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Student Scene October 14, 2002 Healing Touch of a Troubled Mind Alisa Land Photo by Jeff Cleary Though a social worker in my life before medical school, I still entered the locked inpatient psychiatric unit, where I would do my rotation, with a healthy sense of my own inadequacy. I had worked clinically as a therapist for children and adolescents who were deemed high risk in the outpatient world of New York City--a challenge in itself. Yet I knew that this place was a final stop for adults with mental illness of a much more intractable sort. The inpatient psych unit, almost by definition, includes people most would find difficult--so miserable, dangerous, or unmanageable that they themselves or someone else had compelled them to come. Despite my hopes that I was beyond the sort of prejudice most have against the mentally ill, I, too, had my fears and biases. I, too, had underestimated the power of even the most ill to heal themselves and teach others in the process. A Silver Lining My first patient was an HIV-positive Ethiopian man with a diagnosis of chronic major depression with psychotic features. I remember our initial meeting. I acted as the silent observer while the attending and resident tried to encourage him to participate in a treatment plan of new medications and electroconvulsive therapy. I could sense their growing frustration as his sense of overwhelming despair filled the room like a burgeoning cloud. He would shuffle in and slouch in his chair, his eyes staring at his lap and his body nearly motionless. He described his mood each day as "worse and worse" and shared his myriad bodily complaints, from bloating, pain, and fatigue to the foul taste and smell of rotten bowels in his mouth. He believed himself toxic and was convinced that all measures of treatment would fail and that he should be "left to die in peace." Over the month of regular meetings, however, I began to see another side of him. He eventually would greet me with a bit of a twinkle in his eye and a smile, even when I woke him up for morning rounds. Although the content of our discussions did not shift dramatically, I could see him seemingly begin to enjoy our times together. He told me about his gardens and the farm his family had in his home country. He shared his sadness in grieving the loss of the sun, the earth, the clouds, and all the people he loved as he anticipated his coming death. One day he gave me four drawings of plants, flowers and animals--each meticulously colored--that he said had reminded him of his home. I would find him playing cards in the common room with other residents, cheerfully stating that he would beat them all. He seemed to form a warm connection with one of his roommates who had a similar diagnosis, and the two would check up on each other from day to day. He left the day that I left the unit. I cannot say that he was cured or even that I saw some miraculous change, but I learned to appreciate some of his inner strength that enabled him to reach out to others, even in his world of great pain. The Courage to Reconnect Perhaps even more striking was my experience with a 45-year old woman who came to our service from the emergency room following an acute episode of agitation and disorganized thinking. I remember reading the diagnosis in her chart of chronic paranoid schizophrenia and feeling myself utterly at sea about how to care for her. In my time as a therapist, I had never treated a patient with psychosis. Somehow this of all diagnoses seems the most overwhelming, as if the person's entire sense of self has crumbled. Yet over our weeks together, I gained a much more sympathetic understanding of her struggles. Raised by parents who were alternately cold, emotionally withdrawn, and abusive, she experienced early that people could not be trusted to care for her. Her parents moved in elite circles and left her at home with a series of nannies and hired help. In her teens, she was sent off to boarding schools abroad, where she struggled to define her sense of self in the absence of any caring adults in her life. Despite all this, she completed college. But she began to struggle in her early twenties after the death of her grandmother, one of the only people she felt who really cared about her. She experienced disorganized thought and anxiety at 24 and was hospitalized. After this, she became even more estranged, since now she had failed to live up to her parents' expectations of her as a society daughter. As she unfolded her story, I could so clearly see how her "paranoia" about her illness seemed to stem from so many hurts and rejections over the years. She said, "I hid from people and didn't date for years because I knew if they really knew me, they would only push me away." I saw how deeply hurt she had been by those closest to her and how this diagnosis symbolized a final wall that could always divide her from others. Despite her initial anxieties, we were able to explore much of her history. We found ways to consider her strengths as an intelligent woman who sincerely wanted to develop more emotional closeness in her relationships. She was able to recognize that her seeking help represented another strength rather than a failure. In the very act of trusting me, she had already begun her journey toward greater connectedness with others. I came to medicine with the hope of learning how to be a healer of both body and mind. To me, the stories of these two patients are a reminder that our most powerful lessons may be learned from simply listening to the experience and insight of those in our care--that perhaps they may heal us as much as we heal them. --Alisa Land, a third-year medical student at HMS The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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