What does a doctor say when words don’t come? Such was my dilemma several years ago on an inpatient psychiatric service when I responded to an emergency alarm activated by staff in a patient’s room. A young female patient—call her Lisa—had just knotted some latex gloves around her neck, and her face was still plethoric as I entered her room. Staff restrained her while a nurse carefully cut off the gloves. This allowed Lisa to begin taunting me. Fixing me with a malignant stare and a gleefully sadistic grin, she exulted that “you stopped me this time, but I know exactly what to say to get out of here, and when I do I’ll kill myself, and there’s nothingyou can do about it!”
A clinician in such situations has to say something—but what? Stricken with acute speechlessness, I knew that at the very least I didn’t want to swallow Lisa’s proffered bait and retaliate punitively. Fortunately, I liked her. She was in her late twenties and came from a very difficult background, but had married a good man and become an accomplished artist. Yet her demons tortured her, and I admired her willingness to fight them. She was doing her dysfunctional best to metabolize her inner turmoil. In the moment, she herself had become a torturing demon, and I the frightened victim. This thought made me feel sympathy for her rather than hate her.
All well and good—but something still needed to be said. It occurred to me that stating the obvious might be a start, and couldn’t do much harm. Because I already admired Lisa’s toughness, I thought I could also admire her evident talent for sadism. Doing so would at least turn my passivity into something active. “What a great torturer you are!” I said, “praising” Lisa but feeling on thin ice professionally, especially since I had an audience of staff in the room. To my relief she began laughing—indeed, a bit demonically—which I took as permission to continue. “You really love being sadistic, don’t you? If you wanted to scare me, you succeeded!” Her laughter escalated but the tension and fear in the room diminished, and we quickly ended the restraint. Some sort of standard doctor–patient dialogue eventually ensued, of which I remember nothing except that it was surprisingly free of antagonism. Lisa’s provocative behavior stopped, and treatment resumed—with an excellent outcome.
The procedure that I stumbled on with Lisa—collaboratively and nonjudgmentally reframing the obvious—can be useful for the speechless physician. For Lisa this entailed acknowledging her hostility while showing her that I knew it wasn’t personal and that she couldn’t use it to crush me so easily. In more typical cases, the doctor tries to clarify the fact that, despite his inability to entirely share the patient’s perspective, he still wants to find a way to continue working together without doing harm. This message can help the patient feel less alone and may even strengthen the alliance if the clinician can communicate full recognition of—if not belief in—the patient’s desperately held convictions.
Many common clinical scenarios call for this intervention. The patient with delusional parasitosis who demands that the doctor believe in the bugs; the healthy patient who insists on a getting a needless or potentially harmful procedure; the “obnoxious” patient who makes bigoted or sexist comments—all such patients threaten to render the doctor mute, at least briefly. These patients are still seeking help, albeit in ways which appear absurd, dangerous, or offensive. Because professionalism requires a response other than “You’re crazy/misguided/annoying” we resort to comments such as “But there’s actually nothing wrong with you,” “I’m not comfortable doing [or listening to] that,”or—most alienating of all—“I’d like you to see a psychiatrist.” Neither clinician nor patient feels satisfied by this kind of exchange. What might constructive reframing sound like in these cases?
In the case of managing delusions, the utility of shared obviousness was shown to me once when I worked with an engaging young schizophrenic man who was convinced there was a microchip implanted in one of his molars. He had already been to many dentists with his complaints, and some had even taken x-rays in order to make him go away. Of course he did go away, but to other dentists and even emergency departments, an evaluation in one of which landed him on my inpatient psychiatric unit. He was determined to get his tooth and its offending implant removed, and he begged me to help him. “Doc, you have to believe me … I just know the chip is in there … why can’t you just arrange to have it removed? Is that such a big deal? Can’t you at least do a CAT scan? Please,Doc.”
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-Michael W. Kahn, MDa,b
-This article originally appeared in the March issue of The American Journal of Medicine.
