Psychiatric Annals

Letter to the Editor 

Letters

Brian S Joseph, MD

Abstract

I am writing in response to your invitation to comment on what might be done to improve the image of psychiatry in the public mind ("Personal Reflections," June, 1976). I'd like to comment on the appearance psychiatrists may tend to give of valuing their own convenience when the clinical situation requires active intervention. We can easily rationalize these instances by saying that the family or the patient "needs to accept more responsibility." Such behavior is well described in Adams' and McDonalds' "Clinical Cooling Out of Poor People."

Let me illustrate what I mean. In May, I was covering a Mend's practice while he was away at the A. P. A. convention. I received a call from a young woman on Saturday afternoon requesting help with her mother, who was undergoing a manic cycle of a longstanding manic-depressive psychosis, cyclical type. I suggested that the immediate family (two daughters and two sons-in-law) take the mother to the psychiatric emergency room of a well-known general hospital and told them I would keep in contact by phone. The daughter felt that this could not be managed, that her mother would resist.

At this point, it seemed to me that there was more resistance than was warranted. I asked myself: Couldn't four adults be firm and assertive enough to coerce a 60-year-old woman to go to the hospital? I voiced my thoughts. The daughter felt that it "just could not be done."

They also felt it could not wait. Again I felt that there was some resistance, but a plaintiveness in her voice made me decide to involve myself further. I offered to make a house call! There was some further negotiating, and it took until Sunday evening before the family was certain that the mother was now at home after a frenetic weekend of visiting other family members and drinking.

I met the family at their mother's home and talked with the patient. She did appear to be irritable, though not overtly psychotic. She refused all medical help, and I decided to commit her for 10 days' observation. I called the police, filled out forms, and accompanied the patient and her family to a private psychiatric hospital. (I carried injectable Thorazine® and syringes with me, but fortunately it was not necessary to use them.)

At 1:30 a.m. we all parted company. The family members were truly grateful, and we all felt that it was only a matter of time before everything would be worked out.

Unfortunately, real life has a few surprises. The hospital where the patient was placed did not feel that the patient was committable! She demanded to leave, and while hospital personnel could see that her judgment was somewhat impaired, they did not feel that they could hold her any longer in good conscience. She was discharged on the following afternoon.

I counseled the family further. Initially they were quite distraught but were able to recognize the difficulties of the situation. If their mother got better spontaneously, perhaps she would then accept lithium as prophylaxis. If she grew worse, firmer grounds for commitment would become evident. At this point, it seemed that all we could do was to allow the situation to go its own way.

I did meet with one of the daughters later in the week, at her request. And it was only then that I understood why she had initially been so reticent to force her mother to become involved with mental health professionals. When she was 14 years old, she had witnessed an early forced hospitalization. The experience was traumatic, and she wished to avoid such…

I am writing in response to your invitation to comment on what might be done to improve the image of psychiatry in the public mind ("Personal Reflections," June, 1976). I'd like to comment on the appearance psychiatrists may tend to give of valuing their own convenience when the clinical situation requires active intervention. We can easily rationalize these instances by saying that the family or the patient "needs to accept more responsibility." Such behavior is well described in Adams' and McDonalds' "Clinical Cooling Out of Poor People."

Let me illustrate what I mean. In May, I was covering a Mend's practice while he was away at the A. P. A. convention. I received a call from a young woman on Saturday afternoon requesting help with her mother, who was undergoing a manic cycle of a longstanding manic-depressive psychosis, cyclical type. I suggested that the immediate family (two daughters and two sons-in-law) take the mother to the psychiatric emergency room of a well-known general hospital and told them I would keep in contact by phone. The daughter felt that this could not be managed, that her mother would resist.

At this point, it seemed to me that there was more resistance than was warranted. I asked myself: Couldn't four adults be firm and assertive enough to coerce a 60-year-old woman to go to the hospital? I voiced my thoughts. The daughter felt that it "just could not be done."

They also felt it could not wait. Again I felt that there was some resistance, but a plaintiveness in her voice made me decide to involve myself further. I offered to make a house call! There was some further negotiating, and it took until Sunday evening before the family was certain that the mother was now at home after a frenetic weekend of visiting other family members and drinking.

I met the family at their mother's home and talked with the patient. She did appear to be irritable, though not overtly psychotic. She refused all medical help, and I decided to commit her for 10 days' observation. I called the police, filled out forms, and accompanied the patient and her family to a private psychiatric hospital. (I carried injectable Thorazine® and syringes with me, but fortunately it was not necessary to use them.)

At 1:30 a.m. we all parted company. The family members were truly grateful, and we all felt that it was only a matter of time before everything would be worked out.

Unfortunately, real life has a few surprises. The hospital where the patient was placed did not feel that the patient was committable! She demanded to leave, and while hospital personnel could see that her judgment was somewhat impaired, they did not feel that they could hold her any longer in good conscience. She was discharged on the following afternoon.

I counseled the family further. Initially they were quite distraught but were able to recognize the difficulties of the situation. If their mother got better spontaneously, perhaps she would then accept lithium as prophylaxis. If she grew worse, firmer grounds for commitment would become evident. At this point, it seemed that all we could do was to allow the situation to go its own way.

I did meet with one of the daughters later in the week, at her request. And it was only then that I understood why she had initially been so reticent to force her mother to become involved with mental health professionals. When she was 14 years old, she had witnessed an early forced hospitalization. The experience was traumatic, and she wished to avoid such an unpleasant situation in the future. But the fact that the experience with her mother had occurred, and had been handled in a professional manner, allowed her to resolve her earlier guilt. During our meeting many questions - ranging from her mother's prognosis to the genetic consequences for her and her family - were answered candidly.

Despite the fact that this experience was time-consuming and somewhat frustrating to me, it was instructive. It taught me that the role of a responsible, involved physician was indispensable to the attainment of a reasonable outcome. The family was pleased, I was satisfied, and the patient was presented with an opportunity to be helped.

10.3928/0048-5713-19770101-01

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