Thursday, May 14, 2015

Day 2: Naiveté, Falsificationism, and the Counterfactual

Psychiatric Inpatient
Many years ago in my early 20s I read a short story that stuck with me for its nightmarish realism. I can't remember the title or the author, although I think it was G.G. Marquez. I do know it was a Latin American author (if you know the story I'm talking about let me know so I can put a link--it's a great short story). The general plot goes something like this: 

A young woman is touring the countryside and goes into a tourist stop to get some food and use the bathroom. There's also a tour bus full of people at the stop. She happens to exit the store at the same time the tour bus is loading its passengers. One of the "tour guides" asks her where she's going. She says that she's going to her car to drive to the next town. She's on vacation. The tour guide smiles and nods and directs her to get on the bus. She's confused by this and tries to explain again. Again the tour guide gives a similar response, but this time calls over the other "tour guides".  Once again the woman tries to explain that she's not with the tour. They smile and nod.

Anyhow, to make a long story short, the people on the bus were patients from the local psychiatric hospital and the "tour guides" were the doctors. The upshot of the story is that there's nothing she could say to convince them that she didn't belong on the bus (and eventually institutionalized). When she got agitated, they interpreted this as a need for sedatives. When she explained her story, they interpreted this as delusion. 

My naive impression of the psych ward (and psych consult), in some cases, was very much like this. There was no way for the patients to answer  any questions without their answers being interpreted as evidence for some pathology.  In short, a psychiatric diagnosis was unfalsifiable. 

There were, of course, also cases were the patients did have obvious serious psychiatric problems--such as attempted suicide (and usually a history of the behavior)--but some of the patients' behaviors, to my naive eyes, seemed like totally rational responses to their difficult situations. Many were in there after a particularly traumatic and stressful event. 

Since I now have an official visitors' badge I think this entitles me to give a diagnosis. Basically, my visitors' badge plus two days of observations put me at just one level below an expert. Anyway, my evaluation was that there was very little that was abnormal about their response. The major difference between me (and many of my peers) with many of the patients is that we have access to the social and financial resources to weather a storm. Most of the patients didn't. Think about a crisis in your own life. Can you imagine having to go through that without the people that got you through it and, on top of that, having to worry about where you were going to sleep the next day? Very few individuals can bear trauma alone and under additional stressful conditions.

One gentleman's wife was dying. He was functionally illiterate and she had handled all their affairs. He had admitted himself and was very anxious. The staff kept asking questions to try to give a psychiatric diagnosis--i.e., they needed a label for his general anxiety and confusion. He keeps repeating "My wife is dying and I need to take care of her and I don't know what to do." Meanwhile the physicians are asking him to answer math questions and spell words backwards. I literally wanted to scream "Why are you asking him these questions? He's already told you 3 times what the problem is. His wife is dying and he doesn't know how to handle it. How is this pathological? This is the response we'd expect from any normal person."

Here's the thing. What I don't know (and the doctors do know) is the patient's case history. He has a history of various serious psychological problems. While this particular response is normal it could trigger more dangerous responses. And so they adjust his medication.

I don't mean to be an apologist here. Unlike food babe, I don't want to be quick to judge things that I know very little about--despite what my gut tells me (which, incidentally is never wrong--that's a scientific fact). Based on the little I observed, more than anything the guy needs social support. He needs someone to help him manage his wife's care. He isn't literate. How's he supposed to administer the medicines properly? Pay the bills? Manage everything that she had done previously for the both of them? He needs to know/feel that he isn't alone and that there are people that care about him.  Of course, this doesn't necessarily preclude medical treatment to stabilize his behaviors. But it seems to me the emphasis should be on social and emotional support.
. . . .

The psych ward is a strange place. The rooms are barren. No TVs, no radios, no paintings, no cellphones. the patients do, however, have access to books.  Think of a running track. The inside of the track is where the staff are. Most of the desks face outward so the patients can be observed while the staff work. The patients, with nothing to do, walk aimlessly around the island, again, again, and again. They're like zombies. 

This set up strikes me as odd. Why the intentional sensory deprivation? How would you act if you were in a room all day with no art, no TV, no cellphone to text or call your friends, and nowhere to go and nothing to do? I can tell you right now, whatever sanity I had going in would be long gone after a few days. 

Well, that was my first impression. It turns out, they do also get group and individual therapy. There's a stretching class. And there is a TV room--just not one in each room. Not as bad as my initial impression.

I met a woman who seemed quite normal. I can't remember how many days she'd been in the unit. Less than a week. Anyhow, the first time we talked to her, at the end she asked when she could go home. She wants to go home today. She was very polite about it but you could sense the pleading in her voice. The medical student said "I'll talk to the doctor and we'll let you know in an hour". 

We went back with the attending doctor about an hour later. We repeated that previous conversation. "How are you feeling? Are you hearing any voices? To you have any desire to harm yourself?" All these questions were answered just as you or I would answer. Again, she asked if she could go home today. The doctor replied, probably tomorrow. 

I'm thinking: this woman sees totally normal. If I'd asked to go home and someone said no, I'd get agitated (which she didn't). Of course, she probably knows that if she acts agitated it will be further reason to keep her (i.e., problem non-falsifiability).  Anyhow, later I asked the Dr. why she didn't let her go home.

Here's where case history and having more than a visitors' badge are important. When the patient was admitted she was having suicidal thoughts and hearing voices. Of course, I didn't know that part, but given the conditions of the admission, the doctor's caution isn't as odd as it appeared.

And there's more. Every day these doctors must deal with the counterfactual. If a patient comes in (most seemed to be self-admitted) and doctor releases them and something happens--a suicide or homicide--guess who has that on their conscience for the rest of their lives? If you knew that someone in your direct care was a suicide or homicide risk, would you release them the first day they said they felt better? From this point of view, keeping someone an extra day or two doesn't seem so strange.

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