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Fear motivates me to post today. I have come to realize that the “do no harm” approach to patient care is being violated without malicious intent, but still quite concerning. Newly trained psychiatrists are taught that a psychiatric diagnosis is definitive and as such, certain treatment protocols are indicated, and as such, if the patient “fails” the protocol, they are sent to a higher level of care, which in brief, means they could become, what I have termed, “a professional patient”. Kai, age twenty-one, comes to mind. She is a Caucasian young woman who was having trouble at home and at college, and so complained to her friends that she was suicidal and that she was thinking of jumping in front of traffic. This alarmed her friends, who in short order, called the police who then brought Kai to a psychiatric hospital on a 72 hour hold. This hold was quickly turned into a voluntary admission at which time she was diagnosed with “borderline personality disorder” and she was told that as a result of this diagnosis, she needed to be on Latuda, an antipsychotic medication, and she needed to go to Dialectical Behavioral Therapy. She complied and she was discharged from the hospital and two months later the situation repeated itself. This time the hospital told her that she needed a higher level of care, since the DBT and the Latina did not seem to help her, and so she was sent to a residential facility for three months, on the recommendation of the psychiatrists at the hospital. Why does this story alarm me so much?
Reason 1. Kai is twenty-one years old. She needs to find autonomy from her parents, and she needs to continue on her train of maturity and psychosocial development. Hospitalizations, and residential treatment do not, by and large, promote development, but rather they promote dependency. Few decisions have to be made. By definition, institutional settings are regressive, and they create passivity as opposed to forward thinking life-planning skills.
Reason 2: The diagnosis of borderline personality disorder is often applied to women who create a lot of affect in others. That is to those who make their providers anxious because the treatment plan is unclear. This anxiety in the provider, used to be fodder as a way of understanding countertransference, but is now used as a way of pathologizing the patient, and thereby taking away any emotional work that needs to be done on the part of the provider to give deeper and more meaningful patient care.
Reason 3: Psychiatrists are being trained that diagnoses are definitive, and there is no thought that perhaps the diagnosis is given prematurely, and/or needs to be questioned for quite some time, before treatment is recommended. As such, this twenty minute diagnostic evaluation is nothing short of frightening, for both patient care and for physician training.
Have I said all of this before? Of course. Do I feel I need to say it again? Of course. The fictional Kai is going down the rabbit hole of passive treatment, thereby preventing her maturation. That is a tragedy. The fictional physicians are poorly trained to do assessments, and as such, treatment recommendations do not fit the patient’s issues. The fictional physicians will come to understand that their certainty is questionable, and as such, burn-out and dismay are likely to follow as their career progresses. Do I want to sound the alarm bell? Absolutely. Anyone listening?
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Shirah Vollmer MD 