Wednesday, January 26, 2005

Us vs. Them

Every Wednesday morning is Court Day here at the hospital. A judge from the District Court comes across the river, presides over our in-hospital courtroom, and hears the cases of patients who want to leave the hospital before our team feels they’re safe to go. I avoid keeping people here involuntarily whenever possible, and only go to court seeking commitment when the case appears convincing. For that reason, we usually “win” the hearings—which has led patients to refer to the process as “kangaroo court”. They feel the outcome is pre-ordained.

By the nature of the selection, most of the folks who wind up in court are significantly out of touch with reality. Many misinterpret the court proceeding and feel that they are on trial for some crime. The problem is furthered by the adversarial nature of the hearing. Although we have a relatively low-key courtroom (the judge, for example, does not wear robes), it is divided in two like a regular court—with the hospital staff and attorney on one side (like prosecutors) and patient and attorney on the other (like a defendant). During the hearing, “our” attorney will ask questions of me designed to show that the patient has a mental illness, and that the hospital is providing necessary, appropriate treatment. This usually involves detailed description of the patient’s poor ability to care for himself, or threatening behaviors, or poor judgment, or other aspects of severe illness. In most cases, the patient disagrees with virtually every word of my testimony (also known as “lies” or “perjury”) and becomes visibly angry while I speak. It is extremely hard to sit and listen to someone who appears to be listing off all your character flaws. It also isn’t pleasant to be the person doing the listing.

Later, the patient’s attorney will ask me questions designed to cast doubt on my professional abilities, grasp of the facts, and treatment decisions. The patient often sees this dressing-down as just revenge for my previous lies. The lawyer becomes the patient’s champion, protecting him against the Bad Doctor. One patient got so excited that he jumped up and down and applauded as his (particularly ferocious) lawyer needled away at me.

Finally, the judge will decide either to release the patient, or allow the hospital to continue an involuntary commitment. In the latter case, a huge problem follows: the patient is furious for days. Rarely does the patient see the judge’s opinion as one worth considering— rather, he may see it as further evidence that people are indeed out to get him, and that the system is rotten to the core. One patient recently declared that the judge was actually family member in disguise, trying to put her away to get her money.

Most distressing to me, however, is the damage done to the doctor/patient relationship by the adversarial legal process. Usually, I’ve just spent weeks trying to gain the trust and cooperation of a suspicious, angry, or withdrawn person. Now, in their minds, I’ve “turned against them”, embarrassed them in public, and lied for the purpose of incarcerating them. They’re mad as hell. It may take days or weeks for the person to begin to work with me again towards discharge. Sometimes, the damage to our relationship is permanent.

I’ve spent hours, late at night, mulling this problem, trying to find ways around it. In court, I now go out of my way to emphasize (to the extent that I can do so truthfully) each patient’s positive attributes—intelligence, wit, humor, artistic skill, bodily strength, whatever I can find. I try to prepare patients before court, warning them that they may not like what I say, that my concerns don’t mean I dislike them as people, asking for their forgiveness ahead of time. I try to meet with people right after court to undertake damage control. But none of this is highly effective. Are there other strategies? The suggestion box is open.


Post a Comment

<< Home