Guardianship and the behavior of nations: Wondering about sanctions.

I have a patient being discharged tomorrow. No one is very happy about all this. She will be on a Conditional Discharge, which means she will have to adhere to certain rules until 2010 or be returned to the hospital, so she’s not happy. She is 60 years old and resents being told what to do. She will begin resisting the conditions, cutting down on her medications, missing appointments, maybe smoking a little weed now and then. Most likely, her MHC will suspect but be unable to prove this unless they draw a line in the sand and order her to have bloodwork for drugs, or for medication levels. Her non-adherence will get her into trouble sooner rather than later. She will come to the attention of the police and be brought to the ER, and returned to the hospital. She will maintain that she was doing fine, thank you very much, but lost her temper when the police/MH clinician/ER doctor interfered. This has been going on for years.

The mental health professionals are reluctant to pull the plug on this. She is not a murderer, she doesn’t climb up on bridges and threaten to jump, and though she does drive and is alarming, her car runs so seldom that we can wink at it. She is disruptive and threatening. She is not merely eccentric, which her community should just tolerate, but quite frightening to the neighborhood children, whom she threatens, and mildly destructive in stores, throwing cups of coffee or other small objects. She is more likely than the average person to cause real harm, but not flagrantly dangerous.

The situation persists because everyone hopes there is a third way, and tries to reach it. She has a schizoaffective disorder, but will not take a mood stabilizer. She is on, in fact, a horrible combination of Haldol and Mellaril. She is already dysarthric. If we could get her to take Zyprexa…I don’t think she has been tried on Lamictal…did she really have a bad reaction to Depakote or is she just saying that…

She won’t take them. In their heart of hearts, all the psychologists, psychiatrists, and social workers who deal with her know this. But we are trained in Motivational Interviewing, or Strength-Based Interventions, or a dozen other attitudinal trainings which help us get through this discouragement. By personality and by training, we have to believe there is a Third Way, some interest or affection or approach or leverage which will get us out of the dilemma. And because we have occasional successes, some few patients who accept a compromise, which leads to an improvement, which leads to a collaboration, which leads to some poor soul actually having a life again, we hold to our dreams of bringing her ‘round. We don’t want to admit that our choices are only two: endure her hypomania and hope she doesn’t run over some child, or petition the probate court for a guardianship, forcing her to accept what we think is best forever. That the guardians in NH are wonderful people who will try hard to continue negotiation and advocate for her will likely mean nothing. The end result of her next admission, or the one after that, is that she will be assigned a guardian, and then held down and given injections until she consents to take orally something that will actually take away the chronic hypomanic state she loves.

We want there to be more than two choices. Every occasional success in persuading others causes us to cling again to the hope that some person might hold the key, some technique might improve her insight 13% and allow us a foothold. But always, there is that fear of a car running over someone’s kid, or the patient annoying a dangerous person and getting killed, hovering in the back of our minds. The disability rights lawyers, bless them and curse them, don’t have that burden.

Take this whole mess and zip nations into the roles instead of people. As well-meaning as the Third Way people are, hoping that they can persuade, or leverage, or intimidate, or bribe the misbehaving one into some reasonableness, they cannot accept what Tevye eventually was driven to: There is no other hand. Otto Kernberg was the dean of theoreticians and advisors for those treating Borderline Personality Organization (now Disorder). If you read closely, you come up against walls. After lengthy discussion, he then dismisses some to state institutions with no further comment. Gee, thanks, doctor. Ditto Marsha Linehan. So that’s how you do it. That’s why Saddam Hussein never becomes an issue. It becomes Someone Else’s Problem. If we, left to deal with the problem, put the hammer down on a dozen poor souls – or sovereign nations – someone can always come back and insist that if we had tried a Third Way with North Korea, if we had let diplomacy and sanctions do their work in Iraq, if we would try to understand the legitimate grievances of the Palestinians, if, if, if…

The accusation is easy when you only have to look at half the equation.