Medications and Therapy in First Episode Psychosis: Difficult Crossroads

I had been seeing a patient for 6 months now for psychosis but also longstanding personality problems and other difficulties. When she first came into my care, she was not sure if she wanted to be on any medications and so I decided that I would follow along for some time to see how her symptoms evolved and to step in when I was needed.

To my surprise, after several appointments, this patient's resistance softened and she admitted that she was very unhappy with the uncontrollable thoughts in her mind. She tells me she would accept treatment but only if there were minimal side effects, which is not something I can guarantee, but I informed her I would try my best. I have the experience to know that side effects to medications are not my fault or responsibility. What is needed is a thorough discussion where risks and benefits of medication can be put into perspective for the patient to decide for themselves.

Fortunately, in this case, we were able to find a medication she found tolerable and her psychosis resolved. We were now able to better evaluate and manage her ADHD and optimize her treatment for her depression and anxiety. On treatment, she started back to school full-time and we began exploring her other difficulties, which she identified as feeling out of control with her emotions and intensely angry and sensitive in relationships with others. I offered to provide psychotherapy and she agreed. Our typical 20-30 minute appointments became 50-60 minutes.

I enjoy providing therapy, though I recognize the time commitment of it can make it unfeasible to some practitioners. Starting therapy represents a change in the patient/physician relationship. To be an effective therapist, though it is a professional relationship, I would be lying if I did not acknowledge the personal feelings that get involved. For example, to be an effective therapist, genuine caring and liking of one another helps. I know I work best as a therapist when both parties feel valued and respected and given the delicate nature of what is discussed, this takes effort, effort I, as a busy clinician, do not always have in ready supply.

I enjoyed the therapy we were doing together, though when I reflect, I am not sure the patient felt the same. She was stuck in a constant pattern of suffering and rejection. So I do not think she could appreciate my emotional presence and what providing therapy to her took from me. This is in part what makes this job so difficult. To have the energy and commitment to continue doing this kind of work, I need some form of acknowledgement, and it does not come from the patient. This patient in fact, is not able to acknowledge or validate another, because her fundamental ways of relating to herself and others are unhealthy. So with our most challenging patients, that acknowledgement and appreciation often comes from other team members who share in the burden of care. Working in a cohesive team for our most ill is vital, but so rarely available.

My inner dialogue in cases where I am feeling emotionally spent, and unappreciated is to chastise myself. I mean what did I think would happen when I signed up to provide mental health care to a marginalized, traumatized population? But I can tell you that berating myself for the past 8 years of my professional life, denying that this work has an impact on me, and that these patients are difficult for me has not helped anyone. It certainly has not prevented me from growing more jaded and resentful towards a mental health system that I thought at one point, would protect and support me. It certainly did not prevent me from feeling negatively towards my patients, who can take advantage of my time and resources. The question that comes up is, does doing this job mean constantly prioritizing another person's challenges over mine? That because someone has less and suffered more and has a mental illness, that this means they are allowed to treat me in a way that emotionally harms me? I know from this work, the answer to this is, it depends. There are situations where the answer is yes, the physician must come into emotional even physical harm's way to provide good care. I have been in these situations many times. I will no longer, can no longer deny the consequences of this fact. It is therefore understandable that at some point, a clinician may say, this is not ok and step back, shut down.

Back to this clinical case. My patient comes in and requests to stop treatment. She tells me this is because it makes her too tired, and a friend told her that he had stopped his own mental health treatment and is doing really well. So surely she rationalizes, she would be fine too. She tells me about what she believes her risk of relapse would be very low and I am struck by how invisible and useless she is making me feel. She has opted to prioritize the opinion of her friend about her mental illness, rather than her psychiatrist.

I felt a flash of heat in my head and neck, as I wrestled with very difficult feelings within me. On one hand, her request to stop medications is actually not unreasonable. Many of my patients, particularly when they are younger want to come off medications to see if they would indeed relapse. It is a big decision, to gamble on your sanity, but it is not my decision to make. And then I must go into psychoeducation mode. This means a thorough discussion about the risks and benefits so that she can make an informed decision. I am now aware, after I have sat with my reaction and thought about how to best proceed, that I was angry she had decided on her treatment without involving me at all. That I had taken for granted, because of the therapy I had been providing, that she would trust and respect me. I was angry because I was hurt. I was doing my very best. I was offering exceptional care and I felt like she was throwing it away.

I had the urge to discharge her from my care then and there. She discards me, I can discard her! I made it clear if she stopped her treatment, that it was her choice, but it was against my medical advice. She had not tried any other medications, she could try others to see if her tiredness would improve. No, she tells me, she would like to stop her treatment.

I will not discharge her from my care, not yet anyway. This would be retaliatory and harm the patient. I am aware this is a pattern she plays out in relationships which explains some of her struggles keeping friends. This is how taking something personally can affect professional judgement. But feeling like you don't matter to a patient takes a toll, both professionally and personally. Feeling strong emotions that you have to control and then later analyze, so that they do not interfere in your professional decision-making takes time and effort. Time I would much rather spend on other things, like being with my kids, or seeing a friend. Always choosing the patient over my needs is unsustainable, but up until now, that was how I defined the work I do and being a good psychiatrist. This is why the lines between personal and professional blur so much. I register my resentment growing, and it is not even about this specific patient anymore. Everyday, for 8 hours of that day, I talk to patients who will do whatever they want when it comes to their mental health care: smoke marijuana, deprive themselves of sleep, stop their treatment. For an additional 2-3 hours of that day I am talking to my team members and writing notes trying to come up with better treatment plans and approaches to improve the patient engagement. When they relapse or are in crisis, which so far has happened to 100% of my patients who stop medications on their own, I am expected to be there to pick up the pieces.

The emotional toll of trying to manage someone in the community with decompensated psychosis is great. I have had to do it many times. What choice do I have if I want to keep providing excellent care to this population? This is first episode psychosis. This is part of the job.