Reflections on Psychiatry: We're all in the Madhouse

It is a beautiful pre-fall day in Montreal -perfect temperature in the low 20s (Celsius) and bright and sunny without too much wind. I am 3/4 of the way through my psychiatry rotation and think that it's important to reflect a little on all I have learned and am continuing to learn, and to document it, lest I forget the moment I dive into pediatrics at the end of the month.

What have I seen so far -lots of schizophrenia, bipolar disorder, personality disorders (borderlines for ever more turning up in the emerg!), substance abuse, eating disorders, suicidal people, post-suicide attempt people, children with adjustment and attention deficit disorders, anxiety disorders... basically, the heart of the DSM (ha, just kidding! have you seen how thick that book is with diagnoses? probably impossible to see every last one!).

And things have been going great for the most part -lots of work of course, especially on in-patient wards, following five patients on a daily basis, lectures, calls in the emergency, child psych clinic once a week, out-patient consults, etc... I have had a lot of opportunities to practice the Mental Status Exam, talk to different kinds of people (old, young, different backgrounds and cultures, even a patient on the verge of deportation... seriously, society is responsible for quite a lot of these mental health problems -the government is so out to lunch most of the time, honestly). My supervisors have been giving me a lot of positive feedback and of course also guiding me to further improve.

It's enjoyable and varied -psychiatry is probably the specialty of medicine that gets most involved with legal issues because acutely psychotic patients do not think they are sick and do not want to stay in the hospital. So, we go to court to have them mandated to stay in hospital against their will "closed treatment", and sometimes even have the court mandate a treatment order so that the patient receives treatment whether they want it or not. And yes, these are serious ethical issues. But honestly, if you had a patient who had stopped taking their meds and became so psychotic that they were a danger to themselves and to others (walking on the highway, sleeping with a hammer, behaving aggressively with complete strangers), don't you think it's kind of half-assed to just have them locked up in a hospital? Unless they receive treatment, they don't actually get better. For most compassionate and risk-averse human beings, this is a sufficient argument for a treatment order.

For those more materially minded, I might say, this means the patient will be hospitalized for longer, using up your valuable tax dollars in hospital resources and the longer they go untreated, the less likely they will respond to treatment, which means that if and when they do leave the hospital, nobody benefits. Similarly, the government wants to deport people whose children are Canadian citizens because they want to save a couple of bucks on a welfare check, but who benefits when those kids get beaten from foster home to foster home, become delinquent substance abusers which may or may not trigger psychosis, doing damage to themselves and to society, not to mention the deliberate breaking apart of a family against their will? This is not a fiscally nor morally sound action. Sigh. So anyway, I have learned that a lot of "grey area" issues in theory can be very obvious in practice -it's often not much of a dilemma. That's the reality.

The most important and humbling thing that I learned though, was about myself, this past week. I also believe that this understanding is somehow deeply connected to the essence of good psychiatry and good medicine. Perhaps it is all based on counter-transferance, but that does not mean that the lessons learned are not valuable. Doctors are imperfect human beings, like anyone else. I am wholly imperfect, but as Deepak Chopra would say, the positive qualities and the shadows within us make us complete as people since we're not meant to be perfect (I know, this is the hardest thing in the world for someone like me to accept, believe me!). Anyway, so generally, I am caring and compassionate, even patient with my patients. I respect them, I try to understand them and learn from them. But when I am overwhelmed and stressed, I get frustrated, I get annoyed, I wonder why the hell these people won't just tell me openly about what's wrong so that I can help them more efficiently.

I don't actually act this out -I maintain the facade, even though I might feel this way. But non-verbal cues apparently insist on getting in the way of the whole act, and my impression so far is that psych patients are particularly sensitive to how you're really feeling and any judgmental attitudes. Really, you can't hide from them. And they will react in more extreme ways to that emotional reality. So if you feel like you severely dislike one of your patients one particular day, they will act it out for you, reflect yourself back at you. They will tell you to "go to hell, go F yourself" or will stare at you insolently and refuse to answer any of your questions. You may turn around and superficially think, "Wow, I did nothing and look, this dude is so crazy", but really, they're just reflecting the truth back at you. Maybe you're the one in the Madhouse, maybe you're the delinquent thinking one thing and behaving oppositely (hey, don't get me wrong, we all prefer incongruence in thought and action to a French Revolution-style bloodbath -how else would society function?) The point is, you're so going to get called-out on your hypocrisy.

So, this means, you have to make yourself congruent. You can't just walk the walk, you have to think the thought too. Your patients reactions (to some extent -sometimes nothing you do will make a difference because the patient is too hallucinated or delusional) are your barometer of how grounded you are and this will affect the quality of care you give and whether or not you'll do any good. Of course, this is not always the case -borderlines will remain emotionally labile and sever psychosis may be beyond anything you said or did, perhaps even most of the time. Still, your job is to make the alliance. So you failed today, try again tomorrow, and try again in a different way the day after that, and again the day after that. Because it does matter and it does make a difference and it will affect how patients cooperate and how they get better (in conjunction with medication, obviously -good luck trying without it in a psychotic patient; note that it can work without medication in other kinds of patients).

And if you made a mistake, it is actually possible to make ammends. I was never rude to my patients, nor did I verbally indicate any transient callous thoughts or frustration. But I still had to make ammends. I had to change my approach for a couple of my patients, with genuine good-will, renewed respect and transparency. And you have to be delicate. In one such encounter yesterday, my patient asked me, before agreeing to respond to any of my questions and after several long pauses, "Do you perceive me as 'sick'?" If I would have said "yes", I would have broken the alliance, he would not have trusted me, he would have clammed up and that would be the end of the interview. So I said, "I see you as a person who values X, Y and Z. X, Y and Z make you happy, and [only say this if it's true] I can understand that because X and Y (in some way or another) are important to me too. I am trying to help your body stay healthy and strong, so that you will have the energy to continue doing those things that make you happy". Maybe this only worked for me the one time and maybe I established enough trust to last a few days, or maybe not (because afterall, the patient remains somewhat psychotic). But after that encounter, I knew I did my job. I want my patients to see me as the ally that I am and I want to understand them better so that I can advocate for them better. And when I make a mistake, I can go slowly and carefully and make ammends.

I also learned that I have a lot more in common with my patients than one would think. Just because I am in medicine, does not mean that I do not embrace the concept of God and religion (half the medical staff was absent for Rosh Hashana, if you want to put things in perspective here). Perhaps I'm considered even more eccentric because I can appreciate the truth in statements like "everything is energy, the universe is energy" and even "i see the world as a field of energy" (and honestly, Einstein did too: E=mc2 anyone? So it's not that crazy of an idea... so does Deepak Chopra, so do a lot of people who do Yoga, etc...) Psychotic patients will say things like this, but these comments alone are not what make them delusional and psychotic. The best thing is when you are able to show that you 'get them' at some level because then they feel respected, rather than being ridiculed, and are more willing to open up to you. And you will totally recognize the moment when an abstract idea, perhaps held by many, is so obviously taken too far, and even more importantly, when a fixation on those ideas impairs rather than enhances the individual's social functioning. There is nothing inherently crazy about saying "the universe is a field of energy and I have that energy", "I'm going to be Prime Minister" or "God sent me message Q". It's the further probing of these ideas -the hows, the whys, the subsequent meanings derived, the details and most importantly, the emerging behaviours -that reveal the incongruencies and the illness.

And as one of my supervisors constantly reminds us, a lot of famous people suffered from those tabooed mental illnesses. John Nash lives with schizophrenia. Robin Williams and Eminem have Bipolar Disorder, so did Winston Churchill, Ernest Hemingway, Beethoven, Newton and Vincent Van Gogh. All of these people have made important contributions to the societies in which they lived, in their different ways. It is worthwhile to try to understand not only the illness, but the people who suffer from them so that maybe they don't have to complete a poetic and tragic suicide.

Anyway, maybe I'm completely off base. But apart from learning the DSM criteria for various mental illnesses and the mechanism of action of various drugs and their side-effects, I feel these are really important lessons to be learning, and better sooner than later. It probably applies to other areas of medicine too. And also, to other aspects of life on this Earth.