fear of hell

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.

mind control II: yours

I wrote last week about how surprisingly simple it can be to turn around an angry patient. Two small words hold the key to taming the beast: "You're right." Those words are like a magic tonic, a soothing balm. The patient drops his offensive posture, loses his hostile glare. His hackles soften. His ears are open, receptive. Magic.

But it's not enough merely to mouth the two magic words. You need to believe them, to find the grain of truth in the patient's angry accusations and hold it up to the light. Typically that grain of truth contains a failing of your own. That's hard to admit.

In the CBT group I attend we use role-plays as learning tools. We mimic angry patients, throwing harsh words at our colleagues as a challenge to their empathetic skills.
It's curious that even when you are merely acting a role, pretending to be upset, you can feel in yourself the good or bad reaction to the 'therapist's' words. Defensiveness from the therapist provokes further heights of anger. But the crucial initial words "you're right" produce a rush of surprise and disarmament, a shock of pleasure at being understood, a hint of gleeful righteousness, and an intense curiosity and complete willingness to listen to what's coming next.

Rookies never get the task right the first time, or even the first ten times, even after having the strategy thoroughly explained and seeing more experienced members employ it. They simply can't get themselves to say, "You're right; I've failed; you're understandably angry; but tell me more so I can try to fix it." Instead they mouth platitudes like "I hear that you're frustrated," or "Why don't you calm down so we can discuss this," or they get defensive and explain why the patient is wrong to be angry. These strategies are all, of course, bound to escalate the situation.

Never, never on the first try do they plainly acknowledge the patient's anger and the faults of the therapist. I sure didn't, and I've yet to see any other rookies manage it either. It's suspiciously simple, yet incredibly difficult to do.

As I mentioned last week, I've been using this strategy on belligerent colleagues and other assorted meanies as well as on patients. It's been absolutely foolproof so far. But interestingly, when I shared the strategy with some of the psych residents who are not in the seminar, I met stubborn disbelief.

"I don't think it's appropriate to just subdue yourself to the demands of the patient. You have to maintain your own integrity," one woman said.

She'd verbalized the gut resistance to this strategy that comes from your own ego. That's exactly why it's so hard to implement, despite being so simple. Because you have to lose in order to win. You have to cave in order to prevail. You have to drop your ego in the dust and squish it with your toe in order to have any hope of success.

Even in the false environment of the role-play, where your partner flings made-up accusations at you, it's hard to accept and apologize for these acts you didn't commit. In that setting it's really just a script you could recite with no personal involvement whatsoever. "You're right, I did [fall asleep during your session/give you the wrong drug/insert horrific therapeutic sin of your choice], I bet you're feeling really angry right now." That's it, and with minor variations it's pretty much always the same. Yet it takes a long time to be able to do, even under laboratory conditions. How much harder is it when it's truly your own actions that are being assaulted.

Seeing the patient's anger as a threat to your ego integrity is losing sight of the goal of the therapy, which is to help the patient. The goal is not to maintain your own sense of dignity and self-worth; presumably you've already got a healthy dose of those or you haven't any business trying to therapize others. And if you consistently put the goal of preserving your dignity ahead of the goal of helping the patient, you'll have a lot of frustrated patients and that won't be good for your ego as a therapist in the long run anyway.

But we're accustomed to working hard to maintain our dignity and self-worth, because people without them are racked with doubts and insecurities and generally have a difficult time in life. So we're pretty well programmed to protect our egos, which we do in different ways depending on our basic characters, stages in life, and how we frame ourselves to ourselves. But we all do it. When faced with a blow to our egos, we're socialized to parry it, swiftly and surely.

However, it's all too easy to forget that an interaction between a therapist and a patient is not the same as a typical social situation. Your goal is to help the patient support and develop his ego, not to prop up your own. But when faced with a threat, it's instinctive to forget that, and to fall back on the strategies that have always been helpful (defending or rationalizing or denying your actions, deflecting the blame, etc.).

Hence my colleague's assertion that it was important to maintain one's own integrity. But important for what, I'd ask? Important for the patient, I suspect she'd say - to set limits, to teach the patient how to behave calmly and fairly. But the key point here is that there is always a reason for the anger. Truly isolated, reasonless, purely biological anger is a rare thing that occurs with specific brain lesions, typically affecting the hypothalamus. Real humans in the real world have triggers, and if the patient is lashing out at you it's likely that you're at least part of the trigger. It's your job to be the level head and figure out what that part is and what you can do about it. Otherwise your chances of getting the patient to a state where he can be calm and fair are going to be on the slim side of nonexistent.

mind control I: theirs

I'm in a seminar that meets once a week to educate ourselves in the technique of CBT (cognitive-behavioral therapy). This is only one of a plethora of available therapeutic modalities (dialectical behavioral therapy, psychodynamic, psychoanalytic, etc etc etc).

We're learning specific, codified techniques for making our interactions with patients productive. Some of them are very simple; but the results are absolutely amazing.

One of the things that attracted me about psychiatry was how smooth the attendings were about dealing with difficult patients. You'd have an obnoxious patient on the medicine or surgery floors who would have all the docs chewing their stethoscopes with utter frustration. Then the psychiatry consult would walk in and in three minutes he'd have the patient eating out of his hand. Unbelievable. I wondered whether this was a talent they were born with or a result of their education. (Ultimately, as with most things, it's probably a little bit of both.)

It's a bit of a chess game, as one has to think a few moves ahead. If I say this, he'll likely say this. If I don't say this, another chance may not come. If I say it in this particular way, will he react well or badly?

It's perhaps funny to imagine that human interactions could be condensed down into a set of algorithms. One would like to think that individuals are so very different from each other that one size could never fit all. And it's true that one needs to apply one's interpersonal intuition to an extent. But only to an extent. There are definite ways to bring angry or frustrated patients back to a state in which they can engage in rational conversation.

And it doesn't only work in the controlled environment of a hospital or clinic. I've used some of the basic techniques we're learning with other angry, irrational people in my life (mainly frustrated residents from other services) with excellent results. Secret weapons! Psychiatry is incredible.

Next entry: Getting people to be rational is both easier and harder than it seems.

biology vs psychology: false dichotomy?

I was speaking with a very intelligent and insightful patient today who mentioned that he'd felt his problems (depression, some obsessional traits, a mild eating disorder) were all 'psychological' until he found a drug that significantly improved them. From that point on he was convinced they were 'biological,' and embarked upon a quest for the Magic Pill that would solve all his neuroses at a single swallow.

I see references to this sort of split all the time, and not just from patients but also from highly educated physicians and scientists. Somehow they consider that our behavior* arises from two distinct sources: one composed of neurons, synapses, and neurotransmitters, and another composed of experiences, drives, and willpower.

If you buy the biological theory of behavior at all, then it makes little sense to imagine a dividing line between 'biological' and 'non-biological' causes of behavior. Experience alters neurochemistry just as surely as medications do.

Here's a nice (but somewhat technical) piece of work discussing some of the cellular-level changes that have been observed to be triggered by real-world experience (Takahashi, Svoboda and Malinow).

Evidence abounds for the utility of 'talk therapy' in psychiatry. In order to separate the 'biological' from the 'psychological,' one would have to believe that there exists an entirely separate underpinning of human behavior that operates on some ethereal plane, unrelated to the biomechanical world of synapses and neurotransmitters.

If you're going to accept that neurobiology underlies behavior, then there is no clear point at all where you can divide the biological from the psychological. If you accept that experience exerts its effects through alteration of our neuronal activity, and you accept that hearing your therapist is an experience, then there is no room for some nebulous 'non-biological' effect. Your therapist's words tickle your ear neurons, which tickle your brain neurons, which make subtle changes - sticking themselves to some of their neighbor cells, unsticking themselves from other neighbors, changing the rate at which they spit neurotransmitters at each other - and voila! You change your behavior.

That the line between biological and psychological is fuzzy to the point of nonexistence is indeed starting to permeate the general consciousness, at least to a degree. This usually arises in discussions of ethics, where the whole edifice of crime-and-punishment rests on an assumption of free will. This assumption is being radically challenged by evidence that our behavior is heavily determined by factors not under our direct control (genetics and medication in particular).

This opens up another can of worms, because we frequently associate 'biological' with 'beyond our control' and 'psychological' with 'within our control.'  Hence my patient (and many like him) and his Magic Pill search.

But I think the educated world at large is not yet ready to join Steven Pinker in declaring us will-less playthings of our genes and environment. Fine for now, but I'm curious to see what we'll make of coming scientific advances that will no doubt push us even closer to the will-free wall.

*I'm using "behavior" intentionally to encompass all of the workings of the human brain that are manifest to others. I'm doing this very deliberately because the question of whether mind is biological at all is a very sticky wicket and not something I can afford to get into in this limited space.

truth to power

The unspoken derives its power from its very mystery.  To make explicit is to deprive of power. The psychotic patient knows this, perhaps better than we.  Psychotic patients often seem in touch with a deeper, animal reason.

Mr. B. behaved like nothing so much as a cornered animal in the locked psychiatric unit.  Behind closed doors, he admitted his demons to his worried mother, who relayed them to us; but to the doctors he was close-lipped and angry, hiding with insults his fear at what had happened to him.

His threatening, hostile stare fairly made the air vibrate in the room... yet the moment the attending asked of him, frankly and without guile, "Why are you staring at me?" the spell collapsed, deprived of all its power.

"I'm not staring at you," was his only, weak recourse.

But it was nothing so simple as her bare words that disarmed him.  I pictured the same patient on a gritty street corner, leveling his rapier gaze at a fellow thug.  The same phrase spoken in an equally hostile tone by a burly, puff-jacketed swaggart would have but escalated the situation.  It is the opt-out, the calm inquiry, the untroubled curiosity, that undercuts the threat.

Good therapists wield this tool with skill and precision.  They refuse to play the game, choosing rather to analyze it.  All of us, as humans, have some understanding of this complex social game.  We approach and retreat, feint and parry, dance an endless dance of human relations - all without a word, a world of interactions parallel to but separate from our explicit verbal exchanges.

People who play the game well become leaders, extracting what they wish from others while retaining their loyalty and affection.  People who have a shallow or incomplete understanding of it become recluses, frustrated at every turn by interactions that go awry.

But whether they play it well or poorly, in the normal course of human behavior the game is never made explicit.  To make it explicit is to undermine it entirely.  The therapist does this in a controlled manner, slicing the game out of its skin and dissecting it apart, displaying its innards openly to his patient's wonder and, perhaps, dismay.