Letter to the Editor
Authors: PATRICIA ZIPRIS, ADIEL DORON
Journal: World Psychiatry (2009)

Hospitalization in a psychiatric ward is a complex experience that requires patients to cope with new situations and interact with previously unfamiliar people, such as staff members and fellow patients. Living together 24 hours a day in a ward and participating in group therapeutic interventions facilitates an atmosphere where patients can discuss their problems and may sometimes develop close, intimate relationships. Contact with peers from within the mental health system is likely to provide opportunities for ventilation of emotions, reassurance and social approval, problem solving and reality testing 1. The issue of sexual relations between psychiatric inpatients is more problematic. Though 75% of sexual relationships in acute wards are by reciprocal consent 2, dilemmas arise regarding patients’ rights, mental conditions, suicidality, impulsivity, cultural, familial and social norms. The situation becomes more complicated when the involved patients have spouses, come from different ethnic backgrounds, or face adversity due to political strife between two ethnicities. Here we report the problematic case of an emotional involvement which developed between a young man with schizophrenia and a young woman with borderline personality disorder with different ethnic backgrounds. Mr. P is a 21 year-old Jewish Israeli, diagnosed with DSM-IV schizophrenia. While in an open psychiatric ward, P met a 20 year-old Arab Israeli woman and they became deeply involved in an emotional relationship. The relationship's process was very dramatic and unstable, partly because of the strong opposition from both families. The hospital staff was faced with the impact of this situation on P's mental condition, including suicidal thoughts, wedding plans and resistance to discharge. Rehabilitation programs did not progress due to lack of cooperation. The problematic emotional circumstances of the relationship interfered with his chances of achieving a complete remission. He was very tense and at one point was transferred to a closed ward after he exhibited aggressive behavior following a fight with his girlfriend. When his mental condition improved he was discharged, but he refused to participate in any rehabilitation program in the community. Once again, he was admitted to the ward because of his reports of “suicidal thoughts”. It was clear that he came back in order to stay with his girlfriend in the only place where they were able to be together without fear of their families’ reactions. Ms. M is a 20 year-old Israeli Arab woman. She was admitted to the same open psychiatric ward as Mr. P because of depression and suicidal thoughts. Her behavior in the ward was characterized by emotional lability, anxiety, a pattern of dramatic and unstable relationships and short psychotic episodes. She was diagnosed with borderline personality disorder. After her first discharge, she was re-admitted several times, because of violent confrontations with her family, partly because of her resistance to behave according to Arab social norms. The situation became more complicated because of her romantic relationship with Mr. P. M didn't want to return home, even for week-ends, as she was constantly involved in her relationship with Mr. P. The violence at home worsened, so the department staff decided that M's rehabilitation should take place away from her home. However, M did not cooperate, her family was clearly against this program, and finally after nine months she returned home. The relationship between the two patients had several implications for the treatment of each as an individual, as well for management by the professional staff. Considering the fact that Mr. P has schizophrenia, a disorder usually associated with feelings of loneliness and isolation, his emotional and sexual relationship with Mrs. M may suggest a degree of success. However, he was so involved with M, that he lost all motivation to participate in rehabilitation programs and therapeutic activities that did not include her. In his psychotherapy sessions, he did not talk about anything other than his girlfriend. His mood was very unstable and his responses to various situations in the relationship were unpredictable. Although P and M did not have sexual contact in the ward, the staff strongly suspected that they found discreet places to be together. When the families pressured the couple to sever the relationship, P reported suicidal thoughts. During P's long hospitalization, the staff had to reframe the goals of his treatment. P's mental condition was not improving. Although he was not in a psychotic state, he refused to participate in occupational therapy and therapeutic groups, and he exhibited a functional deterioration. The staff faced the dilemma of respecting P's rights but at the same time protecting him from becoming a victim of some level of emotional abuse by M. Decisions regarding discharge were complicated, because outside of the ward he felt that he had nothing and reported that he was feeling alive only in the ward with M. In addition, M's family threatened to murder him and his family if he did not terminate the relationship. M is a young Arab Muslim woman. She acted against the social and religious norms of her society, provoking rage in her parents, even to the point of murder threats. In the psychiatric ward she felt very liberated, and was very popular among young patients. The staff wondered if she was not manipulating Mr. P's feelings, using him as a weapon against her family, or using her disorder to escape the home life which she experienced as oppressive. In her case it was very difficult to establish treatment goals, to cope with her suicidal thoughts, and to appropriately manage her interactions with her family. After several months of trying to define the treatment objectives for each patient, P was discharged and continued visiting M. As far as we know, they are trying to keep in touch, in spite of great difficulties. We evaluated the mental conditions of both patients involved in the emotional relationship, especially the reality judgments concerning the relationship and its consequences. We concluded that both individuals decided to continue with their relationship by exercising their free will, with full understanding of the situation's complexity due to the families’ opposition and political adversities. We decided to respect the patients’ autonomy and not to disturb the process of their relationship. Nevertheless, with the consent of both patients, we met the families and communicated to them our position and the importance of respecting the patients’ rights. Considering the patient's condition, P, for the first time in his life, fell in love and that love was returned by M. M, on her part, received love and empathy from P, which may have been a type of corrective experience, after being a neglected and maltreated child. The treating staff concluded that forbidding the relationship would damage the mental condition of each of the patients. In our opinion, the major aspects that have to be evaluated, when the staff is dealing with emotional relationships between psychiatric inpatients, are included in the Georgetown principles of ethics in medicine 3: benefit the patient's condition; first of all don't damage (non-maleficence; primum non nocere); respect patient's autonomy; keep the principle of justice in conflict situations between benefits to the individual and society. Evaluation of patient's judgment is essential in order to respect autonomy, and also to protect patients that are at risk of being abused by other patients. The staff has to be aware of not evaluating and judging situations according to their own cultural norms. The staff can also consider getting advice from the hospital ethics committee, including about the legal aspects of the situation. Every case of emotional relationships between patients in an acute ward demands an individual evaluation, taking into consideration the Georgetown principles of medical ethics and the importance of a good therapeutic alliance with the treatment staff of each of the patients.