May 17, 2012

December 2009 – Volume 5, No. 6

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Dr. Stanley Yaren challenges his colleagues to inspire medical students by sharing stories which illustrate the joys of psychiatry. He is the director of the Adult Forensic Psychiatry Program for Manitoba and the Winnipeg Region Health Authority and deputy clinical head of the Mental Health Program of the Winnipeg Health Sciences Centre. This is his story…

An intrepid adventure in psychiatry

By Dr. Stan Yaren, MD, FRCPC

The day starts with a trip out to Stony Mountain Institution, a medium security penitentiary. On the way I picked up George, a fourth year med student doing an elective rotation on the Forensic Service. The 30 minute drive on the highway gives me an opportunity to spend some one on one time and to get know students and residents at a more personal level. They seem to appreciate it. We chat about a patient we saw together the day before and about career opportunities in psychiatry. He shares a little about his background and interest in psychiatry. We arrive at the prison, and I think George is somewhat intimidated by the guards, the airport-like security and the clanging doors and locks. I must admit I’m always amused by the first reaction of students—it took me years to become accustomed to the sound of a steel door slamming shut and locking behind me.

We enter this strange world of men living in cages with its unique social structure, culture and language. Talk about cultural sensitivity.

The ever-efficient mental health nurse whisks us off to the high security wing where our first patient is on suicide watch after having swallowed razor blades, confirmed by x-ray. He is wearing what inmates affectionately refer to as a Barney Ruble suit. We inquire about his explanation for what happened. He states in a matter-of-fact manner that he had a bet with another inmate that it couldn’t be done and he resents being put on suicide observation for having won the bet. After assessing him for evidence of psychosis and depression, we agree with his conclusion that it was a really dumb idea to swallow razor blades and have him sent back to his unit.

Our next patient is an older man who has been serving a life sentence for the murder of a family member which took place over 25 years ago. Although the onset of schizophrenia did not declare itself until many years after his incarceration, in retrospect he was probably ill at the time of the offence. He presents an interesting ethical dilemma. He consistently refuses treatment and doesn’t have a shred of insight. He is thought disordered to the point of incoherence. A minute after greeting him and asking him how things are going, he is off to the races talking about microbes and toxins causing his hair loss and politicians creating auras in Alberta that radiate in the atmosphere all the way to Afghanistan. We lose him at the first turn. Incredibly, the feedback from correctional staff is that he functions well at his job in the prison kitchen, keeps himself neat and tidy and gets into no trouble with the other inmates, who steer well clear of him. He is not indicating any distress and appears indifferent to getting out on parole. Involuntary treatment in the past was unsuccessful. After struggling to keep up with his train of though for awhile, we offer him treatment with antipsychotic medication. He declines, very politely thanks us for the chat and agrees to return another time.

After seeing several more patients, we head back to the hospital. On the way, George and I continue to talk about the patients we saw. I smile to myself as I sense his excitement and enthusiasm. I think I have hooked another one.

Back at the office, I meet with my department head to discuss administrative issues, difficulties in dealing with a complaint made by the family member of a patient, a reorganization of services due to some departures of staff and the ever-present update on pandemic planning. I review some correspondence, deal with the constant flow of CPA email and have a quick lunch with a colleague. Then it’s off to the law courts to give evidence in a trial.

Meeting with the defense lawyer and then the crown attorney in pretrial conferences, I think about how this is yet another world as surreal as the prison: there are echoing marble floors, black robed figures sitting behind huge benches and a distinct culture and language. I enjoy the fact that I am treated with such respect in this setting, but I should not feel too flattered: this is an institution that functions on respect for the authority and power of the position more than the individual. The trial of a woman charged with breaking into the residence of a public official in order to enforce her claim that the government owed her sixteen billion dollars for stealing her patent for a cancer cure proceeds as expected with a finding of Not Criminally Responsible. The only hitch comes when the judge gives her an opportunity to speak to the court. She proceeds to explain at great length her theory of the link between planetary oscillations and cancer.

I arrive home for supper, and my wife Marcia asks how my day was. “Nothing special,” I reply. But on reflection, I think about what an incredibly rich array of experiences I have had in just a single day. And tomorrow, there will be a whole new set of fun and fulfilling adventures to embark upon. My patients fill me with awe and wonder. Their resilience and ability to make the best of adversity is a constant source of inspiration. I am amazed and amused by some of the strange ideas they share with me, but not in the sense of ridicule. They, after all, are often equally amused at how ridiculous the real world seems to them. A patient who thought he was a 10-foot-tall bishop and who was resistive to the idea of being treated for psychosis once said to me, “Dr. Yaren, I am sure you are happy in your world, but I have seen reality and it doesn’t impress me.”

© Copyright 2009. Canadian Psychiatry Aujourd’hui. All rights reserved.

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