The most difficult case I was ever charged with the provision of mental health treatment was for a former psychiatrist diagnosed with chronic paranoid schizophrenia. It is commonly known that people with a good knowledge of mental health, medicine or nursing are in fact, the most difficult patients to treat for a mental health condition.
Aside from being able to hide or mask their symptoms – either consciously or subconsciously – from either the result of ongoing denial or misunderstanding or even disbelief in their own diagnosis. This happens more than you may think.
Imagine for a minute, all of the health professionals out there, what happens when they become sick? Succumb to a mental health diagnosis? or develop a mental health condition? The answer is, often, we therapists roll out our interventions when it is already too late and he is already so symptomatic the illness is impossible to conceal or has totally overtaken the person’s coping skills and capacity to self-govern and live independently outside the confines of a hospital or inpatient setting.
One particular patient I treated comes to mind. This patient was a psychiatrist. I was a member of his ACT assertive community treatment team. There were a number of ongoing problematic aspects to providing a psychiatrist mental health treatment.
Aside from the problematic aspects and circumstances around this patients diagnosis, patients with a lot of experience in mental health care are often the most complicated to treat. On the very level of introductions and greeting this patient in session seemingly always was clumsy and already signalled problems ahead for sessions at his apartment.
As therapists, we are accustomed to the power differential in play when we work with our clients. Sure, we like to pretend we don’t benefit from such a power imbalance, but for treatment to succeed, someone needs to be in charge and driving treatment forward. So, when we greeted this patient on a first name basis, he would get agitated, and correct us, reminding us of his status as a psychiatrist – he was in fact the the one to have a final say on mental health treatment.
It was clumsy clinical judgement on our part, and also the narcissism of this patient made treatment even more challenging. The patient seemed to be firmly focused on disputing the expertise of our psychiatrist, believed he was ‘set up’ by extra governmental agents, and was in his position because he was the target of a larger governmental conspiracy.
For this patient, his awareness and judgement were only sporadically intact. He was somewhat aware and remembered our team had the final say on his treatment. Not only was he an AOT Assisted Out Patient, under the provision of the local forced treatment laws governing the rules around his treatment, but he knew, at the very least, that we could hospitalise him if we believed he needed inpatient treatment to re-stabilise. There came a time when we did have to hospitalise him.
This was when the patient became reportedly aggressive with our psychiatrist on our team, a female, and when she ultimately felt too scared to enter his apartment for further medication management sessions, signed the order for this former psychiatrist’s forced removal from the home. Under an order, signed by a psychiatrist, and carried out by a licensed clinician, our ACT team would coordinate with local emergency law enforcement to remove patients from their home when they were at imminent risk to themselves or others. And ultimately, one day, after the order was signed by the team’s psychiatrist, myself and another team member knocked down the door of this former psychiatrist apartment with emergency personal and entered it with a shield for our protection and the protection of the patient.
I still remember this former doctor, sitting on his couch, handcuffed and speaking incoherently about how we weren’t really mental health workers – we were government agents. It was difficult to witness, but the learning lessons are more than evident. When your are working with a psychiatrist, nurse or any other mental health provider with a mental health condition, be vigilant about their general mental status at all times. By the time you detect there is a problem, the likelihood of it being a bigger unnameable problem is even more probable. So watch for subtle cues, be very knowledgeable about your patients’ behaviour and general presentation when he is beginning to relapse. Any further delay in the detection of their mental status free fall can be disastrous.
Max E. Guttman, LCSW is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.
