The Long Flight Home: Managing a Patient's Need to Return Amidst Psychosis
She does not believe she is sick.
Even with her sister supervising, Rita has stopped taking her medication.
Hours after Rita's first dose, her sister finds half-dissolved tablets in tissues hidden all around the bedroom.
In the appointment Rita looks guarded and defensive. My heart sinks. I have not seen her sister look this tired. I just saw them 2 weeks ago and both were doing much better.
"I control her body," Rita tells me in an authoritative voice that is not her usual tone. "I am the chip in her brain here to destroy her life. I control her organs and her limbs. You will not be able to talk to her."
I shift in my seat, exasperated with the idea that I may have to once again engage with Rita's delusion to try to access any part of Rita that may still be there. I wish I could say this was a bizarre Tuesday afternoon, but I have done this before, countless times with Rita and others like her. Patients who suffer from a psychotic illness but have no insight into their illness. It never gets us anywhere: the psychoeducation, reviewing the hospital and police reports, asking her husband for his experience, because with Rita, even when she's not psychotic she does not believe she has schizophrenia.
When her psychosis is treated, Rita is kind and warm, easy to smile and giggle. She is someone who finds delight in the small details of life. Talking to her is refreshing. She is also an incredible cook and generous with her food whenever they have company over.
But despite her endearing personality, her psychiatric care has always been rocky. When I first met her, she demanded I consult a neuroscientist and computer engineer with expertise in nanorobotics to get to the bottom of things. When I confessed that I did not know or have access to such people, and that I felt she was in the right hands with a mental health doctor, behind her gentle and polite demeanor, I could tell she lost respect for me. Her problem was not a mental illness, but a high-security, military-grade, bio-weapon that was within her body, something I could never understand with my civilian, non-technical training.
Her delusion escalates in my office demanding I explain to her/it the pharmacology of the medications I have started. I remind both Rita and the delusion that we have had this conversation extensively and many times. The delusion is not satisfied and demands again. I start by telling Rita/it that the medications primarily affect dopamine. "I am in control of her dopamine, she does not need this" Rita/her delusion says to me.
I turn to her sister who has been her only support since she came from Japan 9 months ago. She knows what I am going to say. I have said it before. We have been here before. There is not much I can do if Rita will not take medication. No, we can not force treatment. We have to wait for her to deteriorate further at home until she is ill enough for an inpatient psychiatric hospital admission.
Prepared for my response, which I can understand is far from satisfactory, Rita's sister tells me she has bought tickets to take Rita back to Japan. They will be leaving next week.
A torrent of emotions and thoughts hit me all at once. How to get her on the plane? Is this what is best for her? What about the people on the plane? Is she stable enough? How do we get her stable enough?
My first instinct is to oppose this plan. It hardly seems to make sense to bring a psychotic person in a plane and overseas to a country where there is strong stigma against mental illness. Surely, she can only fly when she is stable. But then, I also feel a relief I can not ignore.
Rita comes from a large and supportive family in Japan. They have been kept up-to-date with what has been happening. They support medications for Rita's condition. When Rita came to Canada, she knew no one except her sister. Her loneliness was a frequent topic of our conversations as were her struggles with finding purpose. As we saw Rita grow increasingly dependent on her sister, Rita also became more resentful. It was not fair that her sister thrive when she was not.
So returning to Japan makes a lot of sense. She has psychiatric care available to her there and the barriers I felt in connecting with her: that she felt I was not qualified to help her and the many cultural misunderstandings, would disappear. But mainly, I wanted Rita to reconnect with family and to feel taken care of. It is what she and anyone in her situation would deserve in a time of tremendous distress. Invaluable support that no matter how hard I tried, was not available to her in Canada.
Being back in Japan was in her best interest, that was clear. But could we get her there? We had to tackle any safety risks. Will she deteriorate further in the next week? Would she be safe on the plane? In other words, ensuring she and those around her would be safe until she landed in Japan was the task at hand.
There are 2 futures before me: one where she stayed in Canada, and because she refused treatment, she would deteriorate, pushing away the few supports she had, burning out her sister and her psychiatry team. Not because she wanted to, but because here in Canada, there is not enough to convince her to make any other choice. She might eventually meet criteria for enforced treatment, but even then, this kind of treatment has limits and does not guarantee a complete recovery, particularly when the medications are given by mouth. A notoriously unreliable route of treatment administration.
The other future is one where she goes to Japan, and surrounded by family and a doctor she trusts, she can see the impact of her illness more tangibly as it threatens what she holds most dear. In these circumstances, she has a greater likelihood of being receptive to treatment and to stabilize. Only when she is free from her delusions can she make more sustainable and healthier plans about her own future.
The more catastrophic of us will point out the third possibility, the worst-case scenario where Rita decompensates on the plane ride to Japan endangering the safety of everyone on the plane. It is a possibility I must consider too. Fortunately, even when Rita was at her worst, she was never violent or aggressive. She never saw others as a threat. The threat always came from within. So her risk of putting others in danger even when she is psychotic is negligible. Psychiatrists too have to watch our own prejudices and ground any consequential conclusions we form with fact.
The pressure of having someone else's fate in your hands can feel enormous. If I wanted control, I could exert it. I could certify her in my office, prevent her from going to Japan. I could justify this to the most cautious of us, but for what? The impacts of such a betrayal to her and her sister with this authoritarian, heavy-handed approach would be detrimental and long-lasting. We could lose them from psychiatric care completely.
Trying to plan the best, safest course of action particularly when the person at its centre is uncooperative can feel impossible. Impossible because no matter what we choose to do, there is always a perspective where that choice is seen as the wrong choice. But there is no option without risk. It is a matter of evaluating the risk the best we can, with whatever information is available, and respecting the wishes of those who bear the brunt of that risk. It is trying to do the best we can when there are no guarantees.