Having a baby on the way has opened up new conversation trees with my patients. These conversations require vulnerability on my part, relating personal details to my psych patients in a way that would cause some older psychiatrists to shake their head. These conversations also have great rewards, allowing me to ground the clinical discussions in the emotionally rich fabric of parenthood.
The first patient is a few years younger than myself. Admitted for suicidal ideation and bizarre behavior in the setting of a deep depressive episode lasting for the past few weeks and severe anger management issues. He has a deep history of trauma, with his father hanging himself at the foot of this patient’s bed when he was only seven years old and physical abuse from his mother and stepfather until he was eighteen. He lost unborn twins to a car accident several years ago. His girlfriend is now pregnant, about five months along, and they are both homeless trying to find a place to live together.
With me, he is kind, thoughtful and teary. He tells me about how he almost beat his brother’s skull in with a hammer because the brother had the audacity to change the TV channel while he was watching cartoons as a teenager. Later that day, he heard his stepfather call his mother a bitch. The next thing he remembers is being pulled off his stepfather by his mother, after beating him with his fists into a three-day coma. He feels like the anger comes from a different person.
We talked about his past trauma. His current situation. His future anger. I saw in him a young man that has used specific skills to survive, but these skills will not help him as a father. I told him as much and he agreed.
I provided him with some breathing exercises and progressive muscle relaxation techniques. Nothing too fancy, just mindful diaphragmatic breathing handouts and a how-to sheet. I told him to practice these exercises when he isn’t stressed or feeling the anger rise, so that he can use them when he needs them. After all, when we are drowning we need a lifeguard, not swim lessons, but if we have the swim lessons in a pool then maybe we don’t need the lifeguard in the open ocean.
The next day, he told me how much he liked the exercises. His girlfriend had visited the previous night, and she brought ultrasound photographs of his unborn child. I asked if it was the 24wk visit, he wasn’t sure. I asked if they found out the sexual anatomy of the child and if he got a profile shot of the baby’s face. He smiled and nodded a yes. He was having a boy, like me.
A dumb grin washed over my face and we talked about the excitement of becoming fathers before I bopped away for morning rounds. He had been assigned to a different treatment team that week, which meant that I had no clinical reason to speak with him or check in with him in the mornings. I told him as much, but also admitted that I would continue to do so because I wanted to see how he was doing. He liked the sound of that and headed off to a group session.
I saw him briefly before discharge. He thanked me for the techniques, telling me that he will use them on the outside. He called me a good man. I wanted to hug him, but surrounded by other patients and providers, I knew I would be looked down upon for that physical contact.
I wish that I had ignored this self-policing and just embraced him, from one expecting father to another.
The second patient is a bit older than I am. She was admitted while practically mute with visible signs of severe anxiety such as flushing and darting eyes. She had a few episodes of this over the past three years, according to her mother, and each time was a bit worse. She could no longer care for her eight month old son and she didn’t have a stable living situation with her male partner.
I remember interviewing her when she arrived on the floor.
I walked with her into a small room and asked her how she was doing. She opened her mouth, as if to speak, and stopped. She looked at me, with a bit of worry in her eyes. Almost like she had literally choked on her words and wasn’t able to breath. I gave her a few seconds.
I switched to yes/no questions and she was able to let out a barely audible “… yes…” in response to my questions. Her skin flushed and her pupils remained remarkably dilated. I ended the interview quickly, feeling that I wouldn’t get much history out of her and that I was only causing her more stress with my questions.
We began her on anti-psychotics for a presumptive diagnosis of schizophrenia and over the following week, she began to speak more. Each day, the interviews would become more and more fruitful. Each day, more and more of her personality began to shine through.
On a whim and on the advice of my attending, I searched for this patient on the internet. I found her LinkedIn page, which noted her history as a Bernie Sanders campaigner, a teacher, and a community organizer. I found a fundraising website for her and her partner when they needed help as water protectors going from one protest site to another. All painting a picture of someone that I could’ve easily been friends with, of someone that will be a great mother.
She loves to read. She alternated between reading Les Miserables and a book on the Golden Ratio. We talked meaningfully about the state of the environment and the future of urban planning with autonomous cars. We both mourned that the inpatient psychiatry floor was not a more therapeutic environment, that there weren’t more plants or natural light.
And during this whole period, she would sign 72hr notices to leave the inpatient floor. This requires that we either discharge the patient at the 72hr mark or we obtain assessments from two psychiatrists to hold the patient against their will to receive necessary treatment for their own safety. It seemed to us that she would sign these notices after visits from her partner, who wanted her out. After some conversations with the treatment team, she would rescind the notice. This pattern continued for about three notices.
She asked me what I thought, if I felt that she should sign another 72hr notice. I told her honestly: she was improving. She might actually get discharged before the 72hr mark regardless of the signed notice. It might, however, complicate matters if her disposition is unclear since she does not have a stable living situation or if her clinical picture deteriorates. I told her that we want her to be a functioning member of society at the least.
We want her to be well enough to care for her eight month old.
When I brought the focus back to her child, she seemed to relax and understand. Yes, getting out would be nice. But she needs to have the mental reserve to manage a squalling infant. To be present with him.
I noticed in my encounters with her and other providers, I seemed to be the only one that remembered she had a baby boy waiting for her on the outside. The rest of the team seemed fixated on her partner, whose own mother called him a bad influence on the patient, or her 72hr notices. To me, her child was the reason she signed the notices, but he also served as a reason to remain in the hospital and receive the care she needed.
From my knowledge, she is still on the floor. I hope that when I return on Monday, she is gone. If she is still there, I look forward to our conversations and her expedient discharge. She does have a child to care for, after all.
The transference I felt with these patients allowed me to identify with them and to help ground their hospitalizations in a very immediate reality. A preceptor recently told my partner to reflect and pinpoint the exact reasons why particular patients resonate and affect us deeply.
I think this is important because in my year of clinical clerkships, only a handful of patients still remain with me. Speculating on the reasons why allows me to sit with these emotions and to be mindful when they no longer serve me and the patient. It is one thing when transference strengthens the therapeutic bond, but I will not allow these feeling to interfere with their care.
Or at least, I say that now.
Long Form Sundays
- On a good week (or the beginning of Inpatient Psych)
- On the second trimester (or baby chronicles: Part Two)
- On the other side again (or 6 days since Step Two)