CONTRACTING FOR SAFETY and DIAGNOSTIC INFLATION
A Minute with Dr Hancur -Summer 2001
I want to address two important issues with you in this "Minute". The first is, as promised, "contracting for safety" and the second, "diagnostic inflation". I first experienced the concept of "contracting for safety" while interning more than a few years ago at Fort Logan Mental Health Center in Littleton, Colorado. The patient, a chronic schizophrenic man in remission, had become institutionalized to the hospital routine and was being considered for transfer to Colorado's long-term hospital. The move had been attempted before and the patient had made a suicidal gesture which resulted in his continued residence at Ft. Logan. A hospital staff member with Transactional Analysis leanings was summoned to prepare the patient for the proposed transfer. I attended the interview and witnessed the extraction of a verbal "contract for safety" which had the sound of a three dollar bill. Sure enough that evening the patient attempted suicide and remained on his accustomed unit. While the situation had a clear underlying agenda and the act could be categorized properly as a "gesture" rather than "attempt", it still illustrates the principle than mere verbalization by the patient of lack of intent does not substitute for the clinician's judgment. While this may seem obvious, the way that the term is applied in practice seems to say otherwise. Prediction of violence is easily one of the most difficult and anxiety-provoking tasks that we face as providers. We are all asked to do it and yet every research study I've ever seen says no one is particularly good at it. Nevertheless, it goes with the territory. I personally think that we can do a good job of assessing and we can do a poor job. While still being mindful that predicting the future is a high-risk endeavor, I think we increase our chances of being correct if we follow common sense guidelines and rely upon our clinical judgement rather than the patients verbal assurance.
The second issue I want to address is what I am calling "diagnostic inflation". In reviewing inpatient charts recently, I noticed that almost all of the patients had three or more diagnoses. This is troubling to me for many reasons. My concern has to do with the treatment focus. I was taught, and believe, that psychiatric diagnosis is a description of behavior. Unlike medical diagnoses that identify a bacterium or a malfunctioning organ, psychiatric diagnoses are by convention, that is, by agreement. A panel of experts appointed by the American Psychiatric Association convenes periodically and through discussion agrees to call a certain pattern of behavior "such-and-such disorder" and assigns it a number. Next time they get together, they might change the name or drop it altogether. Some of you might remember the term "neurosis". The reason is that psychiatric diagnoses are not definitions, they are descriptions. The recent near obsession with co-occurring orders is based in part on a fundamental misunderstanding of the nature of this nomenclature. Diagnosis is a way for us to conceptualize the person's mental and emotional problems and a shorthand way for us to communicate that understanding among ourselves. It is an exercise that should sharpen our treatment focus and increase our understanding of our patient. It is always hypothetical and therefore always subject to change should new information become known. Multiple diagnoses often represent a failure on the diagnostician's part to see the common thread in seemingly disparate symptoms, much like the detective who names all the clues but doesn't solve the mystery.
Rather than improving the treatment, such a shotgun approach often leads to a disjointed focus in which individual symptoms are targeted, rather than the common root. And in today's world, that can mean a medication dedicated to each diagnosis, which further muddies the clinical water. It should be the rare, unlucky patient who requires an antidepressant, an anti-psychotic, a mood stabilizer and a benzodiazepine. Today, it is not so rare to see such polypharmacy. And it is, in my opinion, the direct result of diagnosing trees instead of forests.
As you probably have guessed from this and my previous columns, I believe strongly that we, as providers, shape much of what happens with our patients. I want us to look at ourselves, to be open, non-defensive and self-critical. I want us to help each other to be better tomorrow than we are today. Our patients and their families want that too.