Menlo Park, CA, United States (Winter 2014)
Liverpool, Great Britain, 1999
In 1999, during my residency in Liverpool, England, I had the experience of observing a supervising psychiatrist make a home visit to a severely mentally ill patient and arrange for her involuntary hospitalization, a process referred to in England as sectioning1. I was greatly impressed at the time with the skill, clinical acumen, empathy, and sensitivity involved in carrying out such a decision.
I was sitting in the nurses’ station when Dr. C stuck his head around the door, “Shaili, I have to go out and see a patient who has not been doing so well. It sounds like we might have to section her. You should come.”
As we walked toward Dr. C’s Volkswagen Golf, he briefed me on the case. The patient, Bessie, had schizophrenia and did well when taking her medication. She was a reserved lady, house-proud, paid meticulous attention to her personal appearance, and kept herself busy doing bookkeeping for her husband’s small automotive garage.
Patricia, the community case manager assigned to Bessie, typically visited her at home every few weeks. Worried that Bessie appeared distracted and irritable, Patricia had been updating Dr. C with her concerns. Bessie no longer politely offered Patricia a cup of tea during her visits and seemed behind on her housework. A few days ago, Bessie’s husband, Dave, had called Patricia and told her that she was no longer taking her medication. Patricia had asked Bessie to come and see Dr. C but she had refused. Later, Dr. C tried to contact Bessie, but she was not returning his calls. Things had come to a head this morning when after chasing Dave around the kitchen table with a butcher knife Bessie had thrown him out of the house. Bessie was delusional and believed her husband was spying on her and was part of a government plot to kill her. She was convinced he had been poisoning her food and had confronted him in the early hours of the morning.
As we drove to Bessie’s home, I noticed how easily Dr. C navigated the side streets and knew the shortcuts in this neighborhood. This was his team’s catchment area and he frequently made home visits for patients unable, or unwilling, to come and see him in clinic. As we were nearing Bessie’s home, Dr. C’s cell phone started ringing, so he pulled over to take the call. Yanking out the antennae of the chunky phone, he looked over at me.
“I have a feeling this will not be good news.”
On the other end was Patricia. Dr. C listened, rolling his eyes at the news that Bessie had now turned her paranoid accusations toward the milkman. Convinced he had poisoned the milk and was also involved in the government plot to kill her, she had hurled two glass bottles of skimmed at him, narrowly missing his head. The bottles had, however, smashed onto the side of a parked Honda, sending its alarm blaring and its owner running out onto the street. Bessie was now barricaded inside her home, refusing to answer to the police, who had been called to the scene by the irate Honda owner.
Moments later we pulled into Bessie’s cul-de-sac and were greeted by a bustle of activity. Outside their home, Dave stood trying to placate the Honda owner. A police car was parked several yards away and a young constable was speaking into a walkie-talkie. Patricia stood at the front door, ringing the doorbell. As soon as she saw Dr. C approaching, she threw up her hands in frustration.
“She won’t listen to me…Good luck.”
Dr. C knocked on the front door with an urgent rap. His door knock was greeted by silence. Shading his head with arched hands Dr. C proceeded to peer through the frosted glass of the front door.
“Hi, Bessie, its Dr. C here…Can you open the door, please?”
We could see her blurred outline shifting behind the opaque glass, but she said nothing.
“Bessie, there is quite a mess out here. I don’t want things to get worse; please let me in.”
“Oh Doc, we are glad you are here.” Dr. C’s negotiations were interrupted by the well-meaning constable. “Do you need me to, you know, call for back up?” The constable gestured toward the door, making a jerking movement with his elbow and shoulder.
“Um, no, that’s okay…thank you, but if you could just give me a few minutes.”
“No problem, Doc. I am in my car if you need me.”
“I’ll call the ward and let them know that Bessie will be coming in,” Patricia whispered and then headed out after the constable.
“Bessie, it looks like you are going to have to come into the hospital.” Dr. C said in an even voice, without trace of judgment or frustration.
Inside, I saw Bessie’s fuzzy outline shift as she slowly headed toward us. She cracked the door and peered outside. She stood in her nightdress, leering at us with red puffy eyes. Her chubby face was smoldering with anger, and her mass of unruly curls served to make her appearance even more intimidating.
“Can we come in?” Unfazed by her glare, Dr. C gently pushed on the door. Bessie acquiesced and let us in. We crossed the threshold only to be hit by the overpowering acrid smell of cigarettes, and Dr. C quietly muttered, “She chain smokes when she gets psychotic.” Following Bessie’s lead we walked to the kitchen, bypassing piles of clothes and unopened mail scattered on every available surface. I took in the stacks of dirty dishes and several unopened bottles of milk. On the counter next to the sink, I spotted a medication bottle almost full to the brim with pills. I glanced at the label—“Prolixin 5mg to be taken twice a day.” Bessie had not taken her antipsychotic medication for weeks.
Dr. C took a seat next to Bessie and calmly explained why she would have to come into the hospital. She said nothing, instead staring aimlessly out of the glass patio doors as she smoked, seemingly lost to a different world and beholden to other voices and conversations.
I watched Dr. C in action. He knew his signature held the power to hospitalize Bessie against her will and this was not a decision he took lightly. He had diligently accrued the data he needed to make his case: Patricia’s troubling weekly reports, Bessie threatening Dave with a knife, and throwing bottles at the milkman. Then there was what he had witnessed: the smoldering Bessie who was mute and hostile, the full pill bottle on the countertop, and the chain smoking. He had known Bessie long enough to know the vicissitudes of her illness–if she did not get back on her medication her psychosis often became severe and hard to manage. It was a serious decision, but he did not recoil from taking action as the circumstances demanded it. Yet throughout it all he was respectful in every interaction with her, did not confront her or admonish her, and kept her informed of what was about to happen.
Ten minutes later, we emerged from Bessie’s home to be greeted by a downpour. The grey skies, filled with plump clouds, were unforgiving in their offerings. Dr. C, using his briefcase for cover, stopped to chat with Dave; I watched Dave’s exhausted face fall in resignation at Bessie’s illness. I saw Dr. C pat his on the back reassuringly. Next, Dr. C stopped by the constable’s car, briefing him on the situation, and handed Patricia a copy of the now slightly damp section papers.
Back in the car, Dr. C took a deep breath and attempted to lighten the situation with an “I suppose that was not so bad” smile. We sat, rain drenching the wind screen, watching as Patricia and the young police constable gently escorted Bessie to his car. Only when Bessie was in, Patricia buckled in next to her, doors locked and ignition started, did Dr. C turn on his own engine and head back to the hospital.
- “Sectioned” is the British term for involuntary commitment (i.e. the act of detaining a person with severe mental impairment who is a threat to themselves or other people, involuntarily in a psychiatric hospital).
SHAILI JAIN, MD currently serves as a psychiatrist at the Veterans Affairs Palo Alto Health Care System. She is a researcher affiliated with the National Center for Posttraumatic Stress Disorder, and a Clinical Assistant Professor affiliated with the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. Her medical essays and commentary have appeared in the New England Journal of Medicine, the Journal of the American Medical Association, and on public radio.