Transcript
Speaker: You're listening to The Wound Dresser, a podcast that uncovers the human side of healthcare. I'm your host, John Neary.
Speaker: Today, my guest is Dr. Dominic Sisti. Dr. Sisti is an associate professor in the Department of Medical Ethics and Health Policy at the University of Pennsylvania. He currently directs the ScatterGood program for the applied ethics of behavioral health care, where he researches psychedelics, long-term psychiatric care, and medical aid in dying for mental health patients, among other topics.
Speaker: Dr. Dominic Sisti, welcome to The Wound Dresser. Thanks for having me. So your work focuses on bioethics in the behavioral health space. What are some of the most widely discussed bioethical questions related to mental health?
Speaker: Great question. There's been, i think, a ah renewed interest in questions related to involuntary treatment for people with serious mental illness, particularly those who are living on the streets who are unhoused or have unstable housing.
Speaker: um A few, well, it's been now a year or so ago, ah the president issued an executive order around homelessness and what he called disorder and homelessness, um essentially making it easier to involuntarily commit individuals who are unhoused um and potentially have mental illnesses. Maybe they're serious and maybe they should be involuntarily committed, but many people um you know, have been arguing about the possibility that this executive order will be um will be abused in certain ways, will be used to justify the involuntary treatment of people who don't necessarily need to be involuntarily committed um or for whom involuntary commitment would be actually quite harmful.
Speaker: um So, so that's been a topic of, of debate. I mean, this is a, an issue that's been debated for, you know, decades now, but it, you know, it reached, I think, a new kind of level of public awareness and scholarly, you know, interest after the executive order came out.
Speaker: um So there's there's that set of issues around um around like involuntary treatment, psychiatric commitment or hospitalization. How do we determine when somebody is too dangerous to be out in public? What what kinds of tools do we have to predict dangerousness or violence? um you know those issues still loom large we don't have a great way of predicting these things still um so uh you know the question around essentially taking away somebody's civil liberties is is a really important question to get right so um so those are some of the areas i'm also i've also been working recently around issues related to psychedelics and mental health care
Speaker: in trying to you know think about how these new medicines will be used, how we can ensure um patient safety, um as well as increase access to the medicines once or if they're approved.
Speaker: And then just some really interesting sort of philosophical questions about what these medicines do for people. ah And, you know, our um I'll be teaching about this actually tonight, our responsibilities to the folks that, to the populations, the people, the cultures that gave us these incredible um potential medicines in psychedelics and and what we owe indigenous persons and um and And groups that have you know shared with us their knowledge that you know we've we've now medicalized essentially to turn into psychotropic drugs for people who have things like depression or PTSD.
Speaker: So those are a couple of ah you know things that I'm working on and thinking about. um But just generally speaking, I'm interested in how to increase access to mental health care for people who are struggling with mental illnesses and um and creating ethics arguments in favor of of you know increasing access and making mental health care more equitable and accessible.
Speaker: I want to ask about um your work with psychiatric nosology. One of the first things you you hear when you get on a psychiatry rotation as a medical student is kind of the ongoing debates or issues or ah questions that come up with like DSM-5. So what are what are some of the ethical issues ah that arrive in classifying psychiatric disease and nosology in general?
Speaker: Oh gosh, it's such a great question and there's so much to say. So just for your audience sake, psychiatric nosology is just a fancy word for taxonomy of diseases. So, um, you know, in psychiatry, the nosology is founded DSM and oncology, there's a list of cancer somewhere. That's the g nosology for oncology.
Speaker: Um, you know, it's so interesting when you think about DSM and we're getting into DSM six now, I don't know if you knew that, but, uh, Dr. Maria Okendo here at Penn is the chair of the DSM-6 task force. So that's coming.
Speaker: That'll be starting up soon, I think, and there'll be, you know, meetings and research and all kinds of things happening towards DSM-6. I think ethically, you know, really interesting questions around the nosology itself, which is to say it's it's it's different than other, I think, medical nosologies in that psychiatry struggles with objectivity, right? and You hear this a lot where it's you know not as scientific as other areas of medicine because in particular, I think the fact that there are really no biomarkers for any psychiatric condition ah makes, you know, makes it feel a little less objective or scientifically grounded, right?
Speaker: um And so the DSM is is always kind of in this weird place where um you know, the the disorders that are listed um really have no objective markers. And when they do, which is also important, when they do have an objective marker, if something, a gene is discovered, let's say, or a mutation for particular disease or disorder, it's taken out of the DSM.
Speaker: So, you know, examples include Rett syndrome, which was removed from DSM-5. It was actually thought to be an autism spectrum disorder before that. And then they discovered the mutation that causes it. And Then it was moved over, you know, to, I guess, neurology or whoever um studies RET. So, you know, in ah in ah in a funny sense, um the DSM-5 is intentionally not as objective as other areas because once you get those biomarkers, you can move the disorder to another area of medicine.
Speaker: um So, it raises, you know, the question of, well, what what exactly are these categories then if, you know, they're not pinned down by sort of biological signs and symptoms that we can measure or see in a microscope or on an MRI?
Speaker: And the answer is they're they're objective in ah in a different sense. They're objective in the sense that you know professional consensus has observed many of these disorders, the patterns, the symptom clusters that hang together. and They've worked you know with ah experts on these panels, study the the research in which you see um how these different disorders manifest.
Speaker: And they often will overlap, but um you know, there are distinct, I think, cutoffs um for certain disorders. And then other disorders, you know, I think will require a more um spectrum-based kind of model where it's not the discrete cutoffs that separate the disorders, but rather, you know, different trait patterns and continua of traits. You know, I'm thinking here of the personality disorders.
Speaker: There was, in fact, a um you know ah ah proposal to make you know to to change the way personality disorders are described in DSM to use more trait-based sort of spectrum models. And I think and i do believe there is a section in DSM-5 on that.
Speaker: um It's like an optional kind of diagnostic um model. DSM-6, I have a feeling we'll see some some changes, more significant changes in how we think about um personality disorders and And that's important because when you think about how we create these buckets of disorders, we kind of carve out different distinct disorders. It's important that we get it right. i mean, we don't want disorders. We don't want to define a disorder too broadly so that we're like sweeping up healthy people into a diagnostic category.
Speaker: right But we also don't want them to be too narrow and strict because then we'll leave out people who might benefit from um treatment right and access. So, it's really important to get that to get the bucket size right for these disorders. um one One other kind of quirk about DSM, at least DSM-5, that was kind of ethically interesting is that the APA solicited public comments for the different categories they were proposing.
Speaker: And, um you know, that to me was interesting. It was, um I think, you know, an important step by APA to get people with lived the experience involved in the process.
Speaker: But it also, again, raises ah a question, like we don't see oncologists surveying the public to see whether a certain form of cancer is a real disease or not, right? Like yeah public opinion shouldn't really matter if we have disorders that are scientifically valid, right? So I found, you know, i think that's just like another quirk about psychiatry is that, you know, these these these categories are not as clearly defined as other specialties. and And for that reason, I think it's important to have people lived experience, you know, join the conversation.
Speaker: um Category changes. um drive a lot of other things. I mean, the DSM, let's be honest, is as much a insurance schedule as it is a diagnostic manual, right? So you change these categories up and you're changing things like insurance coverage, um potential services, right? For particular patients and disorders. Like I'm thinking of how Asperger, how how autism spectrum disorder was created out of other, out of what was once called Asperger syndrome and classical autism and and they were I'm forgetting the other one, profound developmental disability, I think was another one. So the point is people were wary that folks in those other categories would be, you know, would lose services or would have their services cut.
Speaker: um So it raises a lot of concerns when the DSM is being revised and changed from a consumer, client, patient perspective that maybe their diagnosis will disappear.
Speaker: um And so, yeah, so nosology and psychiatry is full of really interesting, fun questions about what counts as normal, how do we define mental illness, what is the role of um free will and volition in some of the behaviors that we think about as, you know, associated with mental illness,
Speaker: Are addicts, you know, for example, blameworthy? Or should we think of addiction as a brain disease for which there's really no moral culpability at all? All kinds of questions like that come come out of the nosology question in psychiatry.
Speaker: Yeah, i um a couple a couple thoughts on that. I i remember hearing ah Dr. Marsha Linehan, founder of DBT, say like all the all the diagnoses are just made up. They're just kind of for... ah created so that we can find treatments for for people and and put them in the the but the most probable like treatment bucket.
Speaker: um and And like you're saying, it's kind of it's kind of hard to practice evidence based psychiatry when, you know, you're excluding any condition that has like, like you were saying, an objective marker. It's like very, it's kind of like a catch 22, I guess. It is. Yes, yes.
Speaker: Yeah, I mean, you know, um this has been a problem with psychiatry since the beginning. And it's the source of, I think, both criticism by other by, you know, other specialists and people within psychiatry. Also, I think sometimes feel a little like, oh, well, we're not as advanced as other areas and psychiatry is still kind of in the dark ages.
Speaker: um which it kind of is. I mean, it's we're still trying to figure out you know some basic things. I mean, yeah you sort of look at something like depression and um and it's a real illness, it's a real condition.
Speaker: but it's just, it manifests in so many different ways that it's just like hard to pin down. um You know, if we could, you know, thats is sort of the common cold of of mental health and mental illness, you know, depression is is itself hard to figure out then,
Speaker: ah Many other, you know, these many, you know, conditions like psychosis disorders like schizophrenia or schizoaffective disorder, you know, these these are clearly illnesses. These are not things that, you know, a functional brain, you know, you would ever think and in, you know, through the lens of evolutionary biology um would bestow a benefit really to the individual, the person's suffering often with horrible um negative symptoms like depression
Speaker: um ah and positive hallucin you know hallucinations and very scary, you know, um um hallucinations, auditory, visual, psychotic episodes that damage the brain. So, you know, these are like these are legitimate medical targets, right? Suicide, right? um So preventing suicide, um treating these these really horrible conditions is, I think, an important um thing to be doing, right? Medicine is in the business of taking care of patients um and and bringing people back to health.
Speaker: ah And for for mental illnesses, it should be no exception. There's really, as they say, no health without mental health. And, um you know, I think that's, you know, that's that's the ultimate end here is to just restore people to health. But getting there is is really hard because these are conditions that are complicated. They're intermingled with social um factors that are hard to disambiguate. And, you know, it it we've been trying for many, many decades now to find pharmaceuticals that can help with many of these conditions. and we We have a lot now, but we still don't have...
Speaker: therapies that don't come with significant side effects and that, you know, work at an efficacy level that's, you know, better than, you know, sort of placebo in a lot of cases with with regard to SSRI. So, yeah, I think psychiatry is a long way to go, but um but we're making, you know, psychiatry is making progress.
Speaker: The other ah big issue we haven't touched on yet is ah medical aid in dying. ah It's you know frequently discussed, particularly for non-psychiatric patients, but even in communities like within Canada or other countries, there's ongoing discussion about how ah medical aid in dying should be applied to to patients with established psychiatric diagnoses. In your eyes, like how is how is medical aid in dying distinct for psych and non-psych patients?
Speaker: Yeah, great question. This is a really tough issue. And as you mentioned, in Canada, it's been highly controversial. And recently, I think they just decided that it would not apply to psychiatric patients.
Speaker: um after many years of debate about that in Canada. Yeah, the idea here is that psychiatric suffering, the the suffering that's experienced by people who have a mental illness, long-term chronic suffering from a mental illness, is is ah is is equivalent to long-term suffering from another illness, from a physical illness. um And so in some countries, um you don't necessarily have to be terminal to access medical assistance in dying or MAID.
Speaker: In the US, you must have a terminal condition to access assisted dying, which is physician assisted dying, which is where a physician prescribes a lethal drug and then the patient takes it. Okay, that's how you that's in in the US. In other countries, euthanasia is actually legal, which is when the physician actually administers the lethal dose.
Speaker: um And in Canada, um medical aid and dying has been legal and it is legal for non-terminal physical conditions. And one of the cases in Canada involved a patient with, it was either ALS or cerebral palsy, I'm blanking on that condition, but it was a long-term chronic condition that the patient and the patient wasn't actively dying. So the question was, can irremediable suffering um be enough? And the answer there was it was and and it is.
Speaker: But um in the case of psychiatric suffering, they're they're they're drawing a line there. Now, other countries don't draw the line between psychiatric suffering and physical illness, such as Netherlands, Belgium, Switzerland. You can have, you can access euthanasia or psychiatric or made for psychiatric conditions in these countries. So with all that being said, what is the difference? Why is why is psychiatric suffering some similar, but different, right? I would say it's in terms of the quality of the suffering, it's equal, right? We can't
Speaker: ah One would never want to say, oh, it's just psychological suffering or emotional suffering. ah You're not experiencing, say, cancer pain, so we're not going to count it. That's not something that is um ethically justifiable just on its face, right? So um so why not extend medical it's medical assistance in dying to individuals with serious mental illness? Well, one of the there are two questions. One is um can we be sure that the person will never recover, right, or never feel better, get relief? And the answer, I think, is in the case of so psychiatric suffering, no.
Speaker: We really don't know, again, how these diseases and disorders work. We have enough empirical evidence, I think, to suggest that there are some cases where person's chances of recovery are low, but we never know for sure. And there are always new and different ways of treating mental illnesses that are investigational maybe, but still um things ah options may appear if you give a person a little bit more time.
Speaker: um ah so So there's that problem, which is that we really can never say treatment psychiatric treatment is futile, which we can, I think, say in say, oncology, right, where there's metastatic disease and you you know you know that more chemo, more radiation is just going to, you know, you could do it, I guess, but you're not going to get much more ah life and the quality of life you get is not going to be great. So, you know, in other areas of medicine, again, we have staging, right? We know when terminal, kind of when when we can declare an illness as terminal, whereas we can't really do that.
Speaker: in psychiatry ah and and can't really determine when a treatment is futile. So futility around treatment. And then again, the idea of terminality is not clear in psychiatry. So in jurisdictions like the US where terminal illness is required that the, know, just ah by virtue of of the psychiatric condition, you know, disqualifies, is disqualifying because it's just not, you're not able to determine it is as terminal.
Speaker: um The other thing I would say about medical assistance and dying for psychiatric conditions is that it, it, it draw It brings up concerns around the fact that people in most countries, you know and even in developed countries, don't really have great access to high quality mental health care.
Speaker: um And so um now we're turning around and saying, well, we'll kill you, right? We'll allow you to die by euthanasia or physician assisted suicide.
Speaker: and and um for your psychiatric illness ah in ah in a context where you know better mental health care isn't even available. So that seems like, again, putting the cart before the horse in terms of, um you know just in terms of justice, really, like why are we offering this extremely grave you know set of options and and not creating a safety net for people to have mental health care throughout their lives or just like a coherent system right um so you know there's those issues um there are just like a number of these sort of questions that loom really large in psychiatric made that make it difficult i think to justify now
Speaker: On the other hand, there are people who really do suffer for many, many years and see no way out um and don't want to die at their own hands. They don't want to kill themselves. They want to die dignified death, less violent, have maybe their family with them.
Speaker: And for those people, it seems hard to argue against you know um psychiatric maid when they're just tired and done with, you know they might have been mentally ill and have been in treatment for 40 years, 50 years or something, right? And they just say, you know what, enough is enough.
Speaker: It's hard to argue against those cases as well. um I guess, you know, and ah a last issue is the doctor's role in all of this, um which gets to just like a bigger question around euthanasia in general, role which is, is it really the doctor's role to kill patients, to kill a patient that's not, you know, um,
Speaker: the the idea of killing a patient, right, flies in the face of everything that healthcare care medicine stands for, right? The idea of a doctor who's meant to be a healer actively um ending the life of a patient seems the seems to defy the ends of medicine. And so i i you know I raise the question of whether Doctors should be doing this at all.
Speaker: um But I do recognize there is a need and that people do deserve a way out when they're really sick and terminal, like in cases of cancer. I just worry that in cases of psychiatric illness, we'll see a uh um you know not necessarily a abuse but it'll just become too too easy in a way i guess for people societies clinicians whoever institutions to offer this to a highly vulnerable
Speaker: population, right, that already is being marginalized and ignored. ah And it worries me that it'll be kind of, you know, it'll it'll be, yeah i guess I guess it'll be abused is my worry. And so um so I'm opposed to psychiatric MAID. I don't think it meets the ethical standards of MAID for a terminal physical condition.
Speaker: And so I'm sitting tight on that one for now. We'll see how things unfold is you know, research continues on mental illnesses to help us understand, you know, the actual brain damage caused by, say, psychosis and things that maybe we'll be able to get to a place where we have better understanding of the longitudinal.
Speaker: kind of, pro you know, but the the way these diseases um kind of unfold over a lifespan. I think we have enough to say that you're going to lose a lot of years, right, with a serious mental illness. We know that about schizophrenia and other illnesses, but You know, what we don't know about many of these illnesses is if it's possible to stabilize people and turn things around with the right medication and therapy. And so I think, you know, I i think that there's too many unknowns right now for psychiatric made to be um ethically justifiable.
Speaker: Yeah. And the thing I get hung up on a lot, and I think you've explored thoroughly and in one of your papers about this is how do you distinguish suicidal behavior and the capacity of desire to die? but um Exactly. ah You know, if you talk to someone who's in the hospital who's suicidal, you it can seem very logical and very put together. And, ah you know, like you're saying, where where where there's just this such a high degree of suffering that it would seem reasonable to end your life. But at the same time,
Speaker: Is that is that of a capacity desire to die? ah what do you think about that? So I mentioned terminal and futility is like the main thing. And then the other the other issue is the capacity question. And you know when you're talking to someone whose illness, it's the illness itself um is driving the ah desire to die. I mean, that is often part of um schizophrenia. There's a high suicide rate.
Speaker: depression, of course, borderline personality disorder. These are all illnesses in the DSM that include suicidal behavior as a symptom. um and um And yeah, it's you you sort of wonder how you can distinguish between a desire to die that's a product of the mental illness versus a capacitated kind of rational disorder.
Speaker: ah wish to be done with the suffering, the treatments, all of that. And in one of the papers we wrote, we distinguish between suicide, which is, I think, I don't think suicide is the right term to be using for physician assisted dying or for, like, I wouldn't call physician assisted suicide or made, right? It's suicide is a, um is a clinical phenomenon that happens when a person takes their own life um of for for reasons that are not you know rational usually. I mean, you could say there are rational suicides, but in the case of like depression or borderline, the you know the the concept is used to to describe the behavior that is often impulsive or um not rationally thought out, right? It's a symptom of a mental illness.
Speaker: Right. So so that's the kind of suicide I think that we always try to prevent. Now, does that mean we should prevent made? Right. Because we're preventing suicide. No, I think made in um say the context of like Oregon's death with dignity law, for example, I would call that more of a rational exit plan.
Speaker: And that's what we call it in one paper um as opposed to suicide. Right. So I think, you know, just in terms of the terminology, that's really important. um But no, you're right, John. I mean, I think one of the the other big issue here is how do you ever determine, which again is is one of the prerequisites of made in all these different countries, how do you determine that a person has capacity ah to to make such a decision, ah particularly when the wish to die is part of the disorder itself?
Speaker: how do you How do you feel we should frame the preventability of suicide? I feel like on one hand, if we we we frame it as a preventable condition, you kind of give hope to those people who are suffering that you know they can get through this. But you know oftentimes you hear from loved ones of of somebody who who took their own life that, um you know was this really preventable? my my My loved one was suffering so much. I don't really know that there was a ah way we could have prevented this. How do how do you frame frame the preventability of suicide?
Speaker: ah You know, I'm not suicide. This is something that I think Maria Okenda would be the person to ask about this one. But I'll just kind of riff on it for a minute here um because I think...
Speaker: you know, it's one of these things that you want to prevent 100% of the time, right? But have to recognize that's not going to be possible. You know, it's almost like trying to eradicate polio or some, you know, infectious disease, which we came close to doing, to be honest. um But, um you know, suicide is such a multifactorial, like, phenomenon that and and And what we call suicide, I think, is different and different cultures of different ways of thinking about it.
Speaker: um That, i you know, it's hard to... kind of put into words for, you know, one, you know, just to kind of break it down and summarize. But, you know, i do think that it's something that society should prevent in general. It's um it's it's death that could be prevented. um and Not all the time. I mean, we do our best just like we try to prevent car crashes and all kinds of bad things. There's ah there's going to be...
Speaker: um there's going to be suicides, but you, you know, you try to prevent as many as possible. And I think the question around psychiatric maid raises, you know, questions by people who spend their lives doing suicide prevention, like, well, now we're allowing suicide, you know, we're offering this to patients who have mental illness. And it seems like a kind of concession to suicide. It's sort of like, well, we'll just not prevent it in this case. Like, we'll just, um,
Speaker: you know, let let suicide unfold. And that, I think, strikes a lot of people as problematic. um So, there is this tension between suicide prevention and psychiatric made that I think exists.
Speaker: ah But again, I think suicide comes in so many different forms. I wouldn't call what people do for say cancer, you know, thinking of the Brittany Maynard case, for example. I mean, you know, did she technically die by suicide? I i mean, I guess, but, um you know, I think she had a rational exit plan and brain cancer and that was how she died.
Speaker: I want to shift gears and talk a little bit more about our inpatient and long-term psychiatric ah systems that are in place. ah You know, well from what I've gathered that, you know, these are things of that have evolved over time. I guess in your, I know it's a kind of a big question, but in in your words, can you kind of explain how ah inpatient and long-term psychiatric care has evolved over time?
Speaker: Yes, I mean, over the course of, i guess, the last, I don't know, we'll go 200 years, maybe 150 years, there have been cycles of institutionalization and deinstitutionalization in the U.S. and um really globally.
Speaker: um But starting in the kind of early mid-1800s, we saw an upsurge in awareness around mental illness and the idea that people with mental illness are sick, actually medically ill, not just morally depraved or, you know, possessed by doubt demons or something.
Speaker: um And they could be potentially treated and maybe even cured. And, you know, there was the idea of moral treatment that came from the um the English ah Quakers and and friends who basically exported that to the U.S. and ah Quaker reformers and clinicians like Benjamin Rush and and others tried to build psychiatric facilities for people.
Speaker: um Here in Philadelphia, the first psychiatric hospital was built and um still is around. was friend's hospital, actually, ah founded by Thomas Scattergood, ah who was a Quaker reformer.
Speaker: um And these places worked relatively ah okay, given the technology at the time was you know not great. ah But you know there are reports of people feeling better and doing okay. But then reports of people being treated poorly. I mean, moral treatment had some pretty barbaric ah treatment modalities um that I think we would consider, you know, torturous, ah you know, in retrospect.
Speaker: um As the years unfolded, you know, these places kind of were subject to lots of political, I think, um well, they they lost a lot of funding over the years. I mean, states' budgets dried up. Most of these places were state hospitals. Some were private pay.
Speaker: um But they they all struggled financially and, um in addition, were being overfilled with people who maybe didn't have mental illnesses or had other kinds of conditions or were just kind of placed there from their by their family because they were problematic for some reason so we have these institutions that are sort of bulging now in the you know 30s 40s with people kind of warehousing people um and then in the 50s and the sixty s a sort of consciousness is raised and people are starting to wonder like this seems really wrong let's figure out a better place for people with mental illness um happens to coincide with the civil rights movement
Speaker: um The patient's rights movement emerges, lots of critical um press and and and and media as well as art. For example, Ken Kesey's One Flew Over the Cuckoo's Nest, a book was written and the movie was made that had a huge public impact on you know the idea of psychiatric hospitals being sort of snake pits. There was a movie called Snake Pit. um and torture chambers and, you know, it led to a deinstitutionalization movement in the 1960s. It started and throughout the seventies and eighties that really ended up closing many psychiatric hospitals and, um,
Speaker: Many places that I think were problematic, some places, you know, that were not so bad, but were closed anyway. There were just too many people that didn't need to be hospitalized languishing in these places. And it was probably, it was good that that those folks got, you know, um placed in the community, hopefully. Many didn't, though. You know, the institutionalization kind of happened rapidly, and there really wasn't a, you a safety net in place at the time.
Speaker: um And this was mostly during like the 80s or so, what like the Reagan administration, when people are getting deinstitutionalized. Yeah, 60s, 70s, 80s, 90s, still today actually. Places are being closed still today, which is wild.
Speaker: um It left us with a ah major gap in our capacity in our health system for people with pretty serious mental illness who need longer term care or more intensive care. There really aren't great places now for for folks unless you can pay a lot of money for a private hospital.
Speaker: So we're kind of stuck. I mean, evidence, yeah you know, this is you can see this in emergency rooms where people with serious mental illness are sort of boarded there for hours or days or even weeks sometimes because there's no psychiatric hospital for placement.
Speaker: So we're kind of at the other end of the kind of sort of pendulum now where the where deinstitutionalization has left us with too few psychiatric beds and uh and that's led i mean i think in in you know taking us back to the beginning the executive order on homelessness i mean i think they're trying to address a real problem i mean it's not like it's not real that there's too many people who are unhoused with mental illness it's just they need to be in a therapeutic place and um and ah you know eventually back in the community not kind of locked away and warehoused
Speaker: um And so we do need psychiatric hospitals. We need more psychiatric beds. we need them We need thoughtful policymakers to figure out you know exactly where and how much we need. And we need the political will to pay for all of this and and do it.
Speaker: um so So yeah, I mean, I think that's just like the the overview. There's a lot of writing on the deinstitutionalization kind of process and and what it kind of left behind. um Some argue that it was really a disaster. Others argue that it led to, you know, improvements in in the way people with mental illnesses are treated. There's probably, you know, it's both are probably true in certain respects. It was a really complicated process that, as I mentioned, continues to unfold.
Speaker: Yeah, it seems to be that like, what everybody can sort of agree on is we need the the right care at the right time for the right person that, you know, you don't want to institutionalize somebody who doesn't need a very high level of care, but at the same time, it's a, it's a bad situation when somebody who does need a really high level of care can't get that.
Speaker: Right. And it's sort of like, how do you, don't know, would you say right now we're on that kind of trajectory though, of still deinstitutionalizing or we kind of, as you were saying, even at the beginning of this episode, like starting to reinstitutionalize people.
Speaker: I mean, it depends on the state to be, to be fair. Some states are still closing down beds and and cutting beds, but others are are building out beds and creating more spaces like California. So I guess, you know, it depends. um I mean, I think the, and we just, you know, saw a ah recent decision that essentially said the Olmstead precedent um was wrongly interpreted.
Speaker: um so um the olmstead case involved two um it was a really important civil rights case involving intellectually disabled um people who were institutionalized and um the olmstead lawsuit led to the the view that a person who is institutionalized must be given the opportunity to live in the community um in the least restrictive setting possible for them right and so that was interpreted as being you know like get everyone out of psychiatric hospitals get them into the community least restrictive least restrictive right so i think that was that interpretation has been subject to criticism i myself have criticized it to a certain degree because i think that there are people that need to be in structured settings and that olmstead decision didn't actually
Speaker: um didn't actually mandate that everyone be deinstitutionalized. It just said that those who can should be. right um But now I think the the interpretation is is now that it was wrong. i think the recent court decision on this um and And so that might make it easier to keep people inside psychiatric hospitals in in in the case of mental illness or in group homes or other kinds of nursing homes for people with physical disabilities.
Speaker: um And that, you know, while I think the interpretation was originally like too broad, we need something that says, no, you need to really place people in the community if they're able to be, you know, supported and live a good life in the community. We need something that that drives that. um Otherwise, we're going to see, I think, a return to warehousing.
Speaker: So in your in your eyes, how the how, though, do we set up the process to... ensure the person gets that sort of like least restrictive setting, but like an appropriate setting. Is it, is it the doctors who are kind of making those calls or, um, it should be doctors, case managers, folks in the community.
Speaker: Yeah. Um, just to wrap up here. I know, ah you wrote a paper, ah or ah co-authored a paper about like the setting of psychiatric care that, that there's, there's kind of been fluctuations in how setting has been established in terms of whether, ah you know, people have more ah open spaces to kind of freely roam or things like that. What, what, what is the ideal setting in your eyes for psychiatric care?
Speaker: You know, i I don't know. I think it depends on the patient population that it's going to be different for kids, different for adults, different for different kinds of mental illnesses. But the point of that paper was simply to say that the physical structure of a hospital, and this is not just psychiatric hospitals, this is like any hospital, actually affects the the way the patient feels and affects outcomes, right?
Speaker: And so we need to think about design decisions as ethical decisions because they will affect the care that a person receives and the treatment outcomes of the patient. It also affects the morale of the staff and others, right?
Speaker: um And so, know, psych hospitals have been, all have always tried to create, you know, there's going all the way back to the Kirkbride, you know, model of of a psychiatric hospital. There's always been this idea of the physical plant, the um the the physical concrete structure,
Speaker: um conveying the values of the institution as well as, you know, hopefully helping patients get better either by allowing in more light or more air, having, you know, these broad wings that stretch out so that patients are kind of positioned in certain parts of the hospital strategically.
Speaker: um But I think, you know, with modern design, technology, concepts, knowledge about psychology, cetera, we can build better facilities that, you know,
Speaker: that will be less traumatizing to the people that maybe have to be there um involuntarily, for first off. you know People who are like really sick and are resisting hospitalization. if we can make their lives a little bit less stressful, that would be good, as well as the folks that are there trying to live you know in recovery.
Speaker: give them opportunities to build, you know, um skills, vocational skills, let's say, um have f sort of opportunities for athletic activity or physical activity.
Speaker: so I'm thinking here, St. Elizabeth's Hospital, the new one in Washington, D.C., which is an important place because it was where the first hospital, the original St. Elizabeth's, is where Goffman wrote his his famous book, Asylums, and described it as a truly a mortifying place.
Speaker: But the new St. Elizabeth's, it it was designed by an architecture firm that included, they they did, you know, focus groups with former patients, community members, clinicians, family members, and really tried to design the place to be um as therapeutic as as possible for everyone involved. so i think, the you know, that that line of research of mine is, you know,
Speaker: kind of set it aside for now, but it's really interesting because it's a kind of overlap between architecture, interior, and, you know sort of design type thinking as well as healthcare. and And so those kinds of decisions I think of as ethical decisions, how to how much light to allow in, how do we accommodate visitors? what What kind of common spaces do we have? Are there opportunities for socializing?
Speaker: These are ethical questions that affect the well-being of vulnerable patients. And so that's why we were at that paper. With that, it's time for a lightning round, a series of rapid fire questions that tell us more about you.
Speaker: All right. Um, so you got your PhD at Michigan, uh, state. What's your favorite memory from East Lansing? Good question. Oh gosh. Um, there was a bar called Crunchies that always had really good Belgian beer. So I really, I enjoyed going to Crunchies with my colleagues and talking philosophy and drinking, um, and either Chimay or Delirium Tremens, which was and another which is another Belgian beer that you can rarely find on tap, but it was there.
Speaker: What a name for a beer, Delirium Tremens. We're in the dog days of summer. How do you spend a 100-degree day? In my house with my cat in the air conditioning.
Speaker: What's your favorite cold beverage to drink in your house? ah I try to avoid soda. But if if it's a special occasion, I'm a big fan of Cherry Coke.
Speaker: What's something that gives you hope? My kids.
Speaker: And lastly, ah what's one big misconception about mental health care? Hmm.
Speaker: I think a lot of people don't really believe that it works ah depending on the condition we're talking about, but really there are a lot of conditions that can be improved with the right mental health care. So I think people misconceive the idea that you can get better from these conditions, whether it's addiction or depression.
Speaker: And I think many people are struggling, right? It is not, you know it's not like it's easy to get better often, but you can get better. And I think for people listening and for, for, you know, clinicians to, you know, just trying to convey that legitimate hope that, you know, improvement is definitely possible.
Speaker: All right, Dr. Dominic Sisti. Thanks so much for joining the wound dresser. Thanks, John. It was fun.
Speaker: Thanks for listening to The Wound Dresser. Until next time, I'm your host, John Neary. Be well.
