Planning for altered mental states

On Friday night I helped my sister-in-law while she gave birth. (I had my own baby strapped to my front the whole time, so I wasn’t particularly hands-on, but I helped Skype in the baby’s father who was in England at the time.)

My own labors were unusually easy, and seeing someone go through a more typical labor was eye-opening. This woman is a medical student who’s done her obstetrics rotation, but the pain made a different person out of her. A frightened, exhausted, anguished person.

One childbirth book I read (The Birth Partner, which is my favorite for women giving birth as well as support people) advocates using safe words for pain relief. It gives you the freedom to say “I want morphine” in the heat of the moment when you don’t fully mean it, and if you really mean it you’ll say “eggplant” or whatever and your support people will know to take it seriously. A birth plan is also good for this. In this case, my sister-in-law had asked in advance not to be given an epidural unless she repeatedly asked for one over a period of time, so when she said things like “I want an epidural” and “I want a c-section” her doula and midwife helped her find other ways to cope rather than calling an anesthesiologist.

It felt very strange to watch her in agony, to hear her asking for relief, and to know that the person she had been 6 hours ago and the person she would be in 6 more hours wouldn’t want her to get it. (Women who get epidurals report less pain but no greater satisfaction with their overall experience, probably because the side effects are so annoying.)

For both medical and psychiatric care, some people use some form of Ulysses contract, named for Ulysses who tied himself to a mast to be able to hear the Sirens’ tempting song without following it to his doom. It’s the act of a person who knows they’ll be in an altered state in the future. It’s treating your future self as a different person with different preferences, and forcing them to obey your current preferences.

The last day of her life chronicles Sandra Bem’s plan for her own death after an Altzheimer’s diagnosis, knowing that by the time her mind had deteriorated she would no longer want the death she had planned. My lovely wife in the psych ward is from the viewpoint of the husband of a woman with serious psychiatric problems.

DuBrul introduced me to the concept of mad maps. Like advanced directives for the dying, DuBrul explained, mad maps allow psychiatric patients to outline what they’d like their care to look like in future mental health crises. . . . We started trying to create Giulia’s map by discussing the pills in the medicine cabinet. Under what circumstances would Giulia take them, and how much would she take? I took a hardline approach: No sleep for one night, pills at maximum dosage. Giulia wanted more time before jumping to medication, and favored starting the dose out light.

They’re not failsafe: a birth plan only communicates your preferences, and you should go in with the understanding that you may need an emergency c-section or whatever. A mad map can plot out actions in anticipated situations, but unanticipated situations may throw the old plans out the window.

But I think we’re much better off planning, to the extent that we can, for times when our preferences will be different than they are now. From my coworker who’s set her computer to shut off the internet at 11 so she’ll go to bed on time, to a person planning how they want their death to go, sometimes it’s better for your self-in-the-moment not to have the reins.

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