The trouble with institutions, Part I

In late January 2004, when Chris was first hospitalized, Chris’s treating psychiatrist wrote that although Chris had a good initial response to the treatment, his condition had worsened over the past week to the point that he was in danger of harming himself. Chris had become disoriented while on a pass with a group of people and had returned to the hospital an hour later. Although no physical harm had befallen him, with the temperature outside hovering around –30ºC, he would not be going out again without one-on-one nursing support. Given the state his mind was in and the need for supervision, Chris was formally asked to withdraw from his university courses. This prompted his rapid descent into a deep depression. He stopped eating and drinking, believing that the world was going to end and resigning himself to his fate.

According to his doctor, his nihilistic beliefs had reached the point that he did not grasp that he had an illness that could be treated. The hospital made him an involuntary patient and deemed him incapable to make treatment decisions. He asked that either Ian or I be the decision-maker for treatment decisions, although Chris had a right to appeal these decisions. Chris had become preoccupied with a number of religious and existential themes and the doctor believed that he could benefit from speaking with his college priest since they had shared a strong relationship in the past. He added that Chris was challenging the finding of his incapacity to make decisions, so no new treatment could be initiated until a hearing took place, which could be as early as the following week.

Years later, reflecting on the psychiatrist’s request to bring in a priest, it occurred to me that this psychiatrist or another psychiatrist should have been the logical first person with whom Chris could discuss his religious and existential themes. What the heck was he a psychiatrist for, if not to deal with a patient’s religious and existential themes? What had become of the psychiatric couch and the empathetic psychiatrist well versed in religion, mythology and psychoanalysis? In Thomas Szasz’s view, he has become the prescription writer for the state. Unfortunately, in a psychiatric institution, the patient and his family give up freedom of choice. The institution operates on a one-size-fits-all mentality. If we wanted something tailored to our specifications, we would have to search for it outside the walls of an institution.

Existential concerns

Chris will soon be released from the hospital after three months. I am concerned that we will be right back to the situation that prompted his hospitalization in the first place. He knows that he needs to get out, he is bored out of his mind, and yet he is not looking like he can blend in with quote unquote “normal people”. He arrived home for the week-end on Saturday morning, attended to his e-mails and fixed a few computer problems. He talked to me very thoughtfully on Saturday evening. Sunday was a different story. We invited him to join us for a lecture and lunch. We went for a walk on the grounds of the lecture hall before lunch. He was in existential despair. He didn’t want to spend his day with “old people”. I can’t fault him there. He said he didn’t know what was real anymore – was I real? Was this scenery real? Was the day going to end and the sun go down? He claimed he didn’t know. I asked him if he wanted to resume his Alexander Technique lessons when he came home. “No, I have learned everything I need to know”, he answered.

The hospital fussed with his medication, introducing a second antipsychotic over my objections. I maintain that despite the elaborate, weird behavior that got Chris committed, his problem cannot be fixed with medication. It is looking likely that I am correct. The doctor is not satisfied with the addition of the second antipsychotic, noting that Chris seemed overall better just after they introduced it in a low dose. So, now they are tapering it back but not discontinuing it. Discontinuing it would be admitting they were wrong. Nobody, not my husband, not the hospital psychiatrist, not Chris’s regular psychiatrist nor anybody having seen Chris in his pre-committal state, understands my objection to the medication. It is they who just “don’t get it”. Chris has problems that persist whether he is on medication or not.

What I think has taken the edge off the situation while Chris has been hospitalized is not the medication but the fact that Chris got away from us, from living in claustrophobically close quarters every day and being treated like the two year old he was becoming. The doctors acknowledge this reality, but medicate anyway. When I object to the fact that this latest med was the fifth antipsychotic Chris has been on, and shouldn’t we conclude that antipsychotics don’t work for Chris, the clear message I receive in return in that it is foolhardy not to use antipsychotics as one treatment modality. My husband is almost threatening to divorce me if I undermine in any way Chris’s staying on medication. He reminds me of the lead-up to the hospitalization. Yes, I am painfully aware of all that but I also know that Chris has exhibited extremely weird behaviour while on medication, beginning with his first antipsychotic. His mind is more powerful than any drug or vitamin. Until he resolves his existential problems, we will continue to weather the storm.