Like a patient etherized upon a chair

“Is it hot in here, or is it just me?”

The patient interrupts himself mid-interview as he shifts in his chair.  He’s sitting directly in the afternoon sun.  He’s squinting.  He fiddles with the zipper on his jacket, pulling the garment halfway off, then back on.

My classmate, the interviewer for the psychiatry session, tells him he is sitting directly in the sun but forgets to suggest he move.

For the remainder of the interview he doesn’t move.  It’s an hour-long interview.  He’s paranoid, suicidal, and incomprehensible.  He lapses into tangents, interrupting those tangents to ask if he’s going on tangents.  Sometimes he forgets the question as he’s answering.  It’s hard to hear what he’s saying because he mumbles.  It’s also hard to hear what he’s saying because the words don’t piece themselves together in structure I can decipher.  Most of what he recalls takes place two decades ago.

He’s still squinting, looking at us curiously, telling us about all the voices he hears at the bus stop.  It’s like they can read his mind.

A large part of me wants to interrupt and drag his chair a foot to his left, or a foot to his right.  Either direction would do.

It’s not hot; it’s just you.

Now he’s quoting a song from 1988.  “Do you understand what I mean?” he keeps asking.  We sense his fervent desire to be understood.  I squint my brain really hard and try to put myself in the literal hot seat with him.  I’m gleaning a vague meaning, but it’s probably not the meaning he means.

And now he’s crying.  He apologizes too much for it.

“Any more questions?” our professor asks as the interview closes, addressing the rest of us onlookers.

What I really want to ask is, why don’t you move?  When you walk out of this room, what other things will paralyze you?  Why can’t I understand your mind’s language, and why can’t you speak my mind’s language?

I don’t have anything to ask, I say.  Not right now.  He’s crying, for god’s sake.  It’s not worth re-opening the topic of his childhood abuse to get another line for the write-up.

After the interview, the professor asks us what we thought of the interaction.  I pause.  The first thought that comes to mind is a rather simple-minded one: I feel really, really bad.

My classmate answers first.  “The patient seemed to have a lot of trouble giving us any sort of timeline.”  I nod in agreement.  The professor talks about the difficulties of having an unreliable narrator.

I feel really, really bad.  I feel really, really bad.  I haven’t said anything yet; I think they’re waiting for me.

Finally, I offer: “The patient mentioned that he was ‘feeling between a rock and a hard place.’  Using an idiom, he seems to have the capacity for abstract thought, which is not characteristic of schizophrenia.”

It’s a good finding.  It’s helpful for diagnosis.  Unlike my original thought, which I eventually share but bury within clinical observations.

I am thinking of T.S. Eliot.  I guess this is how the world has been ending for our patient.  Not with a bang but a whimper.  It’s a series of withdrawals from life, slowly and relentlessly, for decades.  He has no family, no friends, and no home.  He has confusion and sadness in their place.

And he (can’t? won’t?) move his damn chair out of the sunlight.

We draw a concept map on the board to help sort out the 60-minute tangled stream-of-consciousness.

And how should I begin? asks a character in another of Eliot’s poems.


Note: Certain medical, social, and temporal details have been changed to preserve anonymity (while hopefully not altering the narrative and message).

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6 Responses to Like a patient etherized upon a chair

  1. ram3481 says:

    Disclosure: I am a qualified Psychiatrist from India.

    Do I get the message right.

    The trainees don’t show basic social concern for the person in front of them. they objectify the person in front of them as a “case” which need to be studied.

    This person has ability for idiomatic usage.So may be not having Schizophrenia. He unfortunately is having hallucinations(auditory) so is suffering from psychosis. In either case he needs to be treated as an social being.

    His psychopathology can only be explored by detailed interview. The scenario so described happened on a daily basis in the institution I am working. Consent is taken from the family member and genuine regard is given to the person -as a sick person needing care. But probably psychiatric trainees would commonly become a little cold as they repeatedly get exposed to the same situation of interviewing and interpreting, like an army man who is dis concerned about blood and dying.

    yeah felt nice reading your post

  2. Shara Yurkiewicz says:

    Thank you for your comments. Yes, sometimes I get disheartened during psychiatry when we focus more on the case than the person. I can, however, understand the reasons behind this.

    There is so much to learn in so little time, I can see the rationale of using that time to impart knowledge and leave us to get touchy-feely outside of class. As second years, we know next to nothing about diagnosis, and getting the label right is vital for treatment. For example, you must determine if someone is depressed or bipolar (depression with an episode of mania), because the treatments are complete opposites and will do harm if the wrong one is given.

    So, sometimes what will benefit the patient most is to cinch the diagnosis (though empathy and diagnosis are certainly not mutually exclusive).

    But while I understand the importance of improving our clinical skills, I confess that I was surprised by the “coolness” of the entire process, especially considering the reputation of psychiatry to be “touchy-feely.” I have mixed feelings, overall.

    What I will say, however–and this is at my own peril–is that I absolutely abhor the practice of the instructors handing the patients a ten-dollar bill for their time in front of us all (and then having the patient sign a form that s/he received the money). There is something cheap and objectifying about doing this so publicly.

  3. Az says:

    It’s a fine line of compassion and efficiency that’s needed. Learning to call the symptoms in real time is important but takes practice. The mental gymnastics to list and compare symptoms while being able to offer sympathy sounds a bit like acting in the sense that, you need to memorize all those lines, get them in the right order, move in this or that direction and also remember to feel at the same time. It’s an artform that when done well, is truly amazing. And has a tough learning curve.

    It’s hard on the patient and the clinician, I’m guessing. But both are there to learn and to do their best. Hang in there.

  4. Bruce says:

    Having been in that hot seat myself, I wish my therapists would have had your same thoughts and expressed them directly to me. I found later that discussion was more beneficial than just my narrative. It allowed me participation in the analytic process of my therapy.

    Please always remember that your patient is a human and not just a problem to be figured out. Keep up the good work.

  5. Shara Yurkiewicz says:

    @Bruce: Having tried therapy briefly myself with a similar style, I agree with you. I found that I was just talking to fill space, and I wasn’t able to figure out what the therapist was thinking. I wondered, if I’m not getting any input on what I’m saying, may as well just use my friends and family instead…

    I think it’s important to find a therapist/psychiatrist/psychologist who matches your style. Do you want meds? Analytical discussion? A safe place to vent? I suppose it makes sense that one therapist cannot subscribe to all schools of thought at once. Unfortunately, the disadvantaged and less savvy do not have much choice in therapists, so it’s sad to see a mismatch.

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