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. The interview is lightly edited for length and clarity.
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?