Psychiatry

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

10 thoughts on “Trapped In A Role

  1. You remind me of my psychiatrist who takes a similar approach. He’s the psychiatrist the ward nurses call when they face agitated patients. 🙂

  2. Absolutely true. Things are often not what they seem on the surface and it speaks volumes about an ill profession. I had similar experiences at the state hospital. The patients were toyed with and provoked by the staff so they could do a take down.

  3. When I was in high school, I was very impressed by reading Henry David Thoreau, who wrote “If a man does not keep pace with his companions, perhaps it is because he hears a different drummer. Let him step to the music he hears, no matter how measured or far away.” The theme of being “fenced in” (even barbed wire–nice touch! 🙂 ) by the standard procedures of psychiatry appears again and again in your blog. Here, you’ve given it a compelling story form. As a fellow dissenter, I say keep listening for your own music.

    As you might guess, I’m a little concerned about the idea that you let this patient down (abandoned, even if you couch this in terms of his perception–is that really your inner feeling projected on to the patient? Just asking, as usual). Ahem, you did your best, went beyond the call of duty, and even put yourself in a position of personal risk. And all this as a novice. Pretty damn impressive to me.

    • Love the reference to Thoreau! Yes, it does seem to be a recurring theme…i feel most inspired to write out of frustration w/ the system. makes for a lot of material!
      my sister (who’s a therapist) actually mentioned her thoughts about me having guilt (re: letting the patient down) as i was proofreading to her…i definitely did project some of those feelings. I feel responsible for lots of things and am trying to let that go. You picked up on my self-deprecation yet again!

      • let me just speculate a bit, which is something lawyers aren’t supposed to do, but I’m in artist mode on my blog so…
        dissent is a form of anger. it can be a healthy outlet for anger or destructive depending upon various things. my opinion is that your dissent from the insensitive side of your profession is very healthy.
        self-deprecation is a form of anger, that is, anger turned inward. this is a very unhealthy directing of anger. it leads to depression. it seems quite possible to me (a layperson, not an expert) that your healthy expression of dissent can be an alternative to self-deprecation.
        I’ve found it to be so in my own life.
        take care, vania.

  4. Loved this, seriously. You’re an inspiration to those of us who want to make changes in mental healthcare. I cringe whenever I have to bear witness to minute-long checks consisting of the usual suspects (did you take your medication? Areyou hearing or seeing things?) People deserve so much more. I hope I never fall into that bad habit, it’s something I always have in mind. My attendings/residents might say I’m too quiet or I don’t have a great knowledge base, but they can never say (and they’ve never said) that I don’t spend enough time with my patients. I think that trumps answering all the pimp questions in less than 2 seconds. And like the previous commenter said, keep listening to your own music. I hope I can follow in your footsteps one day 😉

    • it’s amazing how a few more minutes during patient interviews can go a long way. as a resident, i challenged myself to get the most “difficult” patients to open up (i hate labels) and learned way more than what i did during rounds by speaking to patients on my own time during inpatient rotations. Your compassion and empathy towards patients will go a long way in the field and you WILL be recognized. Keep doing what you do…I know your patients must really appreciate the time spent w/ them.

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