Not-so-great expectations

I am really tired from over four months of inpatient work. The time requirements of being an intern have meant that I have had little time to maintain aspects of my life that used to define me. When friends or family ask to hear what I've been up to, the answer is work. When applicants to the psychiatry program ask me what my hobbies are, I tell them what I used to do. Though I know this is a very unique and all-consuming time in my training, it is still disturbing for my identity to be reduced to my job and to often be isolated from the healthy majority of people.

On one hand, I love being a doctor. I love working with people and often helping them. I love learning and becoming skillful in different areas. But for all of this, I also resent what I have to sacrifice in order to do these things. My own ability to cope with stress, with sick patients, with anxious families, with abrupt co-workers, is reduced in my state of physical tired-ness and shallow emotional reserve. At my best, I can take things in stride, give myself and others a break, and go home and get a good night's sleep. At my worst, I've taken out my frustrations on family, friends, co-workers, and even subtly on my patients.

One of my mentors told me that the key to maintaining reserve is to offer oneself unconditionally without being invested in the outcome. In other words, give freely, with no expectations of anything in return. So I shouldn't expect patients to agree with a plan I have thoughtfully put together. So I shouldn't expect patients to thank me for going out of my way to make appointments for them. So I shouldn't expect patients to miraculously change their lives because I treated them. Sounds obvious (and I sound narcissistic) writing this, but sometimes, I get the idea that when I spend time and energy on something, that I should get something back in return! Credit, gratitude, a break, kind words...and it just doesn't work that way. It's a weird dynamic between being taught that we are "worth" this and "deserve" that and "our time is valuable"--but do these ideas fall into the categories of self-respect, self-preservation, self-defense or self-righteousness? It's not always clear. By freely giving (and also by asking for what we need in earnest), we can tap into an endless supply of love and energy to share with people.

Basic Mental Health Law

Last month, I went to court. The proceeding was held in a conference room on my hospital unit. In front of a county judge, I stated that my patient should continue to be hospitalized against his will because of his high suicide risk. The evidence to hold him included: a recent suicide attempt, past suicide attempts, recent end-of-life gestures including saying goodbye to his son, and constant thoughts of killing himself. 

The patient, who wished to leave the hospital, sat across from me. An appointed lawyer, a mental health specialist, spoke on his behalf. She appealed for his discharge, stating that he would continue outpatient psychiatric care and that he was making future-oriented decisions such as establishing his social security benefits. 

Mental health law is different in each state, but in California, the rights of mentally ill patients are currently protected under the Lanterman-Petris-Short Act (LPS), which was signed by Governor Ronald Reagan in 1967. Some of the wording includes, "to end inappropriate, indefinite, and involuntary commitment of mentally disordered persons..., to provide prompt evaluation and treatment of persons with serious mental disorders..., and to protect mentally disordered persons and developmentally disabled persons from criminal acts..."

Under LPS law, patients must meet one of three criteria to be held against their will: danger to self (DTS), danger to others (DTO), or grave disability (GD), which is one's inability to provide a plan to get food, clothing, shelter.  Importantly, the criteria must be true because of a mental illness, and not a medical illness (like dementia or brain tumor) or criminal pursuit. 

Out in the community, police or designated mental health workers can place what is called a 5150 and bring a person to a hospital for evaluation. A 5150 is valid for 72 hours and cannot be contested by the patient, though it can be discontinued earlier than 72 hours a doctor. At the end of 72 hours, if a person still meets DTS, DTO, or GD criteria, a doctor can apply for a second certification that allows a patient to be held for an additional 14 days. This is called a 5250, and this CAN be appealed by patients. They have the right to see a judge within three days. 

While it may seem that LPS law imposes on more rights than not, the law ensures prompt evaluation by a doctor and continual necessity for justifying hospitalization, which is in contrast to the old days when mentally ill patients were held indefinitely against their will and subjected to treatments without consent. In addition,  mentally ill patients have other protections against forced treatment. Under LPS law, even if patients are held, they cannot be given routine medications against their will (this requires another court proceding). To administer any medications on a psychiatric ward that affect a person's brain, the patient must given documented consent. Interestingly, these same medications, if prescribed in a general medical clinic or on a surgical ward, would NOT require consent. 

To finish my story, the judge denied my patient's appeal, and his hospitalization was continued against his will. While I do think we were protecting him from self-harm and buying time to help his depression, it made my relationship with my patient adversarial. It felt contradictory to testify against him one afternoon and then invite his trust the next morning in our daily sessions. It was quite uncomfortable and challenging to rebuild that alliance with patient in the following week. It also infused questions into my mind if we are doing the right thing by holding the patient and reminded me of the seriousness of taking away someone's civil rights.