I have written a book, recently published, titled The Day Room, A Memoir of Madness and Mending.  I first thought about writing this book while a patient on a locked psychiatric ward.  I had been hospitalized for suicidal ideation and major depression.  In addition I was experiencing horrendous chronic pain, resulting from an injection I’d received in a hospital emergency room over two years earlier.  I had seen dozens of doctors, and it was generally agreed there was no treatment to reduce the pain, and as depression often goes hand in hand with chronic pain, I would be battling both for life.  My marriage was collapsing, I was on the verge of bankruptcy, and I felt sharply the emotional pain of failing my two young daughters.  The irony was that while the medical profession offered me little hope of recovery, it was always suggested that I ought to “hang in there” and “have hope.” 

Much of my initial promotion for The Day Room  has consisted of interviewers and audiences prompting me to rip the psychiatric profession to pieces:

•  “Wasn’t your psychiatric ward experience like something out of Dante’s Inferno?”

•   “Aren’t psychiatrists at the best arrogant ¾¾ ?”  

•  “Isn’t the area of psychiatry in need of a major overhaul?”

And I always feel they find my response a little disappointing for the lack of hype, and a little sobering too.  I say that yes, my psych ward experience was hellish, and that some psychiatrists I saw were arrogant, and some were far worse.  I say that yes, I hope to see much change in the area of psychiatry, as I hope to see much change in many areas.

But notwithstanding that, I say, I thank God for the psych ward and for the psychiatric resident that saved my life.

Dr. Lee Jones, the psychiatric resident assigned to me on a routine, rotation basis succeeded where dozens of other physicians failed.  It isn’t that he did everything right.  It’s that he did what mattered.

What mattered?

1.        THE BENEFIT OF THE DOUBT.  Lessing said, “There are things which must cause you to lose your reason or you have none to lose.”^[2]  Many times, a psychiatric patient’s actions, while perhaps seeming irrational, are in fact a sane reaction to an insane situation.  Lee Jones treated me as a person, a sane one with a clean slate.   Instead of questioning what prior doctors had called my “suspicious,” “angry,” and “paranoid” demeanor with regard to the medical profession, Lee’s starting point was an assumption that my emotional state was rationally based.  He treated me with respect, as one might an acquaintance going through a difficult time, one you had enough background on to extend the benefit of the doubt.  By avoiding the natural tendency to downplay the insight and awareness of a mentally ill individual, he created an opportunity for mutual trust.  Equally important, it empowered me to grapple with an internal stigma far worse than that of the outside world ¾ I’d never experienced anything as terrifying as my mind failing me. 

2.        THE BALANCE BETWEEN SEPARATION AND PARTNERSHIP.   When Lee Jones asked me, “Now what can we do to get you feeling better?” I could feel the strength of our patient-professional partnership.  When another professional would say, “We should be taking our meds, now shouldn’t we,” I knew he wasn’t thinking about his meds ¾ and I could reach out and touch the wall between us.   Psychiatrists face the challenge of needing to create a bond with their patients, to develop trust and to work as a partnership.  And yet there must be a separation, both for therapeutic reasons and to avoid burnout.  It may be easier for psychiatrists to achieve this bond as they remind their patients (and perhaps themselves) that anyone can develop an illness requiring psychiatric treatment, particularly given the view of psychiatry that mental illness is simply physiology gone awry.^[3]  There was a bond between Lee Jones and me, a sense of working as partners.  And there was a separation, but it was professionalism that stood between us, not mental illness.

3.        ACCOMMODATION.  In a number of instances, Lee Jones accommodated my particular belief system and needs, whether it was waiving the standard 3 day screening period to permit me to see my young daughters immediately after being admitted to the psych ward; or personally doing the weekly blood draw when necessary, recognizing my fear of needles resulting from my initial injury due to an injection; or accepting my decision not to continue on anti-depressants despite his strong contrary recommendation.  The cost of these accommodations was nominal, the value to my treatment was substantial, and the empowering effect was incalculable.

4.        INTEGRATION OF MENTAL AND PHYSICAL HEALTH TREATMENT.  While I had seen many other physicians, Lee Jones was the first to take an integrated approach to my pain treatment and my psychiatric treatment.  Unlike any other specialty, psychiatrists, with their expertise in mental and physical health, are uniquely qualified to recognize and treat the interactions between the two, whether those interactions are due to the nature of the illness (such as chronic pain and depression) or the nature of the treatment (such as side effects to medications).  While this wholistic objective is difficult to achieve given the substantial institutional and resource limitations, psychiatrists can empower their patients and any case managers by making them aware of specific treatment integration issues.

5.        THE VISION OF RECOVERY. The natural reaction when sick is to reach to recover, meaning reaching “to regain a former state of health.”^[4] However, recovery in this sense is often not an option.  And yet hope is a necessary element in healing; the reason why many times placeboes have an effect, and the responsibility of the psychiatrist to generate.  In my case, little sense of hope was extended to me.  It was expected that I would battle lifelong chronic pain and depression.  Lee Jones was able to instill hope in me while not disputing the realities of my health.  As William Anthony describes, “Recovery involves the development of new meaning and purposes in one’s life as one grows beyond the catastrophic effects of mental illness.” ^[5]  It may be that the general meaning of the word “recovery” stands in the way of this powerful concept; perhaps a new word such as “procovery” might be adopted to refer to the recovery of a productive life regardless of the level of health attainable. ^[6]

When I consider my treatment period with Lee Jones, it strikes me that what took place between us is some of the best psychiatry has to offer.   Erich Fromm talks about irrational vs. rational authority. ^[7]  Irrational authority is based on power and serves to exploit the person subjected to it; by creating dependence, it tends to institutionalize itself.  Rational authority is based on competence and helps the person who leans on it to grow; it tends to dissolve itself as it achieves its goal.  I think these opposing uses of authority pretty well sum up what is possible in psychiatry.

 © Kathleen Crowley 1996.