He wasn’t the first person I met days before I was to start my psychiatric residency, but as I walked about in my new city, he caught my attention much more than most. He stood in the middle of the block, not at the beginning or the end as one might expect—a very thin figure twisting one way and then the other, very long hair falling mostly to the side of his withered, young face as he swung about. In between talking to the air, he sucked so hard on his cigarette that at points he appeared to be on the verge of swallowing it whole. He gesticulated, tortured gesticulating of dyskinetic fingers, later jabbing out irregular circles when he appeared to be emphasizing something or other. Sometimes he paused, scanning furtively with glassy eyes as if trying to decipher things, and then just as suddenly he launched into forceful head bobbing with blasts of cigarette smoke and angry retorts.
At 3 o’clock one morning, when I was on call for the psychiatric emergency department (ED), I learned that his name was John. I found him huddled forward, fairly twisted into a knot of a person, arms and legs tightly wrapped in a crisscross, hair mostly scattered about his face, piano-playing fingers flickering up and down, scanning the ground. Initially, he said nothing at all: he simply scanned the ground, flicking his fingers and occasionally puckering his lips. Suddenly, he sat a good bit more upright, stared quite directly at me, screwed up his face into a particularly contorted, anguished expression, and blurted out, “Doctor . . . can I tell you something?” His look was one of both complete terror and rage, nothing less than what one might consider “wild.”
Pressed back by the force of his near-explosive launch into the question, I suddenly felt a bit frightened. Whether I conveyed fear in some way, I don’t know, but I tried to ignore my anxiety and answered that he certainly could tell me anything at all. With that, John fell entirely silent again, folded back over, and returned to scanning and flicking his fingers. After what seemed an interminable time, he sat bolt upright again and repeated the very same thing, “Doctor,” this time, more urgently still, boring into my gaze, breathing deepening to the point of nostrils flaring, he continued, “can I tell you something?” I responded, “Yes, you can,” trying to side step my increasing alarm. Just as quickly, he again returned to his pretzel-like huddle and said absolutely nothing else.
During my entire residency, each of John’s many ED visits duplicated this dynamic—his initial near-desperation of wanting to tell something and then the instantaneous retreat into himself. Many other residents evaluated him along the way and had very much the same experience. We knew his name and where he was from, but little else. John remained an enigma, our identification of him reduced to that of someone suffering from schizophrenia. He never accepted medication, and verbal exchanges were truncated.
Over the years, it was painful to see him still suffering, standing on other city blocks buffeted by the wind and waves of people rushing by, barking out retorts to the things of which he would not speak directly. And for all of his attempts to “tell” something, one couldn’t get inside of him. It used to frustrate me, seemingly bereft of the stuff by which to help him, or so I felt.
Long since that time, I’ve come to feel somewhat differently and not only in regard to John but to all patients. As psychiatrists, we typically assume that we will hear the inside stories, even if in bits and pieces, that will help us better understand and help patients. But perhaps we are too expectant, not as ready to hear that the request for help can be so ambivalently held that the patient’s request to tell us something is essentially rhetorical. We might not learn much at all because the information may be terribly disturbing to the patient—and perhaps to us. The resonance of our fear and anxiety to the patient, no matter how subtly expressed, can make divulgence less likely still.
Psychiatrists are necessarily part of a dynamic that conveys to varying degrees readiness and acceptance to hear more. But in placing so much emphasis on content, we might miss other equally important stuff of the mental status that speaks pointedly to some of our patients’ struggles. The manner in which a patient’s “question” is parlayed also tells us something of value.
As well, the very interchange between the patient and clinician can have some therapeutic power. It may be a fledgling empathic connection that can grow over time, allowing for deeper dialogue and other treatment considerations. Therefore, we may have more answers than we might have assumed and be able to help proportionately, even if only slightly, compared with what we might otherwise effect were we to know more. But at very least, when we ask to be told what ails someone, we have to be genuinely prepared to hear the answer. We can’t draw patients “in” if a part of us wants “out.”
I will forever feel sad, even haunted, that I was not able to help allay John’s torment. When he asked if he could “tell me something,” perhaps I conveyed an ambivalence about hearing something potentially bizarre and disturbing.
Although doubtfully the sole genesis of his reticence, the tendency to be pressed away might have compounded his remaining opaque. I wish I’d felt braver. I still hope that he at least got some comfort by knowing that he could always come to the ED to broach his anguish, necessarily ephemeral and incomplete though that comfort might have been. Long since then, John metaphorically asks me, “Can I tell you something?” More than ever before, I answer, “Always, John, always.”