The patient nobody liked

The authors’ observations

Mr. L triggered hateful reactions among several treatment team members, many of whom felt vindicated by his arrest. Clinicians might react this way if they feel a patient is wasting their time, manipulating them, not recognizing their narcissistic need for the patient to change, or ignoring their treatment plans.¹

Acknowledging the staff’s—and your own—reaction to a difficult patient is critical. Not doing so can lead to treatment decisions based on emotions rather than evidence. In a busy clinical setting, it’s easy to lose sight of this.

The following strategies can help you manage hateful countertransference, cope with a patient’s offensive behaviors, and make appropriate decisions:

• Allow staff members to discuss their feelings. Encourage them to acknowledge and discuss their feelings during team meetings or daily treatment discussions. This helped members of our team recognize that their identification with Mr. L’s self-rejection fueled their desire to “reject” him by discharging him to police or the homeless shelter.
  
• Joke about the patient’s behavior when appropriate. Humor is a mature and potentially healing defense mechanism. When not treating Mr. L, for example, we joked among ourselves about publishing a case report titled, “The case of the poop-eater.” Never joke about the patient in the therapeutic milieu, where it can be disruptive.
  
• See the behavior as a defense mechanism. Viewing patients’ reactions as defense mechanisms—rather than effects of a psychiatric disorder—can help you better understand the patient’s underlying pathophysiology.
  

READMISSION: More bad behavior

After his 3 arrests for public nudity, we readmit Mr. L, restart citalopram at 20 mg/d, and titrate it back to 60 mg/d to target his depression. We also switch back to olanzapine, 10 mg nightly, because the patient has seen little clinical benefit from aripiprazole and feels that olanzapine had improved his sleep.

In the psychiatric ward, Mr. L is once again disturbing patients, smearing and eating feces, and making half-hearted suicide attempts. Upset that staff is “ignoring” him, he enters other patients’ rooms without invitation and urinates in places other than the bathroom.

The authors’ observations

After 3 hospital admissions, Mr. L’s diagnosis remained unclear (Table 2). At his first admission, his symptoms suggested major depression with psychotic features. With his subsequent behaviors in the inpatient psychiatric unit—including primitive suicide attempts and smearing and eating feces—Mr. L showed a strong desire to be cared for. This and his past dependence on his wife and mother suggested a severe dependent personality disorder.

At his first discharge, Mr. L was diagnosed with a personality disorder with significant passive-aggressive traits. His lifelong dysphoria and lack of ambition also suggested dysthymia.

With discharge from this latest hospitalization pending, we searched for options. We considered Mr. L’s ongoing suicidality, persistent acting out, and aggression. Treatment team members discussed his use of “primitive defenses”² stemming from his limited coping skills in the face of severe depression.

Table 2

Mr. L’s differential diagnosis

TREATMENT: A different course

One week after admission, Mr. L’s inpatient psychiatrist recommends electroconvulsive therapy (ECT) to target the patient’s presumed severe depressive episodes and disruptive behaviors. The psychiatrist is experienced in performing ECT, which in clinical trials³ has shown efficacy in treatment-refractory major depression.

After giving informed consent, Mr. L receives 8 bilateral ECT treatments in 3 weeks. Also, the hospital psychologist performs behavioral modification similar to the previous cleanliness plan and again encourages Mr. L to express his anger and anxiety verbally.

By the second week of ECT, Mr. L’s disruptive behaviors have ceased. By the end of week 3, his mood and motivation have improved to the point where he shows interest in becoming independent. He says he wants to show his estranged wife he can care for himself and eventually reunite with her.

As Mr. L continues to improve, we discharge him to outpatient community mental health services and continue citalopram, 60 mg/d, and olanzapine, 5 mg nightly.

Nearly 2 years later, Mr. L is living independently. He has been regularly seeing his psychiatrist at the community mental health center and is maintained on citalopram and olanzapine. He continues trying to make amends with his wife but is still out of work and receives Social Security disability benefits.

The authors’ observations

Mr. L was fortunate that his inpatient psychiatrist could re-evaluate the diagnosis after identifying the staff’s significantly hateful countertransference. This allowed staff to offer ECT, which—despite its documented efficacy for major depression—is not widely available in the United States.