The case history by Parker describes a patient treated in long-term psychodynamic psychotherapy who has precluded certain treatments, such as medication, from the outset. The patient is chronically unwell, often fails to make progress and is very demanding of the treating health professional, such that the treating therapist comes to question what are the limits to their care and responsibility for this patient.
This case reminds me of a dilemma I sometimes got myself into in the earlier stages of my career as a psychiatrist and psychotherapist—hanging on year after year with a patient who is only very partially co-operative, in the hope that the patient will improve with time. My rationale for continuing with a patient of such limited capacity for co-operation was that at least I would be benefitting them by stopping them suiciding, or saving the need for the patient to use other expensive medical services, such as psychiatric inpatient units. These days, I very much try to avoid entering into a long-term treatment relationship with a patient if it is clear that s/he will be unlikely to ever fully co-operate with treatment.
As a psychiatrist, I have a duty to make a comprehensive biopsychosocial assessment at the outset. In the case described by Parker, although details are limited, I think my assessment would include the strong possibility of a psychotic disorder, such as schizophrenia of paranoid type, or delusional disorder. My treatment of that would be likely to include antipsychotic medication, at least for a trial, as an essential part of management. If the patient refused to agree to that management, would I then agree to long-term supportive psychotherapy, or would I pull back at that point? As I suggested above, in the past I may well have persisted with an attempt at long-term psychotherapy even if the patient refused other treatments such as medication. However, there are drawbacks to that approach. One is an opportunity cost issue—is “half-treating” the patient better than no treatment? Would refusing to half-treat bring the matter to a head, with the patient either backing down and agreeing to a more comprehensive treatment, or getting worse and being forced to have more comprehensive treatment? Does half-treating patients deprive them of the impetus to seek a more comprehensive treatment? If we decline to treat them because they are imposing too many conditions, do they suffer a bad outcome or do they just go to someone else?
Sometimes the patient may try to convince us that we have to treat them with one therapeutic hand tied behind our back, but sometimes this says more about the transference and countertransference operating than it does about any objective necessity to take on a half-formed treatment. One of the reasons I try to avoid this situation is that if something goes wrong, I may be seen as responsible for not offering the patient comprehensive treatment, e.g. including medication. Even if I obtain informed consent from the patient for what I am offering, the patient is, after all, mentally unwell and I may still have to consider what is their “right to effective treatment”.
On the other hand, my handling of this type of dilemma is not totally black and white. There are still patients whom I accept for treatment even if they set some limits on their degree of co-operation with treatment options. For example, I have a patient who suffers from schizophrenia and although he takes his medication, he also continues to smoke marihuana. He functions less well because of the marihuana-smoking, but in his case he was very unwell off medication, and so is probably better off seeing me even if he is not fully co-operative. Meanwhile, I continue to strive to convince him of the need to cease the marihuana. Here I am weighing up the predicted benefit of seeing him, given the limits he has imposed on his own treatment, against the predicted result of not seeing him. This general approach applies to all patients.
Sharpness when performing the initial biopsychosocial assessment, early clarity about what treatment is recommended, and detailed consideration of what to do if the patient dictates excessive limits on what treatment can be offered, are factors which can reduce the development of dilemmas such as that in the case described by Parker.