Additional Clinical Insights and Legal Ramifications

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CAUTIONARY TALES: MISUNDERSTANDING AND MISAPPLICATIONS OF RESILIENCE

Five clinical cases, all observed by the author or reported by colleagues, are presented in this (the fourth) and the previous article in a 5-part series. They involve patients who were misperceived by their family, outpatient psychiatrist, and/or inpatient psychiatric team to manifest psychiatric health, recovery, or resilience, leading to tragic results with potential medicolegal consequences.

Case 4: Missing Milieu

A 40-year-old man with a recent history of suicidal ideation was admitted to a locked psychiatric unit after detoxing from a heroin addiction. Initially labile, agitated, and easily triggered, he responded favorably to an inpatient medication regimen involving valproic acid, which aided in stabilizing his mood, and gabapentin, which, along with supportive therapy and a caring and experienced staff, helped to eliminate his agitation.

He progressed in this setting from being irritable, treatment-resistant, and avoidant of his peers and treatment team to presenting as an amiable, positive, engaged individual who was compliant with medications, participating in individual and group therapy and working positively with the team. He also began to show significant insight into his and others’ struggles with drug abuse, enabling him to empathize with other patients on the unit.

Eventually serving as a leading member of the daily group therapy sessions and as a role model for other patients, he increased his engagement with and reliance on this very supportive milieu. With an accompanying increase in self-esteem, he was able to tolerate decreased doses of valproic acid and gabapentin.

After the patient continued to do well for several weeks, his attending psychiatrist was due to transfer to another unit. By that time, the treatment team had agreed on a plan to move the patient to a rehabilitation facility, where he would remain for a few months to continue his stabilization. Eventually, the patient was to live with peers in a group home while continuing his medications and therapy.

With this plan in place (as his former attending psychiatrist was informed some weeks later), due to the patient’s improved stability, insight, and motivation to remain compliant with his medication, the unit administration, influenced by insurance pressures and underestimating the significant role of the very experienced and caring milieu team, had decided that the patient no longer needed to be in a locked psychiatric unit. His increasingly positive attitude and acceptance of treatment brought hope for a positive, drug-free future.

Unfortunately, some of the usual rehabilitation facilities had closed, and those that remained either had a long waiting list or were “private” and did not accept the patient’s insurance. He would have to be discharged back to his neighborhood and attend outpatient treatment without the intervening period of milieu-based drug rehabilitation treatment that was intended to solidify the gains achieved on the inpatient unit.

A few weeks after the patient was discharged, his former attending psychiatrist learned that the patient’s body had been found lying on the grass in front of the medical center library next to a playground where children were playing. The patient had been presumed to be napping until the playground staff had attempted to speak to him as they were closing the park at the end of the day.

Hearing this news, the psychiatrist recalled that the patient, soon after his arrival on the unit, had shared with his therapy group that he knew that if he returned to his old neighborhood and “friends,” all of whom were “in the life,” either selling or using heroin, he would not be able to resist restarting heroin and the agony of the “battle with addiction.” He further disclosed his fantasy that if he was unable to resist succumbing to his addiction again, he would prefer to self-administer a lethal dose of heroin and spend his last hours finally free of all psychological and physical pains while falling into a deep and final sleep on the green grass near a playground, with the sound of happy children playing beneath a warm summer sun.

Indeed, postmortem toxic screens revealed that the patient had died of a large heroin overdose. Foreseeably, the resilience he had manifested was dependent on a very supportive milieu, which, by helping him maintain his self-esteem and hope, sustained him during his time on the unit. The expectation of continued social support provided by a rehabilitation center and eventually a group home likewise reinforced his ability to avoid returning to heroin addiction. Once discharged, with neither family nor friends outside “the life,” he was left without this kind of care, advocacy, and supportive community, which he could have obtained only through either private funds or “better” insurance.

Case 5: A Good Son

An attending psychiatrist waiting for an elevator next to a hospital inpatient unit observed a tall young man involved in a stressful telephone conversation just inside the thin glass partition surrounding the entrance to the inpatient psychiatric unit. The patient was speaking loudly in a foreign language. Intermittently, as the interaction escalated, he would break into English phrases, periodically pleading, “but dad,” before continuing in the foreign language.

As the conversation proceeded, the young man became more agitated and the interchange became louder. Eventually, however, the patient deescalated, appearing exhausted and defeated. “Okay, dad, okay,” he said, followed by a brief goodbye expressed partly in English and partly in the other language.

After he hung up, the patient stood at the phone looking devastated, staring at the floor for minutes, seemingly unaware of anyone being within hearing distance of his conversation. As he began to raise his tearful gaze, his eyes met those of the attending psychiatrist standing near the elevator, who had been unable to turn away from witnessing this painful interaction. The young man appeared shocked and embarrassed that he had unintentionally exposed his most private feelings. He abruptly turned and walked back toward the privacy of the patient rooms.

There were no staff nearby at the time. This psychiatrist was on a different treatment team from the one treating this patient and had learned of his presentation on admission as a student with symptoms of depression and intermittent suicidal ideation. Although she did not know the details of his treatment by another psychiatrist, she felt she should share with the patient’s treatment team the interaction she had just witnessed, so that the team would be informed of the patient’s recent experience of severe, potentially destabilizing stress. She described his emotionally charged argument with his father, in which he initially protested, but ultimately capitulated tearfully.

As she expressed her concern that the patient currently was dealing with a very disturbing development, the psychiatrist was informed by the patient’s team that he had recently shown progress, appearing “resilient,” as he self-reported that he was eating and sleeping better and enjoyed interacting with his peers on the unit. The team acknowledged that they had been observing him somewhat less closely, but he appeared to be eating better, interacting with other patients, and intermittently manifesting positive affect.

As recently as that day, prior to the potentially destabilizing phone call, the patient was interacting more appropriately with the staff and denied any depressive symptoms or suicidal concerns. As a result, the team was unified in the belief, in agreement with the insurance provider, that he no longer qualified for inpatient care.

The patient was scheduled to be discharged from the unit in 2 days, with outpatient follow-up 2 weeks later. He was to bid a formal goodbye to the unit staff in a community meeting that would just prior to his discharge. Because of the troubling phone call, the team did agree to monitor him for any signs that contradicted his presentation as recovered, “resilient,” and ready to restart school classes. In the absence of any such negative signs, he would be discharged.

He had told the team that he did not want them to contact his family due to cultural issues. As this did not appear to be an emergency, the staff, viewing him as an intelligent, insightful, and sensitive young man, complied with his wishes. They were also aware that his bed was to be occupied by a patient scheduled for admission after this patient’s discharge.

The attending psychiatrist, still very concerned about the patient’s phone call with his father, attended the community meeting that included the patient’s parting words to other patients and his team. The meeting occurred without any signs of patient distress. As reported by the staff, he had continued to present as significantly reconstituted and ready for discharge.

In the meeting, as the psychiatrist observed, the patient reported that he was feeling much improved. With a broad smile and what appeared to be warm positive affect, he thanked the staff for all their help, assuring them that he could not have recovered as well as he had without their support and assistance. He showed no signs of the devastation and sadness that had been evident when he spoke with his father.

His discharge was then processed, and the patient was given a copy of his discharge plan, which included the date of his scheduled outpatient appointment. He departed from the unit that morning, continuing to thank everyone for helping him feel so much better.

A few hours later, the unit received the news that the young man had walked to a subway station near the hospital and reportedly said to an older woman waiting on the platform, “Please tell my father that I was a good son.” He then jumped in front of a departing train. Due to the severity of damage to his mangled body, it was initially difficult to identify his remains, even with dental records. Eventually, a bloody, folded piece of paper giving his name, date of discharge from the hospital, and scheduled outpatient appointment was found in the back pocket of the remnants of his blood-soaked jeans.

What went wrong? The psychiatrist who had heard the patient’s side of the fateful phone call had hoped that his team would at least attempt to contact his father and explore what father and son had said to each other. Had the father expressed anger that his son was embarrassing his family by having himself admitted to a psychiatric facility or by sharing his suicidal ideation, both of which could be viewed as shaming to families in certain cultures?

Other factors that potentially contributed to the clinicians’ inability to recognize this patient’s feigned recovery may have included pressures created by utilization review and the anticipated admission of the next patient, as well as barriers to communicating with the patient’s father in a non-emergency situation.

The father, who was unable or unwilling to visit his son on the unit, may have been thousands of miles away, with a limited command of English and no translator available who could speak his native language. In addition, the patient may have refused to allow the team to contact his father because he believed that such contact would bring even more embarrassment to his family. There was also the question of whether the father was paying for the patient’s psychiatric hospitalization.

In any case, widespread distress ensued. The woman the patient spoke to on the subway platform, haunted by the thought that she should have done something to save him, was understandably traumatized. Unit staff were sufficiently shaken to question their clinical skills. Some staff eventually left the hospital unit, possibly in reaction to this traumatizing event.

Dr Baker, who is board-certified in both child/adolescent and adult psychiatry, has practiced and taught child, adolescent, and adult psychiatry on inpatient and outpatient units; also providing ER and unit overnight coverage as well as consult-liaison and crisis stabilization coverage at various Massachusetts hospitals including Harvard Medical Center teaching hospitals. She served as chief psychiatrist for the Residential Treatment Program at the Italian Home for Children in Boston from 2004 to 2021. She has published an earlier article with Thomas Gutheil, MD, in the Journal of Psychiatry and the Law (Volume 39 Fall 2011) dealing with treatment issues resulting from funding changes on a Massachusetts forensic unit and is a contributing member of the Program in Psychiatry and the Law at Harvard Medical School.