Guest Blogger Dr. Jesse Hellman: More Thoughts On Rachel Aviv's Article on Involuntary Treatment

Jesse has wanted to do a guest blog post for a while now, and The New Yorker article finally got him blogging. I wrote a brief post yesterday, but he does a more thoughtful analysis of this complicated and provocative issue. Clink is off somewhere.. I am looking forward to hearing her thoughts after the holiday.
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In “God Knows Where I Am” Rachel Aviv sees the protagonist Linda’s
refusal of treatment as an expression of her illness. The moral
impasse she describes for our profession, though, is real: denial of
the need for treatment, or of one’s illness, can be an expression of
that illness; the refusal of treatment can also be a valid position
which we understand and support.

Mental functioning can be variable, at times better and at times
worse. At times the craziest thoughts are held in check, or do not
manifest themselves, while at others they hold total sway. The
underlying assumptions of our society are shared by us, and these
shape our reaction to the illness that Linda has. Other societies,
with different traditions and philosophical underpinnings, are
comfortable with very different stances.

Before Linda was discharged from the hospital the staff did everything
they could to dissuade her, and to provide for her safety. She
rejected every effort to provide housing and support. The hospital
argued that she was too sick to make decisions which even included not
allowing the staff to notify her sister and daughter. After her death
the family sued, stating that insufficient effort had been made to
protect her. The hospital then argued she was not sick enough to
justify stronger measures. What was true?

When we look at a complex issue, or event, we naturally can only see a
part, and our response is shaped both by what we see as well as the
assumptions we carry. What weight to we place on independence versus
the rights of others? What extrapolation can we make to an unusual
thought, in that do we see it as the harbinger of insanity or of
artistic creativity? Do we value religious musings or find them
suspect?

Aviv lets us see that while a part of Linda’s functioning might have
been creative, artistic, perceptive and so on, it was increasingly
shaped by an imagination which was not tempered by reality. It was as
if she was in a dream but could not awake, a dream which increasingly
dominated the most important parts of her ability to survive.

So what is the proper role of society when confronted by such illness?
What if her fantasies had shifted from thinking spies were all around
her to imagining the world could only be saved if she were to shoot
her congresswoman?

You May Go Now.

I've learned something important from....reading the comments posted to our blog, listening to people talk, being a person who talks....No one likes to feel their concerns are being dismissed (myself included).

It's a recurrent theme in the comments that are sent to us, especially with regard to medications: a reader has a concern about a medication, feels it isn't working or that the side effects are too severe, and either their doctor does not address their concerns in a way that feels validating or the reader perceives that the doctor does not understand....since I'm not there, I can't say which is happening, but the feeling on the part of our readers is clear.

And just so you know, I've been on both ends of the discussion. I once lowered the dose of a medication, found it to be just as effective at a very low dose, and was told this was a "homeopathic dose." I didn't really know what that meant. In my terms, I had a headache that felt very real to me, and after taking a very low dose of a painkiller, my headache was gone. I wanted the least possible medication, so I stuck with the low dose. I'm not sure what was meant by the comment, but I heard it as the dose I was taking was so low it couldn't really be helping and I must have been imagining it's efficacy. This was my interpretation; the doctor may well have said it was simply to comment on how low the dose of medication was and not as a statement related to either the realness of my symptom or the realness of my response. I suppose I would have preferred to have heard that I must be rather sensitive to the effects of the medication, the "homeopathic dose" comment rubbed me the wrong way.

I've learned there a patients who have unpredictable and unexpected responses to medications. Some people tolerate huge doses of medications, others don't tolerate even small doses. Sometimes people have weird responses, and we don't really know what to make of it. My favorite example of this happened many years ago-- a patient told me he saw "trails" of light when he turned his head which he attributed to the Serzone I prescribed. Okay, that's weird, I'd never heard of that type of side effect from ANY medication. I didn't know what to make of it. The next week, I saw a case report in a journal of three cases of "visual trails" induced by Serzone. Go figure.

So why don't doctors just take patients' word when they say they are having a specific symptom: be it from an illness or from a medication? Why don't doctors hear when patients say they are very sensitive or not and need very high or very low doses of medications? More and more, I think we do.

Why not always?
Here are some reasons:
--Sometimes doctors are dumb.
--Sometimes doctors are egotistical.
--Sometimes doctors are frustrated. Especially if a medication helps an illness but causes awful side effects. And it's not just doctors. Family members will want patients to stay on their medications because they are less irritable, more functional, easier to get along with...even though the medicines cause side effects.
--Sometimes patients lie. This is especially true when controlled substances are involved: So a patient says that he's anxious and absolutely the only thing that helps is 6 mg a day of Xanax and he feels slighted that the doctor doesn't just take it at face value and prescribe it. Or believe that he's dropped the pills down the sink? Or never gotten them from his 90 day mail order company
--Some people are very suggestible and develop many side effects that they've read about. I really do wish there was a way of saying this without the word "suggestible" having a pejorative feel. Can't it just be? In medical school, I once heard someone say you can tell if a patient is simply saying "yes" to everything if they said their hair hurts when they pee (hair can't feel).
--Sometimes patients complain of things we've just never heard of .happening before. I don't think these problems should be dismissed, and I've taken to telling patients that I'm not in their body/head and they really need to be the one to determine if the benefit from the medication outweighs the side effects. This can be a difficult decision in the time while they are waiting to see if the medication is going to be effective.
--Sometimes patients misinterpret their doctor's comments. I'm often told I think such-and-such when in fact I don't think that at all. My doc might be surprised to hear I took the "homeopathic" comment to mean any thing other than 'my, what a low dose you responded to."

Finally, I've learned that patients can have very high expectations of their doctors. People often write in angry that their docs didn't warn them about specific side effects, and they'll mention a side effect to a medication I've never even heard of. It doesn't mean I don't think it happened, it just means it's not the usual for a psychiatrist to warn a patient, hey MedX could make your nose turn green and swell.

I think in psychiatry, we're all still just finding ourselves. So many of these medications are so new, and they efficacy and side effects varies so very much from person to person. Why does one patient get better with no side effects at all from the very first medication, while someone else is on maximum doses of 5 medicines at once, and still another patient has intolerable side effects to a tiny dose of anything?

I Forgot

I was driving home from work the other day and I heard a piece on National Public Radio about professional musicians who forget their instruments. I didn't hear the whole thing, but they mentioned stories about symphony musicians who leave expensive instruments somewhere (the Stradivarius left in the cab, for instance).

They asked a mental health professional who also happened to be a musician why people do these things. The mental health talking head said it happened because the musician was "hyperfocussed" or so concentrated on the upcoming performance that everything else was driven out of the mind. He also speculated that performance anxiety was expressed as an unconscious wish to lose the instrument. What he didn't mention, but the first thing that popped into my head, was sleep deprivation or just simple absent-mindedness.

We all do absent-minded things at some time in our lives. We lock our keys in the car, or ourselves out of the house, or we forget to pay a bill or to mail a bill that's already been paid. We forget birthdays and anniversaries and other important dates that we (and our loved ones) really expect us to remember. Fortunately, we also forget anniversary dates of things that are better left forgotten, although I think it will be a long time before anyone forgets dates like 9/11. (Do young people know the date 12/7? Isn't it amazing what we, as a collective national memory, forget?)

Yet we don't consult mental health professionals about why these things happen. Remembering things, and forgetting, are a natural mental process that happens continously outside our awareness. If the problem becomes too severe---if we start forgetting the names of our spouses or children or where we live, or if the memory problem becomes associated with other brain problems like writing or reading or talking, then it becomes a disease.

Age-related memory changes may concern older people, but they are not necessarily a sign of progressive disease. It can also be a sign of clinical depression, in which case memory problems are temporary and reversible.

Of course, none of this explains why I keep forgetting to take my iPod out of my my car when I get home. It must be an unconscious fear of listening to My Three Shrinks. What I want to know is, what's the unconscious wish for forgetting to pick up your kid?