20140626_155127Seeing psychiatric patients outside the office can generate controversy over boundary issues. But over time I have concluded that as long as the encounter is clearly in the best interests of the patient, then “house-calls” are not only justified; often they provide invaluable information.

Other than seeing psychiatric inpatients during my early practice years, my first out-of-the-office encounter occurred when I evaluated a demented nursing-home patient. The man had barricaded himself in his ward room behind several metal bedframes he had dragged into a corner. He also refused his medication—in those days agitated psychotics were given Haldol or Thorazine—thinking the nurses were poisoning him. The nursing home, more of a warehouse than any of the bright Alzheimer units that we see today, looked and felt like a colorless dungeon, the caretakers more interested in reading the newspaper than attending to their charges.

“Living in a place like this could make anyone psychotic from sensory deprivation,” I told myself. I approached as close as the man would allow and performed the standard mental status exam. He was completely disoriented, without a clue of when it was, where he was or how he got there. He thought I was a devil sent to coax him into swallowing the poison the nurses wanted him to take. And what was it he hated about the medicine? He said it made him feel like he was losing what little he had left of his mind—a common side effect of the dopamine blocking agent he was being given for agitation. Upon reviewing the voluminous chart, the notes documented that the man was severely demented upon admission years earlier, had frequent visual hallucinations (very common in dementia of the Alzheimer’s type) and rarely had visitors. The Haldol was relatively new and had been prescribed because of increasing agitation. One of the more talkative nurses said the man had been all but abandoned by his family; she couldn’t remember the last time his son or daughter visited. I suggested trying something other than Haldol, noting that there was a kernel of truth—as there often is—in the man’s paranoia, in that the medicine could be interfering with his cognition. The nursing director said she would relay to information to the physician-in-charge and that was the last of it.  Or so I thought.

Six months later a lawyer got in touch, saying the man had died and the will was being contested. Sometime after my evaluation, the man changed his will, and the disinherited parties were suing. I was deposed and asked whether someone with that degree of mental deterioration could be expected to regain his faculties and be of sound enough mind to understand what he was doing. Although the answer was, “No,” the nursing home scene stuck with me, especially the neglect and lack of stimulation. How much better could the man have functioned were he in better surroundings? Although we’ll never know, seeing him in the setting in which he spent his time made a very deep impression contrasted with the next time an involved family member brought their demented mother, who was still being cared for at home, to my office.

The next “house call” occurred when I evaluated a disheartened man involved in a bitter custody battle over his 4 year old son. The ex-wife, who was under care for a mood disorder herself, wanted overnight and weekend visits with him stopped, alleging child abuse because the boy had bruises on his elbows and knees. The father implored that he would never hurt his child, and that a major goal of continuing joint custody was to secure permission to take his son to Italy to see his aged father—the child’s grandfather, whose health was failing rapidly—before he died. The grandfather had never seen his grandson and was too ill to travel. The boy’s father even offered to pay for his ex to stay in a hotel where she could see the child every day.

The mother and father’s descriptions were so discrepant that the only way to make sense of the situation, I concluded, was to see the father and child together in their natural setting. Naturally the father would be on his best behavior, but there was little likelihood he could coach his boisterous child to act other than his normal self. I arrived late in the afternoon of a midweek sleepover. The father lived in a cozy but not overly-neat rented house. By the time I got there the child had already eaten supper—I could smell the macaroni and cheese—and was wearing a pajama jumpsuit, the kind one steps into before zippering up the front. The boy was busy with his toy trucks and was constructing a bridge made of Legos. He was reticent when the father introduced me, delivering only a brief, “Hello,” and went back to his play, oblivious to my presence as long as I didn’t divert his father’s attention, which he didn’t like one bit. A  Sippy cup and a few toys were scattered about the floor, nothing that looked hazardous. Wanting his father’s undivided attention, the child began playing a game with his dad—the father said it was one of the boy’s favorites—where he would run to the other side of the playroom and rush to his father’s outstretched arms, sliding to a halt on his elbows and knees on the carpet just in front of his father. Mystery solved: the elbow and knee bruises were rug burns. Should the father have known about it? I left that to the judge, but the upshot was that years later I ran into the man at a supermarket. He gratefully recounted that he had been allowed to take his son to Italy just in time before his father died. Had the child abuse issue dragged on—the report based on the home visit dispelled the claim—it would have been too late.

Another home visit story makes a different point. One mid-winter, a middle-aged man deteriorating rapidly from early-onset Parkinson’s disease was brought to my office by his wife because of severe depression. She said her husband wouldn’t get out of bed; that he had lost some thirty pounds; and that he kept saying his life was over and he wished he were dead, although he had no plans to kill himself. She, on the other hand was a vigorous woman in her early sixties who angrily complained he did nothing to help himself, had stopped engaging in physical therapy, and that she was not going to be dragged down the black hole of depression with him. She had grandchildren and volunteering to attend to, and by God she was getting on with her life.

In addition to being severely depressed, a frequent concomitant of Parkinson’s disease, the man could barely initiate movements because of Parkinsonism. He couldn’t drive; he needed help getting to the bathroom. The family had the resources to engage a home health aide, but the man’s days were spent vegetating in front of the television or the computer screens on which he had once been an active stock trader. The man, a one-time avid golfer and tennis player, felt reduced to a worthless lump. What kept him going was looking forward to spending time with his children and grandchildren at the family summer home in the Berkshires. His children were alarmed by their father’s decline and were angry that their mother was so disinterested, but they were strewn all over the country with children of their own and although they called him, and me, frequently they didn’t know what to do.

In addition to dopamine-increasing medication for depression, the man clearly needed therapy to address how he felt about what was happening to him, but he said it was too hard to get to my office for more that monthly visits. So after several monosyllabic and unproductive telephone sessions, I decided to visit him at home. What a revelation! It was depressing. His den was dark and full of dusty golf and tennis trophies, which only reinforced that he was not the man he once was. An avid hunter, the room was surrounded by intricately-carved and meticulously painted decoy ducks, his prized possessions.

The first time we met face to face in his den he announced sharply, “I’m used to getting my own way. No one is going to make me do anything I don’t want,” consciously referring to physical therapy. Then, surrounded by that of which he was so proud, we begin talking about what the disease had done to him, how stripped of his manhood he felt having to depend on an aide to get him to the bathroom. “Why do physical therapy?” he whined, “when I’ll never be what I was.” His desperation made it clear how traumatized he was by his disease. A major goal of the therapy, therefore, was helping the man regain his dignity; and to accomplish that he needed to be confronted with the fact that he had the say about whether or not he could summon the courage to fight and regain whatever mobility he could, even though it would never be what it was. Once we met in the kitchen, where I was astounded to see how little sustenance there was in the refrigerator, next to nothing a man with severe Parkinson’s disease could swallow without aspirating. No wonder he was losing so much weight. He was literally starving. One day he was so pale and dehydrated I had to send him to the hospital where he required IV fluids before transfer to a rehab. When I visited him there, I was struck by the flippancy and snippiness with which he commanded the nurses and aides, as if they were his servants. I would never have appreciated that dimension of the man’s personality had I not ventured more deeply into his world.

Once he got better enough to return home it became apparent that there was no way to guarantee that the complicated regimen of drugs for Parkinsonism and depression was being ingested as prescribed, so we loaded his medi-doser and simplified the dosing schedule as much as possible.

It was time to get to work on his attitude. We always met in his den, “Trophy room therapy,” we came to call our visits. If how he treated the nurses at the rehab was any indication of what was happening between him and his wife, it was no wonder she wanted little to do with him. He perked up slowly, and I don’t think it was solely the antidepressants that helped. He said he liked our visits, and I teased and challenged him, saying I didn’t get on well with couch potatoes, and that he certainly had the capacity to get to physical therapy if he made it a priority. I also counseled him, his wife and the aide about the medi-doser being properly loaded and about preparing appealing nutritional shakes and juices he could manage without choking.

As the man improved, his wife called wanting to see me. Not a minute after entering the office she dissolved in tears, revealing how depressed she felt about her husband’s deterioration; only she manifested her upset with diffidence and distancing herself from him. He reacted to her withdrawal with the stubborn oppositionalism of a spoiled child no longer getting his way—in one of the Trophy room sessions he confessed he had been doted on as a child, especially when he was ill. The wife admitted she was devastated by the loss of the physically-vigorous man she had married. “I want my husband back,” she cried. She needed treatment of her own so we got her a good psychotherapist who she felt, to use her words, “I could really talk with.”

Slowly, the man got up an around, worked out as much as his disease allowed, and regained enough strength to eat sensibly. He made it to the Berkshires that summer and enjoyed his family; he felt his wife was more loving. Although he no longer wanted to die, there was plenty of work to do about coming to terms with the frustration of his physical limitations. Trophy room therapy continued for months; one day he announced that he had progressed to the point he could make it to the office for our appointment, to which he arrived well-dressed and groomed.

The man’s improvement, I believe, would not have happened had not the therapy commenced and unfolded on his own turf. In addition to a lesson about the resiliency of human nature, the experience raises the issue of flexibility and open-mindedness when it comes to considering the optimal setting for psychiatric therapy.

In all three cases, evaluating the patients in their native environment was essential to understanding their issues and putting their behavior into context, allowing for better interventions. After all, in order to get the best results, our patients need to feel “at home” when they are under our care. And as these cases show, sometimes we have to bring our care into their homes in order to achieve the most effective psychiatric therapy.