Thursday, October 23, 2014

Hug o' Tug o' War

"I will not play tug o' war.
I'd rather play hug o' war,
Where everyone hugs
Instead of tugs,
Where everyone giggles
And rolls on the rug,
Where everyone kisses,
And everyone grins,
And everyone cuddles,
And everyone wins."
~Shel Silverstein

Shel Silverstein was one of the preeminent poets of my childhood (along with Odgen Nach and Anonymous). This verse of his came to mind one night while lying in bed and thinking about my psychiatry patients: I want to hug so many of them. The outpatient encounters I have had so far were too brief to learn about many of the patients' hurts. In in-patient hospital medicine those hurts are usually physical. But in in-patient psychiatry, we spend enough time with them to learn about our patients' real wounds. If psychiatry has taught me anything, it is how cruel human beings can be to each other.

The standard psychiatric interview includes a history of the present illness, the patient's psychiatric history, and demographic information. That includes asking about any abuse or trauma the patient has suffered or is suffering. The stories of abuse and rape are horrific. So are the tales of woe about (near) homelessness, unemployment, lack of help caring for sick or disabled family members, missing disability checks, uninsurance (yes, still), toxic family dynamics, and lack of beds at substance-abuse treatment programs. It makes me want to hug my patients when they leave the ward, as if that could apply a thin layer of armor on them as they head back into unpromising situations without much of a social safety net.

Sometimes I want to hug them for joy, too. It is really gratifying to get a patient on a combination of medications that allows them to think clearly after months of agitation, racing thoughts, and frustration. One of them remarked to me, "Where have I been all this time?"

Of course, psychiatry is a particularly fraught field in medicine, unsure if it is more art or science. Do psychiatrists treat the mind or the brain? With the move toward more biochemical explanations of mental illnesses in the recent DSM-V, many of them feel that they can finally base their treatment plans on a materialistic pathophysiology that other doctors will respect. However, that further stigmatizes the disorders without neurotransmitter or genetic explanations as "all in your head." And not everything that is wrong with a patient can be treated with medication.

This tug-of-war between drugs and counseling is as old as psychiatry itself. Even after establishing psychoanalysis as an approach to mental illness, Sigmund Freud never entirely forgot his neuroscience roots. Tensions flared in the middle of the 20th century with the introduction of the first psychotropic drugs, which worked better than talk therapy for some conditions. "Better" at controlling patients and making them artificially compliant, retorted the likes of Thomas Szasz, who argued that without tests there could be few true mental illnesses. Patch Adams continues to advocate an extreme view of this line of thinking: out with the drugs that are overprescribed and just make Big Pharma rich, in with human connection and understanding. Forget haloperidol, hug your psychotic patient until he's calm.

I don't think I can cure any of my patients with an embrace if they ask for one. But it does seem like a positive human expression that cancels out just a little of their suffering. And who knows, maybe the endorphins it activates help their medication work better.

No Doctors Today, Thank You
~Ogden Nash
They tell me that euphoria is the feeling of feeling wonderful, well, today I feel euphorian,
Today I have the agility of a Greek god and the appetite of a Victorian.
Yes, today I may even go forth without my galoshes,
Today I am a swashbuckler, would anybody like me to buckle any swashes?
This is my euphorian day,
I will ring welkins and before anybody answers I will run away.
I will tame me a caribou
And bedeck it with marabou.
I will pen me my memoirs.
Ah youth, youth! What euphorian days them was!
I wasn't much of a hand for the boudoirs,
I was generally to be found where the food was.
Does anybody want any flotsam?
I've gotsam.
Does anybody want any jetsam?
I can getsam.
I can play chopsticks on the Wurlitzer,
I can speak Portuguese like a Berlitzer.
I can don or doff my shoes without tying or untying the laces because I am wearing moccasins,
And I practically know the difference between serums and antitoccasins.
Kind people, don't think me purse-proud, don't set me down as vainglorious,
I'm just a little euphorious.

p.s.--Beaucoup bonus points for anyone who can write a mental status exam on the speaker of this poem!

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