Sometimes there’s a gap between a doctor’s wealth and privilege, and their patient’s lack of them. And sometimes it’s a gulf.
By JP Sutherland
Look at me, sitting here at my desk, on this side of the consulting room. What do you see?
Old.
White.
Male.
Let’s start with those three adjectives. Together they paint a clear picture, and these days the picture is not so pretty. Time is being called for the privilege that comes from this tripartite label, and rightly so. Yet although the clock ticks closer to the end of my fifty-minute hour, the privilege continues even as the mechanism falters.
Now let’s add some extra layers of advantage to the basic benefit of being an old white male. I’m a physician, and I carry with me the elitism and expertise that is perceived to go with that. And being a cisgendered heterosexual has also spared me from some of the obstructions that delay others on their pathways through life.
Now look across the room to see who I’m talking with. They suffer from a mental illness, of course, otherwise they wouldn’t be here. And that is a marginalised population to begin with even if we don’t add the other, compounding, factors. But just as my old white maleness isn’t the whole of my privilege, nor is my patient’s illness the only thing that disenfranchises them. There is wealth. As a doctor I have it, and my patient doesn’t – being mentally ill increases the likelihood that they are poor. They are also more likely to be female than male, in a two-to-one ratio for both mood disorders and anxiety. And finally, because this room is in a hospital in the south of the city, with its high proportion of recent immigrants, my patient is likely to be non-white, bringing with them one of the many different hues from the rainbow of exclusions.
Her name was Chantana, and we were sitting in the psychiatry section of the emergency room. She was female, brown-skinned, and young – in her twenties. There was also a look about her that was puzzled, like all patients with psychotic experiences who are trying to understand the extraordinary perceptions that they are having. And together with her puzzlement she looked, and was, hopeless.
Psychiatrists routinely get to hear stories of great difficulty in our patient’s lives, but this was amongst the more challenging personal histories that I had ever heard. Chantana had just arrived in North America as an immigrant from her home in Southeast Asia. Her partner had come first, a year ago, in order to find work and to organise a future life for them both. Now she had arrived to join him, only to be told (after arrival and not before she got on the plane) that he had married someone else, didn’t want to see her, and would no longer sponsor her as an immigrant.
This left her alone in the country, without any money, without shelter, and with very little ability to speak in English. She had briefly found refuge with a compatriot in her country’s community within the city, but once Chantana became ill then they brought her to hospital.
I was told that she had already been distressed from her situation, as you would expect, but that over the last couple of days she had begun wailing, removing her clothes, and talking to people that no one else could see. It wasn’t an easy interview for me at all, but we managed to exchange a few sentences through an interpreter, in which she told me that her family were angry with her, and that she could hear them in the room with us telling her to die, and calling her a failure. The routine tests for drugs of abuse came back negative and there was no sign of a medical cause for her problems, so the easy-to-make diagnosis was a first-episode psychosis. I admitted her to hospital, and freed her temporarily from her struggles with a dose of antipsychotic medication large enough to send her to sleep.
For some people this was their reality, being repeatedly tossed between the twin walls of disease and financial hardship, and always falling lower.
Most people would agree that there is a spectrum of socioeconomic status (or SES) in society, and yet it is surprisingly hard to pin down, or measure in a wholly reliable way. Many of the accepted methods will arrange people on a class gradient by income, or education, or housing. Sometimes these factors are combined in an attempt to achieve a more reliable definition of class, but no measure is totally satisfactory, and the whole concept of measuring social status is still challenged by some people. But regardless of the nature of the ladder used for measurement, Chantana obviously sat on the lowest rung. She had no money, and had no foreseeable way to obtain any. She was homeless, and wasn’t welcome back at her recent refuge. And although she had completed high school in her home country, the fact that she could hardly speak English would make all her education irrelevant here until she learned the language.
The relationship between socioeconomic status and mental illness is strong, though a low SES actually correlates with increased levels of almost all diseases, whether they are psychiatric or medical. And the relationship between SES and mental illness is usually bidirectional. For example, homelessness and poverty increase an individual’s future chance of becoming depressed, and it’s easy to see how those problems would cause a low mood. But in an unfair symmetry, once someone is depressed then they may find their income is impacted by losing their job, and I have known some patients become homeless as a result of depression, and the consequent financial stress. This means that mental illness can cause a lowering of socioeconomic status, as well as being the result of it.
As I started my professional life, I initially saw this as a dispiriting vicious circle of illness and poverty, and I’ve certainly known some people for whom this was their reality, being repeatedly tossed between the twin walls of disease and financial hardship, and always falling lower. But the circular relationship between the two can also be seen more optimistically as offering multiple opportunities for intervention. If my treatment of someone’s depression is successful, then that may lead to a renewed opportunity for them to earn, and their SES rises again. Equally, if their homelessness can be addressed first, then that may have a positive effect on their mood regardless of whether they are receiving treatment. And from there it is but a small step to intervening in as many points of the cycle as possible, with treatments and social support, to maximise the likelihood of recovery.
Chantana’s illness in the ER was looking most likely to be schizophrenia, and that has its own, sad, connection with low SES. If we look at the social class of a patient’s family of origin, then we find that this disabling disorder is an equal opportunity blight on the lives of people from every group in society. But if you assess the SES of people after they have struggled with schizophrenia for a few years, then there is a slide from their original levels of social class, to a place determined by their diminished earning potential and housing.
All of this means that there tends to be a divide down the middle of the consulting room, with me on one side and my patient on the other. Much of this will be inevitable for as long as doctors are well paid, and mental illness disables people from work. But rather than just accept it for what it is, a physician needs to be aware of the chasm, and strive to make what efforts they can to bridge it.
The next morning Chantana was still drowsy from my prescription. She sat up in bed for a moment when I visited her, but her eyes could barely stay open, and she soon flopped back into sleep. She had hardly been able to talk, and so I put a hold on her next dose of medication and waited to review her again the following day. And that was when she surprised me. I looked for her first in her room, but the bed was empty. I found her sitting in the open area of the ward, where she had taken the shapeless and enveloping hospital gown and turned it into something approaching a stylish dress. Her hair was carefully arranged, and her eye contact was direct, though with a questioning look. Our conversation was still limited by the language barrier and the absence of an interpreter on this occasion, but the change was clear and dramatic.
I started by reminding her of who I was and where we were, and she quickly nodded her understanding.
“How are you today?” I asked.
“Good,” she replied, but I knew that people often said that as a polite answer.
“Can you remember the emergency room?”
She looked down briefly and smiled sheepishly. “Crazy.”
“How was it crazy?”
No reply.
“Chantana, do you remember hearing your family in the emergency room?”
“No voice.”
“But you told me that you could hear them.”
“Then voice. Now no voice. Crazy.”
And she looked like she understood what had happened to her, and she looked as if it was fast receding. I obviously needed an interpreter to get a fuller picture, but when I managed to find one, I didn’t learn too much more than what I had already surmised. However ill Chantana had been when she was wailing and hallucinating and disrobing at home, she was now essentially well.
“I know it’s partly the shame of the failed marriage and becoming ill, but there’s probably something else too.”
Such a rapid recovery from psychosis is obviously a good sign. The hallucinations of schizophrenia almost never recover that quickly, and so the likelihood of that diagnosis lessened. And that is always a relief, because although psychiatrists often manage to control a patient’s ‘voices’ in schizophrenia, there are other disabling features to the disease that we are much less good at helping, which makes us always feel better when our patients appear to have dodged that diagnosis.
Psychosis that comes and goes within a few days is most often substance-induced, and it is one of the all-too-common tasks of an inpatient psychiatrist to look after people while their minds re-emerge from near-drowning in the flood of dopamine unleashed by cocaine or amphetamine. However, Chantana repeatedly denied taking any recreational drugs, and her toxicology screen supported her assertion, as did the lady that she had been rooming with. So if this wasn’t schizophrenia, or a substance-induced psychosis, then what was it?
We don’t see it very often, but there is an illness called brief psychotic disorder that fitted her presentation well. Over a long career I could only remember about half a dozen people with the diagnosis, and Chantana was looking as if she might be another. We really don’t understand what causes this psychosis, even more than our usual inability to fully understand any psychiatric disorder. But the premise is that if you stress anyone enough then their mind may develop hallucinations or delusions, and that different brains naturally have different degrees of resilience, leading some people to present with the diagnosis when stressed, and others not. The stress in Chantana’s situation was certainly extreme, which likely accounted for her symptoms. What is harder to explain is why the psychosis resolves so fast when the stressors often continue. I had intervened temporarily to protect her from having to live on the street, but her basic position of being unsupported and alone in a new country was unchanged, and yet she was largely recovered.
The psychiatric management plan (or what counts for one) in a patient with brief psychotic disorder is to remove any antipsychotic medication quickly, and then watch for a while to see that the hallucinations don’t return, confirming that this wasn’t actually the first sign of a future bipolar or schizophrenic illness. I sat down with Chantana every day for the rest of the week, struggling to communicate properly, but seeing no sign of her previous illness. At that point I would normally discharge someone home again, and follow up with them in successive months to check if all was well. But where was ‘home’ for Chantana now?
“Maybe she should go back to Asia?” said someone at our multidisciplinary team meeting.
“Well, I’ve had to arrange patient transfers all across the country,” said Doreen, our team’s social worker, “but we’ve never done it to the other side of the world. We’d have to find out if her family back home would pay for it.”
“I presume that she would want to go home,” I added, “but I can’t say that I’ve asked her. Has anyone?”
No one had, and yet repatriation seemed to be the easiest thing to do. We all said it would be the best thing for her, though I could see that we were also thinking that it would be the least demanding option for us too.
When I raised the subject with her, I was surprised at the force of her answer.
“Stay here. No go home.” There was an interpreter at her side, but she wanted to make the point in English.
“But Chantana, you don’t have anything here. Your husband was supposed to support you.”
“No go home.”
“We have supported housing and benefits available for people in this situation,” I explained to the interpreter, “and we know where all the English language programs are for new arrivals, but all of them are restricted to citizens, not people whose immigration status has collapsed. I can try and ask the government to make an exception, but it’s most uncertain.”
There was a long wait while this was translated and the two of them talked back and forth. Finally, the interpreter spoke to me.
“She is definite about staying, and wants you to try and help her.”
His words were no doubt an accurate summary of their conversation, but the message came most strongly from Chantana, whose wet eyes were rigidly fixed on mine, and whose only word in English was a very plaintive “Please…”
And so we tried. There was a space in a transitional house for patients leaving hospital after a mental illness, and I knew that their staff were tireless advocates for their clients. I was spared from most of the administrative phone calls, but I had to support her applications for welfare, and language classes, and immigration, as we battled a seemingly impregnable bureaucratic fortress that restricted these benefits to citizens, or citizen-track immigrants.
Natalie was the caseworker who was most closely connected with Chantana, and she would often slip into my office between patients with another sheaf of paperwork for me.
“Just sign here. And here.”
“How is she doing?” I would ask, as I briefly scanned the documents pleading Chantana’s case.
“And here. She’s holding up well, and determined to make it work.”
“Do you know what it is that makes her so scared to go home?” I asked.
“She won’t talk about it. I know it’s partly the shame of the failed marriage and becoming ill, but there’s probably something else too.”
“Is there any sign that the immigration authorities will let her stay?”
“Nothing yet. But we’re giving it all we’ve got. You missed one signature on the last page.”
Look at me, sitting here at my desk, on this side of the consulting room. This is my outpatient office rather than the one in the ER, but they are hardly different, such is the limited palette of interior decoration in a hospital. What do you see?
Old.
Yes, and I’m about eighteen months older than when you last looked. Still white, and male, and benefitting from their stubbornly persisting privilege. Yet beyond the slight ageing, and the greyer hair, you may notice a bowing of my posture that wasn’t so marked before. All these years of working with the ill, and the disadvantaged, and the limited benefits that my art and my science can bring, are beginning to leave a mark.
Now look across the room and see who I’m talking with. It’s Chantana. But if I am looking older and slightly more threadbare, then she looks dramatically different, and for the better. The puzzlement is gone. And where previously her light was faltering, now she shines. Smartly dressed, she sits alert and smiling on the edge of her chair. The person who looks less at ease is the man on her right. She introduces me to him.
“This is Enrique, my new fiancée.”
“Congratulations. When is the wedding?”
“Later, when the paperwork is more certain. I’m also hoping for a promotion at work, which would help pay the bills.”
Her English is almost fluent now, though her accent is as heavy as ever. Enrique looks awkward, but his unease isn’t hard to explain. He has never sat in a psychiatrist’s office before, and although he knows that his future wife ‘had a breakdown’ he is wondering what words of doom he might hear from me regarding his future life with her.
But there is no life sentence for me to impose on them. Chantana is well, and the worst I could predict might be another brief psychotic episode and recovery, if she was ever to be as stressed as before. In place of the hopelessness that I saw last year, now I see her dreaming of a settled future. I also think that I hear gratitude to the New World country which took her in, and softened its immigration requirements, and whose mental health system offered her a life after her world collapsed. But the great divide is still there between us, albeit a little narrower, and because it is hard to hear accurately across such a distance, maybe I am just imagining that last part.
All names and other identifying details have been changed to protect patient confidentiality.
