I just finished reading a heartbreaking article in the May 30 issue of The New Yorker  (Annals of Mental Health, God Knows Where I Am: What Should Happen when Patients Reject their Diagnosis? by Rachel Aviv) which provides much food for thought both about the care provided for deeply troubled people and their civil rights in America today.

The article narrates the tragic saga of a young woman who began to have paranoid delusions and ideas of self-harm shortly after the breakup of her brief marriage. Eventually she was persuaded to check into New Hampshire Hospital, where doctors diagnosed her with schizoaffective disorder. She began taking lithium and Zypreza and, after ten days, she had gained enough insight into her condition to be released from the hospital. Sadly, her insight was short-lived. Once she left the hospital, she did not receive follow-up therapy because, the author writes, "insurance companies place strict limits on the number of sessions allowed," and psychiatrists believe that, in general, psychotic patients are not able to reflect meaningfully on their lives and thus benefit from talk therapy.

With medication as her only form of treatment, the woman relapsed into psychosis, and eventually stopped taking her medication because she no longer had insight into her condition. According to the Diagnostic and Statistical Manual term for this lack of insight, she now had "anosognosia," which means that she did not believe that she was mentally ill. Eventually she was hospitalized again due to a non-violent offense, but was eventually released because a judge did not think she was sufficiently ill to be deprived of her legal right to freedom. The author quotes psychiatrist Edwin Torrey Fuller, who thinks that in this kind of situation the word "freedom" is a fuzzy concept. He told the author "to keep talking about civil liberty is illogical. Patients are anything but free when they are at the beck and call of their own delusions." And indeed, this woman's "freedom" led her to hole up in a deserted farmhouse where she eventually starved to death.

This story raises a myriad of questions: Should patients deemed mentally ill be deprived of their civil rights and forced to take medications? Should patient privacy laws which did not allow the hospital to inform the woman's family about her release be modified in certain cases? This woman, in fact, had a sister and a daughter, both of whom had been long-time advocates for her. Or should a person--whatever her mental state--have the right to end her suffering by ending her own life?

Even more important, to my mind, is the question: would a good relationship with a therapist during a longer hospitalization or on an outpatient basis have helped this woman retain the insight she needed to get well? And if so, why were these options not available to her?

A hundred and fifty years ago, small hospitals called "moral treatment asylums" would have provided this troubled woman with a relationship with a benevolent therapist, fresh air, and gentle occupation. New Hampshire Hospital, to which she was admitted, had started out as this kind of place. On a hundred and seventeen acres, patients farmed, gardened, and cooked together, and gained a sense of community. If we believe social historian Michel Foucault, small asylums such as New Hampshire hospital in the nineteenth century were very effective at rehabilitating even the most severely disturbed patients. But with exploding numbers of mentally ill, and the psychiatric pendulum swinging hard to a biological model of mental illness, small public asylums underwent a metamorphosis. Treatment became limited to psychotropic drugs. Talk therapy was considered ineffective and overly expensive. Insurance companies demanded that patients have the briefest possible hospital stays without follow-up care.

Today, empirically-based research indicates the most important factor for a successful outcome in therapy is a good therapist-patient relationship, something that Philippe Pinel and his moral treatment therapists knew two hundred years ago. Plus ca change, plus c'est la meme chose (the more things change, the more they stay the same). The difference is that this view, however obvious both to common sense and to those who have researched the matter for many years, is not incorporated into our mental health system today.

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