She appeared at the front door at 1 a.m., barefoot and disheveled, asking where her brother lived; asking to use the phone. She sounded panicky and tears had smudged her mascara. She had no idea she was knocking on the door of a psychiatrist who happened to believe in mitzvah, hospitality toward strangers. He remembered Abraham and Sarah welcoming three strangers with a meal. Dr. Ronald Pies let the woman in, even though his inner radar bleeped a warning. “I should have been more wary of someone who had just ridden a child’s scooter to my house,” said Pies, “at 1 in the morning.”¹
He did not know she had already called the police that night about a bomb. Pies quickly recognized her manic state as he listened to the agitated woman speed through a narrative of her life. He was well aware of the danger of untreated psychosis and he tried to calm her down. Her story of substance abuse and health problems, coupled with the smell of alcohol on her breath, made him uneasy, yet he found his attitude changing as he listened. He became less fearful and could see “that beneath the sweating, speeding, mascara-smeared mess of her acute illness, a decent human being longed for a more stable life.”
In his story, “The Madness of a Stranger—In Our House,” Pies points out how psychiatric patients in this country are ill-served. If not for a stop at his home, which included a discussion with the police when they arrived along with an ambulance, the woman would have ended up in jail. Pies knows treatment is spotty and that people like his surprise guest don’t fare well.
The uncertain looming changes in health care and diagnostic labels are making many people with mental health symptoms apprehensive. A Johns Hopkins School of Public Health article dated 2009, “found a substantial level of unmet need for care among individuals with schizophrenia both at community level and in treatment settings.”² Also noted, the “expansion of managed care has led to further reduction” in treatment. With level of care going down, and complexity of mental illnesses going up, where will people turn for help?
Dr. Pies pointed out a need in psychiatric care and another writer pointed out a change in direction that might help meet the need. Stanford professor Tanya Luhrmann states that some families in countries with very little psychiatric care have had better results than we have in the U.S. Why the different outcome?
Two years after people with symptoms of schizophrenia in India first received care from a hospital, “They had fewer symptoms, took less medication, and were more likely to be employed and married,” said Luhrmann.³ Patients used medication initially and had few social services to help, yet had favorable results even with minimal psychiatric contact. Luhrmann noted the following factors that appeared in the homes:
• Family involvement was high. Members appeared at all appointments, managed medications, and allowed the person with symptoms to live at home “indefinitely.”
• Family members “yell[ed] at the patients less,” compared to Europeans and Americans.
• Family members did not put stock in a diagnosis (and doctors often did not mention one), and “As a result, none of the patients thought of themselves as having a career-ending illness and every one of them expected to get better.”
Luhrmann pointed out that “deception” played a role in order to minimize fear and unwillingness to take medication. Mothers (and doctors) said the pills were vitamins, or they simply ground the pills into the flour used for daily bread. Luhrmann did not endorse the deception. Overall, it seems that family members and doctors simply did their utmost to tackle schizophrenia as a sickness that could be healed, rather than a dreadful disease that had no hope of improvement.
The Schizophrenia Awareness Association of India refers to individuals suffering from symptoms as shubharthi instead of consumers, clients, or mental patients. Shubharthi means ‘seeker of well being.’ I don’t think any of us would call the change a deception. More of a kindness. The foundational attitude wrapped up in the term seems to be one of hope and inclusion.
Use of the term shubharthi helps family, neighbors, and community make a graceful shift from an emphasis on stigmatized diagnoses and lack of services to one of health. Practical. Possible. The more loving hands involved in the process, the better.
Here in the U.S. we need a graceful shift in attitude, too. According to Luhrmann, there is an effort within psychiatry in the U.S. to abandon the diagnoses currently used. The overemphasis on medication is weakening, too, because pills alone haven’t worked. The basic blessing of social connections has become a vital link.
Pies said he relaxed a bit as the shaky manic stranger talked with him and drank a glass of juice. Uninterrupted. In his quiet kitchen. In an orderly home like she hopes to have some day. The stranger with her scooter at Dr. Pies’ door was a seeker, too, not yet able to grab that missing link.
Be not forgetful to entertain strangers: for thereby some have entertained angels unawares. Heb. 13:2
1 “The Madness of a Stranger—In Our House,” by Ronald Pies, MD, Psychiatric Times, 7/18/12. http://www.psychiatrictimes.com/blog/pies/content/article/10168/2091296
2 Schizophrenia Bulletin, 2009 July; 35(4): 679–695, http://www.ncbi.nlm.nih.gov/pubmed/19505994
3 “Beyond the Brain,” by Tanya Luhrmann, The Wilson Quarterly, Summer 2012.