An Ordinary Weekend

Last weekend I was on call for psychiatry at United, the hospital in St. Paul that I work for. It's been a moderately busy weekend for me, but not because there isn't any more demand for services, but because our inpatient beds are full. And guess what? So are the inpatient psychiatry beds not only throughout the Twin Cities Metro Area, but also the entire state! Halfway through the weekend we sent a patient to the last open adolescent psychiatry bed in Fargo, ND! So there are two patients this weekend who have had to stay in the emergency department, because there is no place to admit them. I continue to be amazed that I live in a country that would send its mentally ill children hundreds of miles away from their families because it's not willing to pay for the services they need locally.

And as usual, among the patients newly hospitalized whom I saw, about half were addicted to a psychoactive substance, usually alcohol. This is also typical. Now that I'm cutting back on my clinical practice, I'm unable to offer them a new form of treatment, one that is oriented around treating the disease as it is, rather than as we would like it to be. I was able to offer that for the last 2 years, but now I'm moving more into efforts to change things more broadly, to help others provide that kind of service and thus leverage my knowledge and skill. And that is going well and finally seems to be picking up speed. This stuff really takes a lot of time and effort!

But I still find it hard not to offer these patients an alternative to another run through a rehab program they've already experienced multiple times before. Any treatment that has been shown to be ineffective in a particular patient ought no longer to be pursued. I don't continue to prescribe naltrexone or Prozac to someone after it repeatedly fails to alter the course of illness, thinking that perhaps someday it will become effective! But embracing fully another approach is not without its problems too.

That's because to do so takes us right into some painful insights. Our treatments are modestly effective at best. There are many people for whom we have no effective treatment. And it's not their fault, it's because the science isn't yet at a point where we can understand what's wrong and help correct it. Our instruments are crude, primitive. Well-meaning, yes. We can always provide comfort, understanding, and a willingness to stay with someone to the end. But all too often, there is nothing we can do to change what we see as the inevitable conclusion of a process we don't understand: addiction. And I can tell you that it is difficult indeed to stay engaged with someone who is dying of an addiction neither she nor I nor you nor AA nor rehab nor medication nor the criminal justice system nor anyone else can help. We accept that grim reality with other diseases like heart disease or cancer. But we have a hard time accepting that brain diseases like addiction or bipolar disorder can be incurable and ultimately fatal. And most importantly, it's not because the person dying does not want to live or isn't trying in every way to stop the march towards death. We have to stop blaming the victims when our treatments fail and at least offer them succor along the way.