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|Year : 2017
: 59 | Issue : 1 | Page
|Metamorphosis: A reason why many chronic schizophrenics get abandoned by their dear ones
James T Antony
Department of Psychiatry, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
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|Date of Web Publication||12-Apr-2017|
|How to cite this article:|
Antony JT. Metamorphosis: A reason why many chronic schizophrenics get abandoned by their dear ones. Indian J Psychiatry 2017;59:10-3
The famous novella “Metamorphosis” by Kafka has a special message for all of us. In that story, which was first published in1915, the central character Gregor Samsa was a traveling salesman, who toil hard to support his family, consisting of parents and a younger sister. One morning Gregor wakes up to a grim new reality; he has metamorphosed into a giant insect!
From that day everything changed drastically, for that close-knit happy family. The bread-winner of the low middle-class home is no more there; but, the old parents and a naive adolescent daughter are required to look after an uncouth, ugly creature! A creature, which is unable to communicate, move around freely, or even to protect itself, from physical injuries! Yet, despite all hardships, the family made earnest efforts to cope up with their new reality.
Initially, it was the sister who did the most, to take care of her metamorphosed brother. Mother supported her, while the father was just a distant onlooker. By and by, the attitude changed in everybody, and all three reached the same mindset; the “dear one” does not any more evoke any tender feelings in them. Finally, one day when the “despicable creature” dies in abject misery, the family feels a great sense of relief. No mourning for them, but together they have a lively discussion, planning for a bright future for the family!
Kafka's piece is acclaimed as one of the seminal works of fiction of the 20th century. He wrote this after he went through a protracted illness. It has been commented that the sense of severe loneliness that Kafka felt during his illness would have made him believe that his family no more had any tender feelings for him.
Many adaptations of this story have come up in various media, such as film, opera, and theater. In all such creative ventures, the attempt has mostly been to highlight a parallel between the pathetic predicament of the metamorphosed Gregor Samsa and that of many a modern man, who finds himself totally alienated from his own milieu.
The symbol that Kafka uses here is indeed a very powerful one. A normal young man gets “metamorphosed” into an oversized worm! By this imagery, readers would be struck and quite moved by the pathetic predicament of the main character, Samsa. However, we, health professionals, can take another lesson from Kafka's story, if we look at it from a slightly different angle.
As we know, when a serious illness affects a member, the family gives him tender care in the initial phase. But, we often fail to note that as it drags on and turns chronic, the positive attitude may change quietly, to one of apathy, rejection or worse! No one would ordinarily expect this change in the family: Blaming and distancing a dear one, merely because he behaves “badly” while sick! And as this kind of an attitudinal change is paradoxical, most of us are likely to miss it altogether.
But in his classic style of story-telling, besides telling us about the pathetic plight of a young man, in an equally forceful manner Kafka tells us about the drastic attitudinal change that happened in his family. Here what the master story-teller has done quite beautifully is to bring out an ugly side of human nature. When an “illness” brings about significant changes in a person, as a reaction to it, the family attitude towards him also may change in a horrifying manner! A change that perhaps is as ugly and disquieting as a clumsy creature!
Today, mental health professionals recognize the importance of family in shaping the course and outcome of schizophrenia. A “therapeutic alliance” between the treating psychiatrist and the patient's family is viewed as crucial. The manner in which too much of “expressed emotion”,,,, in the family would cause a high relapse rate is also recognized.
On the other side, it is also known that large number of families reject their schizophrenic member, once his disease lapses into a chronic phase. Workers have even developed tools like “Patient Rejection Scale” to measure the extent of such rejection.
But despite all these, most practicing psychiatrists hardly perceive the complete turn-around that takes place, in the attitude of families of their schizophrenic patients, while on treatment. Even on rare occasions when they perceive it, no one has any clue about how exactly the attitudinal change has taken place! Nor does anyone appreciate the extent to which this changed attitude stands in the way of administering further treatments.
It is because of this situation, there is a need for all of us, mental health professionals, to seriously study attitudinal changes that take place in families, of schizophrenic patients. This has to be made an integral part of our routine clinical drill. And when we closely study, it would turn out that in many instances, such attitudinal change is really huge.
It is to emphasize this point about the attitudinal change being one of an extreme degree; one feels justified in borrowing the term “metamorphosis” from Kafka's story. A caring and concerned attitude gets literally inverted to one of total rejection and worse; like a young man getting metamorphosed into a “despicable” creature!
Today, we have a large number of schizophrenics who drift, deteriorate, and in their chronic stage, get abandoned by their own families! They have no chance to benefit from many potent novel molecules, mainly because their families have already written them off! Unless the treating psychiatrist addresses this metamorphosis the required involvement of the family will not be forthcoming. And the whole treatment effort is bound to end up as a miserable failure.
It is, for this reason, there is a need for the profession, to study closely this phenomenon of “metamorphosis.” While doing so, one is required to critically take a close look at many aspects. Why some families abandon their dear ones rather fast? Do such families have some distinguishing features? Is there any critical point of time after the onset of illness, when the mindset of a supportive family gets transformed into one of rejection? Are there any special disease characteristics or other clinical or social parameters that would alert a clinician about impending metamorphosis in a family?
We have no dearth for studies on various aspects of chronic schizophrenia., But there is a need for more researches in this field. Painstaking retrospective studies of chronic schizophrenics who get abandoned by their close relatives are to be undertaken. Similarly, studies of those families, who continue to support and care despite many hardships, are to be undertaken. In addition, well-planned prospective studies of new schizophrenic patients could provide us many useful insights.
But even without waiting for answers to many of our queries on metamorphosis, clinicians can improve patient care by just being conscious of this phenomenon. When such an awareness is there, one could formulate distinct treatment plans that are appropriate for the two phases of the schizophrenic illness, namely for the premetamorphosis phase and for the postmetamorphosis phase.
In the premetamorphosis phase, the main thrust has to be on early diagnosis as well as on instituting vigorous treatment. The objective must be a reversal of disease signs to the maximum possible extent, without losing precious time. This should not be difficult in the early phase, as the family has a positive attitude at that time.
But a huge problem, with regards to the present-day practice of psychiatry, is that the profession generally has a complacent attitude toward this whole matter. Many centers do not even follow a standard norm of admitting every suspected “case” of schizophrenia for a proper diagnostic workup, early detection, vigorous management of early phase and planning a good long-term management!
Some of our popular, new diagnostic manuals , also exert influence in this area, which cannot be viewed as very healthy. It is as though these manuals inadvertently take away the diagnostic acumen from large sections of psychiatrists! The tendency of many professionals these days is to “objectify” everything, and keep on looking for tangible signs of a psychiatric disorder. Added to this, we must take into consideration the fact that patients have an instinctive human tendency to conceal their subtle, nontangible psychiatric signs. When all these influences act together, making a diagnosis in this particular area becomes extremely difficult.
In the presently popular style of busy practitioners, many of the above unhealthy trends have gone a little too far. Schizophrenia presenting with subtle nontangible signs is just being missed, by many! If this sad situation is to change, practicing psychiatrists are required to painstakingly cultivate the ability to judge “mental states” with a new mindset: Social functioning as reported by family has also to be taken into consideration, along with the clinical signs that they elicit. Waiting for exotic investigation results to answer clinical conundrums in Psychiatry, is unlikely to be fruitful, at least in the foreseeable future.
Another important factor, at least in present-day India, is the weakening of the time-old institution, general practice. When specialists see patients directly, with no initial screening by general practitioners, they fail to suspect conditions like early schizophrenia that present with subtle signs.
This situation has to change. Only by strengthening medical education at all levels, early detection of schizophrenia by all medical practitioners is likely to be a reality.
Next to our failure to make early diagnosis, we have the problem of our lethargy, in initiating vigorous treatment, even in those patients who are already diagnosed! This certainly is an issue that the profession has to collectively address.
Today, even many of our treatment protocols and guidelines seem to discourage vigorous treatment, in the early phase!,,, It is time that we consider dispassionately, whether it is right for us to reserve our “best” treatment options for “treatment-failures,” rather than allow all patients to benefit from such treatments before metamorphosis takes place in the attitude of their families.
Not only we have to administer vigorous treatment, but the profession has a responsibility to avert the occurrence of metamorphosis in the attitude of all families. To realize this objective, a basic requirement would be to have a good two-way traffic between the family and the treating doctor. In addition, at the very outset a family must be informed or rather educated about various aspects of schizophrenic illness, with a lot of sensitivity and empathy.
A patient may loose his emotional nearness and warmth toward close relatives as a direct effect of the disease process. The patient should not get blamed for this. And the family should get properly educated about this aspect. It would enable them to resist their tendency to automatically reciprocate a patient's negative attitude towards them. Mental health professionals must persuade the family to put in extra efforts to continue having their love and concern toward their schizophrenic dear one.
It is also important for the profession to keep in mind that the occurrence of metamorphosis may not always be a reaction to a patient's disease-related negative attitude. In many instances, personality characteristics of each family member as well as the interpersonal dynamics within the family may be important issues. Only when a dynamically informed psychiatrist studies all these with a psychotherapeutic mindset, many relevant factors could be brought out.
Many times, it would be crucial to find out the “opinion-maker” or the real leader, within the family. Only through him, it will be possible for a psychiatrist to influence the family. The elaborate clinical casework that may be required in such situations may not be something that a psychiatrist could do single-handedly. A more practical approach will be to get a mental health team involved in the clinical workup.
Accepting the fact that a dear one has a major psychiatric disorder is a bitter pill to swallow for many families. The reason is the prevailing stigma. Families go afer one or other non-psychiatric medical specialist just to avoid consulting a psychiatrist. Many times a schizophrenic is taken to a psychiatrist for the very first time after matamorphosis has already taken place!. At that late hour successful treatment would be all the more challenging. This is a stark reality that the profession has to accept.
And in their metamorphosed mindset, a family would be unwilling for a reasonable spell of in-patient management. Many times, they may not even agree for an intensive out-patient treatment, as it may require their frequent visit to the hospital! Here, the profession has to take up a huge challenge with fortitude. A psychotherapeutic attitude with lot of patience and perseverance will be necessary for a clinician while confronting a family that has already “written-off” its schizophrenic ward!
All that a family may want at that point of time would be to dispose of its “in-convenient” member! Many would be quite willing to shell out some money for this. And some would imagine that they could keep their conscience clean, by sending their ward to a “care-home” run by some religious outfit!
The profession has been conscious, since a long time about social factors influencing significantly, on the course of schizophrenic illness., Issues related to ensuring good quality rehabilitation of schizophrenic has all along been a matter of serious concern to the profession.,, But despite all these efforts, it has been observed that “in 80% of cases, psychosocial rehabilitation is the answer to most of the problems.”
When stalwarts hold such a view that for a vast majority of schizophrenic patients, rehabilitation is the only answer, one must be ready to admit one fact: Our present-day clinical management of schizophrenia is far from what is acceptable. The reason for the poor treatment response, in a vast majority, is metamorphosis. In such instances, our management must start by taking up the family itself for a psychotherapeutic management. Only by that, they could be taken back to their premetamorphosis mind-set.
Today large number of psychiatrists themselves runs rehabilitation facilities. Their simple reasoning would be that we are providing decent care to those chronic patients, whom their families are “unable” to look after. But here, some questions beg for answers. Have all those inmates of “rehab homes” undergone rigorous treatment before being written-off from society? Are there any less restrictive options possible for them, where they could live their lives with dignity, self-respect, and more autonomy?
At least on some occasions, we come across families who even take away the legitimate wealth and many civil rights of patients. In such situations there may be even a need to seek help from law-enforcement agencies, to sort out matters.
Today the world over, the care of chronic schizophrenics is a huge challenge for mental health professionals. This present totally unacceptable situation has to change. Indeed there are many things that could be dealt with only by a national leadership, with the required political will. But even more importantly, the profession has a responsibility to redefine and tone-up the treatment of schizophrenia, especially in the early phase.
To realize this goal, competency of every psychiatrist in clinical-service-delivery has to improve. Any attitudinal change that takes place in families of schizophrenic patients has to be detected early on and addressed. Unless we sharpen our professional acumen in identifying metamorphosis, many families would abandon their schizophrenic wards. And once this happens, our scope to intervene meaningfully would be meager. And a schizophrenic who finally reach a chronic “junkie” state, gets written off even by the civil society!
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James T Antony
Department of Psychiatry, Jubilee Mission Medical College and Research Institute, Trissur - 680 005, Kerala
Source of Support: None, Conflict of Interest: None