psychobabble

pontificatrix

pontificatrix
Bio
I am a resident in psychiatry at an academic medical center. My blog posts describe patient encounters I have had in the course of my training, both past and present. Names and identifying details have been changed. My blog conforms to the information-privacy standards detailed on http://medbloggercode.com. If you believe you have been a patient of mine and have concerns about the effects of this blog on the privacy of your medical record, please let me know and I will be happy to withdraw any offending material.

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AUGUST 29, 2008 12:23PM

demon rum

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This vignette is from an outpatient neurology month I did last year, mostly a pretty calm scene compared to the inpatient psychiatric wards - until Ms Q arrived on the scene.  Forty-five minutes late for her appointment, she stumbled in on the arm of the fellow, mascara streaking down her cheeks.  "She's intoxicated," the fellow murmured gently in his refined hint-of-British, hint-of-Indian accent as he steered her to a chair.  

"I hate it, I hate it," she sobbed incoherently.  An overpowering odor of alcohol wafted about her.  She had been swigging from a bottle in the car all the way from home, over an hour away.  I shuddered at the thought of the unsuspecting commuters who'd shared her road.

I was assigned to calm her down; my few months' worth of psychiatric education had won me this one.  I murmured soothingly, knowing there was little useful diagnostic information to be obtained from her right now.  She was a blonde beach girl, far from home; and it showed in her long yellow hair, bright pink lids and lips, pink toenails in metal-ringed sandals.  
"I hate you," she raged.  "I know you're trying to be empathetic, but you don't understand.  Look at you - you're young, you're pretty, you have cute shoes..." She dissolved into a bathtub of drunken tears.  Cute shoes... emblematic of the good life.  I sighed and patted her on the back.  She was in need of some perspective at the least. 

But she was right, of course.  I don't know what it's like to be an alcoholic.  I have worked in recovery programs, and noticed that the addiction specialists with drug histories often seemed more effective than those without.  Regardless of training and other forms of institutionalized expertise, in the addict's own head it is important that his therapist "understand where he's coming from."  All that training is for naught if you can't even get the addict to listen to you.  For people with their own drug histories, that door is already wide open.
Even a hint of personal experience is worth more to patients than a barrel of education.  I haven't myself been substance-addicted or psychotic; but I've got examples of each among my family and those close to me.  I tend to play those cards pretty close to the chest because I'm not sure myself how it's relevant or useful for my patients to know that.  But in the very few cases when I've mentioned the fact, the response from patients has been overwhelmingly positive.
 
I've also had patients ask if I've tried the medication I'm recommending for them; and somehow I always cringe a bit internally when I must admit I haven't.  (I did sample one commonly used antipsychotic just for purposes of personal education; but I've never been prescribed a psychotropic med and I certainly am not planning to sample the whole arsenal.)  But why is there any part of me that feels as if I should have? 

One wouldn't expect one's cardiologist to have his own history of heart attacks; nor ask one's internist if he's tried the antibiotic or diuretic he suggests.  Yet psychiatry is somehow different, removed from the clearly delineated ethics and protocols that apply in other areas of medicine.  

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Years ago I was a volunteered at a drug counseling center. Most of the clients knew I had a "history", many could just sorta smell it. I never brought it up, but would willingly cop to it if asked.

On several occasions I made unannounced house visits (part of the client's contract with the center), and found the client to be obviously using. Altho' my position required me to report this, I never did. This led to a far greater acceptance of me than of most other volunteers, and even paid staff. Clients would confide their secrets or problems with me quite readily, and even started calling me at home or even just dropping in whenever they need help or reassurance. I never resented these contacts. After all, I had volunteered because I wanted to help, because I has some ecperience of what they were going thru.

You'd be suprised how many were astounded to hear that there are a lot more ex-junkies than there are users.
I suppose I can understand why your patients might want to know that you have some experience with the medication or addiction. It's sort of comforting to know that someone who is caring for you can understand your situation from the inside. Still, you're right, we don't ask medical doctors to be victims of our physical ailments. I suppose that there's still the notion that mental illness isn't physical, that's it's some kind of deficit in the soul or something. It can often feel that way to some people. Maybe it just means there needs to be more care in educating them about the parts of their illness they can't control and they aren't responsible for.
Great post! I do think that sometimes the meds are simply necessary, (no testing required) a conclusion I came to through conversations with my sister........

My sis is now retired, but she was once the nursing director of a MA state psych hospital. Before that she managed various wards, among them the ward where residents of Cambridge , MA underwent treatment. Needless to say, she had some very interesting and intellectual patients, some were students from MIT or even Harvard. Among them was a gentleman who, convinced he was Jesus, kept calling the Vatican as well as the White House to tell them how he disapproved of their actions. Somehow he figured out how to get through the security gauntlet and talk to some people in fairly high places that were not amused.

HOWEVER - probably the most problematic patient of hers was a woman who had been the defendant in a landmark court case that determined that patients did NOT have to take their lithium - or whatever antipsychotic drug they were prescribed while under inpatient medical treatment.

Hearing voices after having NOT taken her meds, she rather quickly ended up back in the Cambridge ward. At each scheduled hour as the other patients lined up, she stood in the front of the line - telling each patient in turn that they had the legal right to refuse their meds.

Good thing my sis has the patience of a saint.
Very interesting! And I absolutely must congratulate you on one of the finest names I've seen on OS - "pontificatrix" is a lovely coinage.
Just today, there was an article posted in the Austin-American Statesman concerning Judge Jean Meurer ordering a brief jail stay for six professionals who were asking the judge to incarcerate a 14 year old girl who had punched her mother (after her mother had kicked the family dog). After their brief lockup, the six unamimously agreed the girl should remain at home. Here is the link:
http://www.statesman.com/news/content/news/stories/local/08/30/0830meurer.html

Certainly, you cannot experience all of the meds you prescribe, but it serves you and your patients if you are able to put yourself in their place (i.e., empathize with them).

Yes, psychiatry is very different from other medical disciplines. The causation involved in arterial blockages and the use of blood thinners as therapy is something a child can understand. The causes and treatments of behavioral problems is quite a bit more complex, and the side effects of any particular treatment are often little understood and thus have to be taken very seriously by the professional who prescribes mind-altering meds. Certainly, you cannot become an addict to gain the confidence of addicts, or even sample the medications you prescribe. But read up as much as possible, and not just the drug studies or industry literature. The anecdotal experiences of patients who have taken particular meds should be something you solicit and evaluate carefully