Listening to Patients With an Open Mind

Roger Redstone is a 55-year-old single man who has lived his entire life within easy commuting distance of the state hospital in which he has been an inpatient for 10 months on his third state hospital admission (one before age 18, one for eight years’ duration).

During his admission, no one has observed Mr. Redstone reading a newspaper, magazine, or book; no one has seen him attending to the news on radio or television.

Mr. Redstone’s diagnoses using DSM-5 criteria are schizoaffective disorder, mixed personality disorder, and unknown substance use disorder, moderate. Neuropsychological testing showed borderline IQ and a high score for psychopathy (30 on PCL-R).

Mr. Redstone, after eight months of severely problematic behavior in the hospital—thought to be a combination of willful behaviors reflecting his psychopathy and impulse-driven behaviors out of his control—changed dramatically after an increase in his dose of fluphenazine decanoate. Prior to Wednesday, November 5, 2014, he had had many weeks without any of his prior intrusive, crude, dangerous behaviors. Mr. Redstone was scheduled to be discharged within a few weeks.

On November 5, Mr. Redstone lost control, regressing to his earlier presentation. I met with him the next day, and the following conversation ensued:

JG:“What happened? You were doing so well.”

RR: “I’m going to lose my SSI/SSDI. I’ll be homeless. I’ll have nothing to eat. What will I do? This is awful.”

Mr. Redstone was frantic.

JG:“What are you talking about? Did something happen?”

RR: “I’m in trouble. I won’t make it.”

JG:“Let’s slow down. Why do you think all this is going to happen to you?”

RR: “The election yesterday!”

JG:“What about the election?”

RR: “The governor.”

Mr. Redstone told me that the person who was elected governor would cut out all funds for people like him.

I informed him that anything the governor-elect might do would not occur for some time and that the impact on him would be very little, as he was mostly in federal, not state, programs.

With this information, Mr. Redstone settled, used the self-soothing skills he had learned during this hospitalization, and the blip in progression toward discharge was over.

I bring this vignette to your attention because it is another example of our frequent misperceptions of what individuals with serious, chronic mental illness are capable of or what they are attending to. Mr. Redstone could not tell me how he knew who was elected governor, and even more puzzling, how he knew the political views and expected social policies of the governor-elect.

Perhaps I should not have been surprised. In 1992, I did a survey about what inpatients at the same hospital knew about Operation Desert Storm.

The patients were well informed, to the surprise of many. We learned at that time not to jump to conclusions about patients’ answers without asking them what they meant when they gave what on first hearing sounded like a delusion. One question on the survey was, “Do you know what Jordan is?” Many indicated it was a country in the Middle East. One patient said, “It’s where I buy my underwear.” Sounds like psychosis. But the interviewer asked, “What do you mean?” The patient responded, “You know, Jordan Marsh.” Jordan Marsh was a department store in Massachusetts, often referred to as “Jordans.” ■