treatmentTreatment controversies abound in psychiatry. An earlier post about a conversation I had with a patient’s therapist in which it seemed that both therapist and patient agreed that being encouraged to come in for an early appointment was a kind of punishment, sparked an interesting dialog with one of this blog’s many dedicated readers.

The reader wrote –

As one who has experienced that climb into hypomania, I just want to shed a bit of light on this topic. If the patient is anything like me, he is getting into that phase of being prickly, argumentative, and maybe even a tad bit delusional,, and all because of what is happening in his brain If he were not in this phase of his illness, the patient would probably not have any qualms whatsoever about coming in to see his doctor.

That is the tricky thing about bipolar disorder, and how it differs from chronic disorders that are not related to the brain. When our brains get sick, we have symptoms and we need treatment. However, unlike a pancreas or a heart or even a bone, our brain is the organ we use to interface with the world. When our mode of interfacing malfunctions, all of our relationships go awry. Even our relationships with our doctors. Depending upon the part of our brain being affected, we may feel that seeing our doctor is punitive, we may want to stop at a casino and gamble on the way to see the doctor, or we may even barrel to the doctor’s office at 90 mph with some wild fantasy flying in our head.

It may be a good idea for doctor and patient to have a conversation, during a time of stability, about how to handle things if loved ones see that the patient needs to come in to the doctor, but his malfunctioning brain is hindering that happening. It is much different than the doctor visit’s being punitive. It is that we can have extreme difficulty relating to others during hypomania.

I am a strong believer in the idea of  conversations in times of stability designed to think through how to deal with challenges like this one. The Wellness Recovery Action Plan is one very thorough format for developing such a plan.

But sometimes such a conversation has not taken place, and the doctor and patient find themselves dealing with just such a situation.

Someone who values individual autonomy highly might say that, in those situations, the doctor needs to just take the patient’s wishes at face value.

One of the things that distinguishes some psychologists from some psychiatrists revolves around this issue. What to do when a person’s judgment appears to be compromised by the condition that they are seeking treatment for.

This difference may, in part, reflect a significant difference in early training. For physicians (psychiatrists) one of the most powerful training experiences is the internship year, the year after graduating from medical school.

For a physician or a psychiatrist, internship is a very stressful and intense year. Part of what is inculcated into the young physician is the need to be responsible and “on top of” a vast amount of information when providing care to acutely ill patients in the hospital. In many ways a hidden assumption of that year is that if there is a bad outcome it is the physician’s fault until proven otherwise.

By contrast, for many psychologists, internship is a year of working in an outpatient setting with more traditional psychotherapy patients. The result is that psychology is much more firmly rooted in the notion that treatment has to be voluntary.

Read the ethics codes of psychologist and psychiatrists and you can see that the emphasis in psychology is strongly on providing patients with information and then letting them make the decisions. The principle of beneficence is not as important as individual autonomy.

There are good and bad aspects of this.

It took me at least 10, possibly 15 years of professional practice before I was able to get over the excessive sense of responsibility that can lead to what is called the “God complex” in doctors.

It also means that I am often wrestling with questions about whether and how to intervene with someone who seems to be escalating into mania or a kind of severe depression where their thinking is impaired. These kinds of questions are much less often ones that psychologists think about.

And this is not an area where there are clear boundaries. “Beyond this line you (the doctor) need to step in and take a more assertive approach. ”

We are constantly dealing with grey areas. This morning a young man seems to be reasonable and able to make thoughtful decisions, last night he was driving recklessly around the city in search of “excitement.”

Ideally, I need to be aware of those grey areas but I also need to avoid “buying in” to the notion that all efforts to encourage someone to be more thoughtful and responsible are wrongheaded, or that telling someone that I disagree with how they see the situation is always a mistake.

For More Information

Bipolar Story in New York Times

Conversations; Kathy Lechter