Mental illness makes people vulnerable to fraudsters, and means that healthcare workers have to try and reduce the potential damage. With variable success.
By JP Sutherland
‘Dear Dr Sutherland,’ ran the email, ‘you have been invited, because of your noted expertise and research in the field of psycho-oncology, to co-chair our forthcoming international congress in the historic city of Budapest’.
Unfortunately for them I had no experience whatever of psycho-oncology, and I had the research abilities of a distractable four-year-old. It wasn’t immediately clear how they would scam me if I replied, maybe by a generous contribution to the overheads of this likely fictitious event, but with one swift press of the delete key the possibility ceased to exist.
Doctors may get their own special brand of junk mail and phishing scams, but we also receive our fair share of attention from the everyday swindlers who have found such an accommodating home on the internet. Further down in my inbox was an urgent message from my bank (though the name was slightly misspelled) to click on a link to verify my security information. As I dispatched the bank into the same dark hole as the international congress, I couldn’t help wondering who really falls for such obviously bogus tricks. Then I closed my computer and walked over to the psychiatry ward, refocusing my thoughts on the day ahead, and clearing my mind of fraudulent emails.
“They say it’s because my teaching is so good, they’ve even heard about it in Nigeria.”
As I walked through the doors of the unit I was met by Giles, until his nurse asked him to step back and give people a little space as they came through the double doors.
“Hey Doc, we‘ve got to talk. I’ve got something really important to tell you.”
“Hi Giles. Let me check in with the staff first and then I’ll make sure to see you early this morning.”
Giles was in his mid-thirties and stood tall and unkempt at the entrance to the ward, clutching a large sheaf of papers, some of which were newspaper clippings, some correspondence, and many were his own writings. He had been hospitalized a week earlier, and was new to me at that time, though his old charts detailed a series of hospitalizations since his early twenties. He was diagnosed with a schizoaffective disorder, that Janus-faced illness that encompasses both the delusions and hallucinations of schizophrenia, together with the mood syndromes of a bipolar affective disorder. He had been a promising trainee teacher when his illness struck, but the schizophrenic side of his diagnosis had disabled him, as it so often does, and he was living off a small public pension in supported housing.
This current episode of illness appeared to be mainly bipolar in nature, and he hadn’t demonstrated any psychotic symptoms. What he had shown was an almost prototypical syndrome of mania. He hadn’t slept for days when he arrived with us, and his speech was racing faster than we could understand. He had overspent wildly on unnecessary items, many of which he had then given away to anyone he met. Once his behavior became sexually disinhibited then he was reported to the police, fortunately before he caused anyone any harm, and they brought him to hospital.
“So Giles, tell me all about it.”
It was one of those days when my caseload didn’t have any new or urgent patients, and I was happy to see him first. Our medications had slowed him a little since his admission, and I could now understand him better.
“It’s a job! They’ll pay me twenty grand, and I get to use all my old teaching skills.”
“That sounds amazing,” I said, trying to keep the skepticism out of my voice, “tell me more.”
“It’s in Nigeria, teaching English as a second language. They’ll pay the airfare and they’re ready for me to start next week. I could definitely use the money after I blew half of my savings, so I just have to give them my details and then it’s all good. They chose me because I’m such a great teacher. I can’t wait to get over there and…”
“Can I see?” I asked, needing to say something to stop his cascading speech. I had noticed him rummaging amongst his papers, and I was hoping that there would be something in there that would explain what was going on. He handed me an email printout, and through the coffee stains and inadvertent crumpling I read the job offer.
It looked official enough. The Gboko Municipal School Board was apparently offering him a job in an elementary school, with housing and airfare included. I quickly scanned the sheet for any tell-tale spelling errors that might demonstrate the fraudulence of the offer, but I couldn’t find any.
However, the final paragraph worried me, and likely gave the game away.
“Giles, they’re asking you for five hundred dollars.”
“That’s just an administration fee, it will be refunded in my first month’s pay.”
“I don’t know how to put this gently, but have you considered that this could be a scam?”
“A scam? Don’t be stupid. This is real. They say it’s because my teaching is so good, they’ve even heard about it in Nigeria.”
“I like to think that you were a good teacher, but I know you haven’t been in a classroom since your illness disabled you years ago.”
“But I’m not ill now. I feel really well.”
I was sure that he did. Feeling on top of the world is one of the characteristics of a manic episode, and one of the reasons why it can be so hard to engage someone in voluntary treatment when they are acutely ill. And his belief in his teaching skills was characteristically grandiose for someone with bipolar disorder.
“Giles, do you have the original contact from them? Was it an advertisement that you saw?”
“It was an email.” He said, and pulled it out from his sheaf of papers.
It turned out to be very generic, using his email name as a greeting, and inviting him to apply for a teaching job in Nigeria- ALL EXPENSES PAID. NO EXPERIENCE NECESSARY – proclaimed the capitalized invitation.
It was a scam.
I thought about how to best proceed. I clearly wasn’t getting anywhere with my suggestion that he might be about to lose his five hundred dollars. However, the Mental Health Act did give me control of the situation in the short term. Giles would only be allowed off the unit when we thought he was well enough. His mental state had improved sufficiently that we were beginning to think of allowing him short passes around the hospital grounds, but if he was going to head straight to a wire-money service (as he said he needed to) then he was going to have to stay on the ward longer.
This news, obviously, incensed him.
“You’re going to lose me my job! My first job in years! I thought you were supposed to be helping me.”
And with that he stormed off. I let him go, and hoped that a longer period on medication would allow him to see things more reasonably. But as I continued to check in with him daily, I kept hearing the same unhappiness at my stubborn refusal to allow him the freedom to destroy his finances.
“She’s probably just a guy hiding behind a photo of someone else.”
After spending each morning on the in-patient unit seeing Giles and my other inpatients, I moved over to my outpatient office in the afternoon to see follow-ups of people who had previously been hospitalized under my care. And within a few days I was dealing with yet another hustle.
Paul was a slightly-built forty-year-old man who had been hospitalized by me some years earlier. He suffered from a bipolar illness, but he had done well, and his prescription of lithium carbonate appeared to have kept his illness in remission for the long term. Unfortunately, his bipolar disorder wasn’t his only mental health problem. He was born with a developmental disability, and when his schooling had turned problematic he was sent for an IQ test. This revealed a mental handicap, which was relatively mild but sadly permanent. However he had an admirable, if slightly stubborn, determination to live a normal life and he had successfully moved away from his family to live alone, but with a support worker checking in on him daily. His family remained at some distance, but they continued to hold guardianship over his affairs.
When I went to collect Paul from the waiting room, I saw his mother with him. This usually meant that something was amiss, and sure enough she asked to see me.
“Let me meet with Paul first,” I answered, wanting him to feel that he was the more important person and not just the mentally ill patient that others talked about, “and then I’ll ask you to join us.”
Once we got to my office, I started the session without referring to his mother’s request.
“How are you doing?”
“Great.” He beamed. “I have a girlfriend!”
“Nice!” I had to reply, though I now guessed why his mother had come too. Paul had previously made a few romantic friends amongst other members of the day center that he attended, and his family were always unhappy about this. I was preparing myself to have another discussion with his mother about his need to be allowed to live as normal a life as possible, when he blindsided me.
“This is her,” he said, showing me his cell phone. “Julia.”
I looked at the picture and saw a beautiful model, professionally groomed and photographed, rather than the cheerful face of someone with Down’s syndrome that I might have expected.
“Tell me about Julia.”
“She’s wonderful. She lives in California, but she’s coming to visit me soon. We chat all the time.”
“How did you meet?”
“On a dating site.”
By now my worry was building steadily, and I had to ask the next questions.
“She looks fabulous in this picture. Does she always look like this when you chat?”
He frowned. “We just chat on my phone, so I don’t get to see her.”
“That’s too bad. I thought you might be using Zoom or Skype or something like that.”
“I tried, but she says she can’t afford a computer that runs them. She doesn’t have much money, so I have to send her some to help her visit me. That’s what Mum is upset about.”
I knew that she would be, and I was instinctively angry about it too. But I wasn’t sure what we should do or could do about it. As I went to invite his mother to join us, I used the walk to the waiting room as an opportunity to think.
Once the three of us were sitting together it was clear that his mother had no difficulty in telling Paul that he was being scammed, and that she wasn’t giving him any more money to help ‘Julia’. He had already sent to California the small amount of spending money that he controlled, but the guardianship arrangement meant that his rent money was never in his hands, and so he wouldn’t be homeless.
“She’s not real, Paul,” said his mother “she’s probably just a guy hiding behind a photo of someone else.”
“Don’t say that. It’s Julia. She’s my girlfriend.”
I could see that we were beginning to go round in circles, and I was wondering how to make the meeting more productive when his phone buzzed.
“It’s her,” said Paul, “I’m going to tell her that you don’t believe she’s real.” And he started typing.
Mum and I looked at each other.
“Paul, since Julia is texting you now, could I have a word with her?” I asked, and I saw his mother nod an approval.
“Why? You don’t believe she’s real.”
“Well, maybe she could convince me.”
He looked doubtful, but after typing one more line he handed over his phone. I looked at the screen. He had written ‘my docter going 2 talk 2 you.’ And the reply had come back ‘No, I only want to talk to you Paul’.
‘Hi.’ I wrote, ‘I’m Dr Sutherland. I’m Paul’s doctor.’
‘I don’t want to talk to you.’
‘Paul’s mother is concerned about this relationship. She’s here too. Maybe we would be reassured if we could talk to you by phone, or video?’
‘No. Give me back to Paul.’
‘She thinks you might be trying to scam her son, so if you’re not then it would be good to show her.’
‘I don’t want to talk to you.’
This wasn’t going well, and I wondered what I should do next. Paul reached for his phone, but his mother leant forward to stop him and whispered, “I’m going to take that.”
Prompted by her plan to take control I was able to try one more approach to ‘Julia’.
‘I don’t know if Paul has told you, but his mother is his legal guardian, and controls all his finances.’
No answer.
‘If this is love then that shouldn’t matter to you.’
Silence.
I laid the phone back on the desk. I couldn’t be sure if the scammer had abandoned us, or whether they were just regrouping and thinking what to do next. But at least the phone remained silent. Paul was unhappy, but he was used to having his autonomy limited by his parents, and he accepted the situation better than I had feared. His mother took the phone, and they left shortly afterwards.
“It makes my blood boil to see vulnerable people exploited.”
For the rest of the day, I found that Giles’s and Paul’s issues kept intruding into my thoughts, just as the unwanted emails did in my inbox, so when I got to the ward the following morning I needed to talk to someone.
“Has anyone had problems with their patients being scammed?” I asked the multidisciplinary team meeting. “I’ve got two going on at the moment.”
“It makes me so angry,” said my colleague, Gladys. “I had someone lose their entire disability cheque to a credit card fraud recently. They got evicted because they couldn’t pay their rent, and it’s been such a disaster for them.”
“What was the diagnosis?” I asked.
“Chronic schizophrenia. It wasn’t the psychosis that led them into trouble, but the negative symptoms have left them unable to see through the scam. It makes my blood boil to see vulnerable people exploited.”
“How can we manage this?” asked Thomas. “I’ve been worried about someone too, though so far they haven’t been taken in.”
“Guardianship,” said Gladys, “or at least a trusteeship over their finances. That limits the damage, but it also compounds the stigmatizing effect of the illness, when they aren’t allowed to manage their own money.”
Together we railed against the unfairness of the world, and the outrageous and uncaring nature of fraudsters and then, having solved nothing, we returned to our more immediate and recurring work of reducing suicidal risk and settling psychosis.
“Giles, I looked up Gboko and its school system.” I said at our next meeting. “The city certainly exists, but there’s no such thing as the Gboko Municipal School Board.”
“Yes, there is. They sent me that email remember, and the title is at the top my contract.”
“But Giles, if they really exist, surely they would have a presence on the internet.”
He thought about it, and his pause gave me the first inkling that he might finally be able to see through the fraud.
“Can we use that computer to check?”
“Be my guest.” I said, happily moving over so that he could use the keyboard.
He failed to find any matches for the school board, and then we searched more broadly for ‘Gboko’ and ‘schools’. By the time we finished we had learned more about the education system in Nigeria than I thought I would ever need to know, and Giles had to agree that their schools were administered at the state rather than regional level, and that his supposed school board wasn’t real.
He left in a more subdued mood, and at our next few meetings he remained pensive.
“They’ve sent me another email, extending the deadline,” he said, a week after he was supposed to have caught his flight. “But I don’t know…”
“Are they still asking for money?”
“They are. I tried telling them that I wanted the job, but wouldn’t pay the five hundred dollars.”
“Good for you. What happened then?”
“They got a bit nasty in the next email, saying that I must pay within forty-eight hours to keep the position.”
“Are you going to?”
“I can’t. You won’t let me off the ward, remember? And anyway, the deadline passed. Though now they’ve turned nice again, and have extended it.”
“It all sounds shady to me.”
“You might be right. I just wish I could be sure.”
As the days went by Giles gradually withdrew himself from the approaching calamity, assisted by the incremental effect of medication chipping away at his manic episode. He promised me that he wouldn’t visit the wire-transfer office, and I eventually took the risk of allowing him off the unit. His illness gradually resolved, and before long he went home, with his remaining five hundred dollars still intact.
After that I was happy to see no further scams amongst my patients for a long while. However, every time that an email told me that my credit card had been compromised and I needed to click the highlighted link, I found myself thinking of Giles and Paul. I continued to share Gladys’s outrage at how fraudsters prey on the most vulnerable, and I no longer dismissed the victims of scams as unthinking fools. But I was pleased at the apparent success of my interventions with the two men, and at times I found myself daydreaming paternalistically about how I had saved them so much trouble.
I was still feeling good about myself when I next saw them both in follow-up after a few weeks, attending on successive days. Paul came first.
“I’m sorry to have silenced Julia.” I said, after he told me she was gone.
“It’s OK.” He replied. “My parents do that with my girlfriends. I’m used to it.”
“Yes, but all your previous girlfriends have been real people that you’ve met. And I’m sorry that your parents don’t want you to have them.”
“Julia was real too, but because she lived in California, I never met her.”
“Did you hear from her again?”
“Just once. She asked for the money to get here for a visit, but I couldn’t send any more.”
I realized that although I might have helped prevent a bad outcome, Paul was no wiser about scams than before, and that any idea I had of him being insightful was naively off target.
The next day I saw Giles.
“How are you doing?” I asked.
“Better. I kind of enjoyed the buzz of being manic for a while, but I can see that it was too much, so it’s good to be back to normal again.”
“I’m glad to hear it. Let’s plan to keep things that way.”
“Sure. Mind you it was too bad about the Nigeria job.”
“Too bad? But I thought we agreed it was a scam.”
“Maybe. I know you showed me lots of reasons why it might be, but you never proved it. And I kind of like the feeling that they’ve heard about my teaching skills in Africa.”
All names and other identifying details have been changed to protect patient confidentiality.
JP Sutherland 