Despite the high stakes involved in making a psychiatric diagnosis, identifying patients' specific forms of suffering can be extremely challenging. Dr. Christine Montross, a staff psychiatrist at Butler Hospital in Providence, RI, discusses the challenges of working with the mentally ill in her new book, Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis. In this personal account of her residency and early years of practice, Montross acknowledges the difficulties involved in understanding and treating a few complicated cases.
I spoke with Montross about her own doubts, the fine line between the normal human condition and illness, and what she sees as the most important aspect of treating those who suffer.
What qualifies someone to be hospitalized for mental health issues?
In our current state of health care, patients only meet criteria for hospitalization if they're a danger to themselves or others in some very acute psychiatric state. Historically, people might have been hospitalized for weeks, months, or years when struggling with a mental illness. They would have a longitudinal course of inpatient care. These days, the average length of stays is 5-7 days in our hospital. Years ago, a "short stay" was counted in weeks or months; now it's 48 hours. When they've reached the point of hospitalization, these patients are in a state of emergency. They need to be hospitalized because it might not be safe otherwise.
What was the first case that you had difficulty diagnosing?
One of my patients, Anna, had thoughts of killing her son. If these were "command hallucinations" where the child might truly be in danger, the course of treatment would be for her to be kept away from her son while she was experiencing the symptoms. If they were anxious or obsessive thoughts she would never act on, the course of treatment would be for her to spend more time with her son to be reassured that she would never carry out these actions.
That example underscored not only the difficulty in diagnosis, but also the extraordinary consequences of getting it right. Her case demonstrated that the two potential courses of action were polar opposites in terms of what would be therapeutic for her. Getting it wrong would have grave consequences.
Your patient, Lauren, made scores of trips to the hospital after swallowing knives, scissors, etc. And various people involved in her care became frustrated at the lack of a solution—some were cynical about the chances of her getting better. How can the hospital environment affect things?
We're trained to begin to recognize when a patient's discomfort begins to breed discomfort in the doctor or the other clinicians in charge of a patient's care. Lauren is an example of someone whose life was really in chaos. She had deep feelings of abandonment and fell very far out of control. She tried to regain control through a maladaptive pattern of swallowing dangerous objects.
The typically orderly, calm hospital environment began to swirl into real chaos when she was admitted. Surgeons and medical doctors and psychiatrists, who were ordinarily very respectful and collegial to each other, began arguing with each other about who was responsible for her care. Nurses were agitated that she was admitted. Hospital administrators began to express frustration that they would have to do other paperwork. Suddenly this one patient's internal chaos began to be visible in an external way, which was made manifest in the people who were caring for her. Because doctors are human, sometimes patients bring up in us feelings that are not entirely pleasant. We need to manage uncomfortable feelings that are brought up in the natural course of treating patients.
Is it difficult to make a diagnosis after a patient already has a reputation in the hospital?
It definitely is. Doctors are very busy and increasingly we have less and less time. Our patient loads have increased. So from an efficiency standpoint, we all take shortcuts in taking notes from the record and historical ways of characterizing patients. Most of us go into medicine with a sincere desire to help and cure people. When we meet patients that are difficult to help and potentially impossible to cure, it can bring up real feelings of inadequacy in the physician. We see this in psychiatry but also in the ways that our medical system resists sending patients into palliative care, often to the detriment of patients. There are patients who are terminally ill, whose illnesses are not responding to treatment, yet we send patients far too late to hospice and palliative care. I worry that it's because of a doctor's sense that he or she has failed if a patient cannot be cured. We need to make sure we don't put our own fears in front of what's best for the comfort of the patient.
How did you feel when Lauren was discharged from the hospital?
I felt frustrated with the system. Increasingly, psychiatric patients have less and less access to adequate outpatient care if they're uninsured or underinsured, so what happens is that they have to turn to emergency rooms and hospitals. We could solve the emergency when Lauren came in the hospital—we could remove the objects that she'd swallowed, we could avert the potentially catastrophic outcome of having a perforation in her GI track. But we could not provide care that was really going to be preventative, in terms of accessing why she was doing this in the first place and providing therapy and tailored treatment so that she would do this less and less frequently, if at all. Yes, I was discharging her from the hospital. But I didn't feel like I was discharging her to a treatment plan that had a high likelihood of preventing the same exact situation from happening over and over again, as it already had.
It comes down to how we, as a community, should treat the mentally ill. Funding for mental health has been ravaged over the last number of years, and as a result, we see more patients hospitalized who are sicker and sicker, with fewer resources. We discharge patients from our hospitals; they cannot afford the medications they need or don't have the resources they need to access them; they are seen, if at all, by publicly funded mental health centers that are woefully underfunded and woefully overcrowded; and they do the best they can to provide treatment, but they might see a patient once every four months for 15 or 20 minutes, and these are patients with serious, serious mental illnesses who need regular longitudinal care with a doctor they know and trust, who knows their symptoms and can monitor them and can provide a treatment plan that's specific to each patient. As funding gets cut for care for the mentally ill, we are relegating them to longer periods of sickness. That has repercussions in our communities. It increases homelessness, it increases drug use, it increases criminal recidivism, court costs, prison costs. So do we, or do we not, as a society, believe that it's a priority to fund care for the mentally ill?
How often are you satisfied with the diagnosis you arrive at?
There are times, as with the patient who had thoughts of killing her child, where the diagnosis is incredibly important. There are other times when diagnosis is less important than treatment. Lauren had numerous diagnoses given to her at various times—bipolar disorder, borderline personality disorder, depression, anxiety—and all along, she was essentially doing the same thing. So it didn't much matter in her situation what her diagnosis was. What mattered was trying to determine what was driving her behavior and how we could interrupt this terrible cycle.
You write, "It's difficult to separate symptoms from the social stressors that exacerbate them." Can you talk about this?
There are often psychiatric symptoms—depression, anxiety, hallucinations—that go hand in hand with the fact that our patients are experiencing incredibly stressful things in their lives. Someone might be hospitalized because they are depressed and suicidal. That person may have just lost his job and have a wife who's threatening to leave him. It's very difficult in those moments to tease apart what is disease and what is circumstantial. So many of our patients have homelessness and trauma and substance abuse that it's difficult to separate illness from context.
Kendra's Law, enacted in several states after an untreated schizophrenic man pushed a woman to her death on a subway platform in New York, is a controversial measure that makes outpatient treatment mandatory. What do you think of the ethics here?
Taking away someone's autonomy is always an uneasy balance. Nonetheless, in my work with the chronically and persistently mentallyke ill, I've all too often seen how periods of treatment nonadherence can extend patients' symptoms and suffering, and can sometimes put them in real danger. I've treated many patients who have been tormented by paranoia or besieged by hallucinations, and without treatment their symptoms simply do not remit. Once court-ordered treatment is implemented, I see people begin to emerge from deep distress, often with great relief Because their fear-inducing symptoms diminish, their quality of life begins to increase dramatically. I write about this in Falling Into the Fire in terms of involuntary hospitalization. Compelling patients to obtain treatment is a tool we must use sparingly and only when appropriate to do so. But refusing to ever compel treatment is short-sighted, as doing so can allow a patient's illness and suffering to persist under the guise of preserving autonomy.
You juxtapose scenes at the hospital with scenes of your life at home. What has your experience as a psychiatrist taught you about your own life?
I feel like I have a much deeper understanding of the capacity of the mind. There was a moment I had a deep fear of dropping my daughter into a lake, and I understood that this extreme fear was irrational. My patients who cannot let go of this level of anxiety are experiencing this all the time. I think there are moments in our lives when we brush up against the kinds of suffering that people endure. For me, that lends a greater capacity for empathy. And what strikes me in seeing my patients is how vulnerable all of us are to losing an equilibrium that we might otherwise have. A huge tragedy can rock your whole foundation.
Those diagnosed with body integrity identity disorder believe that a part of their body—a leg or a foot, for example—isn't meant to be there, and they want it cut off. Which would, in fact, "cure" their condition and help them feel better. You write, "What is worse: to live without a leg or to live with an obsession that controls your life?"
These people are in touch with reality, it's not as if there are strange voices to cut off their arm or pluck out an eye. They just feel, very much, that "my right leg doesn't belong" or "I was meant to be an amputee—my left leg should end above my knee." These are very precise ideas. The research demonstrates that if, in fact, they become amputees, which they sometimes do through very gruesome measures on their own, the suffering resolves. As doctors, we have taken an ethical oath to do no harm. So it's difficult to square the idea of amputating a healthy limb as treatment for someone. But it can stop suffering. So that kind of question is exactly what falls into the category of the "mystery of psychiatry." How do we begin to understand that feeling and the resolution of that feeling? If we have a means of resolving the distress, are we compelled to do it even though we don't fully understand the etiology of the distress or the resolution? Are you cutting off a leg to treat an illness of the brain? It's so difficult to comprehend, but we do all kinds of treatments that we don't exactly know how they work but we know that it helps people get better. It's a real dilemma that has more to do with repugnance and our response to the proposed action than anything else.
Do you see any implications here with gender reassignment surgery? Is gender dysphoria—the condition in which a person believes he or she was born the wrong sex—technically a psychiatric condition?
These are heated waters to wade into. It has, at various times, been classified as such. My suspicion is that increasingly, people understand the appropriateness of gender reassignment surgery and have seen enough of those cases and the positive results that can occur that we understand the plight of transgender people better than those with body identity integrity disorder.
One criticism often weighed at psychiatry is the idea of over-diagnosis. What do you think about this?
It's both true and not true. There are people who are over-diagnosed and over-treated, but many, many patients need treatment. It depends a little on the population. Plenty of people point fingers towards the "worried well," people who are on psychiatric medications that need not be. That may be a reality in that population. On the other hand, working in a psychiatric hospital, the reality I encounter far more often is people with significant mental illness who are not receiving the care they need.
Is it ever a class issue? Do more privileged classes get over-treated? Do less privileged groups fail to get treatment they need?
Suffering certainly does not discriminate. And mental illness doesn't discriminate. There are all kinds of socio-economic groups that have members who are very ill, who are afflicted by every mental illness you could list. That said, there's no question that people with fewer resources have less access to care. I see a lot of college students who experience their first psychotic break, and many of them come from affluent families. They are able to connect with and generate quite a lot of care because they've got good insurance, their families may know physicians they can call in the middle of the night for advice, they have the capacity to drive their kids to major medical centers where they may specialize in illnesses their children are facing. Those resources provide greater access to care. A homeless person has few resources and won't be as able to make the connections needed, have transportation needed. I see so many patients for whom the $4 prescription charge for a month of medication at Wal-Mart is prohibitive.
And what's at stake for those who aren't treated?
Not having treatment can have life or death consequences. A man came into my unit who had been living on the side of a highway drinking stagnant water because he feared the government was after him, and he fled his house and was living in the wilderness. We see patients all the time who are so paranoid that they have stopped eating because they believe it's been poisoned. They barricade themselves into houses. These are patients who are very ill; whose lives become full of suffering if they don't receive the treatment they need. They're besieged by voices that are denigrating them and are so depressed that they constantly try to kill themselves.
You write that doctors are "terrible at predicting [which patients] will kill themselves." How do you come to conclusions you're comfortable with when you discharge a patient?
We're trained to ask about risk, to assess risk. We ask people directly if they have thoughts of harming themselves, and if they do, do they have a plan? We want to understand how specific and immediate that danger might be. We're trained to ask about access to firearms. Many times, that serves us well, and we're able to intervene and understand where someone is on that spectrum. But just about every psychiatrist will tell you a story of someone they really didn't think was suicidal who made a serious attempt, or succeeded. You can have a cardiac-catheterization and determine exactly how blocked an artery is in the heart. We can't do a lab test in psychiatry and check suicidality like we would check a caffeine level. A cat-scan of someone's brain won't tell us if they will commit violence in the next 48 hours. We have to rely much more on intuition and training because we don't have the same kinds of tools that other disciplines have.
Do you worry about the skeptical light you are casting on your own profession?
I think that doctors, in general, all have moments where we feel inadequate or incapable of really getting something right, medically, but we're in a profession where people are less forthcoming about that. There's a time in everyone's medical training where you feel a little fraudulent, like you might not be treating someone the best way they need to be treated. But that's because doctors are human, just like everyone else. I have a lot of faith in psychiatry. There are people who cast psychiatry as a pseudo-science, or beholden to big pharma, but I don't believe any of that. Psychiatry is a science, and the people who practice are, for the most part, well-trained physicians who work very hard with evidence behind them to treat mental illness, and we have some great successes. The book focuses on the most frustrating diseases we encounter, but my goal is to humanize and generate empathy for patients who might otherwise be viewed with repugnance or disbelief. I've written about the most challenging cases. It's not that interesting to write about the slam-dunks.
This interview was edited for length and clarity.
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