Month: July 2019

A Manic Politician of History

~ Frank ~ Leave a comment

The ?Manic Political Long Family of Louisiana

From the pen of the human interest, humorous columnist Jim Bradshaw of the St. MaryNow.com website of Lousiana came the following hilarious piece regarding the Governor Earl Long, scion of the even later and more famous Huey Long, of “A Chicken in Every Pot” Depression Era fame: JIM BRADSHAW: WHEN EARL LONG’S MENTAL STATE MADE NEWS. I am always on the lookout for pieces that document the foibles of the famous cultural figures of our time, both for purposes of humor and for instructional examples to use with trainees in medicine and psychiatry in my work. This piece is worth the read. I would commend it to the reader for a pleasant interlude.

I have another purpose as usual. I had in decades past some older ancestors of my father’s family located in Louisian. Early on in my life in childhood and teen years I was exposed to one great aunt in that state on periodic visits to her home there. She was in 80’s by the time I came to hear family stories about the Civil War and other fascinating tales involving my father’s family’s long gone relatives. A few of those stories involved that branch of my father’s ancestors with the infamous Huey Long who ran for President and was one of the reactive voices of common people’s Populism during the Great Depression which my father and his own family lived through.

The tales I heard about “The Kingfish” as Huey Long came to be known, were incredible. I heard of demoagogic speeches that could spell bind huge outdoor audiences, hard drinking, a talent for non stop off the cuff jokes and so much energy that almost no one could keep up with him.

Gov. Huey Long at the Microphone

Then in later years as accounts of Earl Long’s own clearly “manic” spells came out, I began to wonder about the fast paced, non stop life that was Huey Long’s. In my residency and later practice years, I came be exposed to persons who were not fully manic but who clearly were non stop persons as I called them. I came to view as a distinct type, a diagnostic category in my own mind that was not recognized, and may never be, in the bible of psychiatry, the DSM, the Diagnostic Statistic Manual. These were persons who were always “on,” always hypomanic or just below that level of revved-up-ness. I once knew a salesman who could sell out his luxury foreign car dealership in three months and then spent the rest of his work year languishing at his NC beach house until the new model year of luxury cars came in. He would then return and then proceed to sell the stock out, drive out all the other salespersons and make the dealership owner most happy. He finally had a manic episode and confirmed my psychiatric musings about him. I met and knew over the years such figures who all worked inhumanly impossibly long hours, had non stop energy, could drink everyone under the table, were the dominating person in any room they graced, had insatiable sexual appetites, and were enormously successful. They were company heads, surgeons, attorneys and politicians of course. Most of them never evolved into full blown officially symptomatic manics, but many of their progeny did and that is how I came to know them and suspect the truth about them. Their genetic diathesis, posing as this constellation of lifelong energy and such, sometimes emerged in the full evolution of their hidden “bipolar” subclinical makeup.

And that is my take on the Longs, Huey was a closet hypomanic and Earl was a full blown hypomanic-manic person in times when all this was poorly understood and denied.

I have to not tease the reader with all this. I have reprinted Jim Bradshaw’s article on the late Earl Long below for your immediate gratification and your own judgment:

The Equally Spellbinding Gov. Earl Long

“Sixty years ago Louisiana and the nation watched with a combination of awe, incredulity, and amusement, a political episode that was bizarre even by the standards of Long-era Louisiana.
During the summer of 1959 newspaper front pages were filled daily with the tirades, tantrums, and shenanigans of Gov. Earl Long that caused him to twice be confined in mental institutions, and to briefly act as governor while he was an inmate in one of them.
The manic episodes, family members said, were the result of Long’s return to heavy drinking and taking an assortment of pills either to help him sleep or keep him awake. Long said that was humbug (in much saltier words).
He was always volatile and hot-headed, but reporters began to publicly hint at the governor’s overuse of alcohol as early as April, when the Associated Press reported the governor’s hijacking of a legislative budget hearing “with his bottle of Tichenor’s antiseptic on the table before him.”
But things really began to unravel in late May, when Long railed for more than an hour and a half and, the AP said, “poured out scathing criticism” on legislators and political enemies … “as he screamed into the House microphone in a stinging, stump-speaking style.” They noted that he drank from a glass filled with “what appeared to be grape juice” during the tirade.
Two days later, the governor’s wife, Blanche, announced that Long had been ordered to bed “for several days” and that he was suffering from exhaustion. One of the people helping to make that decision was Jesse Bankston, Louisiana’s director of hospitals, who thought Earl needed more than bed rest at the governor’s mansion.
He thought Long needed to be confined for psychiatric evaluation and that the confinement needed to be outside Louisiana, so that he could not use his powers as governor.
On Saturday, May 30, Earl was strapped to a gurney, put aboard an Air National Guard airplane, and flown to the John Sealy Hospital in Galveston. The doctors were told that Earl had agreed to be admitted. They soon found out differently. The AP reported that Long “refused to cooperate with hospital authorities.” The Galveston Daily News said his refusal included “a couple of violent episodes.”
He threatened his wife with federal kidnaping charges, and court-appointed lawyers in Texas filed papers claiming he was taken to Texas against his will. Long himself signed the legal papers, “Earl K. Long, gov. in exile by force and kidnaping.”
The hearing June 16 on his petition for release, according to United Press International, was punctuated by Long’s outbursts against, among others, “the horse doctors” who were overseeing his treatment. When the judge tried to quiet him, Long said he was just trying to help his lawyers prove he was sane.
Before the ruling came down in Texas, however, Long made a deal with Blanche and with his nephew Sen. Russell Long that he would consent to being moved to the Ochsner Foundation Hospital in New Orleans.
He was there one day before he reneged on his promise. He told Blanche he’d said he would go to Ochsner, but that he didn’t say how long he would stay. There was also a rumor, reported in the Alexandria Town Talk, that once the airplane was over Louisiana, Long planned to order the Louisiana National Guard pilot to take him to his farm in Winnfield, rather than New Orleans. It didn’t happen, but it sounds plausible.
When Earl reneged, Blanche had a friendly judge sign orders committing the governor to the Southeast State Mental Hospital in Mandeville. Once again, “a screaming, cursing Gov. Earl K. Long was hauled to a mental hospital.”
But this one was a state institution in Louisiana. While an inmate at Mandeville, Long called a meeting of the State Hospital Board and had its hand-picked members fire Bankston as state hospital director and appoint a new one, who, in turn, fired Dr. Charles Belcher, the superintendent of the hospital.
Belcher’s replacement saw no reason to continue to hold Long, nor did a friendly judge when the family tried to keep him confined.
The AP reported on June 26, “Gov. Earl K. Long swept out of a jammed courtroom a free man today — a complete victor over his family and state officials who committed him to a state mental hospital.
“Gov. Long immediately set up a temporary statehouse at the Great Southern Hotel … near Lake Pontchartrain. From room 221 in the hostelry, the governor is expected to drop the axe on political enemies.”
Which he did.
A collection of Jim Bradshaw’s columns, “Cajuns and Other Characters,” is now available from Pelican Publishing. You can contact him at jimbradshaw4321@gmail.com or P.O. Box 1121, Washington LA 70589.”

SC State Hospital To Undergo JCAHO Review After Patient Demise

~ Frank ~ Leave a comment
South Carolina State Hospital Historical Marker

The South Carolina state psychiatric hospital, historically called “Bull Street” for decades in the past, Brian (state) Hospital in Columbia SC, recently had a sad and tragic occurrence, a suffocation death of a patient apparently undergoing a hands on restraint for out of control behavior by multiple staff.

In a recent article written by Avery G. Wilkes of The State newspaper of Columbia SC, entitled: “Suffocation Death of SC Mental Health patient under review by group that accredits hospitals,” published July 17, 2019, the sad story of this tragedy is detailed. In this article, there is described the possibility that some of the staff involved in this patient’s restraint event, were not adequately trained in these highly complicated and at times, hazardous to all involved, events. I will try to comment on my own experience with these events below. In any case,

The results of such investigations are made public. This is not a closed process with no transparency. Sometimes the public can be overly suspicious that transparency is not being followed by officials at the state or hospital levels when the media note that officials could not and would not discuss details of these reviews at first until the results are determined and made public. An article published September 8 ,2017 by the Wall Street Journal authored by Stephanie Armour entitled: Hospital Watchdog Gives Seal of Approval, Even After Problems Emerge: The Joint Commission, which the government relies on to accredit most hospitals, rarely withdraws its approval in the face of serious safety violations,” gave a cursory overview of this issue which was taken up by the U. S. House of Representatives in 2018 with a request for documentation (House committee probes CMS, Joint Commission over accreditation process,” published in Modern HealthCare magazine). Unfortunately I have not been able through my searches to find left over record by that Commerce Committee of the House as to what eventually came of the initial inquiry.

But it is my opinion and experience, that one of the reasons the Wall Street Journal found that only 1% of hospitals nationwide are ever de-accredited is that wealthy private hospitals are de-accredited less than the state psychiatric hospitals. Medical hospitals are now usually huge conglomerates and rarely are penalized at such a level. Small poorer community hospitals seem to be more vulnerable to such review based censures. And they are closing across the nation now anyway for reasons of declining revenues but that is another story for another day. Suffice it to say that state psychiatric hospitals, as maligned as they still are, operate in a far more regulated and highly scrutinized environment than private psychiatric hospitals or units/services within large wealthy, private, or university medical center based entities.

States’ governmental laws regulating their health care facilities, as well as private hospitals, require investigations and review by various bodies locally and nationally, deaths of patients by unnatural causes. Local review bodies include legislative oversight committees, the states’ own departments that oversee state psychiatric and private medical/psychiatric hospitals, national bodies such as the Joint Commission for the Accreditation of Hospital Care Organizations (the famous “JCAHO”), CMS (the federal agency for Medicare and Medicaid)C etc. Investigations such as these are very important since failure and loss of accreditation by these bodies can result in loss of ability to receive reimbursements from various insurers, especially the federal ones, Medicare and Medicaid. And for state psychiatric hospitals, this is extremely important. State psychiatric hospitals serve mostly poorer patients on Medicaid and Medicare or the uninsured, and loss of these operating funds means that the state legislatures’ budgets then have to make all the lost funds until the hospital which has lost such accreditation and funding can regain such. This always involves submitting to the mandates the hospital must put into place. This process is always lengthy, detailed and usually requires “corrections,” “actions plans” etc. It is not a trivial event then when a state psychiatric hospital has such a tragedy, and when a “deficiency” is found. The investigative review process is arduous. It requires no questions asked cooperation by the hospital staff and leaders. Staff are subject to detailed interviews and scrutiny. Hospital policies are reviewed and the review personnel check to make sure that the policies are indeed followed and fully implemented. If there are deficiencies found, then the corrective actions are imposed and possible penalties such as loss of accreditation are imposed.

Now there are wealthy(ier) private psychiatric inpatient systems that have been de-accredited in the past few years and I would be remiss in my own ethical standards if I did not mention a couple of them. One was the Timberlawn Hospital of Dallas TX that in its heyday was truly a very good inpatient treatment facility. I had a former mentor from my long ago training days who migrated to work there and did exemplary work with adolescents. But the leadership and ‘mission’ of the facility changed a decade or so ago and it went rapidly downhill, quality of care suffered and tales/rumors of its bumblings, then deaths and such, began to emerge. It underwent investigation, lost accreditation which was a genuine shock to many who knew it in its heyday, and closed only a very few years ago. Another chain of psychiatric inpatient centers in the Boston area garnered such scrutiny, was loudly hectored in the media for a variety of missteps, some of them quite major and involved a lot of financial misdoings and lost its accredited standing also. So this does happen with some monied, strongly capitalized psychiatric inpatient entities, but I feel it does not happen enough and helps the explain the findings in 2017 of the WSJ article/expose.’

At this point I would like to comment on my own experience with at least the aftermath of a state hospital-based investigation regarding the patient death undergoing a take down manual restraint.

After serving as stint for approximately 4 1/2 years is the first psychiatrist at a newly established Native American tribal mental health clinic and substance abuse services, and in the approaching twilight of my psychiatric practice career, I was looking for a more balanced and salaried position for essentially the rest of my career. As I had started out my post residency and fellowship practice career in a the North Carolina state hospital helping to start a new 44 bed acute relatively short-term adolescents psychiatry unit, I made the decision to apply for a position that my current state hospital site of employment. I initially applied through a locum tenons psychiatry job placement firm. I had a few long-term friends, fellow psychiatrists I had known through professional contacts over the years who worked there as well. I had some knowledge that this state hospital provided excellent high quality care and I was eager to apply and see if things would work out for all parties.

I’m was not prepared by the two-way exchange that I was given during the several week application and review process. I was prepared for essentially one way process in which I would furnish information and references about myself and to be judged regarding meeting the qualifications for employment at this facility and providing evidence, references and the best representation of my qualifications that I could. Instead, toward the end of the application and interview process which lasted more than one interview session and multiple visits to the hospital, I found myself being informed by the CEO psychiatrist of the hospital, of the relatively recent traumatic experience that the hospital itself had gone through. He did so for the purpose of complete transparency and honesty so that I would know fully what the hospital had gone through and be exposed to any possible negative information about the hospital organization, its own level of confidence etc. As he began to relate the history of the death of the patient within the previous two year period, I was floored by his openness. Gradually I came to understand that this incident had been traumatic for everyone involved and was witness to the extraordinary links to which the clinical leadership and staff involved at all levels, went to in order to be cooperative with the ensuing mandatory investigations, the patient’s family and the media to the extent that they were permitted by the confidentiality laws. There was no hiding of the incident, no minimizing, no bureaucratic obstruction etc. It did turn out that part of the basis for mandating corrections and deficiencies based on the circumstances of the death by virtue of the physical nature of the episode of manual restraint of a truly aggressive and supremely uncooperative patient were erroneous. I was permitted to find out and review the incident myself and learned with confirmation from the CEO that for instance, the initial pathology exam was erroneous and efficient and that a repeat exam later on in the process essentially demonstrated that the cause of death was a previously unknown cardiac condition of the patient and not the air of the hospital staff in affecting the physical restraint and control measures. But this was not accepted or validated by the investigators and sanctions were imposed including the loss of accreditation for the hospital that lasted approximately a year and a half.

I was simply ethically amazed that the hospital clinical leadership worked actively with the investigators and without any protest whatsoever submitted to the corrective actions in a dutiful accepting way seeing them as an opportunity for positive change. By the time I arrived on the hospital’s staff, the changes had been actively implemented and I was exposed to the most detailed and helpful training course in physical restraints procedures that I had ever witnessed at any hospital at which I had practiced in the past. The hospital had contracted with an outside training and consulting agency in another state and at great expense to itself, instituted a mandatory training policy for every single staff member who has any sort of clinical contact with the patient population, from behavioral nursing assistants on up through psychologists and psychiatrists without exception. This training is mandatory and is repeated annually for all clinical staff and stands witness to the openness, cooperation and commitment to high quality of patient care.

So when I read of other hospital organizations undergoing such thorough reviews and investigations by outside bodies have more appreciation for the difficulty of the task that is endured by both the reviewer in investigators and by the hospitals themselves mutually. I also am somewhat dismayed when I read accounts of hospital organizations who seem to resist these investigations and outside reviews in an almost reflexive defensive manner. I can understand usual human reactions in which we all get defensive about having our professional actions critiqued and criticized and if need be, having to submit to a professional disciplinary action especially if it involves public censure and procedures that create a negative image in the eyes of the public who cannot ever fully appreciate how difficult these processes are.

I hope that this small effort at sharing and observer’s long-term perspective and experience can help any reader more fully understand these very difficult and periodically inevitable said events and their aftermath.

Two Different Forensic Psychiatry Books

~ Frank ~ Leave a comment
Is It a Polemic or a Legitimate Read in Its Field?

The first book that I wish to review, Alone With The Devil: Famous Cases of A Courtroom Psychiatrist, is an earlier book somewhat dated now, published in 1979 by a then fairly well-known West Coast American forensic psychiatrist Ronald Markham MD. First off if one accepts the premise that we are all product of at least her experiences and the times in which we have lived, then it is easy to place this book in an era earlier in Western and American psychiatry specifically in forensic psychiatry. This book may amuse some of the psychiatric readers and it may confuse a non-mental health professional through the use of its somewhat dated concepts and terms.

But it is nonetheless a fascinating read and I was very pleasantly surprised by the writing style, the slight flair for the dramatic in the detailed and insightful portrayals and analyses of the cases that this psychiatrist selected in this book. I was initially drawn to this book as I had read online reviews that it was somewhat of a misplaced, angry and doctrinaire polemic. Also, some reviews accused the author, who if he is still with us today must be in his 80s, of being somewhat of a show-off, and given to tooting his own horn in such a way that it detracted from this book. I did not really find this to be the case.

The cases that the author presented as a forensic psychiatric writer were not very well known for the most part. In the few cases that were somewhat well-known, the author gave details that I was largely not familiar with, though much of my own acquaintance with these few celebrity cases. Instead, he revealed background detail regarding their crimes and legal information that I found extremely interesting. I can safely say that the author did not trade on sensationalism or the common media stories that have long been associated with these few famous cases.

The vast majority of cases that he selected were not very well known if one had not lived primarily in Southern California during the 1970s and 1980s. Each case was selected for features that were quite different each from the next. The author focused just as much on the legal proceedings and upon the very great difficulties that the organs of the legal systems experienced during the prosecution and defense of these heinous murderers. Dr. Markham spared no criticism of figures involved including famous prosecuting and defense attorneys as well as a few judges who did not comport themselves as professionally as they should. The dated nature of this kind of information was part of its charm. The author gave fascinating accounts of courtroom behavior and maneuverings that likely would not be permitted in this day and time and would be regarded as unprofessional behavior at least. He bolstered his criticisms by quoting extensively from actual court transcripts that illustrated his shortcomings that he saw in his work as a forensic psychiatrist both inside and outside the courtroom proceedings.

This kind of detail is quite singular and have not read it in other historical forensic psychiatry textbooks. Likely his repetitive criticisms of the shortcomings of the legal process that occurred in many of these cases during their investigations and prosecutions form the basis for other online reviewers to call this book a bit of a polemic. I have no idea how this book was received in the first just several years after its publication, but I can imagine it was probably roundly vilified and criticized in its day in certain quarters that received acidic and telling critical observations from the author.

Further, the other value that I have referred to above, the selection of lesser-known cases of serial murderers, form the other pillar of value to this book. Each of the cases differed in major respects from the others in this book. Each of the murderers discussed were revealed to largely be very different each from the others. Some of the cases actually served out their sentences and lived to be released which I found somewhat shocking but which I realized, was part of the value of the reporting of these cases has at least one of the figures who was released from an all too short sentence for murder in the presence of a very atypical psychotic process.

Another telling thread that ran through many of these cases was the fact that the investigative law enforcement powers of identifying these killers were very primitive by today’s standards. Law enforcement agencies whose jurisdictions bounded up against each other very often did not coordinate information in an organized manner and in several of these cases, it was by sheer luck that the killers were identified and arrested. Of course, there was no DNA testing in those days, and profiles of types of crimes that could be checked online very quickly also were not yet on the scene. Information was not categorized, digitized or stored in relational databases at all. Comparable to the field of medicine that is only in the last decade or so graduated into the digitized medical record, law enforcement murder files and casebooks were paper-based, sitting in stacks on a detective’s desk. Anna detective investigating a murder committed in his jurisdiction had no idea that only one county and one major city away another homicide detective was struggling to generate leads on the very same murderer who simply drove across the county line to commit yet another murder undetected.

A Compelling Tale of the Actual Development of the Decision to Kill So Many

The second book is much more modern. It is the book written by William H Reid MD, a currently moderately well-known forensic psychiatrist. This is the book: A Dark Night in Aurora, Inside James Holmes in the Colorado Mass Shootings. This book was published in 2018 and concerns only one case that of James Holmes who shot up the cinema 16 theater in Aurora Colorado on July 20, 2012. Holmes was a graduate student at the University of Colorado Denver, in neurosciences on the on shoots medical campus in neurosciences. He had dropped out at the beginning of that current winter semester before the shooting in July 2012.

James Holmes dressed up in bazaar black tactical clothing and carried multiple weapons including a Glock pistol and an AR 15 type assault rifle. He mounted the stage in front of the screen at the midnight showing of the then-new Batman a dark night rising movie. He selected the time because he thought there would be fewer children at the time of the midnight showing. Nevertheless aside from this one feature of perhaps misplaced compassion, he still killed a dozen people and wounded over 50 others. He then went outside lay down his weapons and patiently waited to be apprehended. He is one of the few mass murderers who is not killed by law enforcement or as is still more common committed suicide at the scene such as the Columbine high school shooters Eric Harris and Dylan Klebold who both killed themselves inside the school.

Consequently, James Holmes could be extensively interviewed and evaluated both by law enforcement and by Dr. Reid and another forensic psychiatric examiner. Furthermore, the development of James Reed’s illness psychiatrically, and his thinking patterns both rational and psychotic could be witnessed, examined, and analyzed at great length because his written material in the form of emails and diary materials existed, and were preserved.

Dr. Reid was able to bring this disturbed young man’s development into a mass murderer into stark and very clear relief by quoting extensively from these materials in the book. This is one of the major features and values of this book as the written record left by this young man was invaluable and has come to be an incredible source of information regarding the mysteries of the development of the mass murder. This material alone makes this book more than worth its purchase and will help any reader to gain greater understanding of at least some of our current modern mass murderers and how they come to be who they are and why they commit their crimes. Many of them unfortunately for the purpose of education and understanding these individuals, defeat the possibility of retrospective, after the effects of their crimes, from being subjects of legitimate psychiatric and legal investigations by killing themselves. They remove themselves from our abilities to understand them and the motivations for their crimes forever. I need only remind the reader of the Las Vegas country music concert, Mr. Stephen Paddock who murdered over 50 individuals and wounded upwards of 500 more when he opened fire from his hotel room through its broken window with multiple automatic assault rifles committing the worst mass shooting known in American history to date.

For any reader, this book painstakingly documents this young man’s development beginning with a seemingly intact family and childhood developmental course in life through the beginnings of the earliest self-perceived seeds of intrusive and disturbed thinking patterns that began in middle school years and percolated through his high school years. On the surface and the likely truly internally, this young man had an ordinary happy childhood. He then experienced difficult events in his life that many youngsters in modern American life experience as well. For instance, his family moved at the beginning of adolescence and he took this initially fairly hard, but it was not causative in the development of his future psychotic mental illness. He maintained a fairly happy adjustment through high school and gave little sign during those years that an ominous internal corrupting psychotic process was beginning. And like so many individuals beginning to experience the ravages of adolescent era psychosis, he largely kept it a secret only occasionally leading a very few oddball and slightly bizarre ideas to emerge to those surrounding him in his life circles at that time. The author skillfully traces the development of this ominous process through the college years and into the first year of this young man’s graduate studies. And like any good story, part of the compelling plotline is the slow literary unfolding of the internal events and changes in thinking that led to the commission of this heinous crime in the dark theater during the midnight hour. This grips the reader in a most compelling manner. Dr. Reid never really speculates or theatrically takes literary license in the telling of the psychiatric story. He did not need to. He had over 20 hours of clinical interviews with this young man who was extremely and surprisingly I suppose, open and forthcoming with Dr. Reid. Dr. Reed also had access to voluminous documentation furnished by the young man himself. The author also interviewed many individuals including the family, consisting of the mother father and sister. He also interviewed teachers, high school classmates and college classmates as well. All these people who were also struggling to grasp, comprehend and explain this horrendous event to themselves, poured out their observations, memories and experiences with this young man adding to the detail and progression of the movement from a quiet preteen, teenager, college student, and young adult, to a cold-blooded mass murderer who killed four very bizarre, idiosyncratic reasons.

There are many other notable and worthwhile features of this singular book that I will leave to the future reader of this compelling book. But it also illustrates the maturation of the field of forensic psychiatry in the last quarter-century or so. The practitioners of forensic psychiatry nowadays are far better trained and skillful than at least some of the practitioners in the past. Most forensic psychiatrists have been trained in specialty post-adult psychiatry residency training programs in the subspecialty of forensic psychiatry. And Dr. Reid’s straightforward and dispassionate account of his work in this case ably illustrates the professionalism and skills of the modern-day forensic psychiatrist. This book will give the lay reader an excellent inside, fly on the wall vantage point to observe and begin to understand the complexities of the practice of forensically oriented psychiatry and hopefully a better appreciation for the vital role they play in growing the science and understanding regarding this frightening present day reality and the mentally disturbed violent and murdering offender.