The screech of my pager jolted me from sleep. A soft-voiced nurse informed me that they were having some trouble with one of the patients and his behavior was very disruptive to the others, so could I come by and see him, please?
I asked for some further details. Apparently he was kneeling on the bathroom floor screaming that Satan was trying to remove his soul through a portal in the back of his head.
Yikes. I quickly pulled up the patient's record for a look. He was a young man in his early twenties with a diagnosis of schizophrenia. History of delusions about the devil. Apparently he had presented voluntarily for help with a chief complaint of "getting schizo again." That sounded like an unusual degree of insight for a severely psychotic patient.
I jogged over to the next building and let myself into the locked unit, jiggling my keys about in apprehension. The unit was quiet. I peered into the empty bathroom on my way to the nursing station.
The nurses greeted me with visible relief. "He's in his room, doctor." I walked down the darkened hall toward a square of fluorescent light spilling across the linoleum. I nodded politely to the patient's silent knife-lipped sitter, and knocked gingerly at the door.
He lay flat on his back in the spare, brightly lit room, arms at his sides. Only his wide, terrified eyes moved to follow me about the room. Pale and trembling in his coat of puppy fat, he looked like a round-cheeked child caught in a nightmare. I asked him what was wrong.
He glanced at me sidelong. "Nausea."
Nausea? "Is that all?" He nodded. "Is it all better now?" Another nod. "Are you sure? Because the nurses told me you were having a lot of trouble a few minutes ago." A third fearful, stiff-necked nod. I paused. "Are you afraid that talking about it is going to make it come back?" A vigorous nod. "Okay," I said. "If you don't want to talk about it, I don't want to make you talk about it. But I might have a better chance of helping you if you could tell me what the problem is."
I'd barely finished my sentence when he burst out, "Satan is talking to me!"
Ah-hah.
"What's he saying?"
The patient shook his head, refusing. Sweat beaded his unlined brow. He looked awful. I took his hand. "Can you tell me what's real?" I asked. He looked at me. "I'm real," I told him. "You're real. The hospital is real. My hand is real." I squeezed his damp chubby hand, and he squeezed back, staring at me, and nodded. "Is Satan real?"
"I can hear him talking right now!"
"Tell him to shut up."
"Shut up!" he screamed vehemently at the empty air to the left of his head, startling the others in the room.
"Good," I coached. "Listen to me. Satan is not real. I know this is frightening. But try to keep reminding yourself that it isn't real. Are you okay?"
He nodded. "Are you okay?"
I was confused. "I'm fine. I want to make sure that you're okay."
"You're all right?" he repeated.
"I'm fine," I reassured him, still unclear about the reason for his concern.
He beamed, for the first time, with relief. "So I can't hurt you with my thoughts?"
I understood. "No, you can't hurt me with your thoughts. That's not real, okay?"
He nodded again. "Sometimes I get confused."
"I know. It's okay. If you get confused you can ask the nurses for help, or you can ask for me to come back. Do you want some medication?"
He nodded again. He was already pushing the limits on antipsychotic dosing for the day but the meds didn't seem to be touching him. "You've already had a lot today," I told him. I'm going to give you something to help you sleep, and just a tiny bit more of something else for the voices. But no more today after that, okay?" He was agreeable. "Is there anything else we can do to make you feel safer?"
"Can someone stay with me?"
"Sure." I gestured toward the implacable sitter at the door. "It's Rose's job to stay here and watch you, and she can help you as well if you get scared again."
"No," he cried, suddenly frightened again. "She's with Satan!"
I looked doubtfully at the sitter, who stared back in frizzy-headed indifference. "No she's not," I reassured the patient. "That's not real, okay? She's here to help you just like everyone else."
"Oh, I'm sorry," he said, addressing himself to the sitter. "I get confused sometimes. I didn't mean to be insulting." She nodded silently.
"It's okay," I offered for her. "Everyone here understands. I'm going to go write for the medication we talked about. Do you need anything else before I go?" He shook his head. "Okay. Just remember to ask for help if things get bad again."
“Thanks,” he said, and I stepped out.
This was definitely not toeing the party line on handling delusions. You’re not supposed to challenge the delusion, or even usually imply that you don’t think it’s real – at least not outside of a structured therapy program. (Cognitive behavioral therapy has been found effective in reducing delusions, but that requires a long-term commitment to treatment and a strong therapist-patient relationship.) Normally what you’re supposed to do in an acute situation like this where you don’t know the patient is simply be supportive and offer medication.
On the other hand, this patient had excellent insight. He knew he was ill, and he found his hallucinations and delusions terribly frightening. My instinct was to offer him assurance that his nightmares weren’t real.
For good or ill, this is the way most working psychiatrists function. They are guided, for the most part, not by the studies and statistics of so-called “evidence-based medicine,” but by their own individual combinations of instinct and experience.
This is true even in the realm of psychopharmacology, which is perfectly amenable to randomized controlled trials; but it is especially and unavoidably true for the doctor-patient interaction. This interaction is important in all fields, but in psychiatry it is an explicit and essential part of the therapy. And it is incredibly difficult to quantify.
Two therapists may use the same method but achieve radically different results. The most important factor in the success of the therapy is the individual therapist – not his degree, not his school of thought, but just his individual character. It’s a bit sobering to think that one’s ability to do this job well is so dependent on innate talent. Why all this education if the job isn’t one that can be learned or taught?
I hope my intervention with the patient in this story was helpful for him. In the long run, one short interaction with an on-call resident isn’t likely to have much of an effect either way. But it’s more than a little unsettling to realize I’ve undertaken such a journey with no compass or road map.
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Comments
"the sitter, who stared back in frizzy-headed indifference. "
If the "sitter" and other like her have gotten to the point that they demonstrate their indifference, it is time for them to go.
I feel this attitude is detrimental to gaining any possible trust of the patient.
A patient such as the opne in your article are obvioulsy cognizant of most of what is in the ambience and, more than likely is able to SEE the indifference.
One helpful thing was to get patients laughing. Of course many can't be reached this way, but of those who can, it's a wonderful means of communication.
Nothing I was ever taught in my training or at my university hinted at some of the most effective techniques I discovered. For instance, I was able to deal with very psychotic people by walking with them around the block, or taking them to a sit down meal in a restaurant. In those two years, I only needed to get a single involuntary commitment because that individual was very agitated, but beyond any verbal communication, and he was of serious danger to himself.
One helpful thing was to get patients laughing. Of course many can't be reached this way, but of those who can, it's a wonderful means of communication.
I totally agree. Actually it had never occurred to me that I *shouldn't* laugh and joke with patients who are capable of doing so. There was an article in the NYT recently by another psych resident who felt uncomfortable laughing at a joke made by a patient.
http://www.nytimes.com/2008/11/18/health/views/18mind.html
I was pretty surprised by this. I feel like intentionally not laughing at someone's joke is like excluding them from the human race. That's the last thing I'd want to do to a patient.
It seems to me that the doctor should be pointing out what's real and what is not.
Well in this case it seemed reasonable, so I took the risk. But most psychotic patients won't believe you if you tell them their delusions aren't real. They just get angry at your not believing them.
My guess is that patients respond to medications and other therapies in very different ways, to the extent that a slavish adherence to a "cookbook" approach to treatment wouldn't make sense. Instead, I suppose that part of gaining experience is knowing when to follow the book and when to improvise.
And although the book learning I have cannot give me the answers I seek froma client meeting, the mixture of the book learning and the more intuitive part of my job DO blend together quite well, one informing the other.
As M666 says, to paraphrase him, "you need to know when to use and when to throw away the recipes in the cookbook, and instead, go with the improvisation." But if you pay close attention, many times one does inform the other.
I think your patients are very lucky.
Great instincts.
rated.
Yet, I could see the folly in appointing an invisible hero to do battle with the foe in Mr. X's head. What if Mr. X is an atheist? What if he's agnostic, or if he is a believer in something other than the Judeo-Christian doctrines?
After such considerations, I would find it necessary to sublimate my "instinct" to use a theology-based antidote on Mr. X's psychiatric drama by utilizing a less sacrosanct treatment .
I can't help wondering, though, what would happen if the nonsecular-approach would be effective in the right "head."
Just as doctors utilize individual approaches in their treatments, so are patients very individual in their reception of and their responses to different methods of treatment.
With this in mind, I am confident there is a patient somewhere whose voices would flee at the three-word fix with which most Catholics are familiar. "Go Away, Satan!" would probably banish the evil entity for the time being.
Our five senses are biologically configured to selectively sample the various types of energy around us and present them to our brains in a certain manner so that workable conclusions can be drawn. If someone's brain picks up on different types of energies or draws different conclusions, they have a different reality. We may call them batshit crazy - and I'm no psychiatrist - but I'm guessing that whatever it is they're experiencing is pretty darn "real" to them.
And so, while I agree conceptually that society is better served when psychiatry keeps us from drawing outside the lines, I also have a sneaky suspicion that in a collective way we're suffering from our own delusion and there's a much larger truth "out there" that we'd rather not consider.
I suspect by real, what most of us mean is no more than a commonly held delusion that serves to keep us functioning as a society.
Of interest perhaps, the DSM-IV definition of a delusion stipulates that the belief is not one ordinarily accepted by other members of the person's culture or subculture.
So if everyone around you shares in the delusion, it isn't one.
I was certainly not "indifferent", nor was I "frizzy headed" but that's besides the point.
We "sitters" were all hospital employess with full time jobs in other departments and this was an opportunity to make some extra needed money in a helpful capacity to others....Nine dollars an hour was good money then!
The object was to observe and report to the nurse, just outside the door the way this ward was set up, any upset or problem that the patient experienced...the main thing was to STAY AWAKE !
I read a few great books , and saw and heard things I thought only "made up" for the movies.
One young man masturbated, for nearly eight hours , commenting unrepeatable things to my thirty-something blonde self and interpersed those obscenities with low wild animal growls that were more unsettling than his other behavior. I refused that particular assignment afterwards.
The saddest time was in an all glass room with total visabilty to the nurses's station (this was in pediatrics as the patient was a young teen) his hospital bed in the middle of the room INSIDE A PENTAGRAM! He would only accept care if within that taped out form on the floor.
But the most memorable experience was outside of a room as I stood watching from an "observation" plexiglass window at the nurses's station..I never actually got to go inside that room as the young female patient, quite trim and not even 120 lbs had been brought in by ambulance and three burly, uniformed men were struggling to hold her down and secure her to the low, all rounded corners and edges, attached to floor bed, with wrist and ankle restraints..they could not manage it and called in a fourth person and still could not manage it..she arched her back, screaming and making her arms and legs rigid and then shaking by turns and disabling any attempt to secure her..finally a fifth person, another strong male, came to the rescue with brand new packages of restraints... rugged leather lined with lambswool...I watched as he opened each package and pulled out the strong looking cowhide with thick fluffy white undersides. One by one each wrist, and ankle was secured, they held her down at all four limbs and at the shoulders and head too....they spoke calmly and reassuringly to her. I was as spell bound to the scene as she was to the specially designed "psych bed". When the young woman seemed calm and had stopped resisting...this all without any injections...she was told that someone would be watching her (me) and if she needed anything at all , I would get the nurse....as they turned to leave her room and had opened the locked door..she raised up again,arching her back and neck not unlike in The Exorcist , and screaming a bloodcurdling animal noise she broke the restraints! I saw that with my own eyes or I would not have believed it.
There was a common thread in each case...drug use and involvement in occult activity.
The experience of having been a "sitter" in a psychiatric ward shaped my belief system and informed my worldview. You see, I was not "indifferent".
I do, however, disagree with the shared professional opinion (as stated in DSM-IV) that you summed up thusly: "So if everyone around you shares in the delusion, it isn't one." Delusional behavior, though not necessarily detrimental to society or even objectively unhealthy, is still delusional. No matter how many choose (or are intellectually coerced) into believing the delusion is real. The psychiatric community may be constrained by society from joining the reality-based community, but they need to get their collective head around what, in fact, constitutes a delusion. Seems to me like they've got it bass-ackwards.
Thanks for your work and for your writing.
You recognized a lucid human lost amongst frighteningly real illusions and gave him the help that he needed. Your balance of humanitarian instinct and studied technique will serve both you and your patients well.
I like what you write here and appreciate your sharing your experience and insights. I am easily annoyed by people who take advantage of your candor to tell you that your profession is all a big fake
Hey, thanks for your support. I figure everyone is entitled to his or her opinion, and I'm well aware that psychiatry as a whole has done plenty of harm as well as good.
Overall the responses have been more appreciative than not, and I've even noticed that a few posters who initially were somewhat hostile have changed their approach, which feels really good to see.
I do, however, disagree with the shared professional opinion (as stated in DSM-IV) that you summed up thusly: "So if everyone around you shares in the delusion, it isn't one." Delusional behavior, though not necessarily detrimental to society or even objectively unhealthy, is still delusional.
OK but if a 'collective delusion' is not unhealthy, we as mental health professionals are not going to treat it. Also if everyone in a society believes in a delusion, who are we to say it isn't real? Are we to run around treating everyone whose religious beliefs don't accord with ours, for example?
That is the essential truth I have experienced in 20 years of therapy and 15 years as a social worker. I am very impressed with your work with patients, and I don't impress easily.
I organized a library at a drop in center for the severely and persistently mentally ill. The staff was worried about not having enough books for poor readers and some patients were griping that we didn't have James Joyce or Virginia Woolf. They were absolutely right; these are essential authors for people trying to figure out how to live creative lives with serious mental illness.
That reminds me of a parenting lesson. You can't calm your toddler whenshe has a bad dream about monsters by insisting that monsters are not real. She might become more anxious. "Obviously mommy can't protect me because she can't even see what threatens me and they can sneak up on her at any time."
I went to social work school after almost 20 years of full-time mothering of 4 girls and a lifetime of bi- sistering 5 younger brothers. I wrote a paper inquiring, "Has psychoanalytic theory taught me what I didn't already know as the mother of four." I tried to say no tactfully.
"Two therapists may use the same method but achieve radically different results"
does not mean the method is right or wrong, or that the results are satisfactory,your interaction and present's had at least a calming affect.and his own understanding, nightmares weren’t real