Last night I sat in the Emergency Room with a client who has finally decided to get treatment for a problem which may lead to his leg being amputated. I won't go into detail on the medical issue, but the last doctor to whom I spoke described it as "pretty icky". I stayed there with him until 9:0 p.m., which is the kind of thing I would ordinarily not do, because having clear boundaries betwen work time and my time is essential to doing this job-- if I work too much overtime or spend too much of my personal resources at work, I will burn out and be unable to work at all, so I have to carefully monitor these sorts of things. But, in this case, I was feeling some guilt over my agency's failures with this client, and with the treatment sytem in general's failures with this client, and I also really, really wanted him to go through with the medical treatment before the condition becomes life-threatening.
Let's call him Joe. I don't usually do this, going into detail about a particular client, but I'm sure that Joe represents a kind of client who exists in every city in the U.S. Joe is an African-American product of the generation prior to mine, the flower children. When my mother wouldn't take me to the playground at Centennial Park in the sixties because of all of the hippies there, Joe was one of the ones who would have really frightened her.
Joe uses recreational drugs without a second thought, but he insists that all other medications, from antibiotics to anti-psychotics, make him extremely drowsy, as a result, he says, of an overdose on speed which nearly killed him in the mid-seventies. The contradition between comfort with recreational drugs and an unwillingness to take FDA approved meds is common among addicts; the belief that his overdose made him especially sensitive to meds is Joe's personal delusion. Unfortunately it is one about which he is particularly emphatic, and this causes him to refuse to take any of the new anti-psychotics in use which have good effects (Seroquel and Zyprexa, for eexample)without the risk of the scary side-effects which are associated with drugs like Thorazine and Haldol.
Joe has Bipolar I disorder with psychotic features, and the psychosis includes a grandiose delusional outlook on the world which is the kind of thing which puts the 'irrational' into 'irrationality'. There's no use arguing with these kind of beliefs, because to the psychotic they are simply true. So, Joe is not trying to impress us by lying when he talks about the legal work that he has done in the past and the briefs he is preparing for his defense in his next court case (in which he is also the defendant)-- for him this is all true. He also has a symptom which we call 'disorganized thinking,' which leads him to talk on and on in a kind of random and usually incomprehensible way. I stayed with him in the ER partly to smooth things over if he frightened or offended anyone, and also to try to keep him from engaging the doctors in arguments about the best medical techniques. On this latter mission, I spent a lot of time pointing out the new, cutting edge technology being used around us, and emphasizing that the doctors are learning new things all of the time. When I left him, they had given him some dinner and morphine, and he was being perfectly cooperative and cheerful as they wheeled him away for ultrasounds and X-rays. He has the ability to switch to angry and intractable on a moment's notice, however, so I'm hoping that the reports this morning will be consistent with my last vision of him last night.
Our system fails Joe in a number of ways. He actually can be very sweet and agreeable as long as no one makes him angry, and he has learned, over the years, not to let his anger erupt into violent action, most of the time, but the combination of disorganized thinking and delusions makes it very difficult to get him to accept a case managers' direction and guidance through any important project, like applying for disability or going for medical treatment. He can talk about the problem with his leg using medical terminology (but you'd have to be a doctor to know if what he is describing was really what happened), but he can then say things, as he did last night, like "sometimes I think the leg is a different creature from me, that it's alive", and "Look! [pointing at it], It's feeding. You see, right after I eat, it feeds itself" and "It's like it's full of those little things-- you know, Pac Men, and they're in there just eating and eating and eating." It takes a tremendous amount of patience and self-control to listen to this kind of thing for hours on end without trying to correct him . By some gift of nature, I happen to be an unusually calm person, and even I find that I tune him out periodically and just stop paying attention-- the more highly strung case manager he used to have would get angry and refuse to speak to him unless he had previously made an appointment, or she would try to get him to make an appointment to discuss whatever was on his mind later in the week, which even he realized was impossible-- later in the week his mind would be miles and miles away from the thing that was worrying him today.
The system fails clients like Joe by trying to force them into patterns of treatment which are conveniant for providers, and which actually work well with most clients. The few who can't handle the structure, or are terrified of the medications, or who can't believe your suggestions are correct because they conflict with some delusion or another-- these few tend to get shuffled out of the system, and we find some way to blame them for the failure, instead of ourselves. They are 'treatment resistent' or 'non-compliant' or 'manipulative and untruthful'. A lot of other agencies blame their recalcitrance on their drug use and refuse to treat the mental illness until the drug use has stopped. Then the same client will go to a Substance Abuse treatment center and be turned away because of the untreated mental illness. Our agency's existence (we're about 12 years old) has helped with this problem, because we treat both illnesses at once. But this means that every other mental health agency in town can send the clients who don't fit into their systems to us, if they have any kind of drug use in their history, which they usually do. Joe has been discharged from every other agency in town in the past. We are the last ones for him. If we give up on him, he'll be out there on his own until he gets a long prison sentence or ends up in the city-run nursing home because of the medical issues. But mostly he will be on the streets, because he has proven himself to be quite adept in avoiding both the jails and the psychiatric hospitals.
I just wanted to say that.
In other news, take a minute to read this article about a neuropsychologists' thoughts on the nature of the self; it's really quite interesting. And have a very spooky Halloween-- I'm off to assemble my fairy costume now.
8:16:18 AM 
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