[Content warning: psychiatrists having ethically complicated conversations with patients]

I recently attended the Michigan Psychiatric Society conference. It was all downhill after I heard the name of the first poster presentation. The study – investigating the tendency of anti-Parkinsons medication Requip® to cause nightmares as a side effect – was titled “Requip For A Dream”. I didn’t stay long enough to see whether that won the poster contest, but if it didn’t there is no God.

But I also attended a couple of forums and Q&A sessions, and in one of them a doctor asked the question:

“What do I say when one of my psychotic patients – who is telling me how he is Jesus, or is being pursued by the FBI, or something like that – glares at me and asks ‘You don’t believe me, do you?'”

The lecturer, who was a very prestigious psychiatrist of some sort, said that his standard response was “I believe that what you are seeing and experiencing is real to you.”

This is the sort of nice, pat answer I would expect from a clever and prestigious psychiatrist. It ticks all the boxes. It is kind and compassionate. It doesn’t technically lie. It doesn’t validate the patient’s delusions. And it acknowledges the patient’s emotions without being dismissive or confrontational.

On the other hand, if I was that patient it would enrage me.

Let me distinguish this from a very very similar concept where I think this answer is exactly correct. Suppose someone is having hallucinations, like believing there are spiders crawling all over him. He asks “You don’t believe me, do you?” I think the exactly correct answer is to say “I one hundred percent believe that you are experiencing spiders crawling all over you, that their appearance and features are extremely convincing, and that you’re not making this up. But there are not real spiders on you.”

And if you responded to the guy who thought he was Jesus with “I one hundred percent believe you are feeling a strong, almost irresistible urge to believe you are Jesus. But I don’t think you are actually him,” that would remove most of the creepiness for me (I also don’t think it would be very popular with patients).

But somehow this guy’s phrasing pressed my buttons. It wasn’t just that he wasn’t answering the question. It was that he was denying that the question was the sort of thing that needed to be answered, denying that there was a real fact-of-the-matter about Jesus at all, or denying that it was worth worrying about.

But if you’re worried you’re psychotic, that’s probably the most important question to you. The reason this came up at a big conference is that it’s a really common question. Psychotic people ask it a lot. If you’re psychotic, then the fact that you believe these strange things no one else believes has become one of the central things in your life. And to you it’s less important that the person be Validating And Accepting than that you settle this problem that is tearing your life apart.

And this answer isn’t even subtle about what it’s doing. It’s like “Obviously I don’t believe you, but I’m going to avoid saying so in so many words, and I bet you won’t even notice or care. You’ll just be grateful I’m acknowledging you at all”. It’s condescending, is what it is.

I’m not psychotic (I think). And I’m probably more concerned with there being a Real-World-With-Truth-Values than the average person. So maybe the prestigious expert is, as is often the case with prestigious experts, right. But I really don’t want to follow his advice. It would leave too bad a taste in my mouth.

I haven’t decided what I am going to say in its place. But in a perfect world, where I get exactly the right patient, the response I would really like to give is: “If you were me, would you believe it?”

I think, in this fantasy, if I picked the right patient they would laugh and say “Nope!”. Because psychotic people are smarter than they are usually given credit for, and also usually have good senses of humor, and at least we would both establish where we stood in a non-confrontational way.

And it’s always interesting how often deluded people know in the back of their head that their delusions are wrong, or at least questionable. Like I can just ask people “I’m here to do a psychiatric evaluation of you. Do you have any strange beliefs I should know about?” and they’ll say “Well, I believe I’m being pursued by the FBI.” I ask “Are you being pursued by the FBI?” They say “Yeah.” I asked once, because I was very curious and making things up as I went along, “Then why did you bring it up so quickly when I said I was a psychiatrist looking for symptoms of mental disease?”

My patient didn’t have a good answer for that. I didn’t get the impression it was some very logical “Well, I realize statistically most people who think they’re pursued by the FBI are psychotic, so I’ll just mention it, even though I personally am not.” It seemed more like another example of people, whether psychotic or not, being kind of garage-dragon-y.

This brings me to the other question I get from people a lot, which is “Do you think I’m crazy?” I think the Officially Correct Answer here is to say “Of course not”, which isn’t very convincing precisely because it’s obviously the Officially Correct Answer psychiatrists give to everyone. Even worse (but surprisingly common) is “Crazy isn’t a technical term”. Thanks. I’m sure that must be very reassuring.

Again, a fantasy answer I would like to give if I have exactly the right patient is “If you’re asking that question, don’t worry.” Which I think is sort of true. If you’re in a psychiatric hospital, and your conclusion is that maybe this means you might be crazy, you have some pretty good reality-based thinking going on. If you’re in a psychiatric hospital, and your conclusion is that maybe this means the FBI has found out you’re Jesus and is trying to stop you, that’s the guy who’s in trouble.

And again I worry that I might be getting too clever. Probably some of these patients aren’t very smart, or aren’t very cynical, and a simple “No, of course not” would be reassuring in a way a weird self-referential answer wouldn’t. So far I have just given some version of the simple answer. But when there’s someone I know well, and who’s especially jaded, and I doubt the simple answer would go over well, I really want to try something less cliched and more honest.

But even that’s not the answer I fantasize about giving later on, when I have my own practice and patients whom I’ve known for years and I can pick out the ones who are a lot like I was when I was younger and seeing a psychiatrist. For them the answer will be “Yes, of course. So am I. So is everyone. The interesting question isn’t whether you’re crazy, it’s whether you function anyway. Let’s try to work on that.”