Building Patient Insight

[MDhasbeen]

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How do the clinicians here recommend one go about helping patients gain insight into the gravity of their illness?

I'm currently on an inpatient unit. Have a young twenty-something year-old gentleman who has a long list of legal issues. On the surface he has "antisocial" written all over him. But when you get to know him, you realize he does have a pretty big conscious as well as a moral system which involves others. You also begin to see why his family has all but abandoned him and fear him. He seems to have some flavor of psychotic bipolar disorder with tinges of paranoia and other delusions regarding the legal and health systems. The two of us have built a good therapeutic alliance thus far in the past few weeks and he takes what I say seriously. Mention the word "bipolar" to him, though, and he just looks at you as though he's disappointed in your judgment, as though that's your only excuse to cram pills down his throat (and unfortunately he's pretty sensitive to med side effects). He's very proud of his skills as an artist. I almost want to highlight that lots of people with mental illness lead pretty functional if not creative lives once they get the right healthcare followup. A part of me almost wants to xerox excerpts from Kay Jamison's books to show him how having this condition isn't always a curse per se, but it can become such if left untreated. It seems, however, that at the moment, in the absolute best case scenario, all he'd want would be some sort of Christian counseling.

Thoughts?

 

[DrIng]

One thingthat occurs to me is that insight isn't always a good thing- indeed patients have killed themselves once they've 'developed insight' and realise htepotential impact on their life. I would suggest what you want is not insight at present but a reason to take medication and a reasonable therapeutic alliance (which it soudns like you have). I often used mood stabilisers to : help people cope with stress, improve sleep or decrease irritability- because those are symptoms people find distressing and want to change. Also, be open to reviewing medication frequently to trade off mood stabilising vs fuzzy brain...
Hope that helps.

 

[MDhasbeen]

Good point regarding insight causing self-injury. Hadn't thought of that. I should add that this patient in particular has no history of suicidality or self-injury, although he does seem to seek physical pain through others in a masochistic way (picking fights with other patients on the unit and police/others outside the hospital because he feels "love" when he's beaten). Sadly, in my mind, if this keeps up he won't be around long enough to do himself in as someone else will finish the job, and I've made him aware of this concern of mine. He seems to take it as an acceptable risk, "destiny" as he puts it. The medication issue is key, obviously. Unfortunately he's been tried on several meds since his teens. All the meds ever do is sedate him, give him the "fuzzy" brain syndrome you alluded to, which he despises. He gets pretty bad EPS even with Cogentin/Benadryl (drooling, slurred speach, dry throat, blurry vision). Sometimes he gets a tremor which is unacceptable given his art career. He also loathes sexual side effects. It's a really tough situation. 🙁 I guess I resorted to the insight route thinking that'd help him stick with it, that is, knowing that his life doesn't have to amount solely to a life sentence in prison someday, that others like him have been helped.

 

[toby jones]

How do you mean 'achieve insight into the gravity of his illness'?

Do you mean come to accept the dx label you want to give him?

What does that buy him? The notion that he must take meds to be okay (this is questionable, there is stuff out there on people who manage alright without meds). The notion that his prognosis is poor (which you then plan to help him feel a bit better about by providing him literature which shows him prognosis isn't necessarily so poor?

Uh...

Does he agree that the symptoms / behaviours that you regard to be problematic really are problematic for him?

If he accepts that then who cares about the dx label (aside from the health insurance company).

 

[MDhasbeen]

How do you mean 'achieve insight into the gravity of his illness'?

Do you mean come to accept the dx label you want to give him?

What does that buy him? The notion that he must take meds to be okay (this is questionable, there is stuff out there on people who manage alright without meds). The notion that his prognosis is poor (which you then plan to help him feel a bit better about by providing him literature which shows him prognosis isn't necessarily so poor?

Uh...

Does he agree that the symptoms / behaviours that you regard to be problematic really are problematic for him?

If he accepts that then who cares about the dx label (aside from the health insurance company).

He knows that his situation is problematic. He's suffered quite a few losses and hasn't achieved certain goals in life. And while I do try to motivate him with those dreams and the idea that he can regain some losses, he can't quite connect two and two together, ie the reason why all this has happened is because sometimes he can't quite control what he's doing for some reason hmmm must be the government/military/police out to get me or the poverty he grew up in. He really doesn't understand why he's in the hospital let alone why he needs to take meds that give him horrible side effects. He feels like he's in total control over what he does, which is true to a certain extent, but once mania takes hold that idea gets questionable. I don't personally care what he wants to call the motivation behind his behavior and beliefs. I just wish I could help convey that a lot of the reason why his family has left him, his wife has left him, he's landed in jail/prison multiple times is because of this delusional illness. To some people who feel out of control otherwise (be it due to poverty, poor social support etc), it seems like a diagnosis is sadly the one thing they can wrap their heads around, ya know? And although you're right that many patients can do fine without meds, bipolar individuals really are far better off with a combo of meds and therapy. Now I've asked him if he'd at least be willing to seek some sort of therapy once he's out of jail thinking that maybe the counselor could convince him to stick with meds. But as it is, it really seems that the level of psychosis he has would get in the way of any psychotherapy you'd give him.

 

[toby jones]

So you both agree that he has suffered losses and hasn't achieved certain goals. He has insight into that.

Your concern about his insight is concern that he views the above as being a consequence of his childhood experiences and / or the government / military / police being out to get him?

Instead of the above... He should label himself 'delusional' and take his medication? Is that the idea?

> To some people who feel out of control otherwise (be it due to poverty, poor social support etc), it seems like a diagnosis is sadly the one thing they can wrap their heads around, ya know?

But I thought your concern was that this guy wasn't wrapping his head around his diagnosis. Instead of blaming his problems on the biological causal factor of 'psychotic disorder' he is focusing on social causal factors.

> And although you're right that many patients can do fine without meds, bipolar individuals really are far better off with a combo of meds and therapy.

Every single one of them? If he turns out to be Mr. 0.00001% I'm sure he doesn't give a damn.

> But as it is, it really seems that the level of psychosis he has would get in the way of any psychotherapy you'd give him.

Hmm... So much for current varieties of psychotherapy methinks...

Isn't it possible that... Growing up in poverty can indeed have an impact on ones later actions? Isn't it possible that... He may have been given a hard time by authorities somewhere along the line? It might be that he is externalising things rather instead of facing up to his role. But then that might be a defence because he doesn't see a way he can face up to his role and live with himself.

I'm not sure what to say...

There is an unfortunate tendency towards 'cognitive restructuring' at the moment... Fairly unsurprisingly they are having a problem with high drop out rates. Maybe... He is trying to conceptualise his problems (same as you are) it is just that he is focusing on social and you are focusing on biological and... Instead of being able to meet in the middle somewhere there is just a bunch of talking past?

 

[Solideliquid]

I was rereading through the suicide section of Shawn Shea's "Psychiatric Interviewing" and it mentioned something that got me thinking about this thread.

He was basically saying that patient insight is a good thing in that reasonable thinking, (compared to psychosis) is usually the last barrier to the impulsive suicide attempt.

 

[MDhasbeen]

There is an unfortunate tendency towards 'cognitive restructuring' at the moment... Fairly unsurprisingly they are having a problem with high drop out rates. Maybe... He is trying to conceptualise his problems (same as you are) it is just that he is focusing on social and you are focusing on biological and... Instead of being able to meet in the middle somewhere there is just a bunch of talking past?

It's tough. How can all the talk and meds in the world undo a lifetime of poor circumstances? I'd be an idiot not to acknowledge that growing up in poverty no doubt contributed to his need to steal and do other illegal things to get by. There also seems to be a fundamental reality paradigm difference between us. In his world, a world where the law has already been crossed, he's got nothing to lose by continuing to lash out against others even though he clearly considers himself a "piece of ****" for doing such acts. Thus, the only thing the team can do is sedate him so he doesn't have the energy to act out against others. Despite what he may think, we really do hate seeing him sedated that way; but apparently his mother says that's all psychiatrists have been able to do for him in the past. Now I, as a PGY-1, have nil psychotherapy experience, unfortunately. I don't think our psychologist would touch him with a ten foot pole due to his violent tendencies. He seems to want to speak with me only because he's hypersexual and I am his idea of physically attractive. So frustrating. At any rate, I think I've decided to try to convince him to at least see a counselor if/when his legal issues get sorted out. Of course he has no insurance so once he gets back to jail and (eventually) gets shipped back into the "real world" he won't get hooked up with a counselor for cheap if at all and the cycle will repeat itself until the day he picks a fight with the wrong person and doesn't survive. If only I could think of some way to help him tone the illegal junk down a little.

 

[Solideliquid]

How about he join a boxing club/gym?

 

[MDhasbeen]

How about he join a boxing club/gym?

Interesting you should suggest that! He actually grew up boxing with some neighborhood kids twice his age. Unfortunately, he also has this nasty tendency to abuse anabolic steroids, which I'm sure doesn't help his rage issue.

At present he apparently does tattoo work and seems pretty good at it. I always found it amazing how many psych patients in general gravitate towards the arts, even the less highly functioning individuals. The irony of all this is that I am very interested in art therapy; and yet have I had any time to delve into it thus far in training? Ugh!

 

[edieb]

Have you tried motivational interviewing??? It is a WONDERFUL technique to build people's intrinsic motivation towards change. I have seen MI techniques reach patients I even thought were unreachable. One of the best examples involves a 40 + year-old cocaine-addicted prostitute who was living on the streets. During session one, she had no intention to change. By session 12, she had made plans to go to detox (for concurrent EtOH abuse) and rehab. Now, 3 years later, she is in a community college. MI is taught quite frequently in my clinical PhD program, and I can really, really see why

The book, Motivational Interviewing, is available on amazon.com or at large book stores. You can also learn it in tele-courses.

BTW, it really impressed me that you actually care enough about your patient to post this on here. Just from this one action alone, I can tell you're a great psychiatrist. Your patients are very lucky to have you as a doctor. You will be amazed how much help you can be by just being caring.

It's tough. How can all the talk and meds in the world undo a lifetime of poor circumstances? I'd be an idiot not to acknowledge that growing up in poverty no doubt contributed to his need to steal and do other illegal things to get by. There also seems to be a fundamental reality paradigm difference between us. In his world, a world where the law has already been crossed, he's got nothing to lose by continuing to lash out against others even though he clearly considers himself a "piece of ****" for doing such acts. Thus, the only thing the team can do is sedate him so he doesn't have the energy to act out against others. Despite what he may think, we really do hate seeing him sedated that way; but apparently his mother says that's all psychiatrists have been able to do for him in the past. Now I, as a PGY-1, have nil psychotherapy experience, unfortunately. I don't think our psychologist would touch him with a ten foot pole due to his violent tendencies. He seems to want to speak with me only because he's hypersexual and I am his idea of physically attractive. So frustrating. At any rate, I think I've decided to try to convince him to at least see a counselor if/when his legal issues get sorted out. Of course he has no insurance so once he gets back to jail and (eventually) gets shipped back into the "real world" he won't get hooked up with a counselor for cheap if at all and the cycle will repeat itself until the day he picks a fight with the wrong person and doesn't survive. If only I could think of some way to help him tone the illegal junk down a little.

 

[toby jones]

So it is about jail prevention? About wanting to medicate him into a sedated state so he is less likely to offend and go to jail?

I guess it depends on him really. Weighing pros and cons. I suppose he has been told that he tends to do less of those behaviours he doesn't like when he is medicated.

Is he being over medicated? Why doesn't he like the medication? Sedation?

Does he perhaps want to go to jail...

 

[MDhasbeen]

Thanks for all the responses! Did get a motivational interviewing book but didn't quite manage to get through more than a few chapters before said patient was discharged. (Ain't that the way it always is?). I tried to focus on the patient's desire for a more meaningful relationship with his mother. He seems to focus strongly on material wealth. A lot of his criminal charges are theft-related. He claims he was only trying to get money to help his mother out. This may sound bogus and anti-socially, but his mother did visit him in the hospital despite being terrified of his bipolar traits; so I could tell he appreciates her presence on a real level, especially since his father is deceased. He was hung up on how his mother's upbringing in rural shantytowns in West Virginia had hurt her, how he wanted to acquire wealth so he could help her to never live like that again. I asked him to consider the thought that perhaps she'd rather he help better himself, to avoid legal situations which could ultimately result in his own death in the worst case scenario. It seemed as though he'd never really considered that before. I think he also seriously considered the possibility of at least seeking counseling through a church in the future, which to me at least is better than no follow up with anyone. So I did what I could do. It's rough. At any given time the lives of about 10 patients are on your shoulders and while you acknowledge that it's ultimately not up to you to change their lives per se, it is up to you to offer the tools to help them change if they so desire. The trick is identifying those whom you believe will more likely actually use the tools you give them.

So it is about jail prevention? About wanting to medicate him into a sedated state so he is less likely to offend and go to jail?

Unfortunately, that is what happened due to an upcoming court date, and what apparently always happens. To answer another question below, this individual was exquisitely sensitive to any sort of medications in terms of EPS. By the time you got him barely sedated to touch his mania he was drooling all over the place, slurring his speech, and sleeping all day. Benadryl didn't help and Cogentin merely dried his eyes and mouth out to another annoying extreme. I really felt for the guy.

I guess it depends on him really. Weighing pros and cons. I suppose he has been told that he tends to do less of those behaviours he doesn't like when he is medicated.

Is he being over medicated? Why doesn't he like the medication? Sedation?

Does he perhaps want to go to jail...

He did want to go to jail, though I question his understanding of why he was in jail or even why he was in the hospital. He thought the purpose of his psych admission was to be evaluated for being in the military. Not sure if this was a part of his military preoccupation or someone at the jail lying to get him to go peacefully. He felt as though he wanted to leave the hospital shortly after admission because he wanted to go back to jail, which he viewed as a sort of boot camp where the guards would beat him into submission to fight in the Iraqi war. The violence he experienced while in fights was described as "the best kind of love." Very strange, masochistic line of thinking overall, probably fueled by his extremely poor self esteem and likely neglected upbringing.

He doesn't like medications because of the horrible side effects he experiences as well as the fact that he doesn't understand why he needs to take them. When you see your criminal behaviors (which are no doubt made worse by mania) as being the norm, when you hear that a paratrooper stays up 7 days a week without sleep and so do you thus you're a paratrooper too, well, what's the problem? What purpose do meds serve? An interesting bit, though, was that he did admit to feeling uncomfortable due to the energy associated with the (what we call) mania. Though he stated he does enjoy the feeling of being calm again, his medications of choice are sadly the occasional marijuana, alcohol and percocets. He even asked me if I could Rx THC or medical marijuana!

Chances are the court will set him up for some sort of competency to stand trial eval in the near future. But the one thing that's clear is that he wanted to get his life back together after a nasty divorce and estrangement from family etc. Thus I was hoping that might be the key to helping him turn some of his life around given his young age. Too bad I'll get no follow up on this.