When treating the chronically ill, there are certain skills needed to achieve the desired therapeutic outcome – many of which are utilized during the optimal face-to-face session. With care thrust into a teletherapy format during the COVID pandemic, these skills – along with our rapport and history with patients – have become more important than ever.

As providers, we are no longer able to observe that squirm, change in eye contact, tense posture, body odor, restlessness, or shakiness, to name a few cues often present in patients with chronic schizophrenia. We must mark “not applicable” in appearance and in most of the behavior assessment areas of the mental status exam in the patient’s EHR.

Below are a few ways I have been compensating with clients during recent phone-only therapy sessions.

When it Comes to Schizophrenia, Understand that Context Differs

I primarily work with chronically ill patients as part of a Program of Assertive Community Treatment (PACT), many of whom have diagnoses of schizophrenia, bipolar, and treatment-resistant depression.

Those with chronic schizophrenia do not seem to view this pandemic time as difficult or even different as they have been familiar with feelings of isolation for quite a while. Without the benefit of a smile to help ease discomfort or encourage expanded conversation, teletherapy sessions can be challenging. Twice in one day recently, the patient abruptly ended the phone session.

In one case, after no more than 4 or 5 minutes, a male diagnosed with paranoid schizophrenia spontaneously stated, “Well, I’ll let you go” and ended the call. Mind you, all responses up to that point consisted of “yes,” “no,” and “eggs” (when asked what he had for breakfast). Luckily, I have eyes and ears through his caseworker and family members.

A second patient – also a male diagnosed with paranoid schizophrenia – had requested to talk with me about his medication regimen due to increased depression. His delusions and paranoia had waxed and waned in the prior two months, and dose adjustments had been made to both his prescribed antipsychotic and antidepressant. His paranoia improved after he finally agreed to increase the antipsychotic dosage. Since then, however, he had complained of increased depression to his case managers, even though he told me on several occasions that he was “fine.”

During our call, we reviewed all the coping mechanisms he had learned. While he refused one medication offered, he did agree to a very small, defined increase to his antidepressant to manage his recent uptick in depressive symptoms. I would have liked to try adding a dopamine reuptake inhibitor to the SSRI but he did not agree. We did avoid his strong contemplation to discontinue the antipsychotic, however.

As soon as he made the difficult and anxiety-producing decision to agree to the change, he abruptly stated, “Well, I’ve got something I need to do.” Perhaps he had decided before the session how much of a change he was willing to make; perhaps the anxiety of impending change caused him to stop the interaction. If not for years of experience with similar conversations, I might have felt as though I was being long-winded in this session, which was also under 5 minutes.

Expand the Small Talk When Working with Patients with Schizophrenia

The introductory, soothing small talk, and even humor, that we often use with patients living with schizophrenia to start a session is key. Even if a client has known me for years, it may take a moment for them to realize who they are speaking to without the obvious facial recognition.

From the therapist’s point of view, initial signs of decompensation are not observable in the same way. Without video, for example, I must ask more direct hygiene questions pertaining to the individual’s activities of daily living (ADLs).

I try to address these questions with sensitivity, knowing that if a patient is usually stable, self-caring, and clean, the topic may come across as unusual. So, I might start by asking if they are taking care of themselves during these “different times.”  I talk about how easy it can be to stay in pajamas all day or to shower less often. I ask if they can relate to that experience. Then, I may learn of any changes the patient has made, which may be an early sign of decompensation.

My provider-patient dialogues to date have reminded me of how limited and unstimulated the lives of the chronically ill can be. I use this awareness to ease into gathering more telling information, such as whether they are neglecting to brush teeth or eating a poor and unvaried diet.

Utilize Case Managers and On-Site Staff More

I refuse to let these individuals’ hard-earned socialization progress decline.

While my ability – and that of other mental health professionals – to provide the best care possible has been altered by less face-to-face contact in sessions, we can rely more on case managers, such as those who work with PACT teams, and on-site staff. Some case managers’ roles have become more errand-oriented (ie, necessary shopping for food, in-exam room attending of appointments with patients if permission is granted, and having labs done with patients), giving them additional chances to observe and report back. In addition, the various staff who make daily or twice-daily medication drops to patients can be taught (or asked) to observe more skillfully and, perhaps, to take more time with patients than their usual brief encounters.

In addition, I often encourage outdoor, socially distanced activities, such as walks in the park. Roaming through thrift stores is a favorite of my patients, but may not be a good choice if stores are populated. Making sure an avid reader has reading material on hand is most important with staying home more.

Revisit Self-Care and Nonpharmacological Coping Techniques for Schizophrenia

While anxiety and depression are on the rise even in the general population, it can be especially pervasive in the chronically ill. Many of these individuals are on high doses of potent medications or polypharmacy due to comorbidities. I have found it useful to review with them the therapeutic options they have beyond medication, including self-soothing techniques. Sometimes, patients just need a gentle nudge or reminder to use these strategies.

I start by asking my patients if they have found anything helpful when feeling stressed or down. Many times, the question reminds them of a technique they have used successfully in the past and simply forgotten about. A few standbys include listening to calming or uplifting music, calling a friend, and coloring in an adult coloring book (which often produces a nice product that can help raise self-esteem). In addition, turning on the TV or music can be very effective in drowning out auditory hallucinations.

I use our teletherapy sessions to revisit possible triggers as well. When stressed and not thinking clearly, delusions, paranoia and/or hallucinations may reoccur or worsen.

Finally, I remind patients of our 24/7 on-call service, where they can talk to clinicians about what is bothering them outside of their regularly scheduled sessions. In these after-hours calls, I like to go over relaxation breathing techniques. We inhale together and then I count to at least 6 on exhalation. When anxious, I remind clients that they may not get past the count of 4 but to keep trying, exhaling slower and slower each time. We repeat this several times together so I know they can do it on their own.

When breathing is not helpful, I advise a hot shower or nap to soothe or divert attention. The decrease in stimuli often helps. Other times, I ask them to rest while on the phone by lying down with the phone speaker on – but without conversation. They know I am there for them. Sometimes it takes only a few minutes to exert a positive effect.

We also talk about sleeping hygiene. I explain that getting enough sleep helps them reboot, while a lack of REM sleep could lead to nightmares. And I usually end the call by emphasizing that practicing all of these techniques when not upset is key, so they can be called upon – I use an automatic pilot analogy. (More on why patients with schizophrenia often have trouble sleeping.)

See also, our Clinician’s Guide to treating schizophrenia.

Professional Takeaways

I am very proud and happy to report that we have had no significant increase in average monthly inpatient hospitalizations or crises. One of the PACT teams I work with reports a moderate increase in substance abuse. The inpatient crisis unit has not significantly increased admission rates.  A few patients have requested more attention and more face-to-face encounters with case managers. In these cases, in-person sessions are provided using precautions for both patient and provider.

Overall, chronically ill patients might remain stable on the same medications for months to years and then suddenly decompensate without clear explanation. It takes a team like PACT to serve them with optimal care. This is what I love about the challenges and rewards of this work!

 

 

Last Updated: Jun 1, 2021