disc psy11

Lectures: Schizophrenia and other Psychotic Disorders READING: CHAPTER 13

Additional Readings:

1. Sims has probably one of the best descriptions of the wide range difficulties in psychosis. Best areas are covered from pages 95 to 175

2. Fernandez’s “Am I Crazy Doc?” pages 101-103

Class Participation  

  http://www.nami.org/  (Links to an external site.)

http://www.schizophrenia.com/  (Links to an external site.)

 

Keeping you on track:

1. Read Chapter 13 from your Textbook.

2. Sims has probably one of the best descriptions of the wide range difficulties in psychosis. Best areas are covered from pages 95 to 175. Fernandez’s “Am I Crazy Doc?” is included below.

Enjoy it!

Am I Crazy Doc?

 

The young man sitting across from me appeared a little tense and guarded. He was a new intake evaluation recently discharged form an inpatient psychiatric hospital. Now, he was to follow up as an outpatient in the Community Mental Health center I was doing my clinical practices. As I reviewed his history I realized that he had had several psychiatric hospitalizations and they had given him a whole range of very serious diagnosis; schizophrenia, bipolar disorder, schizo-affective disorder, antisocial personality disorder, etc. This was our first session and he was uncomfortable, evasive and barely able to contain his anger.

Dr F- Mr. B what brings you here?

Mr. B- What the F**K do you think it brings me here?

Dr F- Oh, I take you are not too happy to be here (I smiled)…don’t blame you man, these places can be a real drag.

Mr. B-Yeap

Dr F-Listen I don’t want to push you in any way or make you uncomfortable. My job here is to try to help you and nothing more. ..

Mr. B -Yeap I heard that one before!

DrF- Ok, fair enough, just give me a chance. We will work together to figure S**t out. If it doesn’t work, it doesn’t work and you can fire my ass!

Mr. B- Chuckle…

I felt this first meeting was essential to make a connection to this young guy, and based on his history it was clear to me he had had serious emotional problems and his experience with Mental Health professional had not gone too well. To my pleasure and surprise, he showed up for next appointments and two others after that one. He seemed too together for someone with the kinds of diagnosis he had. He remained suspicious and uncomfortable sitting in the office. We switch our sessions to walks around the Center and that was particularly liberating to him. I requested from the Medical Director to have him psychological tested and the results failed to support any psychotic process especially since he was off medication (his choice). I decided to present him to our regular medical meetings and I suggested his diagnosis were wrong.

Medical Director- Luis for the last two years Psychologists and Psychiatrist have diagnosed him with some form of psychotic disorder and you think he is not? (smiles)

Dr F- I do not know, I can only tell you of my experience these last few weeks with him and the results of Psychological testing and he does not seem psychotic to me at all!

Medical Director- OK Luis, would you want to take him as your regular patient and work with him?

I did and for the next year or so we saw each other almost weekly. One day he told me he liked art and he was “pretty good” at drawing. I told him I would love to see his drawings and poetry, which he also wrote. He brought a few samples of both to our next session and I took them home to look at it. There was very little doubt regarding his artistic abilities; he drew wonderful human figures and wrote perfectly rhymed and lyric poetry. But the content! It was painful and fearful and full of hatred and desperation. I put it away and grew a little concerned. There was so much there! In his art he revealed a subjective world of pain and isolation that was veiled in his otherwise indifferent social presentation. What was I to do with that?

Next session he came in with a little smirk on his face. He sat down and asked me right away:

Mr. B-So what did you think about it?

Dr F-John I think you have an amazing ability, and somehow you are able to describe so much pain and despair in your life through these in ways that are beautiful and engaging.

Mr. B- Do you really think so?

DR F- I do

Mr. B -Doc in my last hospitalization I liked my Psychiatrist a lot. She was a very nice woman who tried to help me and I trusted her. One day I decided to show her the pictures and poems I showed you and she became afraid. She responded by increasing my Haldol and I had a very severe muscle spam and I almost died. I promised myself never again to trust anyone and since then I have refused any drugs they have offered me.

That day something significant changed in our relationship. He was now much more talkative and he appeared more honest in his communication. His mood was pleasant when before it had been sullen and he was making plans for his future. Then one day I got the dreaded call, after nearly 8 months of progress I was told he had been admitted to the Psychiatric hospital once more, and yes he was hallucinating. I felt devastated and lost. He was after all psychotic, perhaps schizophrenic and no degree of compassion or hope could change that fact. As these thoughts were occupying my mind I rushed to the hospital, expecting the worst. When I got there, to my surprise, he was talking to his girlfriend very animated. He seemed happy and relaxed. He was in the open ward and had full privileges. When I approach him, he got up from his chair and came to me and gave me a hug.

Mr. B- Good to see you doc!

DR F- How are you doing buddy? What happened?

Mr. B-Doc, I do not know what you are thinking right now, but it is not what it seems (he was smiling while he held his girlfriend’s hands on his).  You see last night this friend of mine came over and offered me to smoke some “good s**t. I had not done this in many months, well I tried and I got really high and began to hear voices…a bad trip doc, I will never do this s**t again, I promise you.

And he kept his promise. We continued to work for a few more months until we terminated. As we were wrapping things up, one day he appeared pensive and a little worried. Knowing that something was bothering him I encourage him tell me:

Mr. B- Doc, you have always been a straight shooter and I want your honest opinion, do you think I’m crazy?

Then I told him something that I have repeated many times over, in different contexts and to different patients, but something I hold deeply as cherish as part of our shared humanity:

Dr F- John, I can’t answer that question, in fact; I do not know the answer. But the question my friend, is not whether you are crazy or not as you said, the question is what kind of man you want to be even if you were crazy . That is your challenge and your responsibility. Sure, you may have a predisposition to get psychotic, but neither you nor I can do anything about changing that. However, you can do so much about taking charge of your life, assuming responsibility for your choices and act in ways that will enhance and protect your life. The rest is out of your hands.

 To the last I heard from him, he never again used any drugs, legal or illegal. He ended up marrying his girlfriend, and started a family. He went to college and graduate school eventually obtaining a Master’s Degree and many years later he was still free of any psychotic symptoms. I know he continued to struggle with his own history of childhood abuse and other issues, but he was a very different man from the one I had met in the Mental Health Center many years back.

He was the first Psychotic patient I work with in Therapy. The standard belief is that Psychosis, particular those patients who are diagnosed with Schizophrenia do not get better. When I bring up his case to other colleagues, I often hear “well he was obviously NOT schizophrenic”, so I never win this argument, which is a false argument all the same. There are no independent measures for schizophrenia, that is, we don’t have a lab test or any other medical tests that indicates the brain condition we think schizophrenia to be. The diagnosis is based on reported symptoms and clinical observation. If the patient does not get better, he is schizophrenic, but if he does, especially if he gets better without medication, then he was not; isn’t that crazy reasoning?

This young man was the first patient I treated, which responded very well to “talk-therapy”, but he has not been the only one. In my first job as a Licensed Psychologist I was allowed by the Chief of Mental Health, a very kind and insightful Psychiatrist to treat first Psychotic breaks who were admitted as inpatients, to manage them without medication except by giving them sleep medication. Essentially, I would admit the patient to the ward, and after the medical exam, I would run their management for the next 3-5 days. I made sure they were provided a calm supportive environment, plenty of sleep, rest, and food. I would talk to them and let them tell me their stories. I would sit there, just listening and never showing surprise, fear or disrespect. Eventually, they seemed to calm down, and began to relate to me in a different way, more rational, less fearful and anxious. I would provide them with a rationale for their episode, and encouragement they will pull through. I always addressed the “crisis that brought on the psychotic break” and enlisted the help of family friends and community “out-there” in the world where the person lived his or her life.  I don’t recall how many people came through the ER in the three years I worked there, but I would say more than a dozen; of those perhaps two or three did not respond and were eventually started on anti-psychotic meds. I was very fortunate to have that experience that never repeated again. I had a boss who was an outstanding Psychiatrist and who was a good mentor and friend. In addition I was at small overseas military hospital, which made possible for me to have great flexibility and with no rush to get the patient out providing great many resources to work with.

Although over the many years working as a Clinical Psychologist I have treated several very disturbed patients, I do not consider myself an expert by any means in treating these kinds of patients. Others, however, such as Dr Bertram Karon from Michigan State, have dedicated their lives to study, research and treat very disturbed, psychotic patients. In his Book Psychotherapy of Schizophrenia: The Treatment of Choice (1994), he makes a very reasonable argument for the use of psychotherapy with schizophrenic patients. He and many others who attempt to treat serious emotional disorders with psychotherapy often get ignored by our professional community as if their experience is so atypical that it is not worthy of consideration. While Dr Karon is modern, many others have done this in the past going as far back as Carl Jung.

On the other hand, as another friend of mine once told me, “crazy is crazy Luis” and no degree of good-will can change that fact. Yes, perhaps. However, that does not eliminate the possibility that countless of human beings who experience their lives coming apart in the throes of psychosis can’t be helped to regain their health and sanity even without the use of medications. I am also not convinced that psychotic disorders are discrete entities that strike just those who are vulnerable or have the disease.  I believe that within the range of human experiences, we all could be vulnerable given the right conditions. As Harry stack Sullivan once said referring to severely psychotic patients “we are more alike than otherwise” and paraphrasing a well-known Theologian “there go I but by the grace of God”. I would like to think that if I ever find myself and that predicament, I will find the help I really need.