Touched by a Patient

The year I spent as a student on the psychiatric unit was torturous, but it did allow me to learn that many times, patients do not and cannot flourish, not because of an incapacity to express emotion due to their supposed illness, but of having been assigned to a toxic individual to oversee their care. I learned that even a patient with the most chronic form of a debilitating psychiatric disorder could display acts of compassion, gentleness, kindness, and lucidity, that reached far beyond the clinical expectations that my supervisor allowed me to have, and yet, I was to receive the most profound clinical lesson of my career, from my relationship with my patient “Ana”.

I placed my trust in Dr. Izan to teach me the clinical nuances of psychiatric disorders. I instead found myself being reprimanded for saying “good morning” to patients that I would pass in the hall, for saying a few kind words to a patient in the dayroom, and for allowing a patient to stand next to me while we both gazed out the gated window.

I was assigned to a desk in the corner of the room across from the two clinical psychologists with whom I shared the office. Over time, all three had witnessed Dr Izan’s’s verbal aggression mixed with dismissive statements, condescending stares, and overall disgust because I couldn’t recite the DSM in its entirety. Although only a short time into the internship, I was a mess; flustered, insecure, anxious, and nervous. Every day when I arrived on the unit, I ducked into the office when I saw a patient coming down the hall. I refrained from saying anything nice to patients in the dayroom and never stood by that window again.

The psychologists and I often had interesting conversations when Dr. Izan left the office. One topic that was the center of discussion was that of ‘touch’ and the question was very simple; how ethical was it to touch a patient? We all agreed that it depended on the context of the situation. None of us saw anything ethically or morally incorrect with a friendly light tap on the shoulder if the situation warranted as we understood that a patient’s observation of our gestures could significantly influence their delicate emotional state.

Ana

As the year progressed, I became involved in Dr. Izan’s cognitive rehabilitation training (CRT) study. One of the patients that Dr. Izan assigned to this study was a woman named Ana. In her mid-fifties, Ana had been an in-patient on the unit for quite some time. Upon admission, she had presented with severe and chronic paranoid schizophrenia, grandiose delusions, compromised thought processes and ideas of reference. Her insight and judgement were both impaired. Her chief complaint was that the medication was harming her and that vampires were leeching her blood (aka “phlebotomists). She was guarded, anxious, agitated and detached (somewhat like my supervisor). She was poorly groomed and mal-odorous and suspicious of everything and of everyone. She was hostile and angry and would not make eye contact with Dr. Izan so of course, Dr. Izan assigned her to me.

One day, Dr. Izan approached Ana and myself and we were both guided to a conference room where Ana would be informed of the nuances of Dr. Izan’s study. Since Ana was in front of me, I motioned for her to go into the room with my left hand and gently placed my right hand on her left shoulder to guide her in. Little did I know how this small, seemingly innocuous gesture would become the most important lesson of human nature that I’ve ever learned.

Don’t Touch

The three of us took our seats, and Dr. Izan explained to Ana what to expect during the half hour that she and I would be working on the computer. After the meeting was over and Ana left the room, I too got up to leave, but was motioned that I should remain seated. ‘Rule number one’, she said. ‘You are to never touch a patient. This was the worst thing you could have done, Denise. Don’t ever do that again. Do you understand?’. ‘Yes… – but…’, I responded. “I saw that you put your hand on Ana’s shoulder; don’t ever do that, Denise.” ‘Okay… – but I just lightly…’, I replied. “First”, my supervisor reprimanded, “for hygienic reasons. Ana’s dirty, disgusting and she stinks, and secondly because she is extremely paranoid. You never touch a patient for any reason whatsoever. You never know how they’re going to react and don’t, under any circumstance, ever let them touch you. I don’t care what the situation is. Do you understand me, Denise? Do you? I never want to see this happen again; do…you…understand?” I shook my head in dejected acknowledgment and left the room. I thought about this for the rest of the day, and well into the evening when I returned home. I tried focusing on other things, but Dr. Izan upset me to the point of nausea and sleep was out of the question.

The Mouse

Soon afterwards, Dr. Izan informed me that it was time for Ana and me to begin CRT. Because of Ana’s psychological frailty, I was once again sternly and strongly reminded to proceed with caution, and to refrain from physical contact. During our first session, Ana continued to display paranoia, ambivalence, physical withdrawal, poor eye contact, introversion, and an overall underlying sense of suspicion. I sat far away from Ana (mostly because I was scared witless), yet close enough that she could hear me speak. I spoke gently and softly, afraid that a tone any louder than a whisper might upset her too much. By our third session, we began to establish a mutual foundation of trust and respect, so much so, that she allowed me to sit right up next to her, shoulder to shoulder.

Because Ana was having difficulty in controlling the mouse, I made the clinical decision to show her how it was done. But how was I to accomplish that without physical contact? I was already comfortable in knowing that Ana responded well to verbal encouragement, praise, support, and genuine caring, but I felt that for her to really be successful at learning how to navigate a mouse, I was going to have to physically show her, and I felt paranoid and unnerved by what I was about to say.

‘Would you mind if I showed you how to move the mouse around?’ ‘Okay’, she replied. ‘But Ana, you know that for me to teach you, I’m going to have to put my hand over yours to show you how to move the mouse around. Is that okay with you?’ ‘Yes’, she said. ‘Um…so…just to be clear, you’re giving me permission to put my hand over yours so I can teach you how to…’ ‘Yes!’, Ana replied again with a look like alright already…. And with that, I placed my right hand over hers and held my breath and braced myself for an emotional outburst; a full paranoid tactile hallucinatory ‘DON’T TOUCH ME’ response… – but nothing of the sort happened. Not only did nothing happen, but Ana was visibly calm, smiling and thrilled that she was learning to move the mouse around–A MOUSE! – a simple little computer mouse, yet, I couldn’t enjoy the moment because I was feeling guilty for thinking how, according to Dr. Izan, having fun with a patient was completely unethical.

The Fall

Unbeknownst to Dr. Izan, Ana and I had bonded over our time together, and it was wonderful to have been able to experience this seemingly harmful and explosive patient giggle and speak words that Dr. Izan never had the opportunity to hear, but, the day arrived when the study was over. I printed out Ana’s scores and shut down the computer. By this time, Ana stood pretty close and was patiently waiting for me to gather the last of my belongings. A half hour late for a meeting with Dr. Izan, I was already flustered about the wrath to come. I was rushing to get out of the computer room and had somehow managed to get both my feet tangled up in the wires that were on the floor. Within a matter of seconds, I completely lost my balance, and my face was heading for the edge of the table. It happened so quickly that I didn’t have the time to brace myself and so, as if in slow motion, I closed my eyes and waited to feel the sharp edge of the table tearing into the side of my jaw.

But it never happened. I never felt any pain. Strange, I thought. I must have knocked myself out. As I slowly opened my eyes, I realized that I never hit the table. Instead, I felt two arms wrapped around my waist. Ana had caught me in mid-fall and placed me back on my feet within a matter of seconds. ‘Are you okay?’, Ana asked. ‘I was afraid you were gonna get hurt. I didn’t want you gettin’ hurt”.

In the moment in which Ana detected that I was going to be injured, she was transformed from a chronic and paranoid psychiatric patient to this wonderfully caring person who was able to make a split decision and act on it. In those seconds during my fall and then afterwards, all her symptoms seemed to have vanished; her paranoia disappeared, she was lucid, she wasn’t afraid of reaching out to physically touch me, and most of all, she was able to express emotion. What psychological interpretation could I possibly attribute to her behavior?

The only explanation was a simple one; Ana had no time to think. Her reaction was a display of who she really was buried deep within her pure soul. Beneath her mentally ill exterior was a person in hiding. This was Ana at her very core.

We walked to the elevator not speaking and avoiding eye contact. In my mind I replayed what just happened but as amazing as this was, all I could think about was Dr. Izan finding out that Ana had wrapped her arms around me. Ana broke the silence; ‘They’re going to take blood from me, you know.’ ‘Who?’, I responded. ‘The vampires that wait for me when I get off the elevator.’ I looked at her and smiled and knew that Ana was now back to her ‘normal’ self once again.

Touched by a Patient

For Dr. Izan, Ana was her diagnosis and sadly, Dr. Izan was incapable of seeing a patient as a person; a person with a lot to offer, if only deeply hidden, distinct and separate from their diagnosis.

Ana, in her own way, was more of a mentor than Dr. Izan could have ever hoped to be. She taught me about how mental illness masks the true nature of the individual, and that somewhere deep inside, even the most chronic of individuals have the capacity to display kindness, concern, and perhaps even love. She taught me that it was okay to be caring; that I could laugh with her and other patients, and at the same time deliver quality care without overstepping professional, therapeutic, and ethical boundaries. Ana taught me that if a smile is the first thing a patient sees in the morning, that’s not a bad thing, that a walk down the hall before breakfast can change a patient’s outlook and that being touched by a patient can save your life.

Thank you, Ana, wherever you may now be, for teaching me about your mind and your heart, but most of all, for being the kind of person my supervisor could never be.

©2023 Denise M Frank PhD