Nothing To Do…

I composed a song today that I’d like to share with you. It’s called Shifting States, and it is my musical representation of something that happens in all of us all day long. Hope you enjoy it!

Shifting States by Ian M Crooks, MD
To return of clarity, leave it alone…it will clear by itself!

Every year, I have about 2000+ visits in my private practice office with the people who are my patients. I meet with some people more often than with others, but in general, I have the honor and privilege of working with many people from all walks of life. In meeting these people, and getting to know them, I also learn a great deal from them.

Many people in society think that psychiatrists only manage medications. The people with whom I meet seem genuinely surprised when I tell them that I provide psychotherapy as an integral part of my practice. 

The longer I practice, the clearer it is to me that the majority of suffering comes from people being unaware that ‘who’ they are is just fine. At the core of everyone, there is health and well-being. There is a big difference between ‘who’ a person is, and what they are experiencing.

I’m certain that you, like me, have had times when you have felt stressed and upset, (help me out here…it’s not just me, is it?). Likewise, I’m certain that you have had times in your life when, on the whole, life seemed pretty good and a feeling of peace and calmness would describe your state of mind. Isn’t that true?

What we sometimes miss is the realization that our state of mind is changing all the time, even in the course of one day, (I would argue even in the course of one hour).

We are never one mood for hours or days at a time. Take a moment to reflect and see if this is true for you. Consider how you were feeling yesterday afternoon. Now, how were you feeling two nights ago? How about this morning? How about right now?

Even the most depressed person I have met with in my office will have some variation in the intensity of their mood symptoms throughout the day. The person with intense anxiety will admit to some periods of time during the day or week when they are less tight. People with psychosis, who are hearing at times threatening and critical auditory hallucinations, will report that sometimes it is easier to deal with the voices, and they don’t feel as frightened of them during those times.

I do not recall a single morning where I have gotten up, grabbed a piece of paper and started making my to-list: I need to get frustrated at least twice today. Remember to feel insecure for at least 15 minutes. Don’t forget to feel proud and confident once in the morning and then from 3-4pm. Oh, and make sure that some time is devoted to ruminating about a wrong someone did, and make sure I stew about it, maybe even give the other person the silent treatment, that will show them!

No one makes these kinds of lists, but that’s what shows up as we go through the day, isn’t it? All day long, our mood is shifting up and down. When our mood is up, there really is nothing to do, is there? Simply enjoy it. But then what happens? We like the feeling of the good mood, and we want to keep it.

During a good mood, (it might be peace, joy, happiness, gratefulness), have you ever had the thought, “Hey, I finally got it figured out. I’ve arrived! No need to ever feel down again.” (Honestly, it is the same thing when I hit a good golf shot…“There we go! I knew I could hit good golf shots! I’ve got my style down now. It’s going to be all fun and enjoyment from now on.” Until it isn’t, and then I’m tromping around in the woods, fighting with frustration, finding it difficult to understand what happened, and difficult finding my golf ball!).

Well, if there is nothing to do when our mood state is good, what’s the key to dealing with low moods? Would you be surprised if I said, “Nothing to do,”? I know it surprised me when I first started to understand the nature of moods.

The world around us has about a zillion approaches to getting away from low moods and into better mood states, doesn’t it? We can buy stuff. We can recite positive statements to ourselves. We can visualize. We can get the right relationship. We can work out and eat the right diet. We can mediate and pray. We can work towards goals and get awards and create a reputation. We can surreptitiously elicit approval from others, (sometimes we just demand it). We can also drink booze, smoke cannabis or throw back a few pills as we drink and smoke! The list is really too long to include here. Perhaps you have your own approaches to change the way you feel? 

There is nothing wrong with any of the approaches listed above. Our old friend Shakespeare would say, “there is nothing either good or bad, but thinking makes it so.” 

However, here is something worth considering: when experiencing a negative state, a low mood, there really is nothing to do.

Have you ever held a snow globe and given it a pretty vigorous shake? What happens? The snow inside flies around every which way, doesn’t it? 

The snow is like our difficult thoughts and feelings. When challenging thoughts and feelings are flying around in our head, we get pretty busy shaking the snow globe harder trying to get the snow to settle down, don’t we? “If I could just get rid of these thoughts/feelings! Then I could feel better and get on with my life!”

How do you get the snow to settle down in a snow globe? The answer is simple, isn’t it? You need to put the globe down, and then the snow settles by itself. In fact, if you do anything with the globe, the snow will start to fly again. It’s the same way with the difficult thoughts and feelings we can experience. Simply leave them alone, and at some point, they will move on. The entire body, including that mysterious thing called our mind,  is designed for homeostasis, a term that means ‘getting back to the norm.’

There is an oft cited study from 2005, the National Science Foundation that stated that we have about 70,000 thoughts a day. That is a lot of thought, isn’t it?

It is the nature of thoughts that they come and go. If we leave them alone, they arise and then they move on. Don’t take my word for it, see for yourself. Notice in this moment what you mind is doing. What thoughts are arising? Are they the same thoughts that you were having earlier today? 

When we begin to see that ‘who’ we are and what we are experiencing are two different things, it becomes easier notice thoughts and feelings and not be as frightened of our own experience, because we understand that a new thought or feeling is already on its way. 

Some psychotherapy approaches encourage people to get good at spotting dysfunctional thoughts. People are encouraged to look for evidence that their cognitive appraisals are either true or false. Homework is assigned where people are instructed to identify difficult thoughts and then pull them out like you would a weed in a garden and then actively plant more realistic thoughts. Time is spent learning how to reframe the cognitive distortions that arise and try to arrive at a more empowering way to deal with the thoughts and feelings that arise.

Is there anything wrong with this, or the nearly 400 different modalities of therapy currently used in psychotherapy today? Nope. But it does sound like creating a dam in a river that would otherwise be flowing, doesn’t it? Keep holding on to thoughts, and treat them like Play-Do…eventually they’ll improve and you’ll feel better.

Don’t take my word for it. Consult your own experience. What happens if you are simply grateful for the ‘good’ moods that arise, and do your best to be graceful when the ‘bad’ moods show up?

There is nothing to do. You are the experiencer. You are not the thoughts or the feelings that arise and then depart, to be replaced by other thoughts and feelings. When this simple relationship is seen, how much easier it becomes to see that trying to change negative thoughts and feelings is like trying to prevent storm clouds from moving into the sky. Good luck!

The sky has room for everything: clouds, storms, birds, planes, fumes, buildings. None of these things change the sky at all. 

You are the sky, and whether presently your mood is up or down, there really is nothing to do in order for your mood to change. See if this isn’t true for you as you go through your day.

When we give up spending time and effort trying to get rid of difficult thoughts or feelings so that we can get on with our life, we more easily see that we can use our time and effort in this moment in the pursuit of doing things that really matter to us.

Right now is the only moment there is. Our life is happening right now, not in a week from now, and not a year from now. Similarly, our life is not happening yesterday or even earlier this morning when we were eating breakfast.

When we devote each day to taking action in service of our freely chosen values, we experience more engagement, more vitality and fulfillment, not because we got rid of bad thoughts or moods, but because we are living the life we have chosen for ourself. Meanwhile, clouds float by, storms advance and then pass along, planes and birds fly by, noxious fumes float up and then away, and Sky says, “You are all welcome. Stay as long as you’d like. I have room for you all!”

Please feel free to forward this to someone you think might find it helpful.

I’d be interested in hearing your comments, (so, I guess there might be at least one thing to do!).

Riding the mood elevator up and down
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Old Gnus is Know News

Gnu now knew his continual clip-clopping on the crushed circular path could not get him going in the direction he desired.

Gnu knew this. Gnu also knew he was getting nowhere and was depleting daytime doing it. He was tired, troubled, and positively perplexed.

Gnu slowly surmised he was on a ceaseless self-limiting sojurn. The more he meandered, the closer he came to where he had started.

“I’m always going to where I’ve come from,” Gnu softly sighed with self-pity.

“There must be a better way,” he tensely thought, sharply stamping on the solid soil. “If I just try harder, surely I can easily escape and go graze in greener grasslands.”

He tried cantering carefully. Nope. He tried hoofing harder. Nope. He even tried sprinting slower. Nope. 

He tried stirring at sunrise and he tried staying out under the stars of the sky. Nope and nope.

When he arrived at the beginning of the trail, (again!), he snorted sadly, full of frustrated feelings and debilitating despair. 

“I must lack good grit,” he thought, “maybe that is it.” The ungulate grasped the gist of grit, but he was sure that whatever grit he might have got was good and gone. 

Waves of worry washed over the woeful wildebeest.

 “Maybe I’m not good enough,” he thought for the 1000th time that day. Ugghhh! Gnu let out half of a half-hearted honk. Gnu panted pathetically.

Gnu hated headaches, however a honkingly huge one was horrifically hammering in his head.

 “Other gnus know…if I gnu, I mean,  knew, I no, I mean, know, I could find my way! ” Gnu loudly lamented. 

Gnu launched into looking for what he lacked. The longer Gnu looked for what he lacked, the more addled and alarmed he appeared.

Gnu’s gnuddle (scientific name for the gnu brain) was now totally teeming with terribly tumbling thoughts happening within his  hammering headache. 

“If I could just figure out why I’ve been going around in circles,” he muttered to himself over and over, “then I could finally…”

Just then, a lightning bolt abruptly broke from above and landed with a ferocious force five feet from the bewildered beast.

Gnu stood stock still…

He barely breathed…

He had no mental motion…

He slowly slanted his eyes skyward…

Then, out of the blue, it came to him…he suddenly saw in stillness his path to freedom.

What the other gnus knew:

“Overthinking about your problem-based thinking keeps you stuck to the problem and often is an obstacle to finding a solution.”

“A mind with a lot on it doesn’t leave much room for fresh insights or new perspectives to appear.”

“Solutions and helpful thoughts can come from out of the blue if you leave room for them.”

“A fresh start is always possible.”

What no Gnu knows:

Alliteration is the occurrence of the same letter or sound at the beginning of adjacent or closely connected words. 

My rules regarding alliterations are seldom spoken and never heard: alliterations should be used sparingly and tastefully.

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Who Knows?

The following essay is based on an actual encounter I had while I was in residency training. Names and other personal characteristics have been changed to protect the privacy of the patient for whom I provided care late one summer night. As a resident physician, one has the opportunity to begin to practice the skills acquired in residency, which is the four year postgraduate training that follows medical school. As a resident, you know a lot, but the actual practice of medicine in the specialty of psychiatry, in particular, takes a few years before you start to have a true trust in yourself. Moonlighting is the term that is used to refer to working outside of the required daily duties of the residency training program. After a full and demanding day in residency training, one may work an additional five hours late into the night at a different hospital, thus the term, moonlighting.

The mid-50’s guy with a scraggly grey beard and a big old paunch that stretches out his faded, once white T-shirt sits in a slouchy, sprawly way next to his prim and proper wife. She wears a light-blue hospital mask over her nose and mouth, her beautiful brown eyes peering over the top of the mask. She has long chestnut hair and shortish bangs over her forehead that complete the frame of her visible face.

We are sitting about two feet away from each other, our knees almost touching, in a cramped examining room. I’m balancing a clipboard on my lap, stuffed with notes, a police report and forms of all kinds that will need to be filled out at some point tonight.

Outside the room and down the hall in the admissions areas, a woman in her mid to late 70’s is screaming ear-splitting profanities directed at a middle-aged man, perhaps her son, who in turn is looking at the admissions nurse with a wide-eyed expression on his face that seems to say, “See what I mean?”

“Well, maybe I do yell…I’ve been told that I yell,” drawls the slouchy guy. His wife looks down at her hands which are interlaced and locked so tightly, I can see her whitened knuckles. She glances furtively at him and then slowly turns toward me. Not being able to see the entirety of her face behind the hospital mask, I am surprised at how much I got from just her eyes.

“Based on what I just talked about with your son, it seems like yelling was at least part of it,” I say in a neutral tone, hoping to encourage the slouchy guy to be a little more forthcoming. His face breaks into an incongruous half-smile and he emits a deep throated chuckle and a snort, like something funny just occurred to him. 

“I had to use duct tape because he was getting out of control,” he says, continuing to snort. 

About twenty minutes ago, I had started evaluating my fifth patient of the night in this very same room, located in the heart of this dingy old psychiatric hospital. The patient, a 13 year old boy with jet black hair that had been treated with some kind of goo or gel that allowed his 8 inch long hair to stand up in big, undulating waves high above his head, had been brought in by his parents because he was, “out of control.” I was marveling at this boy’s rather extraordinary hairstyle, when I caught him looking intently at my balding head. Inwardly, I smiled. Here I was studying his thick shock of hair that could do tricks, while mine had been reduced to one trick: turn gray and fall out. Oh, well.

As the kid and I talk, it becomes apparent that the boy had poked, or possibly stabbed his father in the gut with a metal guitar stand at home during a heated argument earlier in the evening. The boy then went after his Dad with the actual guitar itself. Dad had cuffed the boy down to the floor, sat on the kid’s legs and then proceeded to duct tape the kid’s arms tight to his body. Somehow, at this point, the kid got loose and ran out of the house, down the street and through the neighborhood, and finally managed to get a neighbor to call 911. The police showed up and escorted the kid, Mom and Dad here to the emergency unit of this psychiatric hospital.

Okay, sure.

The kid has a stock answer to the first handful of questions I ask him, “I don’t know.” In spite of his curt answers, he looks somewhat earnest and hopeful. His eye contact is pretty steady. His face has that fawn-like or changeling appearance, not quite a boy and not quite yet a man. 

He doesn’t know it, yet, but he will likely be staying the night against his will in this old psychiatric hospital. Unaware of this, with less guise than he imagines, I can tell that he is working it, working his plan to get me on his side and get him released.

Back in the room with the parents, the scraggly bearded Dad tells me that the boy has once again broken probation and over the past few weeks has been skipping school and failing classes.

Earlier in the year, the boy had been caught stealing some pricey property from a home in the neighborhood. He had also vandalized some other things a few days before that. The boy had been sent to ‘some kind of juvenile law breaker place,’ according to Dad, and the boy was placed on probation, not for the first time. Shortly after beginning probation, the boy was caught with something he shouldn’t have had, (Dad was vague about this), and things went from bad to worse. The Dad says, “Me and the wife are at our wits end.”

The emerging story was that over the past few years, medications hadn’t been helping. Setting limits had been unenforceable. The legal system wasn’t making any difference. Brute force, apparently, was the only thing that was being used at home, and its efficacy could be measured in our meeting here tonight.

Slouchy Dad hitches up his trouser leg, his legs spread out wide from his chair, and says, “I know it’s probably his testosterone and wanting to be the alpha dog, but we just can’t keep going on like this.”

Over the hospital mask, Mom’s eyes have a beseeching expression tinged with fear. I assure them that a lot of kids go through an adjustment phase during adolescence. I also go on to say that not all kids have this kind of conduct and end up in a psychiatric hospital. As I’m talking with them, my mind is meandering through categories of conduct disorder, oppositional defiant disorder, intermittent explosive disorder, substance abuse, trying to find something that will give a sense about how to move forward with a treatment plan.

I look at the parents and I’m impacted by their despair and confusion. For a brief moment, I imagine them in their younger days. Youthful and in love, wanting to start a family. I know from our earlier conversation that they have three kids. I imagine their first two kids, daughters, separated by two years, bringing smiles to their faces. The daughters go on to do well. Good students, both of them destined for college. Eight years after the daughters are born, a baby boy arrives. I imagine the wriggly, cute baby boy brought home from the hospital. The parents are delighted with him, enjoy playing with him, getting used to the distinctly different energy that comes with a boy compared to the girls. At what point did it start falling apart? Were there signs along the way that the boy would grow up to have problems?

Or did I have it all wrong in my fantasy about this family? Is the Dad some kind of rough character, an overpowering force that browbeats the family, and the only option the boy had was to rebel? I look at the wife, at her fearful eyes. She looks away. Slouchy guy scratches his beard and shifts in his chair.

Out of the corner of my eye, I see that the elderly woman, who has been cursing at the top of her lungs the whole time, has taken a big, lunging swipe at the middle-aged man, whom I am assuming is her son. Something will have to be done soon to get her calmed down before she is transferred to the ward. The admissions nurse is giving me a meaningful look.

Sitting knee to knee with the parents of the once duct taped boy with big hair, I realize that I am not likely to learn the truth tonight about what has really happened that got them here, both from years gone by or from earlier tonight.

I take in sharp breath, suddenly aware that I really hadn’t been breathing. I launch into the professional wind-it-up mode, and tell the parents that I will be admitting their son. I explain that in the morning, the primary team will meet with their son, and later in the day, the social worker will call the parents with a summary of the treatment plan, including length of stay. The parents nod dully at me. No, they say, they don’t have any other questions for me.

The screaming elderly woman is now pounding desperately on the plexiglass of the nurses station and looking suddenly unsteady on her feet. The admissions nurse is now waving at me. Time to make my move.

I stand up and thank the parents for their time and input. Behind her hospital mask, the woman with the beautiful and fearful eyes stares down at her tightly wringing hands. The scraggly bearded man’s half smile appears again. Who knows what is going on here?

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We’ll Keep Her…

The following essay is based on an actual encounter I had while I was in residency training. Names and other personal characteristics have been changed to protect the privacy of the patient for whom I provided care late one summer night. As a resident physician, one has the opportunity to begin to practice the skills acquired in residency, which is the four year postgraduate training that follows medical school. As a resident, you know a lot, but the actual practice of medicine in the specialty of psychiatry, in particular, takes a few years before one starts to have a true trust in one’s abilities. Moonlighting is the term that is used to refer to working outside of the required daily duties of the residency training program. After a full and demanding day in residency training, one may work an additional five hours late into the night at a different hospital, thus the term, moonlighting.

She started crying when I entered the room. Splotchy, red patches suddenly blossomed across her neck. “Please, you can’t keep me here,” she blurted out.

Sobbing, all her words rushing together,”This is going to be so much worse for me. It’s not going to help me. I have a statistics test on Monday. If I have to stay here, it will look bad for me trying to get into medical school!”

I take in a long slow breath, and observe her while she snuffles and wipes her swollen, reddened eyes on the sleeve of her blouse. She uses both hands to replace her thick black framed glasses, pushing them up high on her nose, while a few inches lower, a simple silver metallic ring pierces through the left nostril. Her shortish ginger hair maintains the hint a stylish cut, and her perfectly white teeth appear perfectly straight. She is wearing the latest hipster clothing. I discreetly push a box of Kleenex towards her.

I sit down across from her and introduce myself. I let her know that I am the admitting physician at this state hospital tonight.

Cathy says nothing, averting her eyes, still sniffling. 

“You almost died.” More silence.

I gently ask her, ”How do you think dying might affect your chances of getting into medical school?”

She darts her eyes at me and quickly looks away. Her posture is closed and rigid.

Thirty six hours ago, this attractive twenty-one year old woman had been intubated in an intensive care unit for acute respiratory failure. In short, her brainstem had stopped sending signals for her lungs to breathe.

The story captured by the emergency first responders states that Cathy’s out-of-town friends had returned from a night of partying on the town and found her in the hotel room they were all sharing. When they were unable to arouse her, they had called 911. EMS had arrived and swiftly brought the unresponsive young woman to the emergency room where life saving procedures had been aggressively started, including putting Cathy on a respirator.

Seventy two hours ago, she had driven into town from a neighboring state with her boyfriend and a few other close friends, eager to enjoy a three day music festival that attracted bands from all over the world. The festival had coincided with her spring break, so she and her friends were primed to let loose and have a good time.

After arriving at their hotel on the first day of the festival, Cathy and her friends started drinking alcohol, walking around downtown from bar to bar, listening to bands while dancing, laughing and having a good time in the beautiful spring weather, surrounded by hundreds of like-minded young people their own age, all of them enjoying being alive and celebrating.

Several hours into the partying, with the alcohol flowing freely, Cathy distantly remembers getting into a heated fight with her boyfriend. She doesn’t remember what the fight was about. Her boyfriend and the other friends she was with abruptly abandoned her, or at least that is how it seemed to her. Significantly intoxicated at this point, she suddenly felt very alone, disoriented and overwhelmed in a city with thousands of party-going strangers, all having a great time, all of them except her.

She remembers that she became very angry and distraught. She continued to drink alcohol. She blearily decided to make her way back to their hotel, but was unsure where the hotel was located. She recalls wandering into random bars along the way and ordering drinks, listening to the band that was playing, talking with strangers and then moving on to the next bar. Close to blacking out, she recalls at one point getting in to a car of a male stranger with the understanding that he would give her a ride to her hotel. She remembers chugging a mixed drink she had in her hand while in his car. And that is the last thing she remembers.

Her next memory was waking up in an intensive care unit intubated and on a respirator. She vaguely recalls struggling with staff, crying and trying to yell while intubated that she wanted to be released from the hospital. She recalls pulling out her intravenous line. She faintly remembers having been put in four point restraints, tied down securely to the hospital bed to decrease the risk of harm to herself or medical staff, and of course to prevent her from escaping and stumbling through the halls of the ICU.

Eventually, once it was established that she was able to breathe on her own, the staff removed the breathing tube, but removing the restraints took a little longer.

A social worker had been paged, and when she arrived, she sat at Cathy’s bedside after the breathing tube had been removed. The social worker spoke at length with Cathy as Cathy was regaining more stable conscious awareness.

According to the social worker, Cathy had tearfully recounted how desperate and unhappy Cathy had felt after being abandoned by her friends at the festival. She had felt totally alone. Cathy went on to say that for most of life, she had felt that she never really fit in anywhere.

Cathy also explicitly told the social worker several times that she didn’t want to live anymore. She also told the social worker that she had tried to kill herself previously by an intentional overdose of medication some years ago. The social worker listened while documenting the conversation. Next to the social worker, there were documents from the emergency medical service first responders who had arrived at Cathy’s hotel in time to save her life.

As it turns out, according to the EMS report, when Cathy’s friends found her unresponsive, they also found an empty bottle of Ambien next to Cathy on the bed where Cathy lay.

When I met with Cathy to evaluate her, I met a bright, articulate young woman who elicited within me an almost paternal feeling. I had earlier in the evening heard Cathy’s voice in the background, talking with the staff (orderlies whose job was to maintain order) in the locked waiting room, and her voice had a pleasant perkiness to it, very polite, very upbeat.

‘Likable,’ was the fleeting thought that went through my mind on hearing her voice some twenty yards down the hallway, as I sat in the small, featureless office where I was finishing up paperwork and signing orders for a patient I had seen earlier.

Upon initially meeting with Cathy, there was a part of me that wanted to find a way, right away, to release Cathy from this ancient psychiatric hospital to the care of her family.

In the waiting room of this psychiatric hospital, where Cathy had been escorted to from the previous hospital, there were other people waiting to be evaluated who were intoxicated, psychotic, homeless, yelling and in restraints. Quite a contrast to this nicely dressed young woman who sat before me. It was not clear where Cathy’s family was presently, or if they even knew what had transpired over the last 48-72 hours.

However, even a superficial risk stratification for Cathy, considering the seriousness of the events of the past 36 hours and also the social worker’s report documenting Cathy admitting to past suicide attempts, it became clear that she needed to be in a safe and stable situation, and that safe place was most likely going to be, at least for tonight, in this psychiatric hospital.

Cathy had arrived at the psychiatric hospital on an OPC, or order of protective custody, that had been initiated at the ICU. An OPC is essentially a temporary way of legally depriving a person of their civil liberties. Those documents had been approved by a judge who said, in effect, that Cathy was unable to make decisions for her own safety or that of others, and that were she not involuntarily committed to a psychiatric hospital she would likely be at high risk of harming herself.

While it is possible for a psychiatrist to release a patient from an OPC, it rarely happens, in recognition of the acuity of what has led to having the patient brought to a psychiatric hospital. Better safe than sorry, the thinking goes.

Part of the decision-making, frankly, is the psychiatrist in admissions wanting to avoid being the person who is responsible for releasing a patient who was actively suicidal less than 24 hours ago and who could quite possibly go out and complete the suicide if they were to be released.

“I was wasted, that’s all,” Cathy says, suddenly full of earnestness, looking intently at me.  “People say all kinds of provocative things when they get drunk.”

I nod my head, and respectfully respond to her, explaining that in my experience, people are usually significantly less guarded when they are intoxicated and often say exactly the kind of things they have on their mind at the time. I share with her that it seems counterintuitive to me that she would be telling hospital staff that she wanted to kill herself as part of a strategic plan to get released from the hospital.

Cathy feebly tries to argue me out of this assertion, but it is the argument of a scared, embarrassed, and increasingly resigned person, beginning to realize that the consequences of her earlier actions are now taking shape and form.

There is a shift in the mood and conversation as she adjusts to the reality that she will likely be admitted for further observation and evaluation.

Cathy reveals to me that she has been abusing alcohol for quite some time. She admits to having legal problems related to alcohol, public intoxication convictions, as well as minor in possession of alcohol charges. Without guise, she reports what she calls ‘social drinking’ with her friends 3-4 nights a week, (drinking anywhere from 4-8 drinks per night) as within the ballpark as far as her drinking pattern over the past few years. Yes, she admits to having blackouts in the past, but was quick to add that she currently has a 4.0 GPA average in her post-baccalaureate program, offering that as a kind of counterbalance to show that things could not be that bad, even with the drinking.

She reveals that she had been getting Ambien prescribed to her by her primary care physician. She tells me that she was unaware that taking that medication with alcohol is a potentially deadly combination and could lead to respiratory depression, causing the brainstem to no longer give orders to the body to breathe.

As we continue to talk, she says that she has no recollection of swallowing the entire contents of the prescription vial of Ambien when she arrived back at the hotel. “I really don’t think I did,” she says with determination.

When Cathy was brought to the hospital her blood alcohol level was 270. That means that her level was likely much higher prior to the EMS arriving at her hotel room and rescuing her. A blood alcohol level of 350 means the person is at the level of surgical anesthesia, meaning that sensation and awareness are sufficiently suppressed that surgery could be performed and the person would not flinch.  At a blood alcohol level of 400, coma and death are imminent.

Whether she had tried to kill herself or not hardly matters at this point. She had nearly died, and had her friends not found her and promptly called 911, she would surely have died.

It is remarkable how little insight Cathy displays regarding the events leading to her arrival here, another poor prognosticator for her ability to stay safe. She had a previous suicide attempt that she described in a minimizing, almost flippant way. 

As we continue to talk, I find less and less reasons to release her, and more and more reasons to have her more thoroughly assessed and offered treatment, both here at the hospital and also after discharge as an outpatient.

“I’m afraid you’ll be here overnight for sure,” I tell Cathy. “You’ll be meeting with your primary team in the morning…a psychiatrist, psychologist, social worker and nurse.”

She is looking at me with a blank expression on her face.

“You’re part of that team, too…obviously,” I quickly add, hoping to leave her with some sense of agency, of having a say about how things will progress from here.

At this, Cathy again burst into tears. I slowly lead her back out to the waiting room.

I write the orders to admit her to the hospital. I catch the eye of the nurse at the admitting desk, and handing off the clipboard, say, “We’ll keep her…”

My pager goes off, letting me know there is another patient waiting to be seen…

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Moonlighting Memories

The following essay is based on an actual encounter I had while I was in residency training. Names and other personal characteristics have been changed to protect the privacy of the patient for whom I provided care late one summer night. As a resident physician, one has the opportunity to begin to practice the skills acquired in residency, which is the four year postgraduate training that follows medical school. As a resident, you know a lot, but the actual practice of medicine in the specialty of psychiatry, in particular, takes a few years before you start to have a true trust in yourself. Moonlighting is the term that is used to refer to working outside of the required daily duties of the residency training program. After a full and demanding day in residency training, one may work an additional five hours late into the night at a different hospital, thus the term, moonlighting.

“Hey, Maggie,” I say quietly as I slowly approach a patient seated in an oversized chair. “I’m Dr Crooks. I can see that you are in the restraint chair…” I pause, waiting for a response. Nothing. “Can you tell me what is going on?”

“I’m hearing voices,” she mumbles thickly.

The patient’s chart indicates that she is my age.

Drooling profusely, with her short, dull grey-haired head bowed, she utters something softly and unintelligibly. She is wearing a stained pink velour top and matching stained pants. She has baby blue hospital socks on her feet.

As I start to look her over, I notice that she has a watch strapped on each wrist. The watch on her left wrist is metallic and on her right, a watch made of plastic. I notice that the hands of each watch indicate different times, neither one of them accurate.

Her shoulders, wrists, abdomen and ankles are strapped down snugly to the chipped red metal restraint chair, held in place by no-nonsense grey nylon straps. In the corner of the small, darkened room where she has been isolated, there is, curiously, a large, standalone heavy-duty punching bag, with a pair of worn-out boxing gloves balanced precariously on top.

Just outside of the room, an imposing African-American man wearing several earrings on one ear watches me silently, leaning back in a lounging position on a beat-up plastic lawn chair. He has a lollipop in his mouth and is holding a worn out paperback book in his hand. He nods politely at me as I turn to him. He is one of the helpful orderlies who are on duty to contain the chaos that can erupt in this ancient psychiatric hospital ward.

I turn back to the restrained patient, and hunker down on my haunches in order to be at her level. I remain alert, having learned the hard way that although a patient may be restrained, they still can spit at me.

“What are the voices telling you?” I ask soothingly, as I check the tautness of the straps to make sure there is no restriction of blood flow to her hands or feet and to confirm that she is able to breathe freely. She has frank abrasions on the knuckles of her right hand and a healing wound on the index finger of her left hand. I assume these are souvenirs of the violent behavior that was noted in the patient’s chart during her admission.  I recheck the straps, making sure they are not too tight, but also, not too loose.

“Kill…” she states simply in a wavering voice.

“Kill who? Other people? You?” I ask, trying to engage her attention. She doesn’t answer me. The drool from her mouth is profuse at this point. A thin, white hospital towel has been draped around her her neck, put there to absorb the saliva that courses from her slack mouth. She appears very sedated to me.

“Can you look at me, Maggie?” I ask, trying to judge just how sedated this patient may be. Thirty minutes ago, prior to my arrival on the unit, Maggie had involuntarily been given an intramuscular injection of a strong antipsychotic medication combined with a benzodiazepine, the combination of which can profoundly sedating. She glances up at me briefly. Her sunken eyes are as grey as her hair and as empty as infinity. Her head slumps down again.

Just prior to entering the room to evaluate Maggie, I spoke with the charge nurse who had made the call to put the standing orders into action to have the patient restrained and injected. According to the nurse, the patient had been banging forcefully with her fists on the thick Plexiglass that separates the patients from the staff. Additionally, the patient had been throwing lawn chairs and small tables across the room, threatening staff and scaring the other patients in the common area.

Maggie is not a large woman, but the intensity of her anger is formidable, the nurse tells me. In speaking with the nurse, I am told that whenever the patient is in the restraint chair, (and this has been going several times a day for the past 3 months since she was admitted), the patient will appear very sedated and drool constantly. The nurse tells me that the moment the patient is released from the restraint chair, the patient springs into action, with all previous signs of sedation gone and her drool all dried up, and she will go into a frenzied attack mode.

I gaze at Maggie for a little while. To release or not to release. That is the question that is percolating in my mind.

The patient received some news earlier today that she is going to be transported to a long-term forensics psychiatric hospital later this week. The institution where she is being transported is intended for patients who have committed felony crimes and who have been found not guilty by the courts by reason of insanity. The forensic psychiatric hospital is also the destination of patients from state run hospitals who have been found to be manifestly dangerous. Maggie, apparently, qualifies on both counts.

In review of the initial psychiatric evaluation performed some three months ago when Maggie was admitted, I read that the police had been called to Maggie’s house after a neighbor had observed Maggie out on her front porch, screaming and waving a large knife. According to the officers’ report, Maggie was intent on cutting her wrists and had already taken a few preparatory passes prior to the police arriving. 

While the police attempted to de-escalate things, Maggie ran into her house and brought out a gun, threatening to kill herself and to kill the cops. Fortunately, the officers had mental health training and continued to try and calm Maggie down. Nevertheless, there had been a standoff of several hours before the police officers were able to talk Maggie into putting down the gun.

Maggie is my age, and she is strapped in a chair. No amount of medication is going to make this woman regain any quality of life. Her family has long ago given up, burned out by the nonstop chaos that a medical disorder has inflicted upon this woman. We in the hospital are functioning mainly as crowd control in our efforts to divert Maggie’s fury from erupting on herself, on other patients and staff. And me. I feel a vague sense of hopelessness arising in me, and yet, what else is there to do at this late hour?

I stand up slowly. The watches on Maggie’s wrists reflect different times, neither one of them correct. I sigh and wonder what time will hold for Maggie. For the time being, she will remain in restraints.

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