The most frightening part of helping to take away a psychiatric patient's right to make decisions is that I'm getting good at it.
I have learned how to formulate a patient's history and recount the details of his or her present illness and worrisome behavior in a way that makes the risks of free choice -- of liberty -- unacceptable to a judge. I make the court comfortable with the notion of the state as parent. There are key facts I highlight -- a history of assault or self-destructiveness or caution thrown dangerously and unpredictably to the winds.
I am new at this, a senior resident in psychiatry, yet I have never been denied.
The patients for whom psychiatrists seek medical guardians are generally those at risk of harm, who either refuse widely accepted treatments or are too disorganized or sick to reliably see them through.
We must be convinced that mental illness has so disrupted the patient's thought processes that he or she cannot rationally elect or reject the alternatives we present. Sometimes, the guardianship is temporary -- just long enough to get through a period of worsening symptoms. When the likelihood of restoring the patient's safety and reliability is remote, however, guardianship can be permanent.
I agonize about removing my preconceptions from the process, trying to make sure that I'm not making judgments about what is appropriate, only about what is dangerous. But I am never completely at peace taking such action. From boyhood, my personal evolution has been an ever-increasing bias for the individual and against the status quo. I strongly empathize with people who cannot comply with the demands of society, believing as I do that society itself is deeply flawed and insensitive. No wonder that I bristle at the gates between what we label eccentric, what we call sick and what we brand, finally, as incompetent.
The legal environment is foreign to me. I feel out of place in a courtroom, designed as it is for defense and prosecution. I dislike watching my patient listening to my testimony, as if we were opponents, when the truth is that my gut sinks when I think the lawyers' questions might hurt my patient's feelings. What I love about psychiatry is building alliances and trust. What could be a more graphic representation of my failure than a courtroom?
Some cases are easier than others. One of the easiest concerned a schizophrenic and diabetic patient who had repeatedly stopped taking his antipsychotic medication. He was a big, brawling man and he felt the medicine weakened him physically. It probably did. Unfortunately, when he stopped taking the antipsychotic drug, he began to feel indestructible and also refused to take his insulin. He was transferred to my ward from the intensive care unit, where he had received emergency treatment for ketoacidosis, a sometimes fatal complication of uncontrolled diabetes.
The clarity of the danger against the cloudiness of my patient's insight made illness my clear opponent. I was fighting to preserve a vulnerable person against a faceless intruder that had nearly taken his life. Two against one; we were a team, even if he couldn't quite see it that way. I read his unwillingness to accept a guardian voluntarily as inability to acknowledge weakness, to come to terms with the constraints of his illness. And I told him so.
The judge listened to my testimony and heard the danger. He ordered a temporary guardian who would monitor the patient's medications and consent, in his place, to medical and psychiatric treatment. The guardianship would be reevaluated after 60 days. I felt I had performed a good service. All the more when my patient thanked me and shook my hand.
The art of inviting the courts into psychiatric treatment is in preserving a relationship with the patient, despite the adversarial nature of the process.
It isn't always easy for me to choose sides. The hardest cases are those in which the danger is more remote, and I question how much psychiatry can truly offer the patient in exchange for dependence.
What if the medicines work poorly or inflict severe side effects? What if the patient's life, albeit colored by the limitations and dangers that attend mental illness, is nonetheless more full than it would be once legally bound to the system?
In such cases, I am relieved that decisions to pursue guardianship are made by a treatment team, including senior physicians, and that the judge -- not the medical expert -- is the final arbiter. I take an emotional step back.
I cared for an elderly man who suffered from mania, a disorder of mood marked by too much energy, a disturbing rush of ideas and, often, grossly impaired judgment. He read voraciously, traveled state-to-state and especially enjoyed discussing, at lightning speed, current events. Unfortunately, he also trespassed frequently and approached random strangers as friends. Rejecting the notion that he was ill, he refused all medications and energetically argued that he should be allowed to leave the hospital.
Reigning this patient in hurt me because I found his intellect lively and his nai vete' charming. I was moved by his protest for freedom. It took guidance from the treatment team to help me balance the benefits of maintaining his free choice against the risks of his innocence in an unfriendly world. They helped me to see the pain behind his seemingly carefree demeanor and to see his illness as the real impediment. We proceeded successfully toward treatment. But I felt uneasy all along the way.
Sometimes, however, it becomes clear to me that the best thing to do is to step aside. One of my patients, a young woman, was admitted to the ward with bizarre religious preoccupations. She was preparing, through diet and prayer, for an impending Armageddon. She heard voices that she understood as friendly spirits. She had pledged herself to a communal religious home where she said she felt safe. The patient's psychiatric history included treatment with a dozen antipsychotic medicines that had failed to blunt other hallucinations and delusions.
My initial instinct was to do something, to defend reality. But ultimately, I supported her discharge from the ward.
The fact was that whatever structure my patient's religious beliefs were providing was helping her, hallucinations and all, better than hospitals or medicines ever had.
Part of becoming a psychiatrist has been learning to use the techniques and tools at my disposal. Partnership with the law is an important one. Knowing how to use the courts is an invaluable skill in fighting mental illness.
An equal challenge, however, has been learning when to sit back, to listen to the wonderful, if sometimes painful, diversity of human experience, and to let well enough alone.
Keith Russell Ablow is a resident in psychiatry at New England Medical Center in Boston.