Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The fundamental question that encircles the whole practice of psychiatry

Edward Kai Yan Tie
Conditions
September 19, 2021
34 Shares
Share
Tweet
Share

Mary (identifying information changed) was extremely pleasant, to say the least.

By the time I met her on the senior unit, she had seemingly befriended even the orneriest of our geriatric patients. She wandered and danced about the unit, speaking with each fellow patient she encountered in a style one nurse called “cheerfully mad.”

Her strategy, maximalist and crude but stunningly effective, was to talk your ear off in a joyful stream of consciousness, delivering an overwhelming rush of discourse punctuated by a few sonorous laughs for good measure and general jocularity. “Why nice to meet you ‘student doctor’ Tie!/the weather’s glorious today/even though we’re all trapped in here/what are you gonna do? (laughs)/I guess it’s time for me to break in my new psychiatrist/I can tell you how everyone around me has died/you seem like great fun/we’ll be the best of friends!”

She was manic. She hadn’t slept for five days. To be clear, she was suffering — the human mind isn’t meant to sustain the exertions, the rushed performances, demanded by mania. Yet from afar, she radiated pure joy, an avatar of good cheer bestowing her blessings upon on our normally staid, relatively sedate unit.

I was taught that the therapeutic relationship between psychiatrist and patient cannot proceed without some prerequisites: the essential foundations of rapport-building, successful engagement with the patient, and the engendering of mutual trust.

If, with some patients, this is an incremental process of accumulating empathic connection and gradual respect — a slow accretion over days, weeks, months, and years — with Mary, I felt that I had been inducted instantly into her inner circle of friends within seconds of meeting her. I was being yanked into intimacy. She spoke to me with a friendly familiarity that seemed undeserved and, at times, eerie.

If at first I found Mary fascinating in her constant output of effervescent, positive energy, that feeling soon soured into frustration.

That jocularity of hers, the warmth Mary exuded — it wasn’t a deliberate deception, but it made things difficult. It was an agreeable veneer, a trapwork of affect layered over a profound inner despondency. She had lost five loved ones in quick succession over two months during the COVID-19 pandemic. It was an incalculable loss. To even begin to plumb the depths of her grief in the midst of a manic syndrome would be impossible.

Indeed, I wasn’t even sure I could engage her effectively. The word count she produced as she spoke — for example, “Ed I’ve had 10 psychiatrists in ten years/can you believe that/guess they couldn’t crack me/lunch was INCREDIBLE/but you know what’s the opposite of an incredible lunch/the answer’s LITHIUM cause it numbed me and wrecked my kidneys/but I’m manic anyway so …” — ran roughshod over any response I had feebly cobbled together moments before.

My instinct with Mary over our first conversations was to tame our interactions — to set down boundaries, to discipline and establish rules, to somehow hold back the tide of excess and loquaciousness by offering a kind yet stoic demeanor, responding with silence when appropriate, gently challenging her particularly delusional statements, and prompting her to slow down.
This was a disaster.

In my attempts to micro-manage the interview, I displaced myself from it. Here I was conducting a psychiatric interview from a far-off place, a remote mindscape where my chief concern was triangulation — when to jump in the conversation, when to pull back, when to nudge. I felt an almost atavistic drive within me to wage battle on her mania. I busied myself with reining in the conversation, attempting to suppress and sublimate its swerving chaos into meaning, linearity, and healing by engineering the perfect response to whatever Mary was spouting out.

It went like this: Mary would say something absolutely divorced from reality, for example, a pontification on her messianic delusion. “You know Jesus, the son of god?/well I’m his daughter/and I’m pregnant in a divine conception.” By the time my brain processed a possible response (maybe a gentle challenge to her delusion, “Mary, I’m not sure how many people would believe you on that; that sounds a little too good to be true.”), Mary would be speaking on something else entirely.

So much for wrangling all of it through clever phrases. Ironically, I, the budding psychiatrist, was too in my own head. Mary, of course, immediately noticed: “You aren’t even listening, are you Dr. Ed?”

She was right — I wasn’t listening in any real way.

In my time with Mary, my mind perseverated on a fundamental question that encircles the whole practice of psychiatry — how do we meet our most psychiatrically ill patients, the floridly manic and psychotic, where they are? How do we as psychiatrists sit with them in the depths of their madness and suffering, engage empathetically, and trudge with them towards mental health?

I wish I could say I figured it out with Mary. The truth is I didn’t. Each day I allotted 30 minutes for Mary — I spent that time fully present, listening to whatever she said, trying to glean some kind of emotional truth.

As I worked with Mary, I thought frequently of Michel Foucault and the figure of the “Madman” he writes of in Madness and Civilization. The Madman, also derided as the “Fool,” the “Simpleton,” at once emblematizes ridiculousness, unreason, inscrutability, and madness incarnate, yet simultaneously has privileged access to a divine truth others cannot possess or understand by reason of his madness.

With Mary, I took this to mean that even if her mania seemed impenetrable to my attempts to understand, operating within its own inescapable, internal logic, I could still stand witness to her voice, listen attentively, and offer a therapeutic presence if nothing else.

I thought too of the physicians of old, uncomfortably pressing their ears into a patient’s chest to capture the echoing thumps of their beating heart, listening intently for the rhythms of health. Wasn’t I attempting the same — standing in the swirling, raucous symphony of Mary’s mania, trying to hear Mary beneath the din.

Edward Kai Yan Tie is a medical student.

Image credit: Shutterstock.com

Prev

Where does the joy and meaning in medicine dwell? [PODCAST]

September 18, 2021 Kevin 0
…
Next

The degradation and devaluation of nurses

September 19, 2021 Kevin 7
…

Tagged as: Psychiatry

Post navigation

< Previous Post
Where does the joy and meaning in medicine dwell? [PODCAST]
Next Post >
The degradation and devaluation of nurses

Related Posts

  • Scenes from a medical student’s rotation in psychiatry

    Natalia Birgisson
  • Medical school is more than practice problems

    Kira Kopacz
  • A question to ask physicians: How much is tough enough?

    DrizzleMD
  • The medical education question that needs to be changed

    Bo Cheng, DO, PharmD
  • Improving physician satisfaction by eliminating unnecessary practice burdens

    Yul Ejnes, MD
  • Independent practice: Nurse practitioners respond

    Rebekah Bernard, MD

More in Conditions

  • Overcoming the lies of depression: Senator John Fetterman’s struggle with mental health

    Harvey Max Chochinov, MD, PhD
  • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

    Hoag Memorial Hospital Presbyterian
  • The rising threat of lung cancer in Asian American female nonsmokers

    Alice S. Y. Lee, MD
  • Urgent innovation needed to address growing mental health crisis among children and families

    Monika Roots, MD
  • The importance of listening in health care: a mother’s journey advocating for children with chronic Lyme disease

    Cheryl Lazarus
  • The unjust reality of racial disparities in pediatric kidney transplants

    Lien Morcate
  • Most Popular

  • Past Week

    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
    • Revealing America’s expansion: the dark truth of Native American suffering and unjustified abuses

      Anonymous | Physician
    • A physician’s typical day, as envisioned by a non-clinician health care MBA: a satire

      Jennifer Lycette, MD | Physician
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • From Moscow Mule to the opioid crisis: Unveiling the tragic legacy and urgent solutions

      Osmund Agbo, MD | Meds
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • An inspiring tribute to an exceptional radiologist who made a lasting impact

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Proactive risk management: a game-changer in preventing physician burnout

      Howard Smith, MD | Physician
  • Recent Posts

    • Empathy and awareness: Unveiling the hidden dangers of food allergies [PODCAST]

      The Podcast by KevinMD | Podcast
    • The alarming epidemic of physician burnout and how we can combat it

      Tomi Mitchell, MD | Physician
    • A retired physician’s battle with moral injury

      Hayward Zwerling, MD | Physician
    • Unveiling the secrets to effective resuscitation and overcoming obstacles

      Deepak Gupta, MD | Physician
    • Georgia’s new law promoting truth and transparency in health care credentials

      Carmen Kavali, MD | Policy
    • Physician employment contracts: the key to fighting burnout and improving working conditions [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • FDA Panel Endorses mAb to Prevent RSV in Infants
  • Novel LAA Closure Device 'Promising'
  • Acute GvHD Risk After Allo-HCT Higher With Some Antibiotics vs Others
  • TTFields Therapy Yields OS Improvement in Second-Line NSCLC
  • Mental Health Provider Disclosed Personal Patient Info in Google Reviews

Meeting Coverage

  • Novel LAA Closure Device 'Promising'
  • TTFields Therapy Yields OS Improvement in Second-Line NSCLC
  • Upper Airway Stimulation Device for OSA Holds Up in Real-World Analysis
  • Morning Naps in Elderly People May Reflect Dementia Risk
  • Extra Follow-Up Confirms Benefit of Nivolumab in Muscle-Invasive Bladder Cancer
  • Most Popular

  • Past Week

    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
    • Revealing America’s expansion: the dark truth of Native American suffering and unjustified abuses

      Anonymous | Physician
    • A physician’s typical day, as envisioned by a non-clinician health care MBA: a satire

      Jennifer Lycette, MD | Physician
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • From Moscow Mule to the opioid crisis: Unveiling the tragic legacy and urgent solutions

      Osmund Agbo, MD | Meds
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • An inspiring tribute to an exceptional radiologist who made a lasting impact

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Proactive risk management: a game-changer in preventing physician burnout

      Howard Smith, MD | Physician
  • Recent Posts

    • Empathy and awareness: Unveiling the hidden dangers of food allergies [PODCAST]

      The Podcast by KevinMD | Podcast
    • The alarming epidemic of physician burnout and how we can combat it

      Tomi Mitchell, MD | Physician
    • A retired physician’s battle with moral injury

      Hayward Zwerling, MD | Physician
    • Unveiling the secrets to effective resuscitation and overcoming obstacles

      Deepak Gupta, MD | Physician
    • Georgia’s new law promoting truth and transparency in health care credentials

      Carmen Kavali, MD | Policy
    • Physician employment contracts: the key to fighting burnout and improving working conditions [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...