Bottle of Pink Lemonade

February 2, 2010
Rashmi Ojha, MD

Volume 27, Issue 2

Like every new resident just starting to work in an outpatient clinic, I was nervous about the patients I would inherit from the graduating resident. It did not help when the graduating resident warned me that one particular patient “could be difficult.” I comforted myself with the thought that every psychiatric patient has a “difficult life” and that is why they need our help.

Like every new resident just starting to work in an outpatient clinic, I was nervous about the patients I would inherit from the graduating resident. It did not help when the graduating resident warned me that one particular patient “could be difficult.” I comforted myself with the thought that every psychiatric patient has a “difficult life” and that is why they need our help.

After the first 2 visits with the patient I had been warned about, I began to understand what my senior resident had meant-or at least I thought I did. The patient seemed frustrated and angry with his care providers and repeated that they did not care at all about him and were only there to make money. He carried on about how all doctors were the same and accused them (and me) of being money-sucking parasites who cared only about money and who did not care whether he lived or died. He hated the group home where he was living and was nonadherent to his medication regimen. He was also receiving bimonthly injections of haloperidol, which he seemed to hate.

On our third visit, the patient seemed to be overtly suicidal. I sent him to the hospital, where he was admitted. Shortly after he was discharged, he showed up in the clinic again. When I saw him, I had one of those “I wish I did not have to see him” moments. On this visit, I decided to just listen to him. He was focused on how much he hated living in the group home. We then started talking about how things differ between group living and independent living, and we discussed such practical issues as expenses and bills. He seemed more comfortable as we began to have some meaningful conversation. I realized that I had started to provide psychotherapy after my supervising attending psychiatrist pointed it out, and I was glad that something was working for the patient.

The patient again started to complain about the haloperidol shots. I told him that we could eliminate them if he would take his other medications regularly. Surprisingly, he agreed. He became more adherent to therapy and started to show up early for all his follow-up appointments. He said he always looked forward to his appointment and wanted to use every minute of our allotted time. He required a good deal of reinforcement, but he always followed my directions. He quit drinking and smoking on his own. He was still frustrated with living in the group home and we discussed the possibility of him joining the Assertive Community Treatment (ACT) team, which would give him some independence. He hesitated to take this step, because it would mean that he had to be discharged from my clinic and would have to follow up with a new doctor. He finally agreed, but not before bargaining to be able to keep me as a doctor. (I told him this was not possible.) Ultimately, he decided he needed this chance to show that he could live in a community with some support, and he reluctantly agreed to follow up with the ACT team’s doctor.

On our last visit, the patient said to me, “I didn’t even cry this much when I lost my mother.” He became tearful and offered me a bottle of pink lemonade. I was unwilling to accept it because accepting gifts from patients was not recommended. He persisted and told me how much it would mean to him if I would accept his small token of appreciation. I struggled to hide my own tears. I finally took his lemonade but insisted that I could not accept future gifts.

I don’t like pink lemonade, so after the patient left, I offered the bottle to my colleagues. No one wanted it. I left it in the refrigerator thinking that someone might drink it. When I opened the refrigerator a week later, it was still standing there, untouched. Staring at it, I somehow felt guilty and disrespectful of my patient. I reached inside the fridge, grabbed the lemonade, opened the bottle, and drank the contents at once. Although I disliked the taste, it gave me a real sense of satisfaction. At that moment, I realized, I had a motherly counter transference toward my patient. I have never felt so strongly about any of my patients, and suddenly I had a grown-up man-child of my own.

After I came to this realization, I began to feel more confident of myself. As clinicians, we tend to notice negative countertransference and forget that positive countertransference can also be difficult to deal with. Now I need to learn how to control my emotions and how not to let my man-child act out while he awaits transition to the ACT team. This, I guess, is also part of the process that will help transform me from a resident to a psychiatrist.