“Patient X has come in for the fourth time this month saying she is suicidal. What are you going to do, Doc?”
As I heard those words one early morning not long ago, bleary-eyed, mind buzzing and stomach growling, a thought flashed through my mind. This particular thought was one that had been increasingly emerging as I entered my fourth and final year of residency training in psychiatry: the uncomfortable realization that even though I was soon to be a fully practicing psychiatrist, I continued to harbor misgivings toward the very field in which I served.
Let me provide some context:
My local tertiary academic hospital, the only Level I trauma center in southeastern New England, has one of the busiest adult/pediatric ERs in the country. It is a common occurrence for patients to present in destitute and distressing psychosocial circumstances, ranging from domestic abuse to homelessness. Unfortunately, the acute nature of the hospital renders it unequipped to manage these often chronic circumstances. As a result, perhaps out of a combination of helplessness and self-righteous indignation, medical staff gradually and subconsciously grow frustrated when we encounter patients whom we are classically taught to identify as “malingering,” or inappropriately utilizing medical resources such as the ER for external gain like food, shelter, and so on.
The patient who had come in that morning at 3 a.m., Patient X, had an extensive trauma history of rape and physical abuse, and had grown up in multiple group homes where she’d suffered through a constant shift of caregivers. She was homeless, and frequently presented to the ER in profound distress that would appear to self-resolve during often brief hospital visits. After several consecutive stays, it had become clear to my colleagues and I that Patient X found the hospital to be a safe haven to reach for in a crisis. During the majority of her visits, she would frequently recant her suicidal statements, be adamantly opposed to being hospitalized, and request either to be discharged from the hospital the following day or to be stepped down to a crisis stabilization unit. As ER clinicians, we recognized that the reasons this patient was ultimately presenting did not constitute a true medical “emergency” — and this instinctively engendered in us a reflexive negative response.
Despite our misgivings, however, we did everything we could that particular morning to care for our patient. We provided her food and clothing. Nursing staff frequently went in to check on her to assess her basic vitals and address other needs. We patiently listened to her struggles of being homeless and her desire to find a location that would help lay the ground for her next steps. The next day, Patient X was calm. Smiling, she said, “OK, I’m ready to go.” And thanked us before she left.
After that fourth visit from Patient X, I began to look for ways to manage frustration toward, and provide good care for, malingering patients. I sought out the work of Donald Winnicott, pediatrician by trade but also a pioneer of developmental psychology. Among Winnicott’s ideas was the concept of a “holding environment.” These environments provide a psychological space in which patients can seek respite and eventually feel able to safely verbalize their distress and receive the nurturing response they lacked during development. Though the classic example of a holding environment is a mother who holds her infant when the infant is crying, the analogy can be extended to any form of mother, including a clinician, a hospital, or even just someone who listens.
When I encountered Patient X the morning after she presented, I remember that my initial reaction to her newfound sense of calm was one of bewilderment: “Wait, what did we do?” After all, my colleagues and I did not provide her with cutting edge treatments, engage in any “higher order” medical thinking, or even offer her any profound insights. Eventually, however, it dawned on me that we had actually performed a lot in service of our patient. In Winnicottian terms, we’d provided a holding space — we had tended to her immediate needs, i.e., food, shelter, and a listening ear. We had also worked with her to create a plan to leave the hospital that emphasized her own autonomy in her care. This commitment in itself was essential to creating a space of respect and comfort, and ultimately allowed Patient X to create her own disposition plan.
In psychiatry residency we are trained in both the field of medicine and the field of mental health. We learn about various forms of psychotherapy; about drug-specific strategies for treating a litany of mental health diagnoses; and about the complex brain circuitry that underlies mental illness. We discuss therapeutic boundary crossing; we postulate on the putative mechanisms underlying electroconvulsive therapy; and we opine on the multi-factorial etiologies of depression (hint: we still haven’t come to a definitive answer yet).
While valuable in its own right, this didactic knowledge often does not convey the day-to-day realities of our encounters with patients. It also does not represent all the ways in which we come to learn about, understand, and tend to our most stricken patients. Whether it is giving a patient a blanket, offering a listening ear, or just simply checking in to see how things are going, there are many seemingly mundane actions that can collectively create a therapeutic, nurturing environment.
Today, as I grapple with my motivation to engage in this field, one question pops up: If the goals of mental health are to help patients feel better and to decrease suffering, how are my actions either serving or negating these goals? As I reflect on my interactions with my patients, I pray that I can keep Winnicott’s idea of the holding environment in mind: While knowledge is important, we as psychiatrists should also recognize and be aware of the benefits of truly being able to just sit with others, listen and hold their pain in a safe, nonjudgmental space, even as we may hold our own.
How do you provide meaningful care for patients who may be malingering? Share your strategies in the comments below.
Sen Xu is a fourth year psychiatry resident at Brown University. He grew up in Louisiana, where he did the majority of his schooling before moving up to Rhode Island for residency. One of his major professional interests is Asian-American mental health advocacy, and he currently serves as a professional consultant for the United Chinese Americans Association (UCA), providing feedback on mental health initiatives, assisting and organizing educational webinars, and assisting with grant writing.
Illustration by April Brust