Week One

It's now been about a week since I started work on my inpatient unit. I'd love to tell you an insightful and inspiring story about a patient I helped this week; that looks like it'll have to wait for the indefinite future. The truth is that like many inpatient services, medical or surgical, we can't fix long-standing problems. We're a service for short-term stabilization -- getting someone just to the point of not being suicidal, not being off-the-walls manic, not hallucinating too much. But, just like medical illness, psychiatric diagnoses don't exist in a vacuum. If you're just depressed, you probably won't get anywhere near true suicidality, because your family and friends will drag you in front of a doctor way before that. But, if you're depressed, AND you had a traumatic childhood that left you unable to cope with life stress, AND you use alcohol/drugs heavily to cope with your depression and life stress, AND you're not exactly highly educated/compensated because of the foregoing, AND maybe you've got some chronic health problems to deal with, then chances are that at some point, you're going to just plain lose it. (The polite medical word for this is "decompensate".)

When you do, you'll end up on a unit like mine. My job, as determined by your insurance company, the law, and general custom, is to patch up your psyche, whether it's by increasing or changing medications, getting you a bit of detoxification from your substance of choice, or just giving you a safe and quiet place to hide for a week. What I'd like to do is let you walk out of the doors a few weeks later as a complete and functional person. Unfortunately, I can't. This isn't just the limitations of the medications and my own developing psychotherapy skills; it's the limitations of the world. For 90% of my patients, what's wrong with them is partly in their brain, and partly in their world. Their entire living environment reinforces whatever bad coping strategies got them admitted in the first place. Moreover, those bad early experiences have been burning themselves into the allegorical neural pathways for decades. It's not biologically possible (to the best of our knowledge) to undo years of conditioning in a week, or even a month. The best I can do is boost up the brain chemicals, get some help from our social worker to tweak one or two environmental variables, and then send the person back to their environment with a list of suggestions. Sometimes, they follow them, and over many years, they get better. Sometimes, they don't. Frustratingly, I don't get to find out.

This is, of course, not to say that what I do is useless. Far from it. My short courses of treatment are the equivalent of duct tape and twine, but if you know what you're doing, duct tape can take you pretty far. Moreover, treatment is the difference between one suicide attempt, and a suicide attempt followed by another, and another, until the person finally "succeeds". What frustrates me a bit is the endless list of problems that must remain unfixed. Like all good little doctor-trainees, I've got a perfectionist streak a mile wide. It's very hard to leave valuable work undone, and even harder to look a patient in the eye and tell them that no, I'm just not going to help with that particular problem. I'm sure I'll get a lot more comfortable with that as the year goes on; I'm not as sure that this is a good thing.