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