Empathic Apathy or Who Cares?

Thanks for the story, RobinMSW. That reminds me of the time when we were reading a patient's intake notes during rounds and saw that someone had written something to the effect that "Patient exhibits paranoia as evidenced by stating that he believes George W. Bush is out to get him." We all looked at each other and said, "Well, geez, I think he's out to get me, too." And Robin, of course you can call me Maddie.

I have a patient in-house now who I try to avoid. I find myself stalling all day long, putting off seeing her as long as possible; I sometimes miss rounds on her unit so that I don't even have to talk about her. It's not necessarily a conscious thing that I'm doing, but that I do it is undeniable.

It's not that I dislike the patient, or feel manipulated or disrespected by her, or that she inspires rage or fear in me, as other patients sometimes do. And it's not the still-healing wounds on her arms, or her rail-thin body, or even her traumatic history that I find repugnant. It's her apathy. She says she feels nothing, desires nothing, grieves nothing. She stares into space, shrugs, and whispers "I don't know," in response to almost every question. She's so depressed that she can't even muster the energy to suffer. Today I was grasping for something, anything, that would help her connect to some part of herself that was once alive. She said that her wedding day was the happiest day of her life, yet she can remember practically nothing about it. She says she knows she enjoyed doing her Christmas shopping last year, but only with patient coaxing can she recall the sights, sounds and smells of Christmas.

She has been ill to varying degrees for twenty years, and she has tried to kill herself many times, nearly succeeding on several occassions. Someone always finds her. Maybe she always designs to be found. She says now that she wants to kill herself because she is tired of one of her alter personalities always trying to kill her. I'm no expert in this area, but it seems to me that killing off that renegade alter makes a whole lot more sense. Clearly it's not that simple. But it looks to me as if, having thwarted the alter's attempts at physical suicide only to fail at it herself, the patient has decided to die metaphorically via anorexia and apathy.

The trouble I have with this patient -- or the biggest trouble, I should say -- is that at this magnitude, if the absence of something can be said to have a magnitude, her apathy is insurmountable for me. I can give you many ideas about why this patient is the way she is, and tell you about my belief that there is something in her that can be marshalled, and talk about our goals for treatment and blah, blah, blah. The truth is is that this patient makes me feel helpless and lost, and there is so little to connect with, so little coming back to me, that I can't even say that I can muster up much energy to care about her, either. We've all had patients like this, and in a way this patient can be understood to be making a fairly desperate plea for help, so I'm duly contrite about my own apathy, and have been inculcated enough in my profession to be able to say I understand my response as empathic, and therefore competent. So I'll give myself a little talking-to, and resolve to see her first thing tomorrow and try not to let my apathy now, in turn, rub off on her.

All best,

Madeline

Back in the Nuthatch

Hi there,

As you can see, I'm back from vacation. I'm glad to see that several spammers stopped by and commented on my last past.

Sometimes coming back can be a bit of a hard landing, since you have to pick up a whole new case load all at once, while also trying to get your head back into the game. So it's taken me a couple of days to get a chance to post.

Remember Arnie? (See my post entitled, "So, my day today..." [Again, I'd give you a link if I knew how]). He was finally discharged while I was away. Arnie is a 48-year-old homeless, former Really Bad Dude who now has dementia and a fondness for fist fights and heroin. Right before vacation, I had finally gotten a very promising lead on a nursing home for him. He also had a commitment hearing scheduled for while I would be away; while we thought it very unlikely, it's possible that a judge would order us to release Arnie on Arnie's assurance that he could look after himself. It seemed like better than even odds to me that he would still be here when I got back, but I made it a point to say a proper good-bye to Arnie, just in case. He'd been with us a long time (a few months) and I'd put a lot of time into his case. He'd salute every time he saw me, and I'd salute back and say, "As you were, soldier." Then he'd laugh and snap his fingers to some rhythm in his head each and every time. I'd grown rather fond of Arnie.

Arnie asked God to bless me, which I took to mean that he understood that I was doing what I thought was my best by him, even though he repeatedly expressed his desire to be discharged to the street. He knew I had been trying hard for months to find a placement for him, and, he'd say that he'd rather go somewhere than nowhere, but he was tired of being locked up and thought he'd be fine on his own. I had said to him many times that I wouldn't put him on the street unless a judge told me I had to, because I just didn't think he could keep himself out of trouble. And no matter how big a bad dude Arnie may once have been, trouble is now bigger and badder, I would tell him. I'd remind him that he came to us after having been beaten up with baseball bats by some young punks.

Arnie never went through with any of his threatened court hearings, and in the end was discharged to a nursing home. During his stay, I often wondered if Arnie would cancel the hearings because he realized on some level that I was right, or because he calculated that he stood to lose more of his freedom if a judge committed him, or if he was trying to exert some control over his life in the only way available to him.

But there was something about the look in his eyes as he invoked his God on my behalf that has me wondering if he canceled all those hearings, and let me keep looking for a place for him even though he hated being in the hospital, because he decided that having that feeling as though someone was looking out for him was worth putting up with the unpleasantness of being locked up in a nuthatch. That might seem like a sad compromise for Arnie, but, really, haven't most of us made a similar bargain in our own lives, and how many of us would again if the opportunity presented itself?

Madeline

Vacation!

Hi folks,

Wanted to let you know that I will be on vacation from The Nuthatch after today until Monday, September 19th. Come back then!

Madeline

Wednesday isThree-Day Day, Part II

Well, I was wrong. Both patients retracted their three-days. In case any of you wanted to know.

M.