In my first week of psychiatric training, my mentor suggested several hundred books and some 30 journals as mandatory reading – all to be studied closely. As this risked me qualifying as a nerd rather than a psychiatrist, the list was rapidly refined, with the wheat separating reasonably easily from the chaff. Certain writers stood out like Ruth amid the alien corn, as did several established or nascent publication ‘classics’.
One 1957 paper –The Ailment, by T.F. Main (1) – was an exemplar. Specific behaviours of mental health professionals in response to certain patients were detailed in a mesmerising manner. Subsequently, a ‘Chinese whispers’ approach re-framed this paper as it moved to classic status. While Main described patients with certain interpersonal characteristics –‘flattery and seduction’, ‘revengeful counter-attacks’, ‘need for material tokens of love and goodwill’, and a capacity to widen ‘incipient staff splits’, at that time, the diagnosis of a ‘borderline personality’ had not been operationalised. It was Main’s reference to ‘special patients’ that led to his paper being interpreted as describing the ‘VIP’ or ‘special’ patient. His paper advanced a psychiatric prescription for treating such patients – to not treat ‘special patients’ in any ‘special’ way.
Psychiatrists were not the only specialists arguing against special treatment. Surgeons identified higher post-operative morbidity and mortality in ‘special’ patients – presumably reflecting greater emotional involvement and being more ‘thorough’ than usual (e.g. six sutures rather than three). Moving beyond surgeons, Groves and colleagues (2) overviewed some 60 references indicating that patients with ‘uncommon social standing’ risk compromised medical care.
When medical practitioners were encouraged to treat VIPs exactly as they would treat the ‘average’ patient, most psychiatrists embraced this recommendation – presumably reflecting the then psychoanalytic weighting to psychiatrist ‘neutrality’ and awareness of specialty-weighted traps. Some adopted extreme positions, risking a lack of common sense and sensibility. One of my senior consultants decided that one of his out-patients (also a psychiatrist) required hospitalising. To avoid criticism of ‘special’ treatment he had our junior colleague admitted as an involuntary patient to the regional public ward – where he sat in his pyjamas with several of his own private patients as his acute ward companions.
It is of interest then to now observe greater flexibility emerging in recommendations for managing the ‘special’ patient. However, before considering some management nuances, let’s examine a useful model detailed by Groves et al. (2) which distinguishes between ‘celebrity’ patients, ‘VIPs’ and ‘potentates’.
For ‘celebrities’ (e.g. bestseller authors, entertainers, movie stars, notorious criminals, royalty, politicians and sports figures), they suggested that the clinician’s competence and decision making are likely to be publicly judged, reflecting the impact of the celebrity’s entourage (e.g. bodyguards, celebrity friends, managers). They detailed some practical strategies (e.g. ‘blend the patient into the crowd’, ‘enter the hospital indirectly and with disguises’), and advise that only two non-medical individuals (e.g. next of kin, patient’s administrator) will be given clinical information about the celebrity. Observe the clinician becoming encouraged to become involved in ‘atypical’ behaviours.
Moving on to VIPs, Groves et al. reported that, while legend holds that Winston Churchill coined the term ‘VIP’ to ‘denote a high government official or high-ranking member of the military’, they more used it to describe individuals who generate awe in particular domains and who are important in certain situations – and with most of the relevant literature covering the ‘physician as patient’. They argued that the principal risk is of the managing physician feeling uncertain about their medical competence and becoming indecisive – perhaps deferring to the patient in regard to medical decisions, and so compromising the fundamental medical care contract – to take and maintain responsibility. Grove et al. detailed the doctor’s dilemmas: (i) be overly thorough (e.g. order more tests, consultations, invasive studies), (ii) do the converse to spare the patients or (iii) otherwise deviate from ‘normal’ procedures (e.g. not address drug or alcohol problems, bypass hospital procedures), noting that, as had sometimes happened in John Kennedy’s life, ‘in death, Kennedy received too much awe and too little care’.
‘Potentates’ are defined by Groves et al. as ‘big shots’– and who like to be so treated – but who neither attract media publicity nor have their professional caregivers hold them in awe. They tend to be wealthy ‘difficult’ patients, generating crises over issues of power and privilege, and often with a narcissistic personality style. In essence, they are less likely to accept the ‘patient role’– not being as sick as they portray and unmotivated to address their problems, nor do they display ‘gratitude toward the caregiver’. Groves et al. observed that, as psychiatric patients, ‘potentates’ tend to communicate indirectly through intermediaries, mistrust the professional’s acts of kindness or care and, in demanding special care, cause staff to withdraw, with treatment often aborted.
In summary, Groves et al. argued that ‘special’ patients stir up ‘dysfunctional feelings in their caregivers’: celebrities by focussing public attention on the treating professional, VIPs by generating awe and risking loss of the professional’s objectivity, and potentates by unearthing ‘the issue of narcissism in the care-giver/patient relationship’. They suggested guiding principles that the privacy that celebrities need should be extended to medical staff; the loss of professional objectivity induced by VIPs should be addressed by team leadership and avoidance of deviation from standard operating procedures; and the conflict generated by potentates be neutralised by reassurance that they are ‘special’.
Can we extrapolate their model and management suggestions to contemporary psychiatry? Psychiatrists competent in handling patients with narcissistic and related personality disorders can extrapolate their strategies for handling ‘potentates’– although the risk of therapist negativity (e.g. counter-transference, antagonism, passive aggression) – is both high and counter-therapeutic.
As a consequence of destigmatisation of mental disorders, psychiatrists should now expect to manage a greater number of VIPs and celebrities, and with the key issue being whether to reject any ‘special’ patient component to clinical management or to allow some accommodations. I’ll argue for a mix-and-match model.
In my experience VIPs fall into two principal sub-groups – very imperious people and very impressive people. The ‘imperious’ sub-group are usually very senior in organisations, alpha males or females, and only willing to see a psychiatrist as a last resort as they are innately contemptuous or dismissive of psychiatry. They present with a sense of urgency – demanding an immediate appointment (usually ‘out of hours’) and commonly seek immediate relief of an incipient social catastrophe or of a longstanding problem (such as severe alcoholism). Predictably, Murphy’s law operates – if medication is prescribed, they rarely respond and/or are poorly compliant; they are too impatient for psychotherapy; and they appear to distain psychiatric counselling unless there is a component of ‘rat cunning’ that appeals to them. They commonly forget or rearrange appointments, arrive late and fail to have requested tests or investigations undertaken. Once the crisis situation has improved, they will effectively ‘dismiss’ the psychiatrist quickly – with minimal or no thanks.
Should the clinical psychiatrist seek to retain their usual modus operandi or (as argued here) adapt to their needs? The key issues here are authority and control – the psychiatrist is under pressure to either be subjugated or to become overly controlling. Subjugation – in essence, taking up a ‘personal assistant’ or a ‘yes man’ role – is a poor option for the professional, and as Eleanor Roosevelt observed, ‘no one can make you feel inferior without your consent’. Such patients are often effectively defined only by their work-associated authority and are fearful of any threats to that identity. However, they are usually anxious people who bundle their anxiety into imperious control, and being authoritarian they will respect someone further up the authority ‘food chain’, and dismiss any professional who appears subservient or unsettled. A submissive psychiatrist will frighten such patients. Conversely, the therapist who feels a need to out-control such patients is generally reflecting their own anxiety. While some ‘corrections’ are required, the therapist needs to avoid ‘over-correcting’ (e.g. talking too much or offering too much advice). An ideal therapeutic stance (even if unsuccessful) is to evidence one’s professional authority at all times – and personal authority at those times when the patient is most vulnerable – such as at the initial assessment or when the patient is clearly looking for advice. While many of the benefits of psychotherapy are underpinned by non-specific ingredients such as empathy, such patients are more looking for a ‘rock’– for integral and interpersonal strength in the psychiatrist – and who may have to adjust many of their ‘usual’ therapeutic styles to effect such a position.
To my mind, ‘very impressive people’ comprise the more common VIP sub-group. They respect other professionals, are psychologically intelligent and very aware of boundary issues. As a consequence of their own professionalism – they respect professionalism in others. They recognise the strengths and limitations of psychiatry, and are extremely appreciative of therapeutic gains. While they may not ask about procedures for respecting their confidentiality, the psychiatrist should detail such nuances – both general and (as here) ‘special’ ones. The risk here if for the psychiatrist to be ‘star struck’– of warming to the ‘special’ person who is likely also to be charismatic – perhaps by being too disclosing, attentive or appearing as an acolyte. As Kirk Douglas observed, ‘If you become a star, you don’t change, everyone else does’. Such VIPs usually have enough friends. The psychiatrist does not need to join the long queue of disciples, nor adopt the professional style of being overly friendly (or immediately contactable), nor take up a ‘concierge’ treatment model. Such patients do not want to be idolised by the psychiatrist, they seek the benefit of their skills.
But for all VIPs, it strikes me as central to do everything to protect their confidentiality. This might involve consultations ‘off site’ or, if attending the psychiatrist’s rooms, procedures to ensure that they are not seen by other patients – or at times – other staff. It may involve recording appointments under differing names, encrypting assessment and review notes through a filter, writing succinct notes to referring physicians using an agreed pseudonym, or even detailing that no written record will be provided – and that communication (to nominated individuals) will occur in specified ways (e.g. verbally) and only in specified circumstances. In essence, a variant of the German proverb: ‘He who would rule (i.e. so treat) must hear and be deaf, see and be blind’.
While many will argue that ‘treating patients differently risks leading to worse care’, a ‘mixed model’ for dealing with VIPs is worthy of consideration – in which the clinical paradigm (‘care’ component) remains inviolate, while ‘management’ components are modified to address their unusual needs and pre-empt attendant risks.