Linda was a 20-year-old single woman. Her plans for an exciting year abroad in Asia became instead a journey through Hell. While overseas on a student exchange program, she became engaged to a local man she barely knew. When that relationship collapsed, she then impulsively flew to Europe, disappearing into an extended period of chaos and drug abuse progressively involving a broad spectrum of recreational drugs from hallucinogens to opioids. When she ran out of money, she finally flew home to rejoin her parents.

Several months after this episode, the patient’s parents urgently requested a psychiatric consultation for Linda since her behavior was becoming increasingly problematic for them. She agreed to meet with me under protest, and did so only to placate her parents. Having recently turned twenty, she insisted that “absolute privacy and confidentiality” would be the condition of our working together. So, from the start I was at a disadvantage, cut off from other sources of information that might inform my evaluation and forced to depend on the patient, likely an unreliable historian, for history.

Fortunately, the patient was compliant with medical testing , making it possible to determine whether she was in any kind of drug-induced metabolic crisis or had contracted a serious infection from her drug use. Prior to my first session with Linda, her father provided me with a capsule history. Linda was living at her parents’ home but they were unable to set any limits on her comings and goings. She had begun working at a retail store but was in danger of losing that job because of her unreliability. Although her parents had cut off her access to their money, she earned just enough on her own to buy drugs.

She had suffered a major depression at age 16 when she had taken an overdose of acetaminophen and alcohol. She saw a social worker for psychotherapy and a psychiatrist for antidepressants, but stopped both treatments prematurely. “Everyone loved” Linda in high school because of her expansive and gregarious personality. She was often the life of parties until her behavior became too much for even her “edgy” friends—at times she would engage in tirades about philosophical matters that tried everyone’s patience. In spite of Linda’s volatility, she successfully completed high school and was accepted at a university but decided to defer enrollment for a year to work and travel overseas.

Linda was adopted. Since it was a blind adoption (family of origin information was not available), no one knew anything about her biological family history of psychiatric illness (including substance abuse). Her grandiosity, irritability, and periods of mood changes suggested that bipolar disorder should be a part of the differential diagnosis. An episode of major depression is often the first sign of what will later develop into bipolar disorder. Hypomanic and/or manic episodes are often experienced months or years after an episode of major depression has resolved, where upon a diagnosis of bipolar disorder is applied to the case. The importance of the missing psychiatric background information later became clear only later when Linda located her birth father.

Linda canceled and then rescheduled her first appointment, then arrived a half hour late for a subsequent appointment. This would become a familiar pattern of missed or abbreviated sessions. I soon found myself wondering how much good I was doing for her. I liked her and found her intelligent, intrigued by her childlike inquisitiveness. I enjoyed discussing her experiences with meditation and existential philosophy, but refrained from confronting her with the evident contradictions between her expressed wish to live a “pure, chemical-free” life without medication and her reckless drug use. I was trying to build a therapeutic alliance, reminding myself that the goal of every session with resistant adolescent patients is to get them to come back.

To develop a therapeutic alliance with Linda, I had to walk a fine line between acceptance and confrontation. I had to confront her extreme, at times provocative, behaviors but in a way that did not rob her of a sense of self-efficacy. Humor and irony were important as much in the tone as in the content of what I said to her.

Linda would agree to come to sessions as frequently as necessary to reassure her parents that she was getting at least minimal help. She was clear that she was not ready to stop using drugs. She had just begun, she said, to explore all of the possibilities of various natural and synthetic drugs. She mentioned almost casually that she was using heroin “most days” but methamphetamine “only every other day.” Her closest friends were other substance abusers who had bounced in and out of substance abuse treatment programs . She barely managed to keep her job by relying upon the kindness and tolerance of her boss. She was still living with her family, but in almost daily conflict with them. Each night she would pretend to go to bed and then sneak out of the house after she knew her parents were asleep.

On most days, I received urgent calls, emails, and texts from Linda’s parents daily telling me of the latest screaming fight over her drug use. I had to skirt the margin between confidentiality and my desire to protect Linda from harm. While saying she wanted me to assure “absolute confidentiality,” she nevertheless seemed reassured when I told her that her father had sent me an email. At first her father limited his contacts to these emails but then we exchanged voicemails as he and I developed an alliance for dealing with her drug abuse. To my surprise and relief Linda approved of communications with her parents. It has often been my experience with her patients that adolescents and young adults are comforted by communications with concerned parents, even if they publically deny that that they are. They may overtly rebel to assert their independence but are reassured by expressions of love from their parents.

Highly intelligent and well-informed about the dangers of the drugs she was using, Linda convinced herself that she knew more about these drugs than did I. In spite of her protests, she was unable to stop using methamphetamine , heroin, and a seemingly random and reckless array of injectable substances. In her communications, she seemed to be saying “Stop me before I kill myself.” My technical challenge was to treat her, an adult behaving like a younger adolescent, with a course of treatment that would inevitably require the resources of a dual diagnosis program. She was experiencing both bipolar disorder and substance use disorder.

My initial posture was directed at building a therapeutic alliance despite the chaos she maintained in her life. I repeatedly rescheduled missed appointments and confronted her with her denial and the contradictions between her stated goal of a lifestyle free of artificial substances and her almost daily plunges into drug experimentation. She wrote me long, sometimes eloquent, emails expanding upon her spiritual interests and adventures in meditation. I engaged her in digressive discussions of Eastern religions, seeking a connection with her and looking for opportunities to ground her in reality. It was obvious to me that Linda would not be able to recover from her addictions and depressive disorder without a residential treatment program. However, she resisted and defeated all efforts to rein her in forcing me to find less direct ways of incorporating her in our work.

Creating a therapeutic relationship with Linda occurred in fits and starts. Linda’s father repeatedly reached out to me. At first these communications were one-sided. I listened to his concerns and offered little in response except for expressions of empathy. His advocacy, however, was implicitly welcomed by both Linda and me. His involvement actually assisted me in consolidating a reliable place in our effort, first as Linda’s advocate and then as a mediator in “tough love” discussions about limits and consequences. Often, I feared that I had “stepped over a line” and that my statement or action might destroy my relationship with Linda. If I rolled my eyes or gasped in disbelief upon hearing the fabrications she told herself, I did so with humor. Personally, she and I both knew that she was terribly lost and completely alone as she rationalized her decision to continue to use drugs. Ironically each failed attempt to rein in her reckless substance abuse served ultimately to build a shared case for residential treatment. The process was anything but smooth, however. Her labile mood and the variable effects of combinations of drugs substantially impaired her judgment.

Linda’s father became a critical ally in my work. He sent me frequent emails that I in turn shared with his daughter. Linda slowly allowed her concerns over privacy —really fears of losing her independence—to take a secondary position as she moved toward accepting the need for adult limit-setting. A steady flow of text messages and emails from Linda’s father made the therapy into something of a family intervention.

Note that the kind of judgment called for in this case is actually typical for virtually all therapeutic relationships. Sustaining a working relationship by “playing along,” not challenging the patient, while frequently called for in psychotherapy , is often also appropriate when engaging a resistant patient to comply with other medical treatments. It was my hope that the healthier aspects of Linda’s personality would prevail over her self-destructive impulsivity.

Linda’s father called me after Linda sent an email to her parents and to her three older sisters (who she referred to as “my family of intellectuals”) describing the appeal of suicide . She couched this as concern about her drug-addicted boyfriend and his statements about suicide as an attractive escape from his own nightmarish situation. During this time of extreme crisis, Linda began to arrive at sessions late in an irritable and grandiose state of mind. She was sleeping little as she “couch surfed” with various friends from night to night. She rejected all prescribed medications in favor of “natural” remedies. In my opinion, natural supplements like omega-3 fatty acids might have been useful in stabilizing her mood had it not been for the destabilizing effects of her habitual use of another preferred natural “remedy,” mescaline.

Using whatever therapeutic alliance I could muster, I insisted that Linda meet with her parents and me in a series of family sessions . This effort was critical for channeling her parents’ evident panic into a practical plan of action focused on finding a recovery program that Linda would accept. It became increasingly clear that treatment in a dual diagnosis program was essential. Yet, we had little leverage beyond saying that we loved her, were worried about her, and saw her escalating drug use as putting her on a road to an early death.

While Linda rejected all substance abuse treatment programs, therapeutic progress was evident in a series of seminal emails she sent to me summarizing her life history and her attempts to find a sense of belonging within her adoptive family. She “couldn’t compete with” her older siblings whose accomplishments had eclipsed her own. She became convinced that her “defective genes” inherited from her biological parents were the unseen cause of her problem. She felt damaged and not worth loving. As a deflection from herself, much of her effort was directed at persuading her boyfriend’s estranged parents to do a better job of caring for him. She claimed that she couldn’t ask for anything for herself from her own parents.

Five months into treatment , unable to rescue her boyfriend from his heroin use, she descended into even more extreme IV drug use. At this point, she could not even remember what drugs she had tried from day to day. Any substance suggested to her was the next thing to shoot up with including methamphetamine and DMT (N, N-dimethyltryptamine). She was increasingly exhausted and exhausted those around her. She descended into an episode of depression which, paradoxically, made her more compliant with treatment.

Throughout all of this chaos, Linda maintained a discernable therapeutic alliance with me. She came to sessions late, but if she missed a session she was willing to reschedule. As much as possible, I confronted the contradictions between her intent and her behavior. This approach was tentatively successful and she agreed to an assessment at a dual diagnosis program in Tucson. She was finally willing to give treatment the try we had hoped for. However, en route to Tucson with her parents, she apparently had a psychotic episode, fled at a gas stop, and called 911 saying that she was an adult whose parents had abused her and were now kidnapping her. On the return trip home with her parents, she was pressed to agree to fly to the Tuscon progam with an escort.

She entered the treatment program in Tucson but after little more than a week refused to continue. Withdrawing from the program, she agreed to transition to a SLE (sober living environment) near her parents’ home. While there were doubts about the program succeeding, her parents and I desperately needed help for her and perservered. The SLE proved to be anything but a place of sobriety. Drugs were freely available. She never attended a single NA meeting (which had been a condition of her contract with the SLE). She visited her boyfriend, who was now in jail on a drug trafficking charge.

After several weeks, I arranged to meet with Linda at a coffee shop close to her SLE. She looked tired and disorganized admitting that the SLE was “a joke,” but she refused to return to her Tucson treatment program . Yet she did agree to a psychological testing evaluation in order to have a more objective source of information about the nature of her problem. The psychometric assessment provided further evidence for a bipolar disorder and the need for medications to stabilize her. The psychologist and I met with Linda to interpret the results of testing and the recommendation of a dual diagnosis program where she would initiate a trial of medications.

Four months later, Linda agreed to return to her original residential treatment program . This time, after a struggle, the program psychiatrist and I persuaded her to try valproate to manage her bipolar disorder. The result was impressive. On therapeutic doses of valproate, her grandiosity and impulsivity rapidly diminished. Yet she fled from the program several times and was each time readmitted with new behavioral conditions. I worked closely with the treating psychologist to create a combination of personal support , group therapy, imposed limits, and ultimately medication (without which her mania would have undermined the treatment).

In retrospect I have only praise for the treatment program. On staff were a psychologist, a psychiatrist, and addictions counselors. Many residents were young addicts with whom Linda could identify. The staff had the necessary sophistication to understand that Linda could not be optimally treated without mood-stabilizing medication. And, most important, they had the patience to see her through numerous runaways.

Linda completed the residential program in four months, thereafter moving from the intensive program to a step down facility. She agreed to remain in the Tucson area to avoid problematic relationships with street people near her parents’ home. Four years later, on follow-up, Linda was continuing to live in Tucson where she rode her bicycle to and from work at a restaurant. She was with a new boyfriend who was not a drug user. She remained on valproate and in regular psychiatric treatment.

Author’s Reflections

Linda’s case illustrates the importance of forbearance in the face of opposition from a drug-dependent young adult , particularly when her presentation is complicated by significant comorbid bipolar disorder. A strong alliance with the parents was critical in this case as was a working collaboration with the residential treatment facility before, during, and after referral.

Cases like this one are encountered by PCPs frequently. As in other of our cases, e.g., the girl with anorexia nervosa (Chap. 13), the dedication and continuity of care appears to be central to case success. The patient in both of these cases needed to be “dissuaded” from a self-destructive course of action and “faith in” the treating physician seemed to play a significant part in achieving this. The systemic medical-psychiatric complexity presented itself in a different order in each case. For the patient with anorexia nervosa , the PCP’s trustworthiness was established through her medical expertise. In Linda’s case, medical intervention was not possible until a “therapeutic relationship” with the psychiatrist was consolidated.

Linda could not have been treated successfully without the support of her parents, psychiatrist, psychologists, and substance abuse counselors. Collaboration occurred daily throughout the course of her residential program. Frequent monitoring of her physical health was an essential aspect of her treatment. Her use of IV drugs elevated the importance of this aspect of her treatment in order to minimize dangerous physical effects of one or another of her street drugs.

Complexity Summary

  1. 1.

    Biological (including genetic)

    • Acute:

      Beyond her severe psychiatric illness, the patient did not present with acute systemic medical illness. However, within a year, her drug use became the central biologically relevant pathogenic factor in her life.

    • Chronic:

      While not chronically medically ill, the patient was at risk for systemic complications of drug abuse, e.g., HIV, HCV, cellulitis, vascular and dental complications of amphetamine use, all of which required continued surveillance and much of which she resisted.

  2. 2.

    Psychiatric/psychological

    This woman’s extreme substance abuse, bipolar disorder (eventually responsive to valproate), and ongoing erratic behavior, possibly consistent with a comorbid borderline personality disorder, were a significant source of personal and family distress. Expanding the diagnostic picture, this case illustrates well how “psychiatric multimorbidity,” in this case the combination of personality disorder, depressive or bipolar disorder, substance use disorder, the possible traumatic effect of her adoptive mother’s life threatening illness, and unresolved adoption issues can warrant reclassification of an “only psychiatric” patient to a “complex patient” case.

  3. 3.

    Social (including family and other support system)

  • Throughout high school, the patient functioned adequately using her both intellectual and social skills (“everyone loved Linda”). She came from a family of plentiful financial means and was given opportunities that could have obscured the extreme and unorthodox nature of her behavior. Nonetheless, her earlier reputation was distinguished by being unconventional and popular with peers and adults. It was not until after graduation and a trip to Asia that she distanced herself from her highly supportive family. It is tempting to attribute this departure from her previously more contained lifestyle to her progressive abuse of street drugs.

  • Additionally, as noted above, this patient was adopted, a background that could have provided the basis for a major personality distortion (identity crisis), especially during adolescence. Adoption-based crises in adolescence are often distinguished by impulsive and antisocial behavior. Further destabilizing for Linda may have been her mother’s recently diagnosed life-threatening illness.

  1. 4.

    Care delivery, including access to care

  • Coming from a well-resourced family, she had adequate access to insurance, medical care, medications, and residential care when needed.

  1. 5.

    Fundamental factors supporting or obstructing the treatment, in particular, quality and continuity of the physician–patient relationship

The challenge of establishing and maintaining a therapeutic relationship with this complex patient was the critical variable in this case. Over time, the interpersonally robust therapy relationship provided the substrate upon which the patient’s psychopathology could be effectively addressed. The possibility that her adoption and her mother’s illness could have played an etiological role in her erratic behavior adds to the challenge of doing psychotherapy with this patient.

The tenacity and skill of her treating psychiatrist/psychotherapist were repeatedly tested by the dangerous circumstances in which the patient put herself.