Chaos and catharsis

By Rachel Conrad, MS3

It was a busy afternoon for the Psychiatric Emergency Room. The whiteboard was smeared with bright streaks and dry erase marker scribbling communicating critical patient information. The beds in the hospital’s inpatient psychiatric unit were full, and the emergency room psychiatric holding area was at capacity.  The residents were rushing to see patients, and the attendings struggling to determine which patients could be safely discharged.  A young female patient, 18 years old, had been on our list since the previous day, and the chief complaint was not clear.  The little information we had about her was diluted through multiple handoffs, and all we could gather was that she had been agitated and required physical restraints the previous evening. I decided she might be an interesting person to meet.

The patient’s chart provided little information. The many emergency medicine residents and attendings who had spoken with her during her 18-hour stay in the emergency room suspected drug use, but she had barely spoken to the doctors. Her refusal to tell them what happened seemed odd. I had no idea what to expect as I went to meet her.

I found a petite teenage girl who seemed timid and uneasy.  Her father was beside her bed and expressed his utter confusion at the situation. He described his daughter as a happy, well-adjusted girl who had never been in trouble and had no history of psychiatric symptoms or drug use. He had no idea what had transpired the evening before and said his daughter seemed unusually withdrawn today. He went to get a cup of coffee while I spoke with her alone.

I began asking the patient questions about what had happened, and she provided choppy, confusing responses while avoiding eye contact. She claimed she ingested something she found on the floor. As I pressed her on the details of the story, she became restless and inarticulate.  I continued to probe her patiently while she squirmed, then finally let out a loud sob.  Her behavior was confusing and her emotions were so intense that I wondered if she was still under the influence of drugs. I decided to patiently express empathy for whatever she was experiencing and be present while allowing her time to cry.

After sobbing for a few minutes, the story poured out through her tears. She acknowledged that she had taken a street drug that she bought from her sister’s friend. Fear of her father’s condemnation had paralyzed her and she was drowning in her shame.  Her first time to use hard drugs was a terrifying experience.  She had been so flooded by these intense feelings and so afraid of judgement that she had felt too paralyzed to tell anyone in the ER what happened.  I tried to stay present with her as these emotions poured out. After she finished her story, she looked into my eyes and asked whether I would forgive her. I expressed to her that no one wanted to judge her, and we were here to help her; most importantly, she would have to forgive herself.

We discussed at length the dangers of drugs, her reflections on this situation, and her aspirations for the future. The attending physician came to speak with her about her experience and the choices that lay ahead. By the end of our conversation and until her discharge, she was articulate, appropriate and honest. She told her father the truth, they had an open discussion and acted affectionate towards each other.

Her behavior improved dramatically by simply empowering her to voice her feelings and providing her with the empathy she needed to face her pain.  In the ER, we can be quick to dismiss any abnormal behavior as a sign of psychosis, drug intoxication or a personality disorder. This patient’s behavior and presentation was simply the product of intense fear, shame and confusion in response to a legitimately frightening life experience.  We encountered her at a fork in the road, her first experimentation with hard drugs, which could have a drastic impact on the trajectory of her life.  If this formative experience with drugs had gone differently, she may have not had the opportunity to question her choices. Hopefully, facilitating expression of her feelings, reflections on her situation, and reconsideration of her choices will empower her to take care of herself and change her life course for the better.