Thursday, August 04, 2011


My team presented at Schwartz Center Rounds today. We discussed compassionate care of the homeless. The format is that an individual case is presented, and the general issues of compassionate care that the patient presents are discussed. We presented a young man who came to the hospital suicidal, identifying the fact that his girlfriend kicked him out and he was homeless as one of the things that "made" him suicidal. There were plenty of reasons to dislike the fellow. He doesn't seem particularly depressed, and in fact was cheery and social with the other patients, especially the younger, vulnerable females who he attempted to cuddle up with. He was rude, threatening, and insulting to staff, while reminding them that they had to be polite to him because he's a patient. He is trained as a welder but has not worked since 2003, collecting disability for depression, though not being treated for depression all that much. He drinks too much, but resists efforts to get him into any sort of treatment or lifestyle that would address this. I could go on, but you get the idea.

The unit staff had a great deal of trouble remaining objective, of course, as they w4ere the ones in the thick of it. But even those of us with more distance seethed, not so much for the sneering and insulting attitude, but the interfering with others' treatment.

Yet we are also trained to recognise that things are not always as they appear on the surface, and to be alert for what our own feelings tell us about the patient and the world he likely inhabits. The idea of countertransference is never supposed to be far from our thoughts. As one of the psychiatrists mentioned in the discussion "When I start blaming everything on the patient, it's time to take a vacation. Or get out of this field." Very true.

He did very little to find himself any housing, despite my supplying him with lists and offering to pay the first month's rent. The nurses became increasingly rude in demanding that I find him a place and get him out. They kept making suggestions of what I should be doing, rather obvious suggestions which I had long since tried. They wanted him gone because they didn't like him, and the fact that he was homeless because everyone else didn't like him - well, they didn't want to hear that.

They were quite happy to send him out without shelter, but I am not allowed to do that. Or rather, it happens all the time because the patient is discharged, but I am regarded as having failed because they don't have housing. It's unpleasant, and it still bothers me after all these years to work with people who regard me as a failure. But that's what the job is.

I batted cleanup in the Schwartz presentation, and highlighted the enormous conflict we feel in not wanting to blame the patient for things that they have little control over, but also want them to have natural consequences for their actions, as that is often the last teacher when all others have failed. I talked about volition, and recent research, and some of the issues we have discussed in my May We Believe Our Thoughts series.

I was nearly brilliant. I suspected it, but it was confirmed by those who came up to discuss for the rest of the day. Many comments were simply the polite affirmations of nice people, very nice to hear but not to be taken too seriously, but others were complimentary in a deeper way, referencing exact quotes, which they had even copied down. That sort of thing.

Here's the problem, which I am reminded is the great discouragement of all preachers and teachers who look for insight: everyone seemed to hear the part they already agreed with, while being completely unaffected by consideration of the competing value. Those who felt that irritating patients were being pampered altogether too much by the hospital, and we had to recognise the limits of compassion and take a firm hand yada yada yada... thought I expressed very clearly the need to move these people on and take the consequences of their behavior, and glad that administration had heard me say it so bluntly. Others felt enormously vindicated that I had spoken out about how much countertransference was allowed in current hospital culture and how wrong that was, and our need for...well, whatever. Something that will fix bad staff attitudes.

And a third group felt gratified that I had highlighted the recent research on volition and how indeterminate agency and self-control can be. They wanted references.

All that in eight minutes of presentation, plus about three thirty-second answers to questions. I was brilliant, I tell you. So why do I weep?

I posted the song because of the "Still a man hears..." line, but it's appropriate for the later verse as well:
After changes, we are more or less the same.


Retriever said...

I agree with you on countertransference feelings providing invaluable data. But I don't think many nurses or social workers nowadays are good at thinking analytically about their patients. Which is a pity. If people were nice,'popular and well adjusted they wouldn't end up homeless and alone. In need. Jesus said the healthy have no need of a physician...also, knowing what I do about the undeserved mercies of God and people around me despite my bad character and evil ways helps me reach out to people as obnoxious as I am. :)

Texan99 said...

I've been struggling for weeks with your series on volition. I guess what's bothering me is the doubt of agency. I'm hardly going to come up with the definitive logical or empirical proof that will settle for all time the question of free will vs. determinism, but it does strike me that, if people don't have agency, then there's not much left for their neighbors but a kind of detached compassion (sux 2BU).

Suppose someone has an untreatable brain tumor that compels him to throw knives in all directions. We can do very little to prevent his hurting himself and others, other than to circumscribe his freedom. Sure, there's no reason to hate him for it, but there's also no reason to beat ourselves up because we can't make his life better. He won't be any better or worse off whether we leave him to his own devices or agonize over different measure we might employ for him.

It's only when we believe that there's something he can do to change his behavior (and that we might help him see that) that our sense of duty should kick in. If your patient inspires revulsion in everyone who's forced to interact with him, and he's not really responsible for his actions, what's left to say or do? If he were an animal, we'd put him down. If he has no volition, how is he different from an animal?

I feel I must be misunderstanding you completely, to have worked myself into such a corner from your comments. You can see how ill-suited I would be for your profession.

Assistant Village Idiot said...

Not at all. I believe we over-estimate our volition, but it is still real. The recent research casts significant doubt on the volition of our immediate responses - but I think we might have reluctantly allowed that was true fifty years ago, before the research.

With mental illness, it becomes very difficult to define and measure what we mean. Something in the brain is clearly being interfered with - moods, interpretations, comparisons, memory. How much do any of these things reduce responsibility?

As for working in my field, I cynically think you can just pick a side - patients have very little responsibility or patients have a great deal of responsibility for their plight, and just go with that. You'll have plenty of friends either way, if you choose the right MH profession to start with.

Texan99 said...

Here's my problem. I understand that the healthy don't need a physician, but isn't it equally true that people suffering from illnesses for which there is no known effective treatment don't need a physician? If there is a disease that expresses itself solely in behavior, and the sufferer has no control over his behavior, and we have no power to affect whatever it is that's actually causing his behavior, what does it mean to offer treatment?

I'd have to believe that at least one of those assumptions was false before I could believe myself engaged in anything other than confining people in as much comfort as possible.