When interviewed, Ms. Y describes feeling hopeless, empty, and alone each time 2 of her 3 children return to college after summer break. Her youngest child lives at home but is involved in extracurricular high school activities, and doesn’t seem to need her. Ms. Y is estranged from both parents. Her social support is unreliable because she tends to push others away and isolate herself.
The authors’ observations
Because she has no history of mania, Ms. Y does not meet criteria for bipolar affective disorder. Her multidisciplinary treatment team feels she is too fragile to transfer care to new providers or to foster care, so we schedule a care conference and carefully compose a 6-month contract to formally articulate limits and boundaries within which we will continue to treat her.
The contract specifies that Ms. Y will participate in DBT, take her medications exactly as prescribed, and not receive any early refills of her prescriptions. We arrange with Ms. Y’s health plan to have a home healthcare agency provide her medications weekly. This benefit was not available to other health plan members. Ms. Y signs the contract.
TREATMENT: Contract violation
Ms. Y complies with the contract for 2 months, then abruptly fires her long-term therapist, whom she claims violated confidentiality by giving false information to another provider. At her next session, Ms. Y will not provide details about the alleged incident, and the issue never is resolved. She admits she did not start DBT and is not taking her medications as prescribed.
Ms. Y expresses her disagreement with the terms of the contract. She becomes very upset and asks for her care to be transferred to another psychiatrist. She demands to be followed at the current clinic because “I was born here.” She denies being actively suicidal and terminates the session early. That afternoon, she calls 1 of the inpatient psychiatrists and asks if he would treat her. She also calls the first psychiatrist she had seen to enlist help in obtaining care.
The authors’ observations
In Groves’ description of 4 types of “hateful patients,” Ms. Y represents a combination of an entitled demander and a manipulative help-rejecter. The behaviors and personality disorders associated with these types of patients—and effective management strategies—are listed in (Table 2).3 (Table 3) offers tips for successfully dealing with high utilizers of psychiatric services. High utilizers of medical services other than psychiatry are more likely than patients who are not high utilizers to have a psychiatric disorder (Box).4-9
‘Hidden’ psychiatric disorders lurk in high utilizers of medical services
Ms. Y’s entitlement interferes with her treatment—she has been allowed to dictate her treatment for years and, therefore, has not been managed effectively. She received resources that other patients did not, such as having weekly medication set up by a home healthcare nurse. Rules were bent to help Ms. Y, but allowing her to dictate treatment has made her so dependent that she worsened over time. Knowing that she was receiving special treatment appears to have strengthened her pathologic sense of entitlement.Patients who are high utilizers of medical services other than psychiatry have up to 50% higher rates of psychiatric disorders—particularly depression—compared with less-frequent utilizers.4-6 Screening medical patients for depression helps ensure that these patients are correctly diagnosed and treated.
Depression is a risk factor for nonadherence with medical treatment, and treating depression leads to decreased utilization of medical services.7,8 Patients with successfully treated depression may have reduced functional disability as well.9
Some members of our treatment team began to experience countertransference, which also interfered with Ms. Y’s treatment. They viewed her behavior as entitled, demanding, and manipulative and dreaded caring for her. Failing to recognize such defenses can lead to consequences such as malignant alienation—a progressive deterioration in the patient’s relationship with others that includes loss of sympathy and support from staff members—which can put a patient at high risk for suicide.10