Sunday, March 11, 2007

Between A Rock And A Hard Place


I want to thank Michael (see his comments on my 'No You Don't' post) for sending along a link to a very interesting case. Even if you don't work in corrections people should really read this; it provides a revealing description of the hard place correctional facilities & personnel get stuck in when working with very difficult inmates.

The case is a complaint to the United Nation's human rights committee filed by an Aboriginal juvenile in an adult Australian prison. The 16 year old detainee was involved in a riot in a juvenile facility and took someone hostage. He was transferred to an adult correctional facility (following a conviction for armed robbery) where he was placed on segregation both for institutional security and for protection from adult inmates. While there he attempted suicide and threatened self-harm if not removed from segregation. While being placed on suicide precautions (which involves removing the inmate's clothes) he kicked an officer in the head. To make a long story short, he had repeated episodes both of self-harm and aggression toward officers. He was given at least two additional prison sentences for convictions related to assault on correctional staff. He was prescribed an antipsychotic medication (what's 'Largactil'?). In the complaint it's alleged that the inmate was prescribed the medication without an examination, and that when the examination took place it did not support any diagnosis requiring medication (or so I'm reading a rather obscure quote). The inmate admittedly took the medication voluntarily after a period of involuntary treatment.

I'm obviously not familiar with the legal procedures for transferring Australian juveniles to adult facilties, but regardless the meat of the claim appears to be that once in an adult facility the inmate had no effective legal means of challenging his punishment or alleged inappropriate treatment. He could follow an administrative appeals process but this apparently didn't provide for damages or any judicial power of intervention. (Correct me if I'm wrong, but that's how I read it.) The human rights court found that most of the interventions did not violate the inmates rights except as regards certain episodes of length of confinement (going more than 72 hours without out-of-cell time) and removal of his clothing. It specifically found that giving an antipsychotic medication did not violate the International Covenant on Civil and Political Rights (see point 9.5 under 'discussion of the merits'). It also doubted the utility of a tort claim due to lack of clear damages.

In free society American physicians adhere to certain protocols when giving orders for the use of seclusion. American prisons also have policies and procedures for this; failure to follow policy has been the ground for Department of Justice intervention.

24 comments:

NeoNurseChic said...

largactil = chlorpromazine

Interesting topic.... The phrase that keeps running through my head is, "kick me when I'm down..." People who run into trouble often end up having superiors running them in circles until they are in even more trouble. I think that sucks... It's like red tape - free society has their own way of doing this, but it's not quite as clear - but it happens.

I would think that chlorpromazine would count as a chemical restraint, no? If they say that prolonged confinement and stealing clothing are human rights violations, then what is the rationale behind involuntary treatment with a very potent antipsychotic?

Take care!
Carrie :)

michael said...

I know this case very well and have met Corey several times.

A few corrections and clarifications first.

First some definitions for non-Australian readers.

A 'safe cell' is a form of solitary confinement which is meant to be used when a prisoner would otherwise be in danger, but there are frequent allegations that they are used for punishment in NSW.

A 'dry cell' is what would be called an observation cell in the US and is meant to be used for prisoners at high risk of suicide. It is a perspex fronted cell with no hanging points or furnishings beyond a canvas covered mattress on the floor and a hard rubber toilet bowl and washbasin in an open fronted cubicle. A TV screen is usually placed outside the cell for 'stimulation' but is often inoperative. The prisoner has no human contact but is under 24 hour CCTV observation and often under 24 hour fluorescent light. There has been no research substantiating their therapeutic value in anything other than immediate suicide prevention and there is considerable anectdotal evidence that prisoners are at increased risk of suicide in the weeks following confinement in a dry cell.

Now some corrections.

Corey was not convicted for armed robbery until more than a year after he was transferred to Parklea adult prison. The application to transfer him followed a refusal by Kariong detention centre staff to return to work while he was there. It was essentially carried out as part of industrial negotiations with striking staff.

The court order for his transfer was found to be invalid at the time it was made, but was retrospectively 'legalised' via a hastily carried out Act of Parliament (which had to be later amended due to its many drafting errors).

Corey has never been charged or convicted for taking a hostage during the Kariong riot. The allegation relates to an incident at the time that was considered too trivial for even Kariong staff to complain about - but was later redesignated as a 'hostage situation' in the government submission to the UN committee. More on that in my next comment.

Corey denies he attempted suicide at Parklea and insists that his self-harm was purely an attempt to draw attention to his plight. That gets back to what I was saying in an earlier comment about prisons being run on threat.

Corey denies he kicked an officer in the head. The officers were not removing his clothes as a suicide precaution, they were responding to the fact that he had been using his clothes to obscure the 24 hour CCTV surveillance he was subjected to. The CCTV camera was switched off before the four officers entered his cell and only their matching reports corroborate the claim he kicked one of them. Corey was a small for his age, 16yo Aboriginal boy being 'restrained' by four large, trained, Corrective Services guards. Figure it yourself.

He was initially administered Largactil (chlorpromazine) without a prescription. A prescription was obtained the next day from a prison GP and later renewed by a prison psychiatrist.

In NSW prisons, registered nurses are allowed to get 'telephone scripts' for antipsychotic medications by describing symptoms to a prescribing authority who does not see the patient - however even this formality was not initially followed in Corey's case.

His 'consent' for continued administration of Largactil was only obtained after he was told that it was the only way he would ever be allowed out of the safe cell. Like I said, prisons are run on threats.

You are correct that the prison complaints procedure doesn't allow for judicial or administrative redress, but in addition to that the UN found that someone in Corey's position doesn't even have effective access to most of the inadequate procedures in place. Those that he did have access to, he tried. If they had any effect at all it was only to exacerbate his situation.

I'll post some more information on Corey's case soon, but those interested might like to read the executive summary of the Ombudsman's report [PDF] into the series of riots that landed him in Parklea.

Anonymous said...

You need a picture.

jcat said...

Ok. Disclaimer...possibly not being involved in correctional services environments means that I might not fully appreciate some of Michael's finer points.

But:

Corey has a mild mental disability
- was he receiving any treatment in the free world? Not sure about Australia, but in most of the world a mental disability would be taken into account, but doesn't automatically entitle one to physically abuse the rest of society at will.

So, Corey is a nice sweet little boy. That explains why at the age of 16 he was convicted of 'burglary, assault and causing bodily harm'. Good passive behavious that. From the dates given, his initial conviction was 23 days after he was detained for violation of his parole order. Why was he on parole? For other nice non-violent offences?
Although Michael says that the conviction for armed robbery only took place a year after his transfer to Parklea, he neglects to mention when the offence occured, whether this had anything to do with either the parole violation, other previous crimes, etc.

Even sweeter. A nice non-violent kiddy with a penchant for weapons as well as assault.

The staff at Kariong did react to the hostage taking. Fairly strongly. They refused to return to duty while Corey was there. I'd guess you have to be pretty obnoxious to reach that kind of negative reaction within 39 days of being at a facility (excluding court time etc).

Although in a perfect world a 16-year old boy should not be transferred to an adult prison, his behaviour up to that point seems to indicate that a juvenile facility would just not be able to cope with his level of violence and misbehaviour.

If I was said 16-year old boy, I'd be exceedingly grateful to be on segregation, rather than with a whole bunch of adult men regarding me as fresh meat.

Instead, within 9 days, Corey is smashing a plate after making suicide threats. Within the next two weeks there are upward of 5 episodes involving violent behaviour, repeated attempts to prevent monitoring, a suicide attempt....all in all, demonstrating really stable and compliant behaviour. Not the way to get transferred to either less restrictive custody in the adult prison, or back to a juvenile facility.

To quote from the manufacturers site (www.drugs.com has the same info, but less succinctly), Largactil is indicated for "the management of psychotic conditions. It controls excitement, agitation and other psychomotor disturbances in schizophrenic patients and reduces the manic phase of manic-depressive conditions. It is used to control hyperkinetic states and aggression and is sometimes given in other psychiatric conditions for the control of anxiety and tension." Drugs.com additionally specifies "severe behavioral and conduct disorders in children"

Either way it seems that Corey's behaviour indicates that Largactil was used in an appropriate way. And that involuntary administration is about the only way to treat someone who kicks officers in the head - how likely was he to just take the medication peacefully?

It doesn't appear that there was any lack of administrative appeal, rather that he made absolutely no attempt to demonstrate any willingness to comply with the basic standards of behaviour that would result in effective recourse to these.

And just to add the cherry on top, Corey expects that he should be PAID for his abysmal behaviour? If there is any question of damages being awarded, it should be to the prison officers who repeatedly had their human rights violated by an exceedingly nasty little thug.

I would be interested to hear from Michael what useful contributions Corey has made to society since his release? Has he continued to receive treatment for his mild mental disability?

As I said at the start, perhaps my view of Corey is prejudiced by not being involved in correctional services.
And perhaps as well by being part of the generally law-abiding society that he had victimised before his incarceration...

michael said...

With due respect, jcat, if you believe Corey kicked the guard in the head I have a big steel bridge across Sydney Harbour I can sell you cheap.

Other than that, you make some valid points.

Yep, Corey is far from an angel. He has been institutionalised for much of his life, allegedly has psychological and developmental problems (but not so gross that they're noticeable in the brief meetings I've had with him) and resorts to violence and verbal abuse far too quickly. He has been incarcerated for another violent offence relatively recently.

If you think the appropriate way to respond to that sort of behaviour in adolescents is to subject them to the sort of physical, chemical and psychological abuse Corey copped, I suggest you stick to dealing with wildlife. Its taught him something at least - how to trump violence from others with violence of his own.

Corey is also very charismatic and in spite of his small size, relative youth and alleged intellectual disability he was seen by his peers at Kariong as a natural leader - probably because he doesn't take sh** from no-one and was able to stand up to the barrage of abuse the Aboriginal prisoners in particular were subjected to (Did you read the Ombudsman's report? If so, are you still a fan of the Kariong guards?). The main reason the guards demanded his transfer was because they saw him - with some justification - as a 'ringleader'.

The series of riots that landed Corey in Parklea had been brewing for a very long time, but the trigger came after guards had allowed all the detainees except those in Corey's mostly Aboriginal Keiran North wing to use the swimming pool. One of the guards who made the decision is the one the Kariong manager had failed to discipline for repeated racial abuse of Aboriginal inmates.

Corey's response was to refuse to go back into the wings until his group were permitted a swim. Although the escalating confrontation certainly involved a lot of verbal abuse, Corey did not initiate violence. What happened instead was that he was jumped by five large guards, shield-bashed into a stupor and dragged off, limp and bleeding, into the segregation cell. All of this happened in view of the other Keiran prisoners, who responded initially by shouting demands that he receive medical attention and - when this had been ignored - began throwing things from the windows, smashing up the wings and - finally - setting fire to their mattresses. Thus started the first Kariong riot.

The 'hostage taking' happened during a subsequent riot less than two weeks later. A group of Keiran inmates - including Corey - who were still billeted in the burned out ruins of their wing, closed the door on a guard (actually a prison social worker I think) and said he (she?) would not be released until s/he agreed to take a list of demands to centre management. The list was in the process of being compiled when another guard showed up to demand the release of the first and was confronted outside the wing by a prisoner wielding a home made knife. Its not clear whether those inside knew what was happening. The guard and the prisoner had a tense standoff for a while, but in the end both went to those in the wing and the other guard was released unharmed. The whole incident took less than an hour and only the knife-wielder was ever charged.

You are correct in suggesting that upon being transferred to Parklea, Corey was in real danger from adult prisoners. Just in case he didn't realise that, Parklea guards taunted him about it several times while he was there - including on his seventeenth birthday, which he spent naked and bombed out on Largactil on his cell floor.

Parklea at the time had a reputation for being 'rape central' of the NSW prison system - a reputation substantiated by the study done by magistrate David Heilpern, "Fear or Favour". Heilpern also found that guards often facilitated such rapes by allowing rapists access to victims' cells at night.

The concern that NSW authorities show for this abuse is best illustrated by the 1993 statement of then Minister for Corrective Services, Michael Yabsley, that "Rape in prison is inevitable" and "It serves as a useful deterrent".

Also in 1993 the NSW Independent Commission Against Corruption (ICAC) found that a senior prison officer had been involved in a corrupt relationship with a Parklea informant who was a prison standover man, drug dealer and rapist. The prison officer managed to overturn the findings on procedural grounds. By the time Corey arrived, that officer was in charge of the 'Young Offenders Program' at Parklea. He is now the NSW Commissioner of Corrective Services.

You ask what Corey has contributed to society since he was released.

Well, for starters, he brought some of the routine abuse of prisoners in NSW to the attention of the United Nations. Whether that will change anything is another question of course.

But, as you infer, he has also been involved in criminal offending. So maybe he should be locked up, abused, bashed and chemically restrained again, eh jcat? That'll learn him.

After all, I'm a law-abiding representative of the society that stole this country from Corey's ancestors, stole the children from his more recent forbears, stole the wages from those of them forced to work to help build our fine society and continues to imprison them disproportionately to their numbers or level of offending. So I deserve protection from 'exceedingly nasty little thugs' like Corey, do I not?

After all, isn't he just another one of those uppity black crims like that Mandela bloke you have over there in SA?

ClinkShrink said...

Thanks for the picture Dinah. I tried to install a Gimp module to fix a picture up for myself late last night and ended up hosing three days worth of web development work by accident. I felt sick.

This case is a good illustration of what happens when you have to intervene with a disruptive inmate. On the one hand you have to protect the inmate from himself and/or others from him, and on the other hand you risk outside agencies accusing you of being abusive. Even though seclusion and emergency medications are standard interventions in free society, in corrections they are sometimes looked at with suspicion by courts and advocacy groups. This can make it difficult to treat acutely ill psychotic folks because correctional officers are reluctant to provide backup to healthcare staff when giving emergency medicine, for fear they'll be accused of excessive force (even though all they really have to do is stand behind you and look big).

michael said...

Yeah, clinkshrink, but even outside the razorwire there are certain rules and regulations governing the coercive administration of dangerous medications - emergency or not.

Don't you think that in prison, where the power relationship between patient and therapist is even more distorted, it might just be appropriate to stick to the regulations - inadequate though they may be?

I guess to some legal people it was Soviet psychiatry or the Nazi T4 project and subsequent doctors trials that made them kinda sensitive to how psychiatric treatment was imposed upon the legally disempowered. But here in NSW the recent reminder was the Chelmsford Hospital scandal - in which both voluntary and court mandated treatment was inflicted upon such criminal recidivists as homosexuals and cross-dressers (both illegal in NSW until 1984 as well as being DSM designated mental illnesses until the mid 1970s).

Not really sure how a slightly framed 16yo, already stripped, confined to a safe cell and segregated from general population constitutes such an extreme emergency that its considered appropriate to dose him up with a 1950s style phenothiozine without gaining a medical assessment. But maybe you have to be a corrections psychiatrist to understand such matters.

I guess one tip for reducing the incidence of outside agencies calling you abusive is to try to avoid being abusive.

Roy said...

Interesting exchange. Glad to have Michael's account and viewpoint. This all reinforces my frequent refrain of 'Why would I want to be a prison psychiatrist?'

Yes, these folks need help, and it sounds like Corey got a raw deal, but I wouldn't like the idea of working in a place where I couldn't be sure I could trust the guards, let alone the inmates.

jcat said...

Haha Michael, with reference to the bridge, you've obviously never seen a 5'3" 40 kg girl resisting psychiatric staff. They are obliged to use minimum force - the patient/prisoner is under no such compunction - and a kick in the head is mild compared to some of the damage inflicted on passive staff!

First off though, your knowledge of SA history is pretty lacking (albeit mine of Australia is not that much better). Mandela was first and foremost a pacifist. He was also a qualified lawyer, a renowned mediator, and a leader who supported violent protest only in such ways that people were never harmed. I don't see anything much in common with Corey.

I agree, some of what was done to Corey sucks. But it doesn't appear to have been his prison experiences that taught him about using violence and threats as an effective social tool. He seems to have been well versed in those by the time of his initial confinement in Feb '99. You don't mention - what was he on parole for? And his burglary and assault charges....those were non-violent, non-threatening ways of behaving? Oh, and that small armed robbery...was before during or after his initial confinement at Kariong?

Kariong does indeed sound like a pretty horrible place to be. The staff seem to have been under-trained, under-motivated, intimidated by both inmates and each other. It was also supposed to be the destination of the difficult, dangerous and otherwise unmanagable juveniles. These kids are not angels before they get there, never mind what new tricks they learn from either inmates or staff.

It's kind of dammed whatever you do position that the authorities are in. Rightly or wrongly, society has elected that restriction of freedom is the punishment for anti-social behaviour. The captors theoretically are regulated by law as to their treatment of inmates(given though, that these laws are not always obeyed). The inmates have no such compulsion, other than the possible resultant removal of further personal freedoms. But if those freedoms are removed as a result of their actions, they are then at liberty to resort to more violence and destructive behaviour, and label it as justified because of their restrictions.

Psych meds are a real two-edged sword though. OK - I admit that I am biased. I'm Bipolar II, and when the meds work, they are truly life-altering. I've been on most of the anti-psychotics, both atypical and the older Largactil types - for brief periods, at times when I could be called a danger to myself. Threatening self-harm and suicide generally fall into those categories.

You don't mention whether Corey had been receiving treatment for his acknowledged mental disability before his imprisonment. Or whether he has received such treatment since.

If Corey had NOT been physically isolated, and then involuntarily medicated, and had carried through on his threats to kill himself, what would the human rights position have been then? I'd guess that in most cases, the prison authorities would have been in more crap than they already are, for failing to prevent that, and probably, for failing to medicate him with meds that are proven to be effective. Damned if they do, damned if they don't.

I take your point on drawing attention to routine prison abuse, but questioin again your assertion that Corey learned the value of violence and threats in prison. he seems to have had a pretty good understanding of those well before then.

As to your racist assertions - my country has a shit record. Yours does too. That doesn't make every black a criminal or a victim - and doesn't make every white an oppressor or a victim. Let's leave it at that, rather.

But yeah...I will be sticking to wildlife rehabilitation. At least there we have a proven record of successful rehab, of release, of an ability to give adequate care in the interim. And when our meerkats (and others) bite, we're allowed to tell them that they are nasty little beasts...!

michael said...

Well, jcat, regarding the bridge for sale. I guess I must just be prejudiced against Parklea prison officers. After all, they're so famous for their non-violence and honesty that I really have no reasonable grounds to doubt their word, regardless of the fact that they switched off the CCTV before entering the cell and that none of them sought medical treatment or confirmation of their injuries.

I'm pretty familiar with Mandela's non-violent principles - though he continued to be a member of an organisation that refused to renounce violence. But you're right that I know little of SA history - otherwise I would have chosen as an example a formerly violent 'criminal' apartheid resister who is now a 'respectable' member of the SA establishment. Perhaps you can help me out with a name, because I'd guess there's more than one of them.

The point of the example was to highlight the fact that whether you are designated a criminal (or 'psychotic' for that matter) has a lot less to do with what you have done than who you are (and what colour you are). Do you want to take a guess as to how many of the violent racist prison officers who bashed Corey have ever been charged? I'll give you a hint. Its a very round number.

Corey was institutionalised well before his first brush with the law. I've never asked whether he suffered violence as a result, but the correlation between institutionalisation and violence is well documented. Is that an excuse? Nope, no more than a long history of being stolen from excuses Aborigines who steal. But before you presume to judge 'exceedingly nasty little thugs', try walking a mile in their shoes.

Corey has been receiving assistance for his alleged intellectual disability since leaving Parklea, but I don't know whether he received such assistance before. He also completed an anger management course during his last period of incarceration, but as there is no evidence base whatsoever for these courses I wouldn't necessarily call that 'help'.

Your question about what the human rights position would have been if he had committed suicide is a furphy as there is no evidence that Largactil reduces suicide risk (regardless of your personal experiences of it - which may be perfectly valid for you. Simply saying "we can't just sit by and do nothing, so we should just do anything we can" is what's called a non sequitur - albeit one employed far too often by mental health professionals.

If you are asking about the legal position of prison officers who stand by and ignore someone who kills themself. Well, sometimes they get reprimanded, but mostly they just give a few glib non-answers at a coroner's inquest and that's the end of it. Let me know if you want me to email you any of the coronial transcripts I have if you want a more complete answer.

I can't know how much of Corey's violent behaviour was learned in the prison system but I know several people who have been through the NSW prison system who agree that you either learn to employ violence or become a repeat victim of it. A friend of mine has recently published a book on just that topic. If you can't get a copy, you can get the gist of his thesis from his Online Opinion articles.

Meerkats!
Well I envy you something jcat.

ClinkShrink said...

Regarding: "But maybe you have to be a corrections psychiatrist to understand such matters."

Yes, apparently so. Until you are charged with caring for the uncaring you will not understand such matters.

jcat: regarding "Damned if they do, damned if they don't." Ironically, that was my original title for this post.

Roy: I do trust the officers. I just think it's sad that it's gotten to the point that they're afraid to even touch somebody when it's for the inmate's own protection. We have the extreme inverse of the situation Michael's describing.

jcat said...

Michael...provide a postal address and expect a meerkat delivery about next January! We get roughly 30 ex-pets a year, and then they produce a few more themselves, while we are building them into sustainable tribes. Having just released 3 groups in Feb, the two new arrivals are still manageable. But by Jan, when they have bitten just about everyone around (except my boss...she's never ever been nibbled), we'd quite happily export them!

One of the things I love best about access and time to explore on the net is the huge amount of knowledge and opinion that is available. Debates such as this one are fascinating, in that they give exposure to ideas and people that you'd be very unlikely to get in person.

I have a theory that net self education is the current equivalent of what used to be called a 'classics' degree - a bit of everything, in order to produce a well-rounded individual ?

michael said...

"Until you are charged with caring for the uncaring you will not understand such matters".

I must be particularly slow witted then, because caring for those who don't feel they need care (or necessarily desire it) does happen to be something I have some experience of. Its partly what has made me so sensitive to the gratuitous abuse of the rights of those designated 'mentally ill'.

But for the life of me I still can't see why I would have the moral right to force dangerous psychiatric medication upon a restrained person simply because they have made a threat to kill themselves.

michael said...

Ah, jcat, that offer hurts, because I know what would happen to those little kats when they hit Australian customs and quarantine.

And now I want one.

michael said...

Just got an email from a probation officer that touched on some issues I've raised on this blog - so I thought I'd share an extract.

Nothing to do with Corey's case and as the prisoner involved doesn't (yet) have his name in the public domain, I've chopped it to 'G__'.

"What’s significant about G__, is that just about every government department has had their hand up his back for years, but he was still fighting. Usually we just tell them what to do and they dither about and eventually do it, or don’t. Then we get out the carrot and the stick. The stick is to punish them with, and the carrot is to get them close enough to hit them with the stick.

I wonder why it is that we take a punitive approach or a therapeutic approach with offenders. We seem to be willing to try anything, provided we get to do it for them or to them. I suppose if we don’t have a practice framework within which we can engage them in meaningful ways, that’s all we’re left with.
"

jcat said...

Michael - put some pics of the monsters up for you.

ClinkShrink said...

Barring some new invention in the field of psychiatry, chemical and physical restraints and the use of seclusion are the tools we have to work with when it comes to agitated or aggressive folks who don't respond to verbal interventions. Those are the only tools we have.

I'll guess we'll have to agree to disagree on whether or not I'm a sadistic Nazi.

Those meerkats are looking pretty tempting.

NeoNurseChic said...

This is my favorite rock and a hard place picture: Between a Rock and a Hard Place - I actually used it on a post of mine once, but the post is now taken down along with the rest i took down awhile back!

Take care,
Carrie :)

michael said...

Jcat, I can't post to your blog and don't have an email address for you, so I'm putting this here. Hope the shrink rappers don't mind.

Thanks heaps for the kat pictures. I was impressed enough, but my flatmate completely gushed out when she saw them. The stories make them even better (no prizes for guessing that I identify with the splinted escapee).

Have you got any posts explaining what constitutes a 'viable' tribe and what has to be done to teach formerly isolated pet meerkats to socialise?
Can sanctuary raised tribes be successfully returned to the wild?
What about other tribal territories?

Sorry to hear about the hole you're in.

There's nothing I can say from Aus that won't be banal, so I'll just grit my teeth and do that (i.e. remind you that it passes, that there will be days so sweet you'll have trouble imagining how you could ever have contemplated doing yourself in - and try to avoid mentioning the fact that as well as the good days, there'll also be more bad days).

Although formal DSM diagnoses don't mean much to me, I'd be a shoo in for bipolar myself if I was label shopping. But for the last four years I've been letting my doc call it 'major depression' instead. Either way, the friends who've stuck by me would probably vote me 'guy most likely to be found dangling'.

I'm not interested in the meds. The less toxic ones like SSRIs aren't likely to work in my view (and can increase the risk of suicide during manic phases) and having a fridge full of nasties would be just too tempting during those particularly dark times around 3am. Of course I'm not suggesting you flush yours though - and, as always, if you do decide to ditch them set up as much personal and professional support you can muster and get ready for a rocky ride.

Mostly I count on the fact that when I'm up I want to live and when I'm down I'm too f***ed to sort out dying. For me, making particularly elaborate suicide plans that can't be carried out without a fair bit of effort and organisation seems to have worked so far - but I'm not sure if its responsible to recommend that sort of thing to others.

My criminal justice activism has helped too. Nothing like a confrontation with authority to flip you into an up cycle (I once had a 2 hour screaming match with a police minister who is also bipolar. We both had a great time - too bad about the other people in the room).

Working with prisoners and ex-prisoners (many of whom also have headspace problems) is also pretty helpful as it gives my depression a bit of meaning.

At least when they tell you about ripping up their bedsheets and looking for somewhere to tie-off you can get a bit of a sense of where they're coming from. And when you've heard some of their life stories it helps to keep your own problems in perspective a bit.

Apart from that, its all the same-old, same-old. Exercise, sunshine, a lot of care about my diet (well, my flatmate takes most of the care about that actually - if it was up to me I'd just eat whatever's easiest or nothing at all), vipassana meditation (which I was fortunate enough to have spent a lot of time practicing in the 80s & 90s, because now I really need it) and trying to make the effort to organise things I know I enjoy doing even if it all seems completely pointless at the time.

Does it work?
Don't know - watch this space.

The last few months of 2006 were my worst yet and I'm pretty worried about the next big downswing.

But if I get through it I'll probably start trying to organise an Icarus Project style self-help group with a view to spinning off a consumer activism group and start making some real trouble for some of the smug, power-driven shrinks and health bureaucrats around here.

Hang in there for a while longer jcat. The abyss is always there. Let it wait for a bit. The kats need friends.

michael said...

Clinkshrink, I don't think you are a sadistic Nazi (don't know enough about you to make that call), though I do think you would be well advised to think about whether you would hang the same diagnostic labels and treatment proposals off those in authority who use threats and violence as you do to the disempowered.

But mainly, it seems to me that you are another overtrained and overwhelmed professional running in circles with the same old failed tools imagining that your paycheck and job description forces you to intervene even when you know its unlikely to be constructive and may even add to the load of abuse your patients are carrying (see my note on psychiatric non sequiturs above).

I know the what evidence base for psychoanalysis is (i.e. zip) but an Australian Freudian analyst I know says that his big conceptual breakthrough came after working with central desert Aborigines for a while. He realised that the best thing he can sometimes do is to protect his patients from rushed, ill-informed, unsympathetic intervention. Sometimes the best therapy is no therapy at all, especially when you're dealing with people who have better outcomes when left to manage for themselves.

If you've got access to the online journals, I hope you'll take a look at that Douglas Bell article I mentioned earlier. He too has a lot of experience in (ahem) 'caring for the uncaring' and it seems to me that he has thought his position through carefully. He doesn't really offer any solutions that could be implemented as 'best practice guidelines', but he does suggest the sort of approach individual clinicians might take to avoid being sucked under the moral morass that is prison psychiatry.

In this article, Melbourne academic Mark Brown documents where the ethically unexamined practice of mental healthcare in prison too often leads.

ClinkShrink said...

Well, it's nice of you to consider the possibility that I might not be a Nazi :)

If I actually were the person you describe in your comment I would have called it quits from the prison long ago. The fact of the matter is that I love what I'm doing and I really enjoy taking care of inmates. My blogmates think I'm crazy, but what can I say? Surely as an advocate you know what it means to enjoy helping people. And yes, I do help them. If I weren't helping them they wouldn't come in the door asking to see me. I wouldn't have inmates who run across the rec yard to say hi and to update me on how they're doing.

Here in America there is a small but growing cadre of psychiatrists who are actually interested in providing correctional care. Each forensic psychiatry fellowship program is required to provide correctional experience to their trainees, and this is exposing professionals to an area of medicine they might not have considered before. Some of my former trainees are going into correctional work and they are invested in it.

It sounds like you've had negative experiences with psychiatric care, but I'm hoping this will not cause you to discourage inmates from seeking care when they truly need it.

And Carrie---great pic.

ClinkShrink said...

On a totally unrelated note, you mentioned something interesting in your previous comment:

"Nothing like a confrontation with authority to flip you into an up cycle (I once had a 2 hour screaming match with a police minister who is also bipolar. We both had a great time "

If you read Rach's comment on Dinah's latest post ("Why I Still Prescribe Seroquel"), she says this:

"I know that if I'm able to fight with my pdoc about taking the meds, I know I'm not *that* ill."

It reminds me of some discussions we had here a while back about the effects of exercise on mood---that maybe having confrontations and being able to yell a bit is another form of therapeutic exertion. I've had inmates tell me that sometimes they 'look forward to a good fight', which I usually have interpreted as a sign of boredom, but maybe is more of a defense against depression. I just thought it was interesting that two readers said something very similar on different posts.

michael said...

"I'm hoping this will not cause you to discourage inmates from seeking care when they truly need it".

Mostly I'm into validating the views prisoners (and others) have of their treatment regime.

If they think their therapy is doing them good, I'll go into bat for them if its being denied to them (remember, I started posting to this blog in objection to your criteria for denying some prisoners treatment, not for inflicting it).

Although my science background makes me a big fan of evidence based medicine (hence, very skeptical of most mental health therapies) I'll support someone's right to take pills, do yoga or sleep under a crystal pyramid during the full moon if they think it helps (lets face it, that ole black magic placebo effect leaves most allopathic remedies eating dust).

But if they see their therapy as abuse, then most probably it is (the nocebo effect is also a force to be reckoned with). So I'll go into bat for their right to refuse treatment just as readily as I'll fight for their right to receive it.

I wish I had a simple, universal rule like "If its coerced, its not therapy, its abuse", but unfortunately real people in real life situations tend to slip out from under simple truisms.

But I guess I could generally describe myself as a criticalist. Not so much in the David Healy mould, but someone who thinks that the best chance of achieving constructive and humane treatment - be it in psychiatry, criminal justice, workplace relations or politics - is to try to put everyone as closely as possible onto the same power footing. That usually involves supporting the patient against the doctor, the doctor against bureaucracies and professional bodies and everyone against multinational drug companies.

So you can see why prison psychiatry concerns me so much. Big power imbalances there - even if the doctor doesn't have a bunch of guards standing behind her 'looking big'.

Regarding depression vs aggression.

Yeah, I don't think I'd be the first person to note that they seem to be flipsides of the same coin. If I'm away from mainstream thinking on that it would be because I think aggression is more likely to be suppressed depression than visa versa - but its probably a chicken and egg question really.

To step into the biochemical paradigm for a minute (along with a big dash of evolutionary psychology) I was struck by the results of the Dunedin longitudinal study that seems to indicate that violence in adulthood is linked to both childhood abuse and a mutation on the MAOA gene (yep, you guessed it - one of the two genes involved in the synthesis of monoamine oxidase). MAOA is on the X chromosome, making men far more vulnerable to a single defective copy than women.

So, in any population, there will likely be some men (far fewer women) who are genetically predisposed to respond to abuse by becoming primarily aggressive - while the majority are more likely to respond to abuse by mostly becoming depressed.

The mutations isn't good if the idea is a harmonious, stable, 'civilised' society (though the effect won't be triggered unless there's a bit of child abuse around) - but maybe a good thing if you are part of an oppressed people who aren't going to throw off their chains without a bit of ultraviolent leverage. And as men are essentially genetically expendable, its not a show stopper to have a handful every generation beating themselves to death against implacable authority while the rest of us 'enjoy' the luxury of internalising our violent oppression as depression (violence is usually a worse game plan for women too - all else being equal).

On the other hand, you don't want too many people responding to abuse by attacking people - so having a suicidal self-destruct switch (or at least a psychological self-paralysis switch) in the form of excessive MAO production in response to abuse might be a good way to protect a community from descending into a permanent state of violence. And that's what most of us seem to have.

And no, unless you count confrontations at conferences, tribunals and public forums, I can't say I've had negative experiences with psychiatrists.

A lot of people I know have though, including one friend who had psychiatrists lining up to write reports that he was too dangerous to ever be released. The legislation to keep him in prison was struck down by the high court and he has now spent over ten years as a free citizen, advocating for prisoners rights, mentoring recently released prisoners and helping ex-prisoners to reintegrate into their communities. I doubt that many of the shrinks who wanted to keep him locked up can claim to have made so many constructive contributions to society.

michael said...

Here's another article for those with online journal access who are looking for a path between the ethical 'rock and hard place' of whether to deny treatment to prisoners threatening suicide who want it, or OTOH, force treatment upon those threatening suicide who don't want it.

In "Forensic Practice: Pride and Prejudice", California clink shrink, Jay Adams, looks at the widespread labelling bias in forensic psychiatry and its injurious consequences for patients as well as the way the perception of 'moral defects' - as promoted in Samenow and Yochelson's 'criminal personality' theory - has hindered the effectiveness of forensic psychiatrists and psychologists.

According to Adams:
(1) The PCL-R over-identifies adult survivors of childhood abuse as psychopaths, and as a result, deprives many of them of effective treatment
(2) Most forensic psychiatrists and psychologists do not understand the causes of impulsive behavior and consequently have no way to effectively treat it
(3) Self-injurious behavior is vastly under-diagnosed in forensic settings, and when it is recognized, it is almost always misunderstood as either suicidal or manipulative, and not treated properly, and
(4) Malingering is over-diagnosed in forensic settings because staff are not trained to recognize and treat the long-term effects of early trauma.