Countertransference

I’ve been talking to this patient too long, I thought.

She was a few years younger than me, admitted for suicidal ideation with a plan. She was intelligent and friendly, but she seemed very alone in the crowded psychiatric unit.

“Have you ever experienced any trauma?” I asked.

“Well, I mean, when I was little…” she replied cautiously.

I looked at her—calmly, expectantly—a technique I had acquired at some point during the first 2 years of medical school. I glanced at the clock on the wall. Twenty minutes until the morning team meeting. Two more patients after her.

“…I saw my dad hit my mom once… twice… I mean, probably more than the normal amount…”

“Just to be clear,” I said, quickly writing “witness to domestic violence—dad on mom” on my clipboard, “the normal amount is zero.”

I smiled, breaking the tension, and she laughed shyly. I went through the rest of my checklist —hallucinations, suicidal thoughts, depression, anxiety. Then, I hurried off to find the next patient on my list, mentally reeling from the image of a woman reflected in a child’s eyes, screaming as she was savagely beaten.

Later, I led the intake of a 17-year-old boy with a history of bipolar I and suicidal ideation. We talked about his friends at school, his favorite movies, how his brother had stopped him on his way to the top of their six-story apartment building after seeing his posts on SnapChat. When the patient left, I turned expectantly to the attending.

“That was… pretty good,” he said distractedly, as he flipped through tabs in the chart. Wait for it…

“One note,” he continued (there it is). “Don’t laugh with patients during the interview. Try to maintain a professional distance.”

Later, my thoughts whirled chaotically as the car idled in rush hour traffic, like the wind whipping around a teenage boy’s slender frame as he gazes down at a six-story drop. Professional distance. Emotional detachment. How do I separate myself and still care enough to treat the whole person?

I frowned, reflecting on yet another of my inadequacies in practicing clinical medicine.

I need to review medications and dosing for bipolar disorder… and depression… which class increases the risk of suicide? What if I forget one day when I’m prescribing and because of me someone dies?

I skipped to the next song on my car’s playlist and turned up the volume.

The next morning, I rounded on my patient. She had had a panic attack overnight. What did they give her last night? Why didn’t I write that down, that’s basic!

I mentally shook myself.

“So tell me about last night,” I prompted after some small talk. Seventeen minutes until morning team meeting. Don’t forget to ask about abdominal pain this time.

“I… I had a panic attack.”

“Any idea what might have triggered it?”

“Well… I have a meeting with my mom and the therapist later today, and so after dinner, I was trying to write out the things I wanted to talk to her about, and that’s when I really started to feel anxious. I tried to calm down, but then I started hyperventilating and my chest started to hurt, and I just shut down.”

I nodded. Twelve minutes till team.

“So what is it that you want to talk about in the family meeting that made you so anxious?”

She shifted uncomfortably.

“Well, she didn’t know how bad off I was… like she knows I have depression and that I went to the ER because I was having suicidal thoughts… but she doesn’t know I had a plan and had bought a bottle of vodka to take the pills with…”

“I see, so she didn’t really know the extent of what was going on,” I echoed. Ten minutes till team, make sure you ask about abdominal pain.

“Yes!” She met my eyes suddenly and was talking faster. “And she just acts toward me like she always has, and it’s hard not to slip back into old habits…”

“Does she know that you were cutting yourself?”

“No.” She looked back at the floor.

“Are you going to tell her?”

“I... I don’t know.”

I waited, drops of blood staining her bedroom carpet behind a closed door in my mind’s eye.

“I think I have to. If I’m going to go back and live with her, she has to know… everything.”

She stared, wide-eyed, at the floor. Professional detachment can suck my stethoscope.

“You’ve really taken on a lot since you’ve been here,” I told her. “Everyone on the care team talks about how much improvement you’ve made.”

She looked up in surprise.

“You can do this,” I said, earnestly, “You’re ready.”

She smiled, somewhere between confusion and gratitude.

I ended the interview quickly and slipped into the meeting room a couple minutes late.

“She denies any current suicidal or homicidal ideation,” I concluded in my patient presentation.

“Is she still having abdominal pain?” asked the attending.

“I… I forgot to ask,” I said. Damn it!

“Alright, that was pretty good,” he responded, “but you really need to work on getting all the information during your interviews.”

I nodded, frustrated and humiliated. Why am I so bad at this?

At 5 o’clock, I gathered up my bag and walked out to the hospital parking lot, feeling heavy. I tried to shut out the scenes flashing behind my eyes as I scrolled through my phone’s playlist. I pulled out of the parking lot, headed toward the hour-long traffic jam I had become all too familiar with in recent weeks.

As I rounded a turn, I imagined letting my car fly forward into the median. A loud crash, a crunch, intense pain, then nothing. Relief. No expectations, no pressure, no chance of hurting someone through my incompetence.

I blinked away the image of fire and twisted metal, the motion of the traffic pulling the car along. I gritted my teeth, turned up the music, and kept driving.