This vignette illustrates a not unusual situation, that is, a relatively unknown patient presents with agitation and suicidal ideation, and a not unusual intervention, that is, the patient gets hospitalized. This is done despite the clinician’s doubt about the seriousness of the intention and despite an expectation that another hospitalization is unlikely to help and may even be reinforcing a self-defeating pattern. 


The clinician will usually feel coerced, manipulated, and helpless. Still, in the absence of alternatives that can surely safeguard the patient, he is doing the right thing by suggesting hospitalization. My own approach to this situation starts by making the dilemma explicit. I tell a patient, such as Helene, that hospitalization would be the safest option, but that it is not likely to be helpful and probably will be harmful to her longer-term welfare. 


I explain that hospitalization involves inviting others to assume control for her life and this can discourage her learning self-controls. Moreover, I say that for many patients such as “rescues” become a way of feeling cared for and that being hospitalized feels like being adopted, although it is actually not what it means. “To me, offering hospitalization to you represents primarily a way to avoid my being legally liable should you otherwise commit suicide. I actually believe the more ‘caring’ response would be to try to keep you out of the hospital despite the potential risk to me.” I tell such patients that in my judgment the best way to proceed would be to take the time needed to see why she is recurrently suicidal and to develop a treatment plan that addresses those reasons. Patients will often be unsurprised by such statements, and the discourse moves away from medical necessity. 

 This is the “principle of false submission.” By ostensibly giving the patient what she wants but disarming it of its meaning, the cycle of repeated admissions can be broken. This will not usually happen the first time, that is, the patient will almost always go into the hospital upon hearing this exchange, but being hospitalized has a different meaning when they do.

 The success we had in getting people back to work involved close interaction with a skilled therapist who looked at the particular strengths of a person relative to their goals. As I indicated, there’s an overall cognitive deficit in schizophrenia. In our group as a whole, every function was impaired, ranging from 1–2.5 standard deviations, but actually, 15% of patients are in the lowest quartile in most functions; they never hit the bottom 5%. Therefore, assess what the deficit is in a particular patient. There are differences among drugs in the pattern of cognitive deficits that they can handle. For example, Risperdal, among all the atypical drugs, seems most effective in improving working memory. I assessed a college student who, prior to his first episode, had been valedictorian, but the illness had absolutely devastated his short-term working memory. On Risperdal, the improvement was so dramatic that he was able to return to college. The more typical patient is very treatment-resistant. Job coaching, newer techniques such as cognitive rehabilitation therapy that have been useful in people with traumatic brain injuries, and the like are just being explored in conjunction with the newer drugs. Previous attempts to use that kind of methodology for schizophrenia have all been in people receiving typical neuroleptic drugs, and the results were uniformly disappointing. It is clearly time for another round of investigation to take advantage of the synergy that the newer drugs might present.