Thursday, October 2, 2008

Mind-forged Manacles

"The child's toys and the old man's reasons
Are the fruits of the two seasons.
The questioner who sits so sly
Shall never know how to reply."

Auguries of Innocence

Two fundamental facts distinguish psychiatry from the rest of medicine: the frustrating ambiguity of diagnosis (only partially resolvable by scientific advance because a good part of the ambiguity is philosophical in nature), and the possibility of compulsion that is always implicit in the endeavor. The two difficulties are related of course, for it is one thing to compel an allegedly incompetent person to undergo treatment for unambiguous disease (e.g. appendicitis), and quite another to force treatment for contestable syndromes. While other physicians may occasionally encounter incompetent patients (for whom they usually end up calling in a psychiatry consult), only in psychiatry is the distasteful potential for involuntary treatment always lurking in the background.

Some antipsychiatry fanatics seem to think that psychiatrists delight in forcing treatment on unsuspecting multitudes, but such individuals usually haven't spent much time around psychiatrists. Obviously there are dysfunctional outliers as there always are, but of all the factors that may lead someone to pursue psychiatry or clinical psychology, a joy in foisting treatment on those who don't want it is usually not among them. Arguably, due to the cultural craze for psychotropic medications, stoked not least by direct-to-consumer advertising, the pool of patients who need treatment but won't accept it is dwarfed by "patients" who seek treatment inappropriately or in the wrong places.

Since returning to a public system I have begun seeing the hard cases, of this variety at least, that is, those who are significantly, often grievously impaired by psychotic symptoms but who refuse treatment and do not warrant involuntary hospitalization. Families of such individuals often cannot comprehend how "the system" can allow people to refuse treatment and remain so evidently ill (and as one hapless mother I saw yesterday found out, everything changes in this respect when a patient turns 18). But personal freedom is the default setting here, to be overridden only in the most life-threatening of circumstances. Sure, there is the argument that the psychotic person is not really free, that it is the illness and not the person talking, but society does not have much confidence in psychiatrists' ability to make that sometimes subtle philosophical judgment in the absence of clear and present danger.

So the delusional fellow I saw yesterday who refused to take anything but trazodone seemed somewhat surprised when I didn't threaten him with meds or with commitment. I offered my clear recommendations and said I would see him back next week if he changes his mind (he probably won't, until he gets sick enough that someone does petition him back into the hospital). It doesn't make as good a story as One Flew Over the Cuckoo's Nest, but then again one shouldn't infer much about psychiatry from the big (or small) screen.


Anonymous said...

Didn't psychiatrists start the "cultural craze" for seeking psychotropic medications with reckless abandon for future research about side effects and reassurance that this was the magic elixir?

Novalis said...

Yes, I think psychiatry has certainly promoted the phenomenon in question, but I think it complements a much broader human tendency to aspire to hope in a pill. I'm no booster of mainstream psychiatry (as it exists today).

But when people complain about psychiatry, I think it's a little like complaining about the government. Both institutions are deeply flawed in all sorts of ways, but the people at large--who elect the officials, or who visit the doctors and take the pills--bear some responsibility as well. Perhaps all of us collectively get the government, or the medical system, or the psychiatry (or, individually, the face at 50 as Orwell said) that we deserve. May we aspire to deserve better!

Anonymous said...

I think it's a lot like complaining about the government, as a typical walk-through on FurSeasons comment threads are so steeped in private symbolism it's anybody's guess what the post was actually about. No nuance or discernment (yes, I'm that commenter); just what a bunch of clowns in Congress/psychiatry, throw the bums out. I deal with psychiatrists as I do with everyone, my experience of them person-to-person, not from some inchoate rage directed at an easy target. Try telling the fanatics that.

Anonymous said...

In your bio, you mention being a "recovering academic" yet you seem to enjoy sharing your extreme intellectual prowess much like you would when publishing. Don't you miss academia with its "easier" patients and hand picked colleagues? Either way, this is an excellent, enjoyable blog. Keep up the good work!

Novalis said...

Well, thank you.

These days academic psychiatry is not much interested in these kinds of topics. Esoteric medical journals do exist, in which I have published, but the readership is very limited, and I decided I had said all that I had to say in that formal context. In addition to the obvious flexibility, I like the possibility of reaching more readers.

It is awfully quiet out here though, in rural public work, so keep those comments coming!