November, 2023. “Very Important Persons” (VIPs) come in all shapes, sizes, and stripes. On a daily basis, blazing headlines about VIPs compete for our attention. With interest and sometimes a little envy, we read about dazzling entertainers, sports superstars, business tycoons, world leaders, and many other larger-than-life achievers. But only in special circumstances are we invited to look behind the curtain, to learn about the burdens of being famous, or about setbacks, or family troubles, or guilty secrets. No matter what, all of these VIPs have one thing in common: they are persons who will at some point become Very Important Patients. And some of them will become Very Important Psychiatric Patients. Our challenge is to explore these very personal landscapes with respect and sensitivity, but to keep our medical/psychiatric perspective intact and not lose our balance when VIP winds start to blow.

In my own career, I have felt those winds quite a few times and have managed, most of the time, not to be blown off course. But the success of the treatment is by no means guaranteed. For example: one man in his mid-20s was admitted to my inpatient unit because of out-of-control substance use and disruptive, sometimes violent, behavior. His very powerful and influential family had “covered” for him repeatedly. Predictably, the family started pulling strings, insisting on special treatment. The patient’s mother intrusively demanded information about her son’s condition and the qualifications of the treatment team, although her son had explicitly denied permission for the team to communicate with the mother. The extent of the mother’s influence was illustrated by the fact that she contacted the chairman of the board of the hospital, who, in turn, requested that I and the medical director meet with the mother, at her convenience. The meeting was held in the medical director’s office, at her request, on Thanksgiving Day! We respectfully listened to her concerns but provided no information about her son’s care, per his instructions. Enraged, she stormed out of the meeting. One week later, her son signed himself out against medical advice and was lost to follow-up.

One version of the “VIP syndrome” (a term coined by Weintraub1 in 1964) is when the patient is a mental health professional being treated by colleagues employed in the same health care system or academic department. In this issue of the Journal, Constantino and Spina address a number of complicated challenges when psychiatric treatment is being provided to medical colleagues and/or their families. Issues of confidentiality almost inevitably arise, as do concerns about who’s in charge of the treatment. The authors present 3 representative examples, illustrating complexities from the VIP patient’s perspective, the treating clinician’s perspective, and the institutional perspective.