Clinical Impression - A Smart But Acutely Suicidal Adolescent Girl
Last week I received a call from a leading psychiatrist. The daughter of one of his friends was in extreme psychological distress. While writing a 5585 hold was (and remained) a last-ditch possibility, for various reasons both the psychiatrist and the girl’s parents preferred for her to admit herself voluntarily to a locked, acute care psychiatric facility. This necessitated what turned out to be a complex but revealing task, which was to convince her to do so. In this clinical impression I attempt to outline how this transpired, together with the process of my own thoughts and emotions as it was occurring.
I spoke with her psychiatrist and her father, who was out of town. She came in with her mother and we met in our assessment room. The daughter was 17 years old and gorgeous. She had long auburn-colored hair, strong facial features, a beautiful complexion, and a well-proportioned figure. She was highly intelligent. Although she was a poor historian, it transpired that for the last month she had been on a wild binge of polysubstance abuse and reckless behavior, culminating in a suicide attempt by hanging that left her in the emergency room of a local hospital, from which she was transported directly to our facility. She had experienced acute renal failure at the hospital and may have been as close as five days away from dying. She now had detoxed, her vital signs were stable and within normal range, and she was medically clearable. She was not psychotic. Though her thought processes were logical and coherent, she clearly lacked judgment and insight. She was casually but not inappropriately dressed. She was well oriented. Her affect, however, was subdued and withdrawn, and she spoke softly. She was quiet and introspective, as if contemplating each word carefully before she uttered it. She was curled up in a ball across from me, avoiding eye contact.
What steps could I possibly take to establish rapport with her, and convince her to admit herself? In order to be effective, all therapists must be Rogerians at heart, at least initially. Empathy can be tricky; it’s not enough simply to aver that you understand the subjective, phenomenological reality of your patient’s experience. If it’s obvious you don’t, then the patient – particularly an intelligent one – will see right through you, completely disrupting the possibility of any meaningful interaction. Rather, you have to convince the patient, typically using words, of your sincerity. You must beguile, and in a way, enchant them, in order to demonstrate your sincerity. This inevitably involves some extent of self-disclosure. It’s difficult, however, to know where to drawn the line. Too much disclosure will bore the patient, or confuse the patient into thinking it’s all about you, not them. Not enough disclosure, on the other hand, will be ineffective to induce the patient to believe you truly comprehend the complex dimensions of their own personal experience, at least on a level that’s sufficient for you to accomplish some form of therapeutic result.
This is an art form, not a science. It concerns me that many younger therapists, freshly minted from graduate psychology school, say in their mid-20s, do not understand this dynamic. It’s not their fault; they simply are incapable of doing so. Many are taught, for example, to classify their patient initially on the basis of some salient characteristic – say, ethnicity. This then becomes the premise upon which to understand not only the substantive propositional content of the patient’s thoughts, but also the reasoning process by which the patient retrieves them. It is the most relevant classification point and entirely explains their pathology. You put them into a box. In fact, in some cases, if the patient denies the psychological influence of the salient characteristic, then it is the therapist’s obligation in effect to alter the patient’s consciousness, and convince them this lies at the root of their presenting problem, even when it doesn’t. There is something fishy about this. Most patients’ experience is far more multi-dimensional, and not amenable to analysis using such a simplistic template. The whole purpose of the initial encounter with a patient is not to snap them into seemingly obvious diagnostic categories, but rather to comprehend their world-view and the set of circumstances that caused, or created the possibility of, the life-crisis they now face.
I am in the process of developing and refining a facility for doing this. Some of it comes from being older. I have a broader palette or repertoire of experiences, upon which to draw, in order to be effective. I can speak with authority. Conversely, this also enhances the prospect of dystherapeutic counter-transference, which I must militate against. I don’t want to confuse patients into thinking I’m their father, or some other authority figure in their lives. That would provoke a panoply of recoils and reactions, none of which would be likely to be positive. I think it fair to say that many psychologists are mildly schizoid, in that they want to empathize with their patients, yet at the same time preserve a bright line between them. One must cultivate an “I – thou” relationship, while at the same time remaining in an impermeable bubble that protects you from being sucked into the swirling, tornado-like vortex of your patient’s own psychoses.
I took a few tentative steps. “Hey, what’s going on?” I asked. She sat there, blankly. “I absolutely am not going to consent to being here,” she said. More conversation about her stay in the hospital and the circumstances of her suicide attempt.” “I can’t make sure you’re safe at home,” said her mother. “I don’t care,” daughter said, “I don’t want to be here, I don’t belong here, and I’m not going to admit myself voluntarily.” I began to think of her as a nihilist. She was beyond feeling despair, because despair implies the absence of hope, and both of those categories were far behind her. She was teetering right on the brink of the edge of simple non-being itself, and was in the process of preparing to jump over that cliff, or permit herself to fall over it, into a real of pure nothingness. I thought of the steep descent described by Dante into the inferno, an elaborate and intricate network of stairways leading down sheer, vertical cliffs. Rather than tip-toe her way through them, she was on the verge simply of plummeting, avoiding all of the intermediate stepping stones, way-stations and points of observation and reflection.
I thought of my daughter, when she was 17. She too was (and is) whip-smart, a tall, blonde-haired Valkyrie. My mind raced back a half-dozen or so years. Had she ever been like this? I didn’t think so, or if she had been, it certainly didn’t seem that way. But how could I be sure? Then, I thought of my own experiences, when I was 17. From time to time I felt depressed, although in retrospect this unquestionably was transitory, situational depression. I had a small group of true friends, all of which now have vanished in the wind. But for a while we provided subjacent lateral support to each other, if only tacitly; all of us belonged within the same tightly self-defined group. If somebody was in a hole, the objective wasn’t necessarily to throw them a lifeline, or help them dig their way out. Rather, it was to physically support them in their natural state by not extracting psychic assets from the adjacent diaphragm of support; put simply, not to excavate adjacent holes, or burrow into theirs, and to help them prop up their own personal walls and boundaries. I still do this today, by interposing (perhaps over-interposing) personal walls and boundaries between myself and experience, if only to protect myself against it in all of its raw, viral, untamed, unmitigated majesty. I told this to her, not by just using words, but by literally enacting the experience, like an actor on a stage – getting myself into her frame of mind and putting myself into her shoes, as best I could.
Acute care psychiatric facilities provide this same form of containment. They are a safe place, yet one that is sharply contrasted from the milieu of the patient’s day-to-day experience. While psychiatric services (medication) and psychological services (individual, group counseling) are important, some significant part of the therapy comes simply from just being there and participating in the environment it presents. It is startlingly dichotomous to the timbre and texture of one’s ordinary, day-to-day life. I suspect that, as they grow older, many adolescent in-patients will look back on their stay at such a place as a kind of fulcrum or pivot-point, sharply defining their mode of interacting and coping with the world.
My mind raced as I thought about how to express all of this. I ended up telling her, “In my experience, many people with suicidal ideations aren’t necessarily wrong about what they’re thinking. They have a vivid, pulsating, throbbing ideation, which propels them forward. They even may know what it is, and are able to describe it in intricate detail. Nonetheless, they go astray. What’s wrong is the means by which they choose to express themselves. Suicide never is the right solution, because it entails the negation of the possibility of any further experience. This includes high points (for example, my patient expressed the excitement and joy she recently had felt while riding on the back of a motorcycle). It also includes low points. Although they may seem averse, they too are worth experiencing, if only for their content qua experience, that is, as experiences that are deserving in and of themselves to be experienced.”
This may seem like a complex, overly intellectualized argument, but as I was putting it forth, using different words of course, I saw a glimmer of interest in her eyes. If I was she, it was a series of inferences that would have worked on me, and I sensed we had developed enough of a shared understanding, that it also might work with her. “How long would I have to stay here?” she asked. I could tell we were making progress, because we were moving from theory to praxis. “At least 72 hours,” I said, referring to the initial period of the 5585 hold. “What happens after that?” she asked. “A psychiatrist will evaluate you to make sure you’re safe. There’s a possibility you may stay a while longer, but only as long as you need to.” “How do I know you’re telling the truth?” she asked. She was a true empiricist, indeed. I quickly turned to the computer, managed to find and then print out for her, a copy of the relevant legal provisions outlining the scope of the 5585 hold. “Here you go,” I said. She perused them carefully. After a few more minutes, which seemed to pass very slowly, she slowly picked up the pen, and signed the form for voluntary admission. I silently rejoiced, and told her, to affirm her: “You’re doing the right thing.”
I have summarized our encounter only briefly. In truth and fact, it lasted for over 90 minutes. I was exhausted at the end, fully depleted by the experience. I felt as though I had summoned all of my inner resources and powers. It had been intense and emotional, but it was the kind of intensity and emotion I craved, because only the most acute cases illustrate the true modalities of authentic being-in-the-word and the unfathomable complexity of its epistemology and ontology. I stepped outside for a few minutes to get some fresh air, tears welling up in my eyes. I have seen dozens of adolescents in various stages of acute distress. What was it about this particular patient that I found so resonant? The answer is simple – we had broken through the physical and mental boundaries that separated us and, through a process of hierarchal, mutual calibration and attunement, and had come to a shared outcome. We had experienced a form of kinship, based on intersubjective experiences of isolation and alienation. I had been able to communicate my own private state of psychological certitude, that this was the best outcome for her. She was able to perceive this, came to trust it, and then acquiesced in it. To encounter a patient with this level of acuity, combined with this level of intelligence (leading to insight and comprehension) was a rare experience, and I was privileged to have interacted with her.
*stock photo - not my actual patient