He grew up on the streets, sold drugs, was involved in gang violence, sneaked drugs into prison for his father, became an addict himself, and aspired one day to go to prison. But his own path to healing from this violent upbringing began the night that he and his gang were beating up a homeless man.
The victim looked into his eyes and told him, “Please help me…You’ve got more compassion in your eyes than any woman I’ve ever met.” His life was rocky for several years after that event, but it was never the same.
His name is Vinny Ferraro. He has devoted his life to working with the Mind Body Awareness Project (MBA) in California. He teaches mindfulness and emotional-intelligence exercises to at-risk youth so that they can make better life decision and learn alternatives to violence, drugs, and other self-destructive ways of living.
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It’s probably happened to all health care professionals at some point: Patients, especially those considered “difficult” for some reason, fail to improve despite our best efforts. Eventually we become frustrated enough that we then blame them for their lack of progress.
There are endless possible scenarios where this might occur:
- A depressed patient, who transiently appears to have a personality disorder because of her inadequately treated depression, is not progressing in psychotherapy and has not responded to two different medication trials.
- An elderly man bounces back for readmission to the hospital for a CHF exacerbation. He arrives in the ER with a pack of cigarettes in his shirt pocket.
- A morbidly obese woman continues to have poor control of serum glucose, blood pressure, and lipids despite aggressive pharmacotherapy. Yet the patient has lost no weight despite being counseled for years about the need to do so.
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Antisocial personality disorder (ASPD) and psychopathy have similarities, and there is overlap between the two diagnoses, but the diagnosis of each of the two conditions is made differently.
Before I describe these two conditions, I want to clarify the terminology further.
In psychiatric language, ASPD, or describing a patient as “antisocial,” has nothing to do with whether one socializes with other people. Of course in everyday language, the term antisocial is often used to mean just that. In psychiatry it means to go against the rules and norms of society.
Likewise, the term psychopathy is not related to the term psychosis. Psychosis refers to a break from reality. The vast majority of psychopaths are fully aware of their actions.
Antisocial personality disorder is a diagnosis described in the DSM-IV TR, the current diagnostic manual for psychiatric diagnoses. It is a diagnosis mostly reflective of a person’s behavior.
Patients diagnosed with it may exhibit any of the following: repeated acts that violate social norms (i.e., illegal activity), deceitfulness, impulsivity, aggression/irritability, repeated disregard for the safety of self or others, irresponsibility, and lack of remorse. For the sake of brevity, I am not including the full DSM description. Click here to view the full DSM-IV TR criteria.
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The below YouTube video is a decent overview of how, since the deinstitutionalization movement of the 70′s, the prisons and jails in the U.S. have been housing a large percentage of people who previously would have been in mental insitutions. It explains some of the challenges of providing mental health treatment behind bars. What it does not address, though, is the significant problem many mentally ill inmates face continuing their psychiatric treatment in the community after they are released.
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As correctional health care professionals, there may be times when we are tempted to conduct ourselves in a less than professional manner simply because we can.
We may be able to get away with speaking to our patients rudely, using profanity profusely, or wearing inappropriate clothing. After all, we work in jails and prisons. This culture is far from prim and proper. And, our patients are inmates. Many may tolerate misbehavior from us that patients on the outside would not and should not tolerate.
I’ve previously written about how I’ve found the book, Games Criminals Play, to be an invaluable resource. One key point that I learned is that many inmates, especially those trying to set up and manipulate staff, want to know whether each prison worker is a fellow inmate or “the police.” In other words, do we side with the inmates, or are we professional workers who take our jobs seriously?
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I know an elderly psychiatrist who used to do some small-time farming. I was always impressed with how many things he could buy without his wife objecting. Many of the items he purchased could have been considered, depending on one’s viewpoint, “tools” or “toys” (power tools, trucks, old tractors, etc.). There seemed to be two reasons he was able to do so. First, he had a great strategy. Anytime he bought something for himself, he either bought the same thing for his wife or bought her something equivalent. If he bought a Grand Cherokee, she got one, too. It must have been expensive, but it probably helped him to avoid years of marital discord and ultimately Dr. Phil telling him to “get real.” The second reason he got away with buying so much stuff was, as he told me, because “the tool always creates the job.” He loved all of these toys, and he had a special knack for always proving how useful each of them was because he inevitably would find the “need” that the tool would fulfill.
Is the social media craze similar to my psychiatrist friend’s farm tools?
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How many times do we condemn or agree before hearing the other side of a story? How many times do we stand accused of not listening carefully? How many times do we misinterpret or misunderstand a gesture, a word, an intention? Why do we assume that we know so much about other people’s lives even though we clearly do not? And, even if we did, why do we think we know what’s best when it comes to how others should live their lives?
Through our cumulative experiences in life, the figurative spectacles through which we see the world become tainted. We, unlike small children, lose the ability to see all things as they are. Instead, we see things through our tainted lenses and think we know best.
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Fortunately most patients are honest. They mean what they say, and they realize that ultimately it is in their own best interests to be truthful about their health issues. However, it is a stark reality that many patients lie to health care professionals.
According to a WebMD survey about patients lying to doctors, out of nearly 1,500 respondents, 45% admitted they had either lied (13%) or “stretched the truth” (32%).
It is likely that an even larger percentage of jail and prison inmates lie to health care providers.
Patients are untruthful for different reasons.
People everywhere typically want
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Assume for a minute that you do not have an underlying psychiatric or neurologic condition. You’re healthy. If you could take a pill that would significantly improve your memory, help you to concentrate through great distractions, keep you full of energy even though you’ve slept little, help you to be more social, or keep you from worrying much, would you take it?
That’s really the issue at stake with the concept of cosmetic psychiatry. Is it okay for psychiatry to evolve beyond simply treating disease and relieving suffering to the point where the goal is also enhancement of “normal” functioning?
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I used to have a more “normal” job.
Early in my career I worked in a large medical center and hospital and rotated through a call schedule. I got called into the ER regularly. I covered the inpatient unit and performed consultations on the medical and surgical units. I did all of the typical work tasks associated with a traditional practice.
Then I left it all.
I started working half-time in correctional psychiatry. I have worked in various other less traditional settings to fill the other half of my schedule over the years, but most of it has been spent working with people with developmental disabilities.
My work life is
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