by Brenda Roman, MD; and Gayatri Patel
Dr. Roman is Associate Professor of Psychiatry, Ms. Patel is a fourth year medical student, and Dr. Gillig is Professor of Psychiatry—All from Boonshoft School of Medicine, Wright State University, Dayton, Ohio. Dr. Roman is also a psychiatric consultant at the Homeless Clinic, where medical students rotate with her.
Editor’s Note: All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points, and are not meant to represent actual persons in treatment.
Abstract
For people who are disenfranchised from society for other reasons, especially homelessness, a paranoid delusional system can create an additional obstacle in the therapeutic engagement and treatment of such individuals. In this article, we describe a composite case of a homeless woman with paranoid schizophrenia. Through this case example, we will explore various obstacles to treatment and discuss strategies to overcome these hurdles to treatment, initiate a therapeutic alliance, and further facilitate and maintain therapy.
Key Words: homelessness, paranoia, engagement
Introduction
In any population, patients with a paranoid psychosis are often among the most challenging to treat. For people who are disenfranchised from society for other reasons, especially homelessness, a paranoid delusional system can create an additional obstacle in the therapeutic engagement and treatment of such individuals. Mental illness and substance abuse are among the main causes of homelessness, with an estimated 23 percent afflicted with mentally illness and 32 percent with substance abuse.[1] In this population, many individuals are mistrustful or paranoid of the healthcare system; this challenges the psychiatrist to utilize an approach that first engages the patient and subsequently develops an effective therapeutic treatment alliance. In describing a composite case of a woman with paranoid schizophrenia, we will explore various obstacles to treatment and discuss strategies to overcome hurdles to treatment, initiate a therapeutic alliance, and further facilitate and maintain therapy.
How Homelessness Causes a Loss of Autonomy
Being self-sufficient and independent is something most people take for granted; however, autonomy for some people is something that can be taken away with a blink of an eye and unfortunately may be difficult to recover. Loss of employment can eventually lead to lack of funds for gas for the car, food for the table, clothes to keep warm, and utilities for the house, and ultimately one may be without shelter for safety. Lack of financial independence may occur for many reasons, such as psychiatric or medical illness, drug or alcohol abuse/dependence, death of the primary breadwinner, lack of education or training, paucity of employment opportunities, or a combination of these factors. Without an address or phone number for an application, funds for a resume, means to travel to a potential employer, or even appropriate attire for an interview, self-sufficiency can be difficult to re-establish. Also in order to gain access to government and state services, individuals need permanent contact information, which is difficult if one is homeless. Healthcare professionals need to empathize with this loss of autonomy in the homeless patient. Additionally, physicians should acknowledge that homelessness alone is a significant impediment to introducing any kind of successful treatment, as the patient’s priorities most probably will lie in securing food and shelter and therefore may be very different from the healthcare professional’s, whose priorities for the patient may include, for example, advising a low fat diet due to hypercholesterolemia. The patient and psychiatrist must work in collaboration with a common goal of reestablishing autonomy for the patient as well as initiating therapy for treatment of medical and psychiatric disorders.
Case Presentation
Alice was a thin 52-year-old African American woman who was brought to the outpatient homeless clinic by her son because of increased paranoid thoughts and delusions. Recently, Alice was evicted from her apartment complex because of the increased disturbances she was creating for the other tenants, causing them to have concerns for their safety, as well as her inability to make rent payments. When we questioned Alice on why she was threatening the other residents, she said they were breaking into her home at night. She later added that they were “pumping a chemical” into her apartment that caused her inner ears to itch. Alice’s son described his mom historically as an overtly suspicious person with few friends; however, her paranoia was never to this extent. Years ago, Alice had required hospitalizations for mental health treatment and had been on various medications. However, the son was unclear of the specifics because he was very young at the time of these hospitalizations and his family was very guarded about the subject.
Upon gathering more history, the treatment team learned that six months prior to the initial encounter, Alice’s husband of 20 years passed away in an automobile accident. Alice had worked a few odd jobs throughout the years, but her husband had been the primary individual supporting the family. Due to her increasing paranoia, businesses were reluctant to employ her, and hence her ability to uphold financial responsibilities was dwindling. Alice had few close relationships with people other than her husband, and she had few family members on whom she could rely. In the months following her husband’s death, Alice’s increasing paranoia was initially disregarded as her manifestations of grief over the loss of her husband, until the development of her recent homelessness.
Alice had been homeless for a few days before her son became aware of her eviction, thus when he found her, she was disheveled, in dirty clothes, and in apparent ill health due to lack of food and water. Even toward her son she acted very suspiciously and guarded, and it took a great deal coaxing by him to convince her to come with him to the clinic. The son was quite concerned for his mother’s wellbeing; however, due to the progression of her symptoms, he was reluctant to keep her at home with him because he had two small children of his own at home. Alice had another child, a daughter; however, the daughter was living in another state and was unable to provide care for her mother.
Practice Point—Overcoming Hurdles to Treatment with the Homeless, Paranoid Patient
Having the patient identify her goals and needs is the first step on the path to treatment. The patient should then classify the possible obstacles in achieving those goals and needs. Some patients may even recognize that the mental illness itself is a significant obstacle in achieving ambitions and a sense of autonomy. However, this may be challenging if the psychiatric illness is severe enough to interfere with reality and future planning. Even though this may be a slow and frustrating path for the psychiatrist, the patient should not be rushed as this could break down the therapeutic relationship between patient and psychiatrist. After some of the primary needs of the patient are met, such as food, shelter, and access to healthcare, introducing mental healthcare while keeping patient goals in mind are the next appropriate step. In addition, impediments to adherence to treatment need to be identified. In collaboration with the patient, long-term adherence with treatment should be reiterated as a way to help the patient to achieve the stated goals. Therefore, strategizing to remove barriers to encourage the benefits of treatment is a worthwhile effort. All these areas should be periodically reassessed as goals, treatment needs, and obstacles are bound to change.
Case Presentation—Addressing Basic Needs
Alice clearly indicated that if she had a “safe place to live,” she would be better. She was terrified that she would be poisoned in the transient shelter, so the social worker at the clinic was able to assist in obtaining a temporary efficiency apartment in which Alice could reside. This social worker was also able to arrange for Alice to buy her own food by quickly getting her approved for food stamps; in this regard, Alice felt safe when she could prepare her own food. Once Alice felt safe in her own apartment, versus a shelter, she seemed less suspicious and more trusting of healthcare professionals. With less worry about food and shelter, she was able to begin to accept that medication could also be helpful.
Key Point—Initiating a Therapeutic Alliance with a Homeless Person
The first step of initiating the therapeutic alliance is referred to as engagement. Engagement is simply understanding the needs of the homeless person from that person’s point of view. The homeless population in Buffalo, New York, identified the following as important needs: safety, education, transportation, affordable housing, medical/dental treatment, and job training/placement.[2] Many of these needs were also ranked as difficult to obtain.[2] Even though mental illness may be playing a crippling role in an individual’s life, quite logically the homeless individual is more interested in obtaining basic needs then seeking treatment for a psychiatric illness.
However, if psychiatrists and the treatment team are viewed as assisting patients with their goals of acquiring basic needs, engagement generally follows. Mental health professionals can be a source of information about local pantries, shelters, and employment services via their clinics. Patients can be referred to social workers who can help them apply for housing and other social services. By helping to identify resources in the community for food, housing, and clothing, the psychiatrist also is establishing rapport and trust.3 By involving the patients in setting their goals according to their perceived needs, the patients are empowered, facilitating a sense of self-determination and autonomy.4 As the primary needs of the patient are met, attention can shift toward the patient’s own goals and assist in breaking down the obstacles in achieving long-term goals, including appropriate psychiatric care.
Case Presentation continued—Beyond Engagement
Alice appeared to be highly functional previously, and this recent deterioration seemed to be linked to the loss of her primary social support system in her husband. The increasing severities of her symptoms then secondarily led to loss of her home. Therefore, our initial approach was to link the patient to a social worker. Alice needed secure shelter, temporary and then long term, access to food and water, and other social services.
Another aspect of her illness was a complaint of pruritis contained within her ear. She had seen the primary care physician at the clinic twice for the same complaint. The physician had completed a thorough physical exam, as is done with all initial visits to the healthcare clinic, and no foreign objects, infection, or other problems were noted. She had also received a computed tomography (CT) scan of the head in the local emergency room approximately three months after her husband’s death due to similar complaints over several emergency room visits. With no evidence of a medical foundation for this complaint of pruritis, it was felt to be a tactile hallucination that accompanied her delusion of being subjected to poisonous gas. According to the patient, this was initially caused by the chemicals pumped into her home after the death of her husband; however, this complaint did not resolve after becoming homeless. The patient herself was convinced she only needed an antihistamine, such as diphenhydramine or hydroxyzine, to treat the pruritis within her ear and that no other medical or psychiatric treatment was necessary. On many occasions, even prior to her homelessness, she sought out diphenhydramine or hydroxyzine from different emergency rooms in the community. Regrettably, her requests were often gratified by unsuspecting emergency room physicians who may not have had the time to understand her underlying pathology. As her use of antihistamines accelerated, Alice would go through a typical month’s supply in a week, leading her to increasingly frequent emergency room visits. Initially, the psychiatrist at the homeless clinic continued prescribing an antihistamine alone, not only to prevent the patient from continuing to access the emergency rooms for it and quantify her use, but more importantly to help establish a therapeutic relationship. Only a week’s supply of medication was given at a time, so that Alice would have to return on a weekly basis. Through this weekly interaction, Alice became less suspicious toward the psychiatrist and other members of the treatment team. Once a therapeutic relationship was fostered, then treatment to target the psychosis could be introduced.
Practice Point—Facilitating and Maintaining Therapy
The paranoid patient should be allowed flexibility in establishing the pace of a therapeutic relationship. Gentle outreach efforts help these individuals gain trust in mental health providers.[3] Housing contracts, entitlement contracts, mental health contacts, and supportive services have been shown to be significant mediators of treatment.[5]
Practice Point—Introducing Mental Healthcare
Once rapport is established, motivational interviewing and harm reduction are potential strategies to introduce mental healthcare. Here the patient can be helped in identifying symptoms and how they interfere with reaching his or her goals.[3] Common challenges are denial of symptoms, denial for the need for treatment, and mistrust in institutions. With some paranoid patients, a great deal of time, up to several weeks or even months, may be required to establish a therapeutic relationship. Although frustrating, trying to hurry the process may be detrimental.[3]
The next step is the introduction of medication. Adherence is an important issue to consider. For the patient with previous treatment failures, reviewing factors in the past that interfered with adherence would be an important area to focus on before re-initiating pharmacotherapy. Some patients stop treatment because of difficulty remembering complex dosing regimens or due to side effects from the psychotropic medications.[6]
Other patients are reluctant to maintain long-term adherence due to beliefs, either personal or societal, that one should be capable of managing symptoms without medications.[6] These physical, social, and psychological obstacles need to be addressed. A routine is much easier to follow if a patient’s basic needs are being met in a predictable way. Stable housing provides secure surroundings for storage of belonging, a dependable site to leave messages, and a consistent milieu for the patient.[3] In this way, physical obstacles are lessened. The social and psychological obstacles often present more challenges. Having a patient establish a routine improves adherence; without such there is a high risk for treatment failure. By utilizing supportive techniques of encouragement to strengthen coping skills, advice when appropriate in managing new life situations, and making comparisons of taking care of oneself psychologically just as one must take care of physical problems, such as hypertension, through medications, the psychological barriers can be lessened over time. Additionally, psychiatrists need to be sensitive about the impact the side effects of medications can have on their patients and work with them to achieve the most tolerable regimen.
Practice Point: Discussing Side Effects with a Paranoid Patient
Starting psychotropic medication with paranoid patients does raise some ethical issues. Should the full possible range of side effects be divulged to the patient? In a paranoid patient that is already reluctant to trust a psychiatrist, could informing the patient about benign and not so benign adverse effects impede initiating treatment? If side effects are not disclosed and later develop in the patient, will this damage the patient-psychiatrist therapeutic relationship? There are no clean cut answers in these gray areas of medicine; however, they must be taken in account when beginning psychopharmacological treatment. In the essence of autonomy, patients should be involved in the decision making and planning, and informed consent should be obtained.[7]
However, psychotic patients present ethical challenges in treatment, especially patients who are reluctant to engage in psychiatric treatment. In these cases, a conflict between the principles of autonomy and of benficence/nonmaleficence is created.[8] One could argue that if a patient is psychotic, he is unable to make an informed decision regarding treatment, so it is therefore acceptable to treat without consent or without explaining the possible risks, given the expectation that medication will result in improvement of the patient’s psychiatric condition. In fact, using an antipsychotic may result in restoring autonomy to a patient.[8]
Historically, a certain amount of paternalism has been accepted in the doctor-patient relationship; however “strong” paternalism, such as overtly deceiving a patient by allowing a liquid antipsychotic to be mixed in a drink without any discussion, is more likely to be questioned or viewed as problematic than “weak” paternalism, such informing the patient of the medication but minimizing the associated risks.[8] At a minimum, the psychiatrist should discuss the medication with the patient, explaining the risks that the patient is able to understand at the time, and as the psychosis resolves, revisit the topic with appropriate documentation of the discussion of the risks and benefits. Including patients in treatment decisions to the greatest extent possible also tends to improve attitudes toward treatment and therefore enhance adherence.[9]
Case Presentation Continued—Management of Symptoms
Alice’s presenting symptoms of paranoid delusions and tactile hallucinations appeared consistent with a diagnosis of paranoid schizophrenia. After gaining the therapeutic trust and confidence of Alice, she was started on risperidone. Alice was informed that the risperidone would likely diminish the pruritis that had troubled her for months. It was further explained that while the sensation of itching was real to her, that something had gone awry in her brain to cause that sensation, which would be better treated by risperidone. Since the hydroxyzine had not completely alleviated the itching for more than a couple of hours, Alice was accepting enough of this explanation to try the risperidone. She was informed that an “inner sense of restlessness,” some weight gain, and in rare cases, possible nipple discharge might occur. Since she was already underweight, she was not bothered by potential weight gain. While apprehensive about other side effects, the psychiatrist informed Alice that she could immediately stop the medication if she developed restlessness or nipple discharge and was encouraged to come to the clinic if she had other concerns. The low risk of tardive dyskinesia was not discussed with Alice since telling her about a potentially irreversible side effect may have resulted in a refusal to take medication, and in a paternalistic way, we felt the benefit of medication to her in improving her life was more significant than the risks of the medication. Hydroxyzine was continued, at Alice’s insistence, so as not to damage the doctor-patient relationship. An outreach worker through the homeless clinic visited Alice in her new subsidized apartment to encourage medication adherence. After a trial for a few weeks, Alice and her son reported a noticeable reduction in her paranoid symptoms and hallucinations. However, during the titration of the risperidone and in attempting to wean Alice off the antihistamine, the patient had complaints of akathisia. It was then deemed appropriate to continue the hydroxyzine to treat the extrapyramidal symptoms as well as the added benefit of maintaining cooperation with the patient. Alice continued to tolerate and progress well on the risperidone. Alice was approached about the idea of injectable risperidone, but she was quite opposed. Since she was doing rather well with medication adherence, the topic was not broached again.
With the control of her symptoms, Alice’s son felt more comfortable and agreed to monitor his mother more closely and become her payee in hopes of avoiding another episode of homelessness. Alice soon returned to her baseline functioning with the continuation of treatment and the rebuilding of her social support system. Alice was pleased that she was doing so much better on the medication, so willingly continued the medication, even when other potential side effects, including the rare possibility of tardive dyskinisia, were later discussed with her.
Key Point—Identify Obstacles in Maintaining Adherence
Once a patient has established care with a psychiatrist, the goals are to understand what the underlying issues are, if any, that may cause this patient to refuse appropriate treatment, to overcome any misconceptions the patient may have, to restart an antipsychotic, if necessary, and to minimize any obstacles that would impede adherence. Obstacles interfering with treatment may include mistrust of healthcare professionals, side effects from medications, difficulty remembering dosing schedule, and personal beliefs regarding treatment
Along with the mental health treatment, it is crucial that all supportive services for the patient be maintained. As basic needs remain maintained, adherence to therapy is generally improved. Collaborative treatment planning includes working with the patient to develop a treatment that takes into account the needs, values, and beliefs of the individual patient.
Conclusion
The five common tasks innate in the model of outreach are (1) establishing contact and credibility, (2) identifying mentally ill individuals, (3) engaging individuals, (4) assessment and treatment planning, and (5) providing ongoing services.10 Working with a paranoid patient requires using different strategies than typically used in more common scenarios, moving at the pace of the individual, and being particularly understanding and patient, as this can be a lengthy process. As the patient’s basic needs are met, the beginnings of a therapeutic alliance are created. These initial encounters can lay down the foundation and motivation for treatment. As planning begins for treatment, challenges in meeting adherence should be identified and challenged to help facilitate maintenance with treatment.
Again, a patient’s personal goals and treatment goals should be periodically reassessed to ascertain if they are being met and if not, what steps need to be taken to reach those goals. Together the patient and provider can work collaboratively to a common endpoint of not only therapy but also the reestablishment and preservation of the patient’s autonomy.
References
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2. Acosta O, Toro PA. Let’s ask the homeless people themselves: A needs assessment based on a probability sample of adults. Am J Community Psychol 2000;28(3):343–66.
3. Falk N. General concepts of outreach and engagement. In: Gillig PM, McQuistion HL (eds). Clinical Guide to the Treatment of the Mentally Ill Homeless Person. Washington, DC: American Psychiatric Publishing, Inc., 2006:9–19.
4. Cohen MB. Social work practice with homeless mentally ill people: Engaging the client. Soc Work 1989;34(6):505–9
5. Morse GA, Calsyn RJ, Allen G, Kenny DA. Helping the homeless mentally ill people: What variables mediate and moderate program effects? Am J Community Psychol 1994;22(5):661–83.
6. Heinssen RK. Improving medication compliance of a patient with schizophrenia through collaborative behavioral therapy. Psychiatr Serv 2002;53(3):255–7.
7. Brabbins C, Butler J, Bentall R. Consent to neuroleptic medication for schizophrenia: Clinical, ethical, and legal issues. Br J Psychiatry 1996;168(5):540–4. Review.
8. Wong JGWS, Poon Y, Hui EC. “I can put the medicine in his soup, Doctor!” J Med Ethics 2005;31:262–5.
9. Hamann J, Cohen R, Leucht S, et al. Do patients with schizophrenia wish to be involved in decisions about their medical treatment? Am J Psychiatry 2005;162:2382–84.
10. Morse GA, Calysyn RJ, Miller J, et al. Outreach to homeless mentally ill people: Conceptual and clinical consideration. Community Ment Health J 1996;32(3):261–74.
