I have seen this type of patient only 3 times in the entire length of my practice–a certain expectant, determined-to-be-closed patient who’s unwilling to work with me either by “opening up” to the process of treatment, or by being honest about their intentions and their ability to commit to whatever is involved. When I first started I wanted the experience of working with anyone I could get–it didn’t matter, I wanted to be able to figure the case out, try every angle I could, and see if I could make something happen. But when patients don’t want to work with you, and actively work against you, the result is often painful, physically. Painful for me, as well. We’re trained to watch out for that, to keep the kind of unbiased professional distance we need to operate: there is no place for “the personal” to interfere in the process. But it always, always hurts, even though now it seems to be that much less of a shock. I now recognize the signs, get a referral list out, and tell the patient I’m no longer available, even if their actions are nasty (or in one case, just plain illegal).
I’m grateful there have only been three such patients in nine years–but each time I’ve encountered the phenomenon, I’ve focused on the feeling involved, and I’ve missed the remedy I needed to give.
I’ve been told that as practitioners, we get the patients we need to see. People we need to learn from, people who choose us to help them because they find something “in kind” with us, even if it can’t be named. The person who told me this also told me that when he started his clinic work, almost every patient he saw had schizophrenia.
I noticed that in my own list of patients, the majority of them were the type who will develop cancer, if it isn’t interrupted. They can be excessively controlling, fastidious, ordered. They are fascinated by music, and beauty (the beauty of nature in particular), and harmony. They put themselves last on the list when everyone else’s needs call to be met. They grieve (but don’t know why) and smoke (and don’t know why) and hide themselves as well as they can muster, at first by working really hard to “be nice”; then with firm resistance, and finally by lying outright. Underneath everything, though, they just don’t trust. That feeling is the engine that runs the whole show–they don’t trust the physical world around them (so it has to be cleaned up, organized, changed, beautified); they don’t trust others (and feel like others try to pull the wool over their eyes, or will abuse them in some way–often because they do); and they hide as much as they can about themselves, weaknesses they feel make them vulnerable. They don’t trust their own bodies and feel that on a very deep level, they and their health are incredibly fragile.
They’re right, of course: their health is fragile, and they are fragile. They can’t trust others because they really don’t feel they can place any trust in themselves (and they are blind to the fact that others find it difficult to trust them in return). And so they will often tell me that they will simply not tell me anything. They will refuse to answer direct questions because they don’t believe I need to know the answers (but I do!) and they’ll be set in their ideas despite whatever I can do to demonstrate that their beliefs simply don’t apply to what’s actually taking place in terms of the work we’re doing. In short, they face me with the same kind of doubt, the same kind of questioning stubbornness and tendency to fixed ideas I can have about them, and we can languish in this back and forth dynamic forcing us into its dance. It’s taken me a lot of time to figure out that “getting stuck in that dynamic” is the problem–and that if I step back and look, everything the patient does is a demonstration of all that I need to know to prescribe well.
When the third patient of this type presented herself, I thought, “What the hell am I doing wrong?” and felt completely insulted. I’d put in a lot of time, unpaid; I’d gone out of my way to see the patient via house call, since she couldn’t come to see me in my office–and because she complained of not having enough money, I never charged her mileage. I listened to her protests of an inability to afford the cost, despite knowing she came from a well off family and completed a post-graduate degree which placed her in a well-paying full-time position with the university even before she was done with her studies. I knew she’d managed to travel most of Europe, study full time, and buy her own home in Toronto long before most people her age could scrape up enough to pay rent on their own apartment–and yet I listened to what she was telling me instead of seeing what she was showing me. I spent hours trying to cajole her into answering my questions, when really I could have saved myself all that effort if I’d just let what I was seeing register.
"makes an excellent living fence"
Instead I locked everything I knew to be true about her away in the insult.
But I never stopped thinking about her case. And finally it dawned on me that if I just considered what I’d observed–the stubborn refusal and insistence on hiding herself; the persistent physical pain and its location, which hinted at grave problems with sexual relationships; the unguarded criticism she would launch at a particular man and his behaviour (again, sexual) and the unhappiness she hid regarding her current relationship; her responses to all the medications she’d been given, which actually brought her state even more clearly into focus–it was an easy case, I don’t know how I missed it. But I do know that when we take things personally and react to them that way instead of looking at what we’re being shown and what it tells us, we can become lost.
It’s taken me a while to figure out what to do next, with this case, how to initiate the way we continue on with each other after cutting off communications several months ago. After putting together my own research and taking another look at the case with a very critical, inductive eye, I repertorized only what I knew to be facts about her behaviour and symptoms. That was the easy part: the difficult part was figuring out what to do with that information.
So I took a dispensing envelope and the vial of medicine, wrote out a label, and twisted out a number of pillules to enclose in the envelope. On a plain piece of stationery, I wrote out very simple instructions for use. I wrote more, of course–a brief note on what I was sending, and why. In the end, the patient is still suffering, still dealing with pain on a daily level. I have something which might alleviate that pain once and for all–and I decided that I couldn’t withhold it, and that everything else that came to pass should be seen as the means to which this possibility could be explored. So I packed it all up in an envelope with instructions, and sent it off to my patient’s address in the city.
The choice to take or ignore the remedy is not mine, but in my note I tried to cover every angle of the decision. If she takes it and decides to go ahead with it, I’ll manage the case. If she doesn’t, and discards it, that’s good too. I don’t know if sending the remedy is selfish on my part–I want to think of it as payment for a good lesson, long past due. And hopefully well learned.
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