The Apple Doesn't Fall Far From the Tree

Often I enjoy meetings with patients' families. I like the appreciation they show when they can talk to someone who seems to understand their kid (or brother, sister, whatever) , or who can help them understand their kid and his or her illness. Especially when I'm working with patients whose illnesses are really chronic -- schizophrenia, for example.

One of two things often happens. Either I'll hear that anxious edge in their voice soften when I respond relatively matter-of-factly to a description of how Johnnie came to be in the hospital.

They: "Well, Johnnie stopped taking his meds three weeks ago, and started decompensating. He was doing ok for a while -- he barracaded himself in his room, covered the windows with black plastic bags, and started sleeping with a butcher's knife under his mattress. We tried to get him to come in on his own, but he refused. We finally had to put our foot down and call the police last night when he ran out into the street without his clothes on, waving his knife around and trying to cut his own tongue out."

Me: "Guess he didn't want to get blood on his shirt."

I think these families brace themselves for the shock, horror or pity that they just can't seem to get used to, and so are relieved when they can talk to someone who underresponds.

The other thing that often happens, especially for families who are trying to get their heads around a new diagnosis, is that they come in fairly overwrought and. In addition to being agrieved and angry, they haven't found the internal logic of this kind of craziness yet. It's as if Johnnie really were being controlled by aliens. I can help them see that it's just like that for Johnnie, too -- that some problem in his brain is making all his thoughts, and everything he sees and hears and touches so jumbled and overwhelming that the only possible explanation he can come up with is that he's possessed. And that the last thing that will be helpful to Johnnie is to try to convince him that he's not being controlled by aliens, because then he'll believe you're controlled by the aliens, too, and he definitely, definitely won't let you give him his meds. On the other hand, you also don't want to humor him about the aliens, because then he'll dig in and his delusional system, as we call it, will become both more elaborate and entrenched.

I give them tips and tricks: Try to respond to the emotional content, not the literal content, as in, "I can see how upsetting it is for you to believe you are being called back to the mother ship. How can I help you feel less frightened?" or Agree to disagree, then redirect, as in "I know you believe the mother ship is sending you messages, but I'm having some trouble believing that. So what would you like for dinner?." They often find these things helpful.

But then there's that third category of family. The ones who are just plain nuts themselves. These interactions are rarely gratifying for the clinicians or therapeutic for the patient. There's denial, paranoia, grandiosity, sabotage of treatment, control issues, hysteria, you name it, all writ large. We've given up on the idea of the "schizophregenic mother" causing schizophrenia, but it's pretty hard to discount the role of nurture in mental illness all together.

Such was my family meeting today. I have this young, paranoid patient whose father came in insisting that we discharge Manny. He does this pretty much every day, in fact. Today, the doctor joined Manny and me for a chat with Dad.

"It was those special ed. teachers who made Manny sick when he was 8, you see, with their intellectual terrorism. You don't know my son," says Dad, "only I know my son, and only I can cure my son. I have rights, I brought him here and I can take him out." When Dad is reminded that Manny is an adult who signed in voluntarily, and so Dad's consent is not required to treat Manny, Dad ups the ante.

"Manny? He's sick," he says, "he knows nothing. How can you listen to him?" Clearly he's in no mood for tips and tricks from the social worker.

"Well, Mr. Manny's Dad," the doctor and I tag-team in saying. "Help us understand what you're saying. Manny got sick at home and you brought him to the hospital so we could help him. Now you're saying that Manny is well enough to leave the hospital, even though he's the same as when he came in. As you yourself say, he's sick, and he got that way while he was at home with you. Can you help me understand why you feel so strongly about his discharge?"

That didn't help matters much. Manny's Dad said to me: "I see you smiling. I know why you're smiling; it's because you're nervous," he says in a patronizing tone and puffing up his chest.

All right, that's it. I put my hand up and say, "With all due respect to you, Mr. Manny's Dad..." Sure sign of trouble if you have to start a sentence with "with all due respect."

The conversation ended badly. Mr. Manny's Dad had to be escorted from the building. I realize the guy's bananas, but if you could see this kid -- young man, really -- trying to get a word in edgewise, then being shut down by Dad, ("I'm the father. I speak for Manny.") you'd understand why he sleeps on the floor between the bed and the wall, and pretty much just stares at the wall the rest of the time, and you'd be pretty pissed off at this guy, too. Maybe you would've been able to finesse Mr. Manny's Dad better than I did, or maybe you'd've been able to convince your attending doc that Dad needs to be pink papered into a hospital himself, but sweet Jesus, please not here. If so, I would've liked to have seen it.

Madeline