Trapped In A Role

I met some of my most memorable patients while moonlighting on an inpatient psychiatric ward during my final year of residency.  One of the patients I was assigned to was labeled as the highest-risk for agitation (he was restrained and placed in seclusion two nights prior), so the staff warned me, remained on standby, and closely monitored the cameras as I approached the patient to conduct my first interview.  Instead of standing during the meeting, I sat in a chair to take a more submissive stance.  After all, I am the doctor and patients with chronic mental illness and histories of multiple involuntary hospitalizations understandably perceive psychiatrists as possessing the power and ability to determine their length of stay and which medications they must take.  Sitting in a chair below his eye level demonstrated my attempt to even out the perceived sense of power and control.

He remained standing and proceeded to yell at me: “You’re the psychiatrist?!  You don’t look like a typical psychiatrist!  Are you going to ask me if I’m suicidal ‘cus I’m not.  Are you afraid I’ll hit you?  I don’t want to talk to you!”

I wanted to bolt out of the chair immediately, but instead remained calm and allowed him to scream his frustrations, for he was likely projecting onto me a build up of anger based on past experiences with psychiatrists.  I assumed psychiatrists kept interviews brief and never asked in-depth questions beyond those pertaining to his psychotic symptoms.  As a medical student, I observed meetings that lasted as quickly as one minute, which usually consisted of the standard questions:  Are you hearing voices?  Are you suicidal?  Do you want to harm others?  Did you take your meds?

Once he finished yelling, I told him that I read his chart, but emphasized that I wanted to hear his side of the story.  After a few minutes of allowing him to talk without interruption, he eventually sat in the chair across from me.  He paused a few times with suspicion, but when he saw that I remained engaged with the conversation, we later moved on to discuss topics such as his hobbies and interest in art.  When I asked about medications, he told me that his antipsychotic made him tired during the day, which tends to make him angry.  He tries to fight the sedation side effect in order to stay awake, so he often refused to take it (patients get marked as “noncompliant” when they refuse their meds).  I asked if he’d be willing to take the med if switched to nighttime dosing in order to help with sleep.  He agreed.  I slowly got up from my chair and thanked him for allowing me to speak with him.  As I extended my hand out to shake his hand, I caught a look of shock on his face (perhaps doctors never shook his hand?), then he informed me that he doesn’t like shaking people’s hands.  I told him, “no problem, I understand” and we both left the room.

When I returned the following day, the report from nursing staff was that my patient willingly took his medications and there were no reported issues with agitation.  One staff member even said they were able to have a short and pleasant conversation with him for the first time.  I was pleased, though I also felt bad because I was his psychiatrist temporarily for the weekend only.  Later that day, I told him that another psychiatrist will be seeing him tomorrow.  He proceeded to scream obscenities at me, but this time I ran into the medical room and slammed the door shut.  I was scared, but not upset with him the slightest bit.  My intuition told me that in that moment, I became just like all the other psychiatrists who proceeded me, who made headway only to leave him in an even more vulnerable state.  When the nurses asked whether or not they should give him a PRN (a medication given “as needed,” in this case for agitation), I quickly said “no.”  He allowed himself to open up to me and in a sense, I abandoned him.  Based on his history, he has experienced abandonment from several others throughout his life.

I can’t automatically change a patient’s pre-existing, negative perceptions of psychiatrists, but he changed my perspective of patients labeled as “agitated.”

Total Time for my first one-on-one session with him = 13 minutes + a sense of feeling heard + a developing therapeutic alliance.

Total Time to call security, obtain back-up staff to restrain the patient, and monitor the patient while placed in seclusion = several hours + long-lasting, negative, traumatic experiences that the patient will forever associate with psychiatrists and the psychiatric ward.

Photo by Marlon Santos