Nursing Home Blues: One Man's Challenge of the
Psychiatric Dugging of Our Elders

by John Breeding, Ph.D.
The Necessity of Madness
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Chapter 13

Chapters 9 and 10 pointed out the shameful use of electroshock to suppress elders in our society. The last two chapters addressed issues around psychiatric drugs. This chapter provides an example of psychiatric oppression from my own experience in the form of the large-scale use of psychiatric drugs to control elders in nursing homes. The chapter also shows some of the difficulties we are up against in challenging this oppression.

When my private practice recently hit a slow spell, I responded to a nursing home service agency seeking psychologists to assist elders. Elders were much on my mind as I'd just testified before the Texas legislature against the use of electroshock. When the agency, Senior Psychology Services (SPS), asked for my services full time, I had serious reservations. Taking the job would mean giving up some of the private practice I'd developed, and confronting biopsychiatry head-on. It would mean doing battle in personal terms over the practice of electroshock, a brain-damaging form of psychiatric abuse -- I consider its use predominantly with elders in this country a national shame. I am also deeply concerned with the routine prescription of psychiatric drugs to chemically restrain older people. I discussed these issues at length with my interviewers at 'Mountain Valley', a pseudonym for the 'home' at which I'd be employed. I insisted that electroshock be forbidden wherever I worked, and I spoke vigorously against over-reliance on psychiatric drugs. From my standpoint, spiritual law holds that if you participate in an unethical situation, you must change it, or become unethical yourself. The administration at Mountain Valley assured me that they, too, were concerned about the overuse of psychiatric drugs, and saw their alliance with SPS as an opportunity to reduce the amount of psychiatric drug use in their facility.

Because the facility was clean, the staff seemed sincere, and the administration appeared to agree with my concerns, I accepted a part-time contract, anticipating becoming a full-time SPS employee as my caseload developed.

The Situation

Mountain Valley is a pleasant and well-respected skilled nursing facility in Austin, Texas. Most of the residents have significant medical difficulties. Many have heart conditions or have had strokes; some are on dialysis; many have conditions requiring therapy from the in-house rehabilitation staff. Wound and skin care are issues for a high percentage of residents; many are bedridden from surgery or other disability; sores and skin tears are a constant problem. A profound trend in many nursing care institutions is the greater disability of residents because of the reimbursement requirements of our welfare system.

Mountain Valley has an average daily census of about 210, though capacity is slightly greater. Space is a major problem. Some staff members office in converted closets or bathrooms; patient roommate conflicts are a constant challenge. Outdoor space is limited to a small sitting area at the front entrance and a slightly larger concrete back patio with a few tables and chairs. The patio, surrounded by walls and a chain link fence, leads to the parking lot, which serves as the smoking area. Most residents never go outside. For those who do, the most popular activity is smoking. Indoor activities include church services, hymn-singing once a week with a volunteer piano player, an exercise group, and an occasional volunteer entertainer.

Staff, for the most part, are friendly and respectful to residents, although staff turnover and shortages are a constant problem. Mountain Valley lost one of its two social workers and the admissions director within the first month of my tenure. The other social worker, my primary contact, had been there about six months in her first job out of graduate school. She was covering the entire facility plus admissions until a new person could be hired.

Life in a nursing home often means the profound alteration of time. Many residents have significant short-term memory loss; some have Alzheimer's and are profoundly disoriented or impaired. Those who still have the mental capacity (and many do) must have a strong will to stay focused despite major boredom and incessant routine in an enclosed, never-changing interior.

For many, the loneliness and isolation are extreme; physically, it's cold air and sterile conditions. A skilled nursing facility is much like a hospital. It's better, in the sense of more community, because residents stay a longer time, and many are ambulatory and socially active, at least to a small degree. It's worse in the sense that most hospital stays are brief and patients go home sooner. Most families just can't keep up the support and visitations long-term, at least not at the level of acute hospital stay.

The most anguishing aspect of being with the residents at Mountain Valley was the fact that virtually none of them wanted to be there. Some thought that since I was a "doctor," I held the power to liberate them. They wanted out of there. Others saw the situation more clearly, but still wanted my help to get out. One delightful woman, on dialysis three times a week and having been "cut on" at least twelve times, had lived there seven years and called it "home." She was president of the resident council, and had very good support (regular weekend visits, letters, etc.) from her extended family. She was the most spirited fighter I met there, constantly angry and frustrated about food or conditions or staff negligence. She felt neglect of place or people as a violation of her home. A few others I met in passing appeared to have achieved some degree of peace; mostly, there was resignation, despair and a great deal of bitterness.

Nursing Home as Psychiatric Hospital

From my point-of-view, the biggest problem was that nursing homes today are so like psychiatric hospitals. This is not readily visible on the surface, although I worked with one woman whose combination of dementia, fear, chronic pain and throat problems resulted in a constant screeching and yelling which leads many to immediately think of madness; another called the place a "loony bin" and used these plaintive screams as evidence for her assertion. A third woman, head hung in her wheelchair, roamed the halls plaintively crying out "Help me!" Lost in time and desperately pleading for help or fighting off perceived threats, these lost souls inevitably evoked images of a madhouse.

Much of the time it was quiet, but so today are psychiatric hospitals. In the 1940s, electroshock was discovered. It became immensely popular as a mechanism of restoring order and quiet in mental asylums across the country. The advent of psychiatric drugs, the so-called neuroleptics or major tranquilizers in particular, gradually replaced electroshock as a more "humane" means of controlling so-called madness.

Shortly after beginning work at Mountain Valley, I was provided a list of all residents on psychiatric drugs. Although prepared to expect a goodly number, I was taken aback when handed a 28 page computer printout. According to the pharmacy consultant, roughly 20 percent of the residents were on each of the categories of anti-psychotic, sedative-hypnotic, and anti-anxiety drugs, respectively. Over 30 percent were on anti-depressants. Including PRN (as needed) orders, over half of the residents had prescriptions for psychiatric drugs. My own supervisor, when I wondered out loud about it, assured me that Mountain Valley is fairly representative of the overall picture in nursing homes today. This picture, with its heavy reliance on psychiatric drugs to control mood and behavior, is a focused snapshot of the overall trend in our society at-large. Jerry Avorn, MD, was quoted in the Boston Globe ten years ago: "My concern is that people are having their minds blunted in a way that probably does diminish their capacity to appreciate life." He was commenting on a study of 850 residents in 12 Massachusetts nursing homes which found that during a one-month period "nearly two-thirds of the residents had prescriptions for one or more psychoactive medications." (1)

A June 1998 press release by the National Center on Addiction and Substance Abuse at Columbia University (CASA) highlights the results of a biopsychiatric world view from a slightly different angle. CASA surveyed primary care physicians with a significant number of women patients over 59 years of age. Results showed that when presented with the classic symptoms of alcohol abuse in a mature woman, only 1 percent of primary care physicians considered substance abuse. Instead, more than 80 percent of physicians considered a diagnosis of depression, which might lead to prescriptions for sedating psychiatric drugs, a potentially deadly mix with alcohol. The report also revealed that one in four mature women (6.4 million) are using at least one psychiatric drug, and an average of five prescriptions, psychiatric and otherwise, at the same time. The study lists a host of deleterious health effects in the vulnerable population.

Former Secretary of Health, Education and Welfare, and President of CASA, Joseph A. Califano, stated that "For a large percentage of (these women), we have written off the last quarter of their lives, years that should be rewarding and fulfilling ... We leave millions of grandchildren without grandmothers and children without mothers. We saddle others with the avoidable burden of caring for an ailing parent. What's inexcusable is that these tragedies are readily preventable." (2) The biopsychiatric world view blinds physicians and others to what is really going on, in this case to substance addiction and neglect of our elders.

The fundamental argument in defense of psychiatric drug use is based on the belief of biopsychiatry in biologically-based mental illness: therefore, the value and necessity of psychopharmacology as "treatment" to hold these "diseases" at bay. A common justification is that to withhold such "medication" from the "mentally ill" is a form of cruelty. From this vantage point, it is argued that to let an elder be anxious or depressed when these drugs are available is immoral. A corollary of this is the argument that it is more humane to use these drugs and therefore allow a resident to remain at the nursing home, then to discharge the resident and send him to a psychiatric hospital. The belief is in the biological or genetic cause of "mental illness;" other causes are either minimized, ignored or regretfully considered as useless to think about.

There was another important factor, in part common to nursing homes today, and in part unique to Mountain Valley. The common factor was the active role of a consultant psychiatrist in the facility. This psychiatrist was one of a growing number of geropsychiatric specialists; his practice consisted solely of nursing home consultations. He travels with two psychiatric nurses who handle the charts and record-keeping while he consults and prescribes "medications." This particular psychiatrist is active in many local nursing homes and has interfaced a lot with SPS. The uncommon aspect was that the Mountain Valley administrator and director of nursing were not pleased with the psychiatrist's work, and told SPS prior to my own hiring that they intended to have him excluded from working at their facility. The director of nursing told me one day, when the psychiatrist showed up to make his rounds, that she thought he had been fired already. When I queried the director, he told me that he planned to talk with the psychiatrist as soon as possible.

Dealing with Doctors

In approaching the task of reducing the heavy reliance on psychiatric drugs in the facility, I had decided to follow proper etiquette as much as possible, communicating with the doctors primarily via facsimile notes mediated by the nursing staff. My first communication of this nature was regarding an 84-year-old woman referred for "failure to thrive;" eating virtually nothing and complaining of constant nausea, she had reportedly been withdrawing and declining for about six months. Her doctor had started her on ten milligrams of the antidepressant Paxil just days before I met the woman. I wrote the doctor a note suggesting she consider discontinuing the Paxil as a frequent effect of the drug is nausea and appetite suppression, and since we were just beginning a psychosocial intervention. The doctor cancelled the order immediately. The woman continued to have a hard time for awhile, though consistent (every two hours) attention by a speech therapist who gave her very small amounts of food each time began a slight positive trend. The doctor ordered a stay at the hospital for a week of intensive medical tests and tube feeding. The tests revealed no identifiable medical condition; the feeding intervention, however, appeared to help the woman begin to come out of a severe deficiency. I encouraged the family and had regular sessions with the woman. The Paxil was obviously not the major issue in this woman's situation, nor was it necessary. Getting some nutrition made her at least minimally available energetically. The relative flood of caring attention was a massive contradiction to the despair and discouragement that had contributed to this woman giving up. The positive response of this particular doctor (a young female resident) to my suggestion about the Paxil was encouraging.

My next fax went to the consultant psychiatrist who had approximately ten percent of the residents on his caseload. (Remember that most psychiatric drugs are prescribed by non-psychiatric physicians.) I was referred an 85-year-old woman, having difficulty with "adjustment to the facility;" staff reported incidents of combativeness and resistance to care. When I visited her, however, she was in a stupor; extremely lethargic, she slumped in her chair, spoke in a mumbling whisper, and seemed to have great difficulty pulling up her thoughts. What she did say was coherent, though she was not well-oriented to time. Orientation to time often seems the first to go in senility; many residents know very well who and where they are, but live in a world frequented by long-dead friends or family members. This particular woman had lived independently until just a few months ago when she reportedly had a "psychotic break" and was admitted to a psychiatric hospital where she began a heavy-duty regimen of psychiatric drugs. She came to Mountain Valley from the psychiatric hospital. When I met her, she was on the following drugs: 15mg of Remeron, 10mg of Zyprexa, and 1mg of Haldol PRN.

Haldol, one of a class of drugs known as neuroleptics, is extremely powerful , and has been very popular over the years for use with people labeled "psychotic." Neuroleptics are widely used in a variety of institutions including psychiatric hospitals, institutions for the mentally retarded, children's facilities and, of course, nursing homes. Peter Breggin declares that: "Psychiatry has unleashed an epidemic of neurologic disease on the world. Even if tardive dyskinesia were the only permanent disability produced by these drugs (i.e., neuroleptics), by itself, this would be among the worst medically-induced disasters in history." (3) Tardive dyskinesia is a neurological disorder, usually permanent, marked by rhythmical, involuntary movements of the mouth, tongue, jaw, and/or extremities; it is often accompanied by impaired mental functioning (i.e., dementia). Breggin calls the therapeutic effect of these brain-disabling drugs a chemical lobotomy. Ron Leifer, another leading critic of psychiatry, says that Haldol is "internal ropes." Social control is the therapeutic effect of Haldol and other similar drugs.

An interesting phenomenon within medicine in general, and psychiatry in particular, is the annual or biannual release of the newest and latest pharmaceuticals, touted as miracle drugs: better, more accurate, more specific, fewer "side effects," etc. Typically, these drugs are the rage for awhile, with glowing testimonials and ever more incredible marketing claims. The twentieth century is replete with examples: cocaine, amphetamines, benzodiazepines (eg., Valium), etc. After usage becomes widespread, effects begin to show, disenchantment sets in. Sometimes the drugs become illegal, as in cocaine and certain amphetamines; usually people become resigned as in Valium, and other newer, "better" substitutes come to the fore. Zyprexa happens to be another one of these "newer and better" drugs, touted to be a significant improvement over other antipsychotic "medications." It also happens that Eli Lilly and Company's ten percent gain in third-quarter earnings in 1997 was due in part to strong sales of one of its newest products, Zyprexa. In its first twelve months on the market Zyprexa sales totaled $550 million. (4)

There are a number of people in nursing homes who have come there to end a long identity as "chronic mental patient." Generally subdued and on "maintenance" drugs to keep their "schizophrenia" under control, these individuals are usually passive and compliant, resigned to die quietly in whatever facility they reside; they are generally not referred to a psychologist for counseling. The 85-year-old woman on Remeron and Zyprexa was not a "chronic mental patient," however. She had been involved with psychiatry only a few months, but she was labeled "psychotic," and in the business of psychiatry, psychosis is generally not considered a transitory phenomenon; the use of brain-disabling drugs will usually ensure, in fact, that it is not transitory. This particular woman did have some organic complications, including a syphilitic condition with neurological effects. I could not help wondering, however, to what extent her so-called psychosis was about anger and frustration with her situation and with her daughter's decision that mom needed to move from her own apartment to institutional living. Not that the daughter was necessarily inaccurate in her judgment that her mother's declining abilities of self-care precluded independent living, just that rage at daughter as conveyor of such a doomsday message might be understood as an emotional response to an awful reality, rather than as evidence of a psychopathological disease. Too rapid grasping of a biopsychiatric interpretation almost always precludes genuine consideration of the human factors involved.

I have just revealed a glimpse of the thorny issues involved in this woman's life, not unrepresentative of many nursing home residents. My immediate concern was that I perceived this woman to be in a lethargic stupor, and I suspected that it was largely drug-induced. Her referral to me was due to her anger and combativeness, energetic behavior that was a far cry from the woman I was seeing. The social worker completely agreed with my hypothesis. Interestingly, however, many of the frontline staff didn't even consider that drugs might be a factor. A wonderful occupational therapist who had worked there for six years, and was both respectful and affectionate with the residents, liked this woman; yet he was taken aback when I suggested that we didn't have a clue what her personality was really like unless we got to be with her in a drug-free state. In any event, I faxed the psychiatrist a note saying that the client appeared to be in a stupor and did he think a dose reduction might be appropriate. He didn't respond to me, but he lowered the Zyprexa dosage from 10 to 7.5mg. I detected a slight improvement, but things became complicated with the doctors before going further with this direction.

I had begun working with a blind woman whose primary physician gave consent for me to work with her. This man, call him Dr Z, had the largest number of residents at Mountain Valley under his care, next to the medical director of the facility who reportedly was a primary mentor of Dr Z. The woman was referred to me for "ineffective coping with the loss of her husband," who was also blind. They had moved to Mountain Valley several months ago from another facility because she was extremely dissatisfied with the quality of care they received at the former institution. The husband had been seriously ill for awhile and died several weeks prior to this referral. Staff were concerned that this woman, normally very active, was showing signs of withdrawal, and that she was avoiding talking about and grieving for her lost husband. They were also concerned that the woman was suspicious and distrusting, both of her daughter and of the facility; the psychiatric label is "paranoid." This woman's first reaction was to have nothing to do with me, a not uncommon response I soon found out. In her case, the primary reason was a "bad experience" with a former counselor; she changed her mind when I assured her that I would not push her to explore painful feelings that she preferred to leave alone. As I began meeting with her, however, she quickly opened up and used me as a listening resource. She talked a lot about her husband, and about her frustration and dissatisfaction with his care at both Mountain Valley and at the former facility. She was angry and I could see her fear. She had some ideas about her daughter conspiring against her. Although I never got to really check this out, it was the kind of talk that quickly gets labeled "paranoid." My definite sense in her situation was that, while she probably dramatized some of the literal facts, there was also truth, especially about her own experience of her situation. Like almost all of the residents with whom I worked, she did not want to be there. A large portion of her counseling time was spent complaining about her frustrations and the inadequate responsiveness of facility staff. Complaints about food and food delivery were by far the most frequent with all the residents I met, with medications second. My client had major complaints about both.

I had been working with this woman for about four weeks when she was admitted to the hospital for a weekend of intensive blood and gastrointestinal testing after routine blood-work had shown some anomalies. Early the next week, Dr Z had left a message indicating his concern that she was psychologically disturbed. She was refusing to take all of her medications (these were not psychiatric drugs), and told me she did not at all trust her doctor now. She had doubted the necessity of the medical tests; the negative results had convinced her there was deception going on, especially since the pills she was taking were slightly different. Being blind, she relied mostly on tactile feel of the pills to verify their consistency. The form of Tylenol she was given at the hospital was a gel-cap which she had taken previously on her own and which she liked because it did not upset her stomach, whereas she did not like the hard form at the nursing home. She was on strike, a determined non-cooperation until this was resolved.

It quickly became clear to me that the hospital visit had scared my client. The procedures were highly invasive and had hurt her; she was suspicious and felt that some negative results must have been kept secret from her; after all, why else would she have had to go through all that and why would the pills be different. I had a strong impression that honoring her request for the other form of Tylenol would have resolved the situation, but this option was refused because Medicare would pay for the hard tablets, not the gel-caps. The social worker's suggestion of taking a little petty cash and going to Walgreen's for the gel-caps was ruled out as against policy. So I found the most involved nurse and we met with this woman and began answering all her questions about the medications in detail; her questions were clear and specific. All along, despite her fears, I was impressed that the woman was one of the clearest thinkers of all the facility residents. She could be most stubborn and difficult, she became confused at times, but she was persistent and independent-minded. She was still refusing the medications, but I thought we were making progress in restoring trust and good communication.

I then learned that a psychiatric consultation had been ordered for this woman. I called Dr Z to discuss this with him, explaining my thought that his patient had been extremely frightened by the hospital experience, and that I and the facility staff were actively engaged with her in re-establishing safety and trust. I also told him that, as his patient was feeling a lot of fear and distrust of doctors just now, another consult might exacerbate the situation. I told him that her thinking, as evidenced by the questions she was asking, appeared clear and strong. I did not express my experience that psychiatric consultation virtually always results in a prescription for psychiatric drugs. Dr Z told me that he had already gone over in detail the medications with his patient, that whatever I was doing apparently wasn't helping much, and that he wanted a psychiatric consultation. He wanted me to support this; I told him that I would certainly do nothing to interfere, but that I did not agree with the decision. We hung up the phone with tension between us. I was delighted and encouraged that he called back in a few minutes, and expressed his desire not to "get off on the wrong foot," and that he favored the general direction of my work. I told him that I did not want to come across as if I had all the answers, that I greatly appreciated his calling back, and that I really wanted us to be able to work together. He went over again his reasons for a psychiatric consult, that maybe this psychiatrist could help, that maybe anti-depressants would be helpful, that he wanted more input. I listened, then reiterated my perspective on the woman's situation, and concluded that we disagreed. The next day, he called to cancel his order for psychotherapy, firing me from the woman's case.

Another patient of Dr Z's with whom I worked was an 86-year-old Spanish-speaking woman who spoke very little English, and who had a serious heart condition. She was referred to me for "physical abuse of staff and residents," anger, combativeness, and verbal communication deficits. I spoke enough Spanish for limited communication, but I also included her bilingual daughter-in-law in some of our interactions to make sure all communications were clearly understood. The woman was far from robust; it was hard to imagine her being physically abusive, but staff reported that there had been incidents of angry verbal tirades and physical striking out. She had been at the facility for less than six months, having lived independently until that time. She seemed resigned to being there and had good family support. Upon interviewing the staff and meeting this resident, it was clear that she had genuine difficulty adjusting to the facility, and that she became afraid and frustrated. These reactions are common due to the loss of so much in the way of family and home, typically compounded by a frightening decline in both physical and mental condition. Impairment of short-term memory, as in the case of this woman, tends to be scary in and of itself. She communicated in Spanish, and few of the nursing home staff could understand. My impression was that, besides the anguish associated with her illness and having to be separated from her community, the immediate cause of her "abusive" incidents was frustration with an inability to be heard and understood. I worked closely with her and her family and facility staff, assuring her that I would do everything I could to see that her needs and desires could be expressed and understood. I found facility staff who were bilingual and who could be called upon when anyone did not understand what she was saying. I took a strong interest and kept in touch with her, and I asked her daughter-in-law to stay closely involved and help monitor the situation.

When I got this referral, I also discovered that the woman had, just a few days prior, had a psychiatric consultation and been prescribed a small dosage of the aforementioned Zyprexa. After my initial contact, I saw absolutely no reason whatsoever that she should be on so-called anti-psychotic medication. In speaking with the family, I found out that, as is so often the case, they knew nothing about the "medication." The policy of this facility, common to nursing homes in general, is that a blanket consent to doctors' decisions regarding "medications" is required as a condition of residency. (I did not address the question of whether such a blanket consent to medical treatment, including psychiatric drugs, is a gross civil rights violation.) The family did not think she needed it; they were mostly concerned about the burden of any extra medications, given the severity of her physical condition. (I later found out that my talking about "medications" with family was a significant black mark against me in the eyes of not only the doctors, but also the administration.) With this information, I approached the administrator and director of nursing to discuss how to proceed. The administrator had already told me that he was going to speak to the psychiatrist about his desire to discontinue working with him. I had already been counseled by my supervisor to stay out of the middle of the conflict between the facility and the psychiatrist, so when he asked my advice, I simply suggested that it seemed necessary to have his medical director strongly aligned with this decision. After all, the doctors were making referrals to the psychiatrist; their cooperation was absolutely necessary. In any event, I gave my assessment of this woman's situation and expressed my opinion that it would be nice to work with her for awhile and see if positive change could happen without the Zyprexa; since she had just started the drug, it would be good to discontinue it as soon as possible. The next day, the nursing director informed me that she had called the medical director, and that he immediately discontinued the Zyprexa. I continued to work with the woman, and over the next three weeks, she showed improvement in her mood. There were no more "incidents."

As I said earlier, Dr Z had already fired me from the blind woman's case. We had had a few phone conversations by that point, but had not met in person. When he showed up in the first floor nurses' station just a few days after firing me from the one case, I took the opportunity to introduce myself, and to confirm that he still wanted me off the case. His response was that yes he not only wanted me off that case, but was canceling orders for my involvement with two others as well: the Spanish-speaking woman and the 85-year-old woman discussed earlier about whom I interacted with the psychiatrist regarding what I perceived to be a drug-induced stupor. Dr Z let me know that he would have liked to have removed me from all his patients, but there was one other whom he thought I was helping. The bottom line, he said, was that he couldn't work with anyone who didn't agree with him.

Physicians are like kings --
They brook no contradiction. (5)

He gave the example of a heart surgeon calling in a consultant; if the consultant didn't agree with the procedure, how could they possibly work effectively together? I was amazed. I thought the idea of a consultant was to get another opinion, but at least he was clearly defining his conditions. He brought up the Spanish-speaking woman, and when I responded that he was obviously very angry about this, he reacted and let me know in no uncertain terms that he was not angry. When I said that it sure felt like it to me, he said that feelings were my business and that he did not appreciate my speculations about his. So I said that, in any event, he strongly disapproved, and he acknowledged that. (I later learned from another source that he had been offended by this remark and by my, at some point, touching him with my hand. I also learned that he had verbally attacked at least two nurses and the social worker about the changing of this woman's medication. The social worker's subsequent frustration with and distancing from me is a good example of what often happens when someone challenges authority; it is similar to the anger and scapegoating one sees in alcoholic families when one member courageously confronts the alcoholic and gets attacked by the others for doing so.)

Dr Z took great pains to let me know that these decisions were his responsibility, that he was the doctor. My explanation that I thought I was going through proper channels, that I convey my opinions to the nursing staff, that they contact the doctors, that it remains the doctor's decision as only they can give orders regarding medication. I explained that the medical director had apparently been on call for him when this happened, and that if he had an issue with the director's decision, he should handle that with him. He acknowledged that he would do that, but he was far from satisfied. He went on to let me know that he had worked with SPS psychologists before and that they had always been "seen but not heard," and that this was how it should be. Our talk got heated at times, and at one point when he made it clear that it was really the psychiatrist's order (collegial loyalty is always a major factor in any attempt to challenge medical authority), I shot off that at that very moment the psychiatrist was in the administrator's office, and my understanding was that he was being told that the facility did not want him there. He didn't say much, but the social worker who was sitting with us assured him that it would be a gradual termination, that the man couldn't just be fired from his current patients, and I agreed.

Restoration of Order

Later that day, Dr Z met with the administrator for a long time. I queried the administrator later, and he said that it was no big deal, that after being a nursing home administrator for awhile, his back was like leather, the anger and conflict just rolled off. He said he had discovered that the psychiatrist couldn't be dismissed, and that we needed to try to work with what were "appropriate" levels of medication. I nodded, but also pointed out that in the conflictual case of the Spanish-speaking woman, our consensus (the administrator, the head nurse, and myself) had been that no medication was appropriate. He shrugged. The psychiatrist and Dr Z had met with the administrator on Wednesday. I don't know what else happened, but when I approached the director of nursing, she was extremely distant and reticent. My own supervisor showed up on Friday saying that there was a hubbub, and wanted to know everything I could tell her about what happened as she was preparing to meet with the administrator. I filled her in with as much information as I had. The one comment that most disturbed my supervisor was that I told the doctor during our heated exchange about my understanding that the psychiatrist was being told he wasn't wanted here even as we spoke. She reminded me that she had counseled me to stay out of the middle of this; my comment was a big mistake in her eyes, a significant failure to keep my boundaries.

On Monday night, my supervisor called and informed me that the administrator wanted to replace me with a psychologist who was "more experienced in long-term care." He had presented her with a list of examples that demonstrated my inexperience. She went over the list with me. Most of it was factually accurate; I had been very upfront from the beginning about my inexperience in this setting, asking a lot of questions, etc. I learned quickly, though, and am sure that I was doing a good job. My supervisor listened to my interpretation that "more experienced in long-term care" means "passive and unquestioning of doctors," that I was being scape-goated as the administration quickly backpedaled to appease the doctors. She didn't say much in response to this. Senior Psychology Services wanted to work in that facility and in the chain of which it was a part; the bottom line, my supervisor told me, was that they needed to do whatever the administrator wanted; in this instance, replacing me. The next day I went in, saw the rest of my clients, and began vacating my office. I went back the next Monday and terminated with all of my clients, letting them and some of their families know that the facility had decided to replace me. I said a few good-byes, but never really talked about what happened with anyone there except one physical therapist who was curious about a note in the chart canceling orders for individual psychotherapy. I passed my keys to the social worker and left. The supervisor had asked me if I would talk with my replacement(s) and I said yes, but they never contacted me.

The saddest part of the whole affair is that so many of these elder residents remain unnecessarily on toxic psychiatric drugs. The doctors were more interested in asserting their authority than in listening to what I had to say and looking at what was actually happening with their patients; they put the Spanish-speaking woman right back on Zyprexa even though she clearly did not need it. It was more desirable for the administration and staff to allow and accept unnecessary drugging than to risk conflict and job loss.

Afterthoughts

It is my view that the primary role of psychiatry in nursing homes is as an agent of social control, allowing facilities to handle large numbers of individuals in need of extensive care with inadequate numbers and preparation of staff, and inhuman environment. The result is oppressive, and as usual money plays a major role in oppression. There is big profit in nursing homes. Figure Mountain Valley at 210 residents. Medicare pays about $85/day; a rough estimate of daily income would be $17,850. That translates to well over $6,000,000 per year for just one facility. The doctors bill separately, and we know that drug companies are exceedingly profitable. My own primary concern is that so many of us are literally blinded by psychiatric beliefs and rhetoric. The psychological problems of nursing home residents can be roughly classified in two categories, each of which involves a perfectly understandable human response:

DESPAIR. Also known as loneliness, grief, sadness, helplessness, hopelessness, and giving up, despair leads to withdrawal and decline. Our elders experience these feelings in response to abandonment by friends and families, loss of a decent home, and ongoing loss of their ability to function in various ways. It is not difficult to imagine humane and helpful care for individuals feeling despair. It's called social involvement, caring friends, warm affection, colorful and engaging environment, opportunities to be of service, etc. Instead, psychiatry helps to promote and allow the obscuring of common sense by attributing human problems to a medical, biologically-based "mental illness" and "treating" it with drugs.

FRUSTRATION. Also known as irritation, anger, hostility, non-compliance, and being difficult, frustration leads to belligerence and rejection and alienation of friends and helpers. Elders who still have emotional energy and are what we call spirited individuals experience intense frustration at everything they've lost. They often feel humiliated at the loss of autonomy and at having virtually everything done for them. Common sense would address these feelings as completely understandable and work to create an environment which allowed opportunity for many varying levels of personal responsibility. I listened to elders yearn for an opportunity to prepare their own meal, for example. Blinded by irrational belief in the tenets of biopsychiatry, common sense is sacrificed to the complicated world of drugs and diagnosis. "Medication" is the very first line of defense in the war against incipient "mental illness."

Let us not turn our backs to the immoral and unethical psychiatric drugging of elders in nursing homes. It is tragic and unnecessary damage and it needs to stop. To stop it we all need to grow up and become our own authorities. We must sacrifice once and for all the childlike illusion that societal authorities, in the guise of medical doctors, know more than we do and can be trusted to take good care of our elders.