Give your psychiatric patients a reason to trust

By | December 29, 2019

I had been diagnosed three days prior, given lithium to stabilize and a benzodiazepine to sleep. I went home. Things did not get better.

I had been admitted just that morning after a long, confusing night in the ED. I did not yet understand the severity of what had happened — or even what had happened. The mania was still mostly euphoric and speckled with bursts of joy, but between these bursts were moments of sharp panic and of swelling terror. Though I smiled and bounced as I worked on a puzzle during the morning hour in the group therapy room, the paranoia was already seething inside. I was too elated to ask my own questions, but I was sufficiently shaken to wonder if it was wise to answer the questions of those around me. I had dipped into psychosis enough to realize that the more I spoke, the worse things got.

I wasn’t even twenty-four hours into the stay, and already I was wary to trust. And this was while my insight was, as the records declare, “limited.”

The second-year resident came to get me from the group room for rounds. We stepped into the hallway, and I clapped and jumped and squealed when I saw the large floor-to-ceiling windows, for it was raining outside.

“I love the rain!” I pronounced, thoroughly jubilant.

The resident was mildly amused. “Oh?”

The corners of my mouth grew sore with wonder as I continued: “It’s so cold and so beautiful and so gray — the sunlight is normal, right, the default is sunlight, we get sunlight every day, and it’s so normal, so usual, so uneventful — but the rain, the rain is loud and messy and wonderful! It’s music, and it’s chaos, and it’s an adventure, to go outside in the rain, and it’s hated by most people — most people, they despise the rain, they don’t like the rain — but that only makes me love it more, oh my, how I love it! Do you know zephyranthes bloom after rain? They’re lilies, a type of lily — rain lilies! Oh, I can’t believe it’s raining! It’s amazing!” and on and on, I let it spill out of me, all the fervor and intensity and fascination.

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Of course, my speech was pressured and fast, and I didn’t notice it, but the resident did. And of course, he smiled politely at me the entire way down the hall as I gave my impassioned speech. Yet when we reached the door of the meeting room and stepped inside, I was reminded of where I was. Of what had happened in the past couple of days. Of who I had been talking to.

I sat down, and three strangers stared at me. Three strangers with ID badges that could open the doors I was trapped behind. Three strangers who had the power to take away my few remaining rights, if they so wished, who could determine my capacity and order medications against my objection and have me restrained if, for some reason, it came to any of that.

I sat down, my love for the rain evaporated, and the paranoia set in. It always did during rounds — the fear caught my tongue, manic or otherwise. There’s nothing quite like a lack of insight to make you question the motives of anyone around you — anyone in touch with reality enough to believe that you were not fine when, in fact, you knew in your heart of hearts that you had never been better.

Thus, I was quickly petrified by the situation. The resident, however, was eager to show the attending and the intern my symptomatology. “Tell them what you were telling me in the hall,” he said, still smiling.

And immediately I knew that, no matter what I said next, it absolutely positively could not be what I had said in the hall.

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My chest was tight, and my hands were shaking, and I could not make eye contact. And to make it even worse, I was acutely aware of the fact that they were aware that I could not make eye contact.

“I, uh, I love the rain,” I managed, my voice newly weak and raspy, my eyes drinking in the placid furniture and the pale floor. “A lot.”

I wanted to tell them just how much I loved it, I ached to tell them, I was horribly tempted to leap up and dance around and scream it to the sky — or, rather, that dull gray ceiling — but I could not. This was not a safe place. These were not people I could trust.

Because I didn’t even know what was happening — why I was here, who they were, what we were supposed to be talking about. All I knew was what I’d discovered in the ED: If someone seems interested in what you’re saying, you should probably find a way to shut up.

By the look on the resident’s face, he was displeased, to say the least; he was disappointed. I’d thrown him under the bus. My impassioned speech was over. My love for the rain — my classic, textbook-description manic manifestation — was temporarily subdued. I could see it in his face.

The attending would ask him about it later.

The intern would miss a nice little learning opportunity.

The patient would be more difficult than he’d initially thought.

It’s strange, how no one tries to explain anything to you while you’re manic. I’m now a medical student in pre-clerkship, and already we’ve learned to avoid the word “futile.”

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But I suppose it is futile to try to explain some things to a manic patient. Because they don’t know what’s going on, right? They’re not going to be compliant, right? They won’t be willing to listen, right? They won’t be able to understand?

But we can understand more than we’re given credit for. And if there’s one thing your psychiatric patients need that you can’t find on a medication list, that doesn’t require money or better community resources, and that will make both of your experiences much less turbulent, it’s a reason to trust.

You leave the white coats at home and dispense with the stethoscopes, but we still know you’re the physician. And that ID, you see, doesn’t earn you status and prestige with psychiatric patients. That ID earns you suspicion.

The author is an anonymous medical student.

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