I had a medical dream last night. I was in a clinic of some sort and the nurses pointed me in the direction of a talkative woman and a silent man in her company. They weren’t in an exam room, more like a pergola of some sort. I was given a tray with syringes and other medical paraphernalia. There was neither a paper chart nor any kind of computer medical record.
The woman spoke about having Graves’ disease but also a host of symptoms that she connected with it that I knew were likely unrelated and instead signs of florid psychosis. She had seen many doctors before and none of them had understood her or offered to help her. She had her own expectations of what that treatment would look like and it was all endocrionological, but made little sense to me.
The man in her company was deferential, soft spoken, as if afraid to upset her. I couldn’t tell what their relationship was. At one point, I think I heard her refer to him as her driver.
With no medical record and a tray of museum-like medical equipment I felt a little helpless. This woman needed an antipsychotic, that was clear, but I didn’t know where we were, what was available or how to reach her in her delusional state.
I told her I thought that not only did she have Graves’ disease, but she was also suffering from exhaustion trying to figure all her symptoms out on her own. I said that I wanted to help her, even though I didn’t really know how and with what.
I started to become aware that this was probably a dream, but I hesitated rising to full consciousness. It was as if I didn’t want to give up on my patient, my improbable clinical challenge.
The dogs’ rhythmic breathing, the cool morning air through the window and the sputtering noise from the coffee maker in the kitchen drew me away from my imaginary duty and into my Saturday morning reality.
How familiar, I thought to myself. A sort of parallel to the experiemcee I had in the psychiatric ER in 1980 back in Norrköping, Sweden.
That time, I admitted a psychotic patient for observation. He was the only one who knew that very soon, earth was going to switch places with another planet and our lives would be switched, too, into what the inhabitants on our opposite planet were living. I got him to accept a sedative (this was before the Swedes invented Seroquel, so it was a first generation antipsychotic) so he could get a good night’s sleep while things were still quiet, to gain strength and prepare for the next day; a back door to a first dose of treatment.
I had spent great effort aligning myself with his suffering, not challenging his delusion, but instead focusing on his distress. It didn’t work badly.
A few hours later, he tried to escape through a skylight.
Ever since then, I have used the same non-confrontational, low key frame of mind to try to form a therapeutic alliance for very small or incremental goals when treating patients - psychotic, disbelieving, hostile or otherwise unreachable.
But that time my overnight clinical experience provoked a dream after my shift where his powerful delusion suddenly played out in my own mind. All of a sudden I became him and in my dream I was convinced the planets were actually going to switch places.
https://acountrydoctorwrites.blog/2010/05/19/switching-places/
i love this: "I had spent great effort aligning myself with his suffering, not challenging his delusion, but instead focusing on his distress. It didn’t work badly."
this approach should be taught not only to clinicians who work with folks with psychosis, but also to the general public who think their political peers are delusional! there would be less arguing & more empathy.