Therapeutic Needs and Inadequate Treatments

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CAUTIONARY TALES: MISUNDERSTANDING AND MISAPPLICATIONS OF RESILIENCE

This second of 5 articles addresses the kinds of therapeutic support needed to foster genuine resilience, the pressures (psychodynamic and economic/institutional) that impede the provision of such support, and the inadequate treatment offered in its place.

Resilience Real and Factitious

Resilience training is best informed by an understanding of how resilience naturally develops. For example, Abenes¹ sees resilience as a buffer of mental fortitude that develops over time and can be modeled and nurtured by parents and other primary caregivers. With children and adolescents who are susceptible to psychiatric illnesses (70% of which manifest by the age of 24 years), an environment of safety, maintenance of healthy routines, and emotional regulation on the part of parents can help children regulate their own emotions.

Resilience training in psychiatry, such as the program presented by “health experts” from Benson-Henry Institute for Mind-Body Medicine in 2022² and a lecture series offered by Massachusetts General Hospital,³ has the best chance of success when a therapeutic alliance has been established. Without the attachment and trust formed through a supportive alliance, the patient may not be able to release their defenses and incorporate the resilience-promoting factors that contribute to developing a robust and flexible capacity to maintain emotional stability during and after trauma.

This restabilizing response can be understood as positive resilience, to distinguish it from a toxic form of resilience in which an individual recovers from trauma, but reactivates in the direction of a vengeful, hostile, and/or destructive (to themselves or others) goal.⁴ In clinical settings, patients who do not experience secure attachment and trust during what purports to be resilience training are at risk for developing a feigned or pseudo-resilience. That is, they decide to appear as if they have experienced a positive, resilience-promoting process or what they have been taught to manifest as recovery from psychiatric symptoms.

They are observed to be no longer isolating or avoiding contact, but instead engaging well socially, expressing positive affect, eating well, sleeping well (by self-report), denying nightmares or suicidal or homicidal ideation, and engaging in creative activities. They essentially appear as if they have recovered fully and “bounced back” from the trauma or symptoms that led to their seeking or being referred for treatment, whether inpatient, residential, or outpatient.

Appearances to the contrary, patients who are experiencing significant psychiatric symptoms usually do not develop the ability to return to the challenges of their lives, unmediated by structured treatment, after a few days of instruction in “cognitive reappraisal.”

One of the most deceptive qualities that can underlie or support a superficial, misleading presentation of resilience is stoicism, which has been defined as a form of emotional and behavioral control that reflects an indifference to the vicissitudes of fortune and to pleasure or pain. Such a presentation can easily be mistaken for resilient qualities such as “grit and toughness” (as described in the previous article’s references to Tang et al).

Although the concern for one’s appearance, reputation, or image that characterizes stoicism bears an external resemblance to resilience, it can mask what amounts to an unexploded emotional grenade. Sadly, inexperienced clinicians and trainees often have difficulty distinguishing the constricted affect of the stoic from the balanced affect of a genuinely resilient person.

Lessons From Clinical Experience

Given the complexities inherent in the development and manifestation of resilience, clinicians should be cautious in responding to a patient’s apparent resilience. As analyzed by Simon and Gutheil,⁵ a number of factors complicate an accurate assessment of the ongoing status of a patient undergoing psychiatric treatment after an attempted suicide or serious suicidal ideation. Patients who present as cognitively reconstituted still need to be assessed for disordered affective states that can impair their capacity for decision making and self-care.⁶

A patient who presents as ready for discharge may simply want to be free from the hospital, may wish to restart drugs, may have decided on a plan to complete suicide after discharge, or may believe mistakenly that he or she has truly improved as a result of the activating effects of medication, the supportive milieu, group therapy, improved sleep, or a “flight into health” (involving denial of ongoing symptoms). A stoic demeanor can contribute to such a misleading presentation.

Moreover, some clinicians may avoid difficult questions or explorations because of cultural taboos or unexamined problematic feelings (their own or the patient’s) about suicide. This problem can result from the clinician’s subconscious or conscious discomfort in dealing with the issue of suicide or, not infrequently, from an unfounded concern that raising the issue of suicide with the patient will cause the patient to think more about committing suicide and then act on those thoughts.

Such concerns add to pressures, including that created by the utilization review process,^7-10 complicating staff reactions to patient presentations. These pressures have brought about a recent national movement among physicians to unionize out of concern that they cannot give their patients proper care in corporate environments (including hospitals, health insurers, and private equity) that now employ more than three-fourths of physicians in the United States.^11-12 These pressures, both internal and external, may exert at least a subconscious influence on how staff focus on and process a patient’s presentation.

Clinicians who feel pressure to view the patient's appearance, behavior, and interactions as positively as possible may overlook or minimize signs of ongoing illness or emotional instability. They may fail to ask directly about suicidality, fail to question the patient’s self-report of sudden improvement and denial of suicidal ideation, fail to seek communication with the patient’s collateral contacts to take into account relevant family dynamics and interpersonal interactions, or fail to share pertinent concerns. Instead, a misperception spreads among staff and clinicians that the patient’s apparent rapid recovery will be “durable enough to sustain the patient’s safety after discharge.”⁵

Meanwhile, the patient may be providing clues which, in the past, experienced clinicians usually have observed and reported, such as poor appetite, continued disheveled appearance, an absence of consistent social interaction with staff or peers, or an inability to trust, attach to, or develop a therapeutic alliance with clinicians. Other warning signs include possible delusions or self-dialoging and inconsistent compliance with medications (including possible “cheeking” of pills). Particularly concerning is the patient’s refusal to allow clinicians to speak with family or other collateral contacts, since “approximately 25% of patients at risk for suicide deny having suicidal ideation to their clinicians but do admit it to their families.”⁵

As pressure from the utilization review process grows, clinicians may not ask as often as they should whether the patient is having thoughts about self-harm or suicide. Thus, when the insurance reviewer asks whether the patient has expressed suicidal concerns, the clinician is able to say “no” because the question was not addressed recently, allowing the clinician, perhaps unconsciously, to collude with utilization reviewers and perhaps the patient in a contagion of “magical thinking”¹³ in which the patient is misperceived as significantly improved and “resilient.”

As it becomes more and more challenging to resist the pressures for a shorter inpatient stay, it is all the more important for clinicians to examine possible urges, both external and internal, to perceive the patient as resilient in response to pressures from the patient, insurance companies, or the administration.

As noted by Rufino, et al,¹⁴ citing a study by Appleby, et al,¹⁵ “the majority of deaths by suicide post discharge happened within the first week, with most suicides occurring the day after discharge: 186 of those suicides occurred before the initial follow-up appointment. In a comparable study, Bickley, et al,¹⁶ identified risk and protective factors for suicide among 100 psychiatric patients who died within 2 weeks post-discharge. Of these patients, 55% had died by suicide within the first week after discharge and 49% died before their first follow-up appointment.”

As we continue to learn what factors can support and what factors can undermine resilience in all its complexity, we must remain alert to the risk of perceiving resilience that may in fact be either fragile or entirely absent, a misperception that can impede proper clinical care.

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.

References

1. Abenes M. Teens in America: how the COVID-19 pandemic is shaping the next generation. Psychiatric Times. November 12, 2021. Accessed June 1, 2024. https://www.psychiatrictimes.com/view/teens-in-america-how-the-covid-19-pandemic-is-shaping-the-next-generation
2. Building resiliency through cognitive reappraisal and lifestyle modification. Program presented by Benson-Henry Institute for Mind-Body Medicine. September 6-October 18, 2022.
3. Henin A. Integrating resilience into everyday practice. Program presented by Massachusetts General Hospital Psychiatry Academy.
4. Bursztajn HJ, Levy-Carrick N. A pandemic of false choices. Psychiatric Times. December 21, 2020. Accessed June 1, 2024. https://www.psychiatrictimes.com/view/a-pandemic-of-false-choices
5. Simon RI, Gutheil TG. Sudden improvement among high-risk suicidal patients: should it be trusted? Psychiatr Services 2009;60:387-389.
6. Bursztajn HJ, Harding HP, Gutheil TG, Brodsky A. Beyond cognition: the role of disordered affective states in impairing competence to consent to treatment. Bull Am Acad Psychiatry Law. 1991;19:383-388.
7. Baker JO, Gutheil TG. Effects of funding cutbacks in the mental health field on patient care and potential liability issues. J Psychiatry Law 2011;39(3):425-440.
8. Lang M. The impact of mental health insurance laws on state suicide rates. Health Economics 2013;22(1):73-88.
9. Glied S, Frank RG. Economics and the transformation of the mental health system. J Health Polit Policy Law 2016;41(4):541-558.
10. Insel TR. Federal court gives green light to deny coverage. Psychiatric Times. 2022;39(10).
11. Purifoy P. Doctors move toward unionization amid post-pandemic merger wave. Bloomberg Law. August 16, 2023. Accessed June 1, 2024. https://news.bloomberglaw.com/daily-labor-report/doctors-move-toward-unionization-amid-post-pandemic-merger-wave?context=search&index=4
12. Pifer R. More than three-fourths of doctors are employed by corporations, report finds. Healthcare Dive. April 12, 2024. Accessed June 1, 2024. https://www.healthcaredive.com/news/doctor-corporate-ownership-growing-hospital-insurer-pai-avalere/712988/
13. Bursztajn HJ, Gutheil TG, Brodsky A, Swagerty E. Magical thinking, suicide, and malpractice litigation. Bull Am Acad Psychiatry Law. 1988;16:369-376.
14. Rufino KA, Beyene H, Poa E, et al. A false sense of security: rapid improvement as a red flag for death by suicide. J Consult Clin Psychol. 2022;90(5):405-412.
15. Appleby L, Shaw J, Amos T,et al. Suicide within 12 months of contact with mental health services: national clinical survey. BMJ.1999;318:1235-1239.
16. Bickley H, Hunt IM, Windfuhr K, et al. Suicide within two weeks of discharge from psychiatric inpatient care: a case-control study. Psychiatr Services. 2013;64(7):653-659.