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Ask the Mental Health Expert Archives 2001-2004

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Conning Schizophrenic?

Q. I am caring for a schizophrenic man, he has been homeless for about 20 years and not medicated. He hallucinates much of the time (he denies it but it is quite obvious), and if he thinks he is alone and will not be detected, talks quite extensively. He often misinterprets people's actions and statements, thinking they are threatening when they are not.

While he usually stays out of trouble, recently while living in a group home, he was arrested for indecent exposure. His description of the incident is totally different from the police report. The other day he told his case worker he could not pay me his rent as I was in my room, asleep. At the time I was awake and accessible. I realize this appears to be lying.

My question is this - is it possible to tell when he's conning us and when he is actually delusional? If he realizes he was lying, I can understand giving him some consequences (depriving of some special privilege). But if he is delusional, why should I punish him? How can I tell the difference between manipulative behavior/lying, and his delusions?

A. I don't mean to sound elitist, but without knowing your professional credentials, it's hard for me to answer your question. The simple fact is, even highly-trained mental health professionals often have a hard time telling the difference between manipulative behavior/lying, on the one hand, and delusions on the other. However, since you seem convinced that this individual truly does experience hallucinations and also misinterprets people's actions and statements, it is very likely that he suffers from delusions of some sort at some time.

This, of course, does not mean that he is always leveling with you. Some individuals with chronic schizophrenia do learn to use their illness to their advantage, sometimes attributing intentional lapses in behavior to "the voices", "the Devil", etc. Rather than focusing on your psychiatric assessment skills, I would strongly recommend you find a way to work with this individual's case worker, so that your requirements as a landlord/director are met.

This is not a question of punishing the individual who suffers with a mental illness. It is a matter of setting up reasonable expectations, and holding the person accountable for meeting them. Thus, you might say to this tenant, "I expect you to have the rent to me by the 15th of the month, without fail. If you don't, for whatever reason, you will lose a privilege." The only exception might be a situation in which this man was hospitalized, or unable to function rationally as per either his case worker or a psychiatrist. That takes the assessment job out of your hands, which is as it should be.

Keep in mind that psychosis is an explanation for certain behaviors, not an excuse. Just because a patient hears voices or believes the FBI is out to get them does not automatically render him incapable of paying a bill on time! There are many thoroughly reliable and responsible individuals who suffer from schizophrenia, hear voices, have delusions, etc., who nevertheless manage to show up on time for their appointments, pay their bills, and behave appropriately. It's not unreasonable to hold these individuals to their obligations, delusions or no delusions, unless you have a mental health professional's assessment to the contrary. This stance stems from the common-sense and legal position that adults are presumed competent until proved otherwise-and competency is ultimately the determination of a judge, after consultation with a mental health professional.

Of course, if your tenant requires a guardian to handle his financial affairs, that's a different matter. A guardian could see to it that you receive your rent each month, by withholding a percentage of this tenant's funds. Again, this is something you may need to discuss with his case worker. Finally, any way this individual might be induced to take medication would be well worth pursuing. The recent arrest might be reason, in some states, for a judge to insist on involuntary antipsychotic medication on an outpatient basis. For more advice on how to deal with this troubled (and sometimes, troubling) individual, I would also recommend speaking with someone at the National Alliance for the Mentally Ill (NAMI). Their hot-line number is 800-950-NAMI, and they should be able to provide you with a local number.

April 2001

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