Challenging a diagnosis

One of the things that I love about my role is working with people over a long period of time as it gives both of us the opportunity to develop a strong therapeutic alliance and to work at a much deeper level where you can truly advocate for the client due to having gained a better sense of them. In this case, I had been working with somebody that had been under the care of psychiatric and disability services for all of his adult life (over 35 years at the time), has had many different diagnoses documented and follow him around and essentially had become institutionalized. This particular person repeatedly presented to emergency departments when distressed and attempting to get his needs met and was always registered on entering the hospital with the same issue. ‘Schizophrenia’. Unfortunately, this diagnosis had initially been listed against his name about 20 years earlier and had followed him around, regardless of any change in his circumstances. At this stage I should explain that this person had a significant trauma history, a learning disability along with a few other comorbidities just to make things a bit more complicated. But despite this, whenever people met this person, they kept the label of schizophrenia, even though it was a one-off (and very questionable) diagnosis that was not reflective of the person currently presenting to ED.

My initial attempt of discussion around this issue was faced with replies regarding medicolegal factors and how it is risky for the Psychiatrist to suddenly change the diagnosis as then a justification is needed for why they have been receiving a particular treatment. Although this justification was in the minority, to this day I am still amazed that this mindset continues to exist and reinforces the reasons that consumers can sometimes feel alienated and untrusting of the people providing care. Fortunately, there were others that felt differently, and rather than this becoming a philosophical argument I focused on providing practical observations and tailoring my interventions to what was required in the present moment. This approach moved treatment away from psychosis and the focus became on interpersonal skills such as communication, emotional and social intelligence plus neuropsychological testing. All of which align more with the existing issue, this being his intellectual disability and struggle in coping with how to interpret the world around him. At this point, a parallel process is taking place, I’m taking an object relations approach with my client as I’m wanting him to internalize me as a positive object based on his very black and white view of the world, plus I am attempting to introduce new ways for the system around him to view and work with him. After approximately 12 months of working in this way, I finally had enough objective examples to revisit the diagnosis listed and have ‘schizophrenia’ removed. This was a great moment for my client as it was one less condition that he had to carry around with him. During this process, it made me reflect on how quickly some people can put a label on others with little regard for the significance or consequences of doing so. The main example of this would be the label of ‘antisocial personality’, but that’s another reflection for some other time.

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