Expanding the Envelope

When I first saw her, I was surprised by how young and vital Ms. A looked. Her skin was full of color and she was at a healthy weight for the 29th week of pregnancy. Just days after a serious suicide attempt, she giggled and smiled while talking on the unit telephone. But she refused to speak to me when I approached her; she screamed at nurses and slapped another patient over a remote control. Everything I learned about Ms. A’s short, difficult life came from her chart: she had been born with fetal alcohol syndrome, then placed into foster care in Texas before her aunt raised her in New Jersey (some details have been changed to protect the patient’s identity). In her early 20s she developed bipolar disorder and cocaine abuse, leading to violent behavior and incarceration on narcotics charges. Then came the unplanned pregnancy and a serious overdose.

Over the first week in the hospital her symptoms were refractory to antipsychotics and she would not accept lithium despite the recommendations of our obstetrical service. Her baby was breech, but she refused to discuss the possibility of a C-section.

As we discussed Ms. A's case in rounds, her bleak circumstances demoralized our team. “What can we really do?” a medical student asked.

“This woman’s life has been extremely hard and she probably isn’t used to being treated very well,” I said. “So that’s where we’re going to start: We’re going to be nice to her and get to know her.”

Every 6 weeks a new group of medical students arrives on the service to begin their psychiatry clerkship. They meet patients like Ms. A, who was manic, angry, and hospitalized against her will. Invariably they ask the same questions: How can we help someone who does not want help? How can we reason with patients whose illness renders them irrational? The residents I supervise struggle with similar questions. And, of course, I do too. Preoccupied with teaching the trainees how to assess the patients’ signs, symptoms, comorbidities, and risk factors, I sometimes forget to encourage them to just talk to these people we are trying to help: About their lives and how they want them to change in the future. About the significance of a tattoo, why the Red Sox are falling apart early in the season, or their child's favorite cartoon.

Being genuinely curious can sometimes expand the envelope of treatable patients to those who may initially refuse care or act irrationally. Ms. A loved her unborn baby, so I encouraged the team to appeal to her maternal instincts. Accepting treatment—both psychiatric and a C-section if necessary—might help her deliver a healthy baby. This strategy seemed reasonable, but Ms. A continued to refuse obstetrical care or to simply walk away when I tried to engage her.

So instead of talking to her about treatment I sat with her as she watched music videos on our unit computer. She liked makeup and clothes, and I asked her about her lipstick instead of how fast her thoughts were going. When her boyfriend visited, I chatted with him about fatherhood while Ms. A watched us from across the unit. Instead of individual sessions with Ms. A, we began meeting with her as a team. I asked our social worker, also a young mother, to lead the first group conversation. She asked Ms. A about her baby.

“You know it’s not easy,” Ms. A began, telling us about arguments with the baby’s father. Sometimes she felt like killing herself. Cocaine made her feel better, but she stopped using it because she knew it was bad for the baby. That's all she could tolerate in our first group meeting. Abruptly, she stormed out, but we could tell the door was slowly opening.

We kept meeting with Ms. A as a team over the final weeks of her pregnancy. As her due date approached, we invited the obstetrical service to join us. “These guys delivered my kids and I wouldn’t ask you to trust them if I didn’t trust them myself,” I said, letting her get to know me a little better too.

Not long after, Ms. A began to take lithium. Her manic symptoms by no means resolved, but they became far more manageable. Partially treated, Ms. A was charming at times.

The baby was still breech, but eventually Ms. A agreed to a C-section.

“This baby’s coming one way or another,” she said with a smile.