a chase, which might indicate that Routh was aware what he did was wrong (part of the determination of insanity in Texas). I must say that the CNN commentators I’ve seen are doing a fair job of presenting these issues.

Feb 5 2015

Who’s who is mental health

Psychologist, psychiatrist, LCSW, LFT. Have you decided you need some sort of shrink in your story but have no idea what the differences are? You definitely are not alone! The long-running tv show “Law and Order” often gets it wrong, or at least confused. Here’s a quick, handy guide to help you differentiate the different professions dealing with mental illness.

Psychiatrist

These are medical doctors who have gone through a residency* in psychiatry. Like all medical doctors, they can prescribe medication. In fact, nowadays that’s what they do the most. They do very limited psychotherapy, but do monitor how the medications are working and any side effects. In my years in practice, I often sent a client to a psychiatrist for medications. For a client or patient to see both a psychiatrist and a psychologist is common. Psychiatrists are also the ones who most easily can hospitalize a patient. The issue is whether or not they have admitting privileges at a particular hospital.

Psychiatrists have an MD after their names and are referred to as “Doctor.”

Psychologist

Psychologists have either a Ph.D., PsyD, or EdD in psychology and, if licensed, have passed an examination for licensure. Psychologist perform both therapy and assessment. The use of psychological tests is exclusive to them. Such tests include such instruments as the MMPI (Minnesota Multiphasic Personality Inventory) or (less common nowadays) inkblots. All practitioners do some sort of assessment of a patient, but only psychologists are trained in the interpretation of psychological testing.

Psychologists typically cannot prescribe medications and only occasionally have gotten hospital privileges that allow them to directly admit patients to a hospital.

BTW: EdDs typically work in school settings and are often referred to as school psychologists.

Social Workers

Social workers typically have a master’s degree, though some do progress to a Ph.D. They work in a variety of settings including hospitals and Child Protective Services. They can also have a private practice or work in organizations like the VA. They can provide diagnosis and therapy, often with entire families or couples. They cannot prescribe medications or interpret psychological tests.

Here’s a resource that might be helpful: http://www2.nami.org/Content/ContentGroups/Helpline1/Mental_Health_Professionals_Who_They_Are_and_How_to_Find_One.htm

Feel free to post a comment or question. I’m happy to help.

* A residency is supervised work, usually in a hospital, during which a doctor gains hand-on experience in a particular specialty in medicine.

Feb 1 2015

She’s been in the Hospital How Long???

According to the CDC (Centers for Disease Control and Prevention), the average length of stay in a hospital for mental illness was 7.2 days. That was in 2010 in the US. (http://www.cdc.gov/nchs/fastats/mental-health.htm). I have no reason to expect that hospital stays are getting longer. In fact, they’re likely getting shorter. A 2006 study (http://www.hcup-us.ahrq.gov/reports/statbriefs/sb62.jsp) found that the average mental health stay in a hospital was 8.2 days.

The reduction in hospital stays took off during the Reagan administration. The idea was to shift care of the mentally ill to the community instead of long-term hospitals. Unfortunately things didn’t work out quite as expected, but nevertheless the trend continues. Managed care has a lot to do with the trend now since costs are cut. Check out this article if you’re interested in what has happened with mental health hospitalizations: http://content.healthaffairs.org/content/26/6/1548.full

(A mental health hospital in Michigan: http://www.mhweb.org/wayne/reuther.htm. Not quite the idyllic image so often seen in media.)

(A mental health hospital in Michigan: http://www.mhweb.org/wayne/reuther.htm. Not quite the idyllic image so often seen in media.)

So, what does that mean to you as a writer?

First off, it means that if you have a patient hospitalized for months or years, you’ve gotten it wrong. I love the show “Criminal Minds” but Reid’s mother being hospitalized for years and years just rings false. Much more realistic would be to have her bouncing in and out of a psych ward, living off disability and struggling to make ends meet. That could easily be done by having Reid help her out financially. This would give Reid a realistic source of stress.

BTW: there is a way to have your character be hospitalized long-term. Have him found to be “insane” and set by a court to a locked mental health hospital. The truth is, the only way to get hospitalized for years and years is to commit a crime and plead insanity and be found insane. That’s how John Hinkley, Jr, the man who attempted to assassinate President Reagan, has wound up in St. Elizabeths Hospital in Washington, D.C.

Next time we’ll look closer at voluntary and involuntary admissions to a psych unit or hospital.

Jan 31 2015

Hello fiction writers!

Have you ever watched media or read a book that got things wrong about your profession? I think most of us have had that experience. I know I have, way too many times and now I want to help change things. Thus this blog. What I want to do is help you, fiction writers, get it right when it comes to writing about psychology stuff. Things like:

  1. How long is a typical hospitalization?
  2. What’s the difference between a psychologist, a psychiatrist and a social worker?
  3. How do schizophrenics act?
  4. What is bipolar disorder?
  5. Are veterans with PTSD “ticking time bombs”?

I’m sure you can think of more questions and I encourage you to ask. If there is a topic you’d like me to address, just say so. Please, though, let’s not talk about your family or friends or yourself. This is not supposed to be a therapy session.

So, what makes me qualified to do this? Well, I’ve been a clinical psychologist for around 30 years. I’ve worked in a variety of settings and with various clients. I’ve worked mostly with adults, so my ability to comment about mental illness in kids might be limited. Also, as a psychologist, I am unable to prescribe medication so my knowledge of meds may also be limited. Of course, I’ve had to pay attention to the medications being used to help my clients so I can address some issues there.

In addition to my professional background, I’ve also been doing some fiction writing myself. I write mostly science fiction and had a short story published a number of years ago in an online magazine. Unfortunately it’s no longer available though I am thinking of reprinting it.