Albuquerque, New Mexico, United States (Fall 2011)
“I wasn’t trying to kill myself,” Jessica insisted, running a black-tipped, artificial fingernail through her black, gelled hair, which flashed blonde at the roots. “I was drinking, and I miscalculated. I didn’t know this could happen.”Jessica had been admitted to my adolescent psychiatric unit after she fell down drunk on a street corner and friends could not rouse her. She was a petite, high school freshman, dressed in a black hoodie and skin-tight jeans that clung to her slender legs.
Since the school year began, Jessica had been sneaking out at night to go to parties. Binge drinking, taking pills, and cutting on her arms, she risked failing out of school. Jessica confessed that she had been thinking about suicide for months, “But not seriously . . . just thoughts. I’d never do it.”
“My Dad thinks I’m acting out because of my mother,” Jessica said. “She has drug problems and moved away to California when I was in elementary school. She gets in touch sometimes on holidays and my birthday. This year she forgot. Dad tries to make up for my shit of a mom by knowing everything about me. It’s like being in prison with a super nice guard, but it’s still prison. I feel so hopeless sometimes.”
As Jessica was speaking, I mentally ticked off the symptoms of major depression. She had more than enough to make the diagnosis. “I think you have depression,” I told her gently. “You may not have been trying to kill yourself when you drank so much that night, but depression is underlying all the problems you’re telling me about.” Jessica burst into tears. I sat with her while she cried. Finally, she agreed to stay in the hospital and begin treatment.
My hospital treats depressed teens with antidepressant medication and therapy. A social worker does the therapy, and my job is the medication management. Beginning this new position only a month ago, my previous work was exclusively with outpatients, which suited my relaxed style. If a patient wanted to start medication—fine; if not—that was fine too. Psychiatrists, however, are more aggressive on inpatient units because their patients’ illnesses are more severe; worse, they often only have a few days with the patient before the insurance companies threaten to deny payment. I was eager to prove that I could handle the job. I knew I needed to toughen up.
I called Jessica’s father on the phone. He agreed with me that his daughter was depressed but did not want her to take antidepressant medication. He refused to consider it. He wanted to wait and see how she did with therapy alone.
That seemed sensible, but I worried I was not being firm enough. As if on a television infomercial, I spewed out more facts about major depressive disorder and its treatment. “Yes,” he said impatiently, clearly waiting for me to finish, “but medication has risks. How do you know it won’t hurt my daughter?” In an effort to reassure him, I explained the excellent safety profile of the newer antidepressants and how studies showed the increase in suicidal ideation in teenagers to be extremely rare. But he was not convinced.
Three days later, Jessica was feeling more hopeful with the therapy but still had urges to cut on her arms. Thoughts of suicide recurred after any difficult encounter with staff, the other patients, or family. I spoke daily to Jessica’s father about antidepressants. If he was not visiting the hospital at the time I made rounds, I phoned him. I dreaded our conversations but forced myself to keep trying. Jessica herself was willing to take medication if it might help her. The problem, clearly, had to be me. If I were a better psychiatrist, he would agree to let me start his daughter on a medication. Yet the more strongly I suggested medication, the more he resisted.
A week into Jessica’s hospital stay, the head nurse asked to speak to me. She looked embarrassed. “What is it?” I asked, feeling my face flush. She told me that Jessica’s father had visited the previous evening and asked if his daughter could have a new doctor because I did not listen to him.
I was stunned. My pulse accelerated. Did not listen? I prided myself on my sensitivity. Struggling through my feelings for a long moment, my thoughts raced. I know physicians make mistakes, yet shame flooded me. The only other psychiatrist on the unit was my resident. How could I explain that I was transferring a patient to her because the family had fired me? Even more humiliating, what if the medical director found out? Clearly I did not possess the thick skin medicine required of me. My simplest errors often took me years to forget. A small nagging voice even questioned whether or not I was cut out for this work at all. Perhaps I should resign.
Beneath the familiar self-recrimination, I was angry with Jessica’s father for not confronting me directly and ashamed of myself for pushing a treatment I was not certain his daughter really needed. This confused mix of feelings energized me enough to pick up the phone. I knew his number by heart. Before I lost my courage, I dialed.
“I’m calling to apologize,” I said before he could speak. “I think I came on too strongly. I wonder if there is something that concerns you that I didn’t hear because I wouldn’t let you tell me.” Then I shut my mouth.
Provided the opportunity, Jessica’s father opened up. His sister had died shortly after starting an antidepressant medication, and, though the hospital said the death was not due to the medication, he was terrified the same thing might happen to his daughter. He also admitted that he was still reeling from the discovery of Jessica’s alcohol use, which he had never suspected. Now that she was receiving counseling and had stopped drinking, he was hoping Jessica’s depression would lift. Of course, he said, if Jessica did not get better, he would reconsider the medication.
Relieved to have come to an understanding, we moved forward. Jessica remained off medications for the duration of her inpatient stay. Discussions about changing her doctor also came to a close. Continuing to improve, she was discharged to residential treatment. She and her father felt hopeful about their relationship, and thanked me warmly for my care.
Events like these contain a lesson, often more than one. Occasionally the lessons are new. More commonly they remind me of known but forgotten truths: it is more important to listen than to impart information. When a patient encounter goes badly it is embarrassing but possible to reassess and repair. My encounter with Jessica’s father taught me something new: the dangerous power of shame. When mired in shame’s self-centered, all-consuming morass, I could not see where I was failing or how to rectify the situation. Shame prevented me from listening to Jessica’s father’s concerns and nearly prevented me from calling him to apologize. But shame is a signal, not a sign of failure. It is the internal tap on the shoulder: course correction needed. Now, whenever I fumble, I remember Jessica and her father, and I try, oh so hard, to think through my shame.
Names and identifying details of the patient and her parent have been changed to protect confidentiality.
JEANNE BEREITER, MD is a child and adolescent psychiatrist and associate professor at the University of New Mexico School of Medicine, where she leads a residential treatment center for adolescents. She has a background in family medicine and creative writing. She is interested in the use of narrative to deepen understanding and in the ways that our thoughts and emotions can lead us astray from, then bring us back to, uncomfortable truths.