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Personal Accounts: Good, Better, and the Best Psychiatric Care I've Received… And What Has Gone Wrong
Deborah Michelle Sanders, J.D.
Psychiatric Services 2002; doi: 10.1176/appi.ps.53.10.1241
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I have seen it all in my 28 years as a psychiatric patient. My bipolar I disorder was first diagnosed 16 years ago, but I had many psychotic breaks before that. I was diagnosed with a toxic psychosis, schizophrenia, and schizoaffective disorder in those first 12 years.

I have been a patient in community mental health settings at times, and I spent a year each in a health maintenance organization and in a Kaiser-Permanente plan. But for the most part I have been a private patient, paying fee for service. (All of the physicians I write about here were fee-for-service with me.) I have experienced what can go wrong, and I have also seen good, better, and best psychiatric care. Let me relate to you some of my odyssey.

The psychiatrist who properly diagnosed me, Dr. X, holds a prestigious academic position. I expected him to prescribe medications for me on an ongoing basis. But one day I happened to mention that I was in psychotherapy with a psychoanalyst. He roared, "If I had known that you were in therapy, not to mention psychoanalytic psychotherapy, I would never have taken you on as a patient!" I was intimidated, and I never returned to his office. This was substandard care: a physician needs to respect the patient's values and choices. From a legal perspective, a physician may not try to abandon a patient, even if he or she finds the patient's values and choices abhorrent within his or her own value system.

Dr. Y had been a general practitioner before he turned to psychiatry. He felt that he was capable of prescribing medications for general medical conditions that his psychiatric patients had, and he saw no ethical bind in doing so. This was a boundary problem. He had me taking lithium, thiothixene, and divalproex sodium as psychotropics. When I had what seemed like a gastrointestinal flu in December 1996, he prescribed Donnatal (a combination of belladonna and phenobarbital) and codeine together, and he kept me on the combination intermittently for six months, as I never seemed to get well. I got more and more dehydrated, but he never had my lithium level checked. Because my dehydration interfered with my ability to think, I did not ask for it to be checked either.

I asked after Dr. Y's health at one point the next spring, because he was leaving ostomy supplies in plain view. He said, "You are being intrusive," and, after I asked again, he added that I was violating his privacy and dignity. In correspondence we had during the fall of 2001, he continually referred to those exchanges in the spring of 1997 as an indication of my having been unduly angry at him. In contrast, on the basis of that correspondence, I feel that he had become less than attentive to my condition and was unaware of my increasing dehydration because he was "sore" at me. This was inappropriate countertransference. In June I suffered hypernatremia and extreme dehydration, which led to a brain injury through hypoxia. The brain injury had physical sequelae that persist five years later. This was frank malpractice. My physician had responsibilities to me—to determine my serum lithium level, to avoid boundary problems and refrain from inappropriate countertransference, and, of course, to avoid prescribing dehydrating drugs to me when I was already dehydrated—but he breached those duties, causing injury to me and damages to my physical, cognitive, and financial conditions.

Dr. Z, who had been my provider for a year, relied on a statement made by psychologist A in deciding not to respond to a message I left one December, telling him that I was suicidal and needed an antidepressant. The psychologist, whom I was seeing for psychotherapy, had telephoned Dr. Z after my own call to Dr. Z, and told him that he thought I was no longer suicidal. This hardly comported with how I was feeling and thinking; I was making definite plans. Nearly three weeks later, Dr. Z still had not phoned me back, and, in exasperation, I changed providers. By failing to follow up on my call for help, Dr. Z had abandoned me unlawfully. I cycled to mania shortly thereafter.

I paid and paid for these three errors by Drs. X, Y, and Z. Had Dr. X modulated his outburst, I would have enjoyed high-quality medication management at the beginning of my bipolar history and may have avoided the onslaught of negative symptoms that characterized the next several years for me. Dr. Y's malpractice resulted in my being unable to read normally for two years. My memory remained severely impaired for three and a half years. Today I still have a tendency toward dehydration, with accompanying dizziness and ataxia. I did not sue Dr. Y or report him to the disciplinary board, in part because I feared that my long psychiatric history would be twisted in an attempt to discredit my character. As to Dr. Z, his abandonment of me led to my cycling to mania, which soon turned into a psychotic state that I most likely would not have suffered otherwise.

With regard to the state of affairs posed by Dr. X's interaction with me, what if I had insisted on seeing two psychiatrists, given his objection? What if I had insisted on herbal therapy while my practitioner believed, to take one example, that St. John's wort is worse than useless? At some point, patients cannot be accommodated within the basic rules of the dyadic relationship. One such basic rule is that the psychiatrist need not and must not collude in poor care arrangements. To avoid abandoning the patient when the psychiatrist believes that the patient must withdraw, the psychiatrist must not only give the patient several referrals but also follow up to ensure that the patient has found a new provider.

I have also enjoyed excellent care, by practitioners whom I have gratefully stayed with over the long haul. Like all patients with severe and persistent mental illness, I have biological, psychological, and social needs that must be addressed together for care to meet the mark. I need medication management, psychotherapy, and attention to my financial comfort. I will never again accept anything but one-on-one care to avoid the team-care setting or "splitting" of care in which the errors by Drs. X and Z occurred. Yes, managed care enforces a team approach. But in fee-for-service care, patients need and deserve psychiatric physicians who are as experienced in psychotherapy as in psychopharmacology.

Throughout my experience, one physician met two-thirds of these needs, and two met all of them. Dr. J, of Berkeley, California, was a "good-enough" practitioner, to amend Donald Winnicott's phrase. As a supervising and training psychoanalyst, he was a superb therapist, aiding my social and my psychological needs. However, I would have been better off receiving medications as well, because I had previously had a toxic psychosis, and I fell into a psychotic break that ended our years of working together because I fled cross-country. Dr. F, of San Francisco, is a "better" practitioner, a superb psychopharmacologist who is also gifted in the way he does psychotherapy, with tact and respect for the patient. For a number of years, my "best" psychiatrist, Dr. P, of New York City, was available to me; however, he is now deceased. He was a psychoanalyst who developed an "information processing" theory of psychotherapy, an early variety of cognitive therapy. He never let his research interests override his concern for and sensitivity to my unique needs. Furthermore, he was capable in the prescription and management of medications.

What can providers learn from my experience? To avoid having things go wrong, providers should periodically review the elements of their state's legal requirements for ethical practice. These requirements are that providers seek informed consent, avoid boundary violations, avoid malpractice such as Dr. Y's, avoid the abandonment demonstrated by Dr. Z, and avoid the inappropriate transference reaction of Dr. X that led me to feel abandoned. Psychiatrists' work habits should be evaluated against these floors of adequate practice.

"Good-enough" psychiatry can be attained, according to my model, by addressing only part of a patient's tripartite needs—today, typically the biological alone. Most psychiatric patients are having their psychological and social needs met by team members, just as a majority of patients have third-party payers. But providers should strive to meet all three types of need and be "better" psychiatrists when patients are in a position to contract with them privately. To become a "best" psychiatrist, one must be a "better" psychiatrist who has matured into middle age, with concomitant humility, understanding, and experience.

"Strive, and hold cheap the strain," as Robert Browning taught. Anyone can succeed, if one only give enough yearning.

Ms. Sanders is a writer and an inactive lawyer living in San Francisco. She is executive director of the Sapling Project, which provides high-tech jobs for persons with severe mental illness. This essay is drawn from a book in progress. Send correspondence to Ms. Sanders at P.O. Box 642833, San Francisco, California 94164-2833 (e-mail, deborahmichelle@earthlink.net). Jeffrey L. Geller, M.D., M.P.H., is editor of this column.




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