One Flew Over 2: Can't, Won't, Oops.
March 4—WRITING WEDNESDAY
Even though I’ve switched to Peds, I’m still finishing up the writing from my psych rotation because I can’t do anything on time now that I’m a third year medical student.
This is the second piece in my psych series, the first piece as well as the rest of my writing about third year can be found here!
P.S. Before you click through to read the rest of this story, it’s very very very important that you be warned that this piece deals with suicide and suicide attempts, specifically suicide attempts by teenagers. I’m tagging this with appropriate trigger warnings, while I think this piece is very hopeful and positive and avoids any explicit details of the suicide attempts discussed, be warned that it might be triggering for some of you so be warned.
One Flew Over 2: Can’t, Won’t, Oops.
As a complete and gross generalization, can I just say that psychiatrists are a pithy, clever bunch? They often seem to have unique ways of saying things, unique ways of looking at things. They manage to drop these perfectly worded sentences into the middle of otherwise normal conversations. They’ll take the last paragraph of what has been said and perfectly summarize it in three words.
They were the kids in class who always managed to answer essay questions in just one page, having fully and completely addressed the topic in only thirty lines. I was never that kid. I have always been the kid that writes three pages more than the maximum limit and then is forced to agonizingly cut down. Sweetheart makes fun of me because I will make the same point in a conversation four times, each time in a different way, but never less than four times. I am emphatic. Thorough. Never succinct.
I’m envious of that ease of neat packaging.
It’s likely necessary that to be a good psychiatrist you must possess this skill. You must be able to listen to the last ten minutes of someone’s diatribe on their life and be able to pull out the most salient points. It helps to focus people when you give them the “so what I’m hearing you say is that you resent your mother for not being around”.
As evidence of this incredible talent, I hand you a statement made by a psychiatrist just the other day in a conversation about why people fail to perform their responsibilities: “There’s the rule of three: can’t, won’t, or oops.”
Can’t, won’t, or oops.
I loved this. I immediately scribbled it down on the corner of a page in my notebook.
It was the perfect representation of human failing. We all fail a great many times in our lives, sometimes because we are incapable of doing something (we can’t), sometimes because we refuse to do something (we won’t), or sometimes because we simply make an error in judgment or execution (oops). I think it’s important that we assess our own failings (and those of others) this way. Were we incapable of success or did we decide not to succeed or did we simply have random chance work against us?
Doing pediatric psychiatry and Interacting with teenagers is this constant game. They are reaching a certain level of social intelligence where they understand how to manipulate and play the game, but they often lack the required skill to aptly communicate how they feel, get themselves out of bad situations, or speak up for themselves and what they truly want.
Doing child psychiatry is… quite a task and I admire anyone who is up to the challenge. Some kids will cleverly learn all the right things to say so they can be discharged back home to the same situation that landed them here. Some of them are manipulative, lying, telling different staff members different pieces of information so we have to attempt to put together the real story. Some of them are resistant, not willing to participate in their own care and unable to see that there is more to life than what they have experienced so far (I don’t blame those kids at all).
Right now I’m working with three teenage girls, all of whom attempted suicide.
I have an incredibly hard times sitting down with some of these girls when they first come in and listening to their stories. It’s hard to listen to someone else tell about what brought them to the brink, what brought them to the place where they decided that the only answer for a temporary problem was to seek a permanent solution.
They are young and bright and they have whole lives in front of them.
But they decided they had no way out.
The suicide of young people is not easy for me to deal with. It hits close to home. Sit in a room full of people in their twenties and ask those of them who have known a friend or family member who committed or attempted to commit suicide before their 18th birthday and most of us will raise of hands.
I will raise my hand.
I remember high school, sharply, acutely, the same way that I think a lot of people who didn’t quite fit in remember high school. I remember this incredible sensation of being trapped in the endless cycle of uniform skirts that never fit right and incredible boredom. I realize now that a lot of the people I know didn’t feel accepted in high school—maybe life has selected for those of us who were the “weird” kids, meaning my exposure to other medical students, people with similar hobbies, etc creates a sample set of social rejects, or maybe a lot more people feel isolated in high school than we’re lead to believe by movies and TV shows.
I have such clear memories of my feelings at sixteen and seventeen, not only because I have a quite adept (but also fairly narcissistic) memory, but also because I have always been a writer. There are boxes full of journals and stories at my parents house. They’re pilled up in the closet of my childhood room. They’re a strange assortment—composition books the first half of which is filled with biology notes and the second half with bad poetry, bookstore diaries left half empty, paper clipped scraps of paper, folded notes passed between friends, and binders stuffed with hole punched print outs of typed stories.
I remember feeling immensely isolated. As though no one really understood what it was I was experiencing, sure I had friends and family and even boyfriends. But no one understood the incredible agony that it was to be me.
It all seems incredibly foolish now. Looking back I can remember so vividly the things that would send me spiraling out of control. I remember fights with friends, the crisis of having a boyfriend cheat on me, the cheek-burning shame of gossip. Now, it all seems silly. It’s all been dwarfed by a thousand larger crises in my life. I can look back and laugh at how strongly I thought I loved someone only to realize that ten years would prove to me what love really was. I can look back and remember the aching desire to not be quite so isolated, to be accepted, to be “in”—only to now realize that other people’s opinions are… pretty damn irrelevant to my happiness.
I can look back now on all the classic angst of high school and laugh, but at the time it was hard to see any of it as funny. In the midst of it all, however, there was always hope. Hope that I would get out of this damn town, hope that things would get better, hope that there was always an out, that high school was temporary.
Hope is what made me resilient through the dark times.
I realize now what an incredible gift hope is, one that not everyone is given.
The first of these three girls is one who couldn’t hope.
I’ll call her Sam.
Even though Sam tried to drown herself two weeks ago, she reminds me of someone who is still drowning. Her depression is swallowing her alive. The incredible overwhelming nature of it is such that she has a specific type of depression where she hears voices that tell her to kill herself; they tell her that a terrible person like herself doesn’t deserve to live.
I just want to grab her hand and pull her out of the water.
I have talked to a great many depressed people in the hospital; it’s not uncommon for people hospitalized with serious medical conditions to have comorbid depression. I’ve talked to a great many depressed children in my time on child psychiatry. But none of those people have been as profoundly depressed as Sam.
I cannot imagine what it would be like to live day after day with the crushing sensation in your chest that the world would be a better place without you, to feel that so profoundly, to believe it so fervently that your own mind begins to shout it to you over and over again.
Sam tells me about the incredible and profound guilt she feels when bad things happen to her. That she must have caused them because she is such a terrible person. I try to explain to her the impossibility of that, but I’m shouting against the storm that’s raging on inside her. I’m not sure my voice is heard over the crash of the waves.
Sam tried to end her own life because she couldn’t get herself out.
She couldn’t swim.
I hope this can pull her out of the water, or at least give her the strength to one day find shore.
The second girl is the girl who won’t hope.
Let’s call her Jane.
Talking to Jane reminds me of talking to a wall. There’s nothing, only hardness. She has no emotion, no sadness, no remorse, no concern—just nothing.
She’ll answer you—barely. If you push her you’ll get more than a couple words for an answer. I have learned so much about depression, about suicidality, about mood disorders over the last couple of weeks and I understand the definitions of “flattened affect”, but with Jane it’s not that. It feels like she’s not even trying.
Finally, after a week of these incredibly circular interviews where I feel like the rest of the medical team and myself are banging my head into the Jane-wall, I give up on the nice questions. Finally, I ask her, point blank what she thinks would help her. Instead of letting us talk round and round about how communicating with her family, and medication, and therapy will assist her. I just ask her what she thinks might make her feel better.
The questions probably come out a little harsher than I intended them.
“How do you want to feel?” I ask her
“Happy.” She says flatly.
“So you want to feel happy, you don’t want to feel like this forever—so what do you think would help you be able to feel happy again?”
“You don’t think anything will help?”
She looks up at me and makes eye contact with me for one of the first times in the hours I’ve spent talking to her, “Not really.”
“Do you think you could ever be happy?”
I know what I’m asking her and it’s not really a question about whether or not she expects to be happy, it’s a question about whether or not she has any hope.
She shrugs her shoulders. “I don’t know.”
Those are the three words Jane has said to me the greatest number of times.
I want to shake her.
I don’t. I let her go back to the common room and watch as she sits back down in the same spot on the same couch and picks up the same dogeared copy of Twilight and begins to read.
There’s more to this story. There must be. I refuse to believe that Jane is simply unwilling to even try to help herself out, but I know she could do it—if she wanted to. I wonder what it must be that’s going on at home or at school that makes her want to stay here, living on a psych ward over sleeping in her own bed.
She simply won’t.
The third girl is the oops.
I’ll call her Amanda. I think Amanda’s suicide attempt must have come as a bolt from the blue for her family. She was doing well in school, involved in sports and music. She’s close to her older siblings and parents.
Then one morning she didn’t wake up.
Amanda experienced an intense and well-organized campaign of bullying. Bullying so intense that it managed to rewrite her internal dialogue convincing her that she should kill herself, that she didn’t deserve to live.
This went on so long and so fervently that she began to internalize this and chose to sit down in her bedroom in the early hours of the morning and swallow pill after pill.
Her choice of medication was the scariest suicide attempt I’ve seen inpatient so far.
It was all bad luck. She could have picked any other set of pills in the house; she didn’t know those ones would be the worst possible combination. Her medical records read like a John Grisham novel for doctors—all thrills and no moments of down time. Intubation, dialysis, liver failure—sometimes I find it hard to reconcile all these things with the bright young woman who sits across the table from me.
But in Amanda there is so much hope, so much incredible, powerful hope. She tells us that she thinks that she was hurt so much by what was said because “good people can get hurt more easily than bad people because they actually feel things, they’re not cold inside”.
Twelve years old and already more articulate and insightful than most of the adults I know.
I am not an expert at psychiatry, far from it. Four weeks of this rotation do not give me enough knowledge to make any judgments that are not subject to the correlation—causation fallacy, but I’ve noticed that the people who improve, who find a way to go home and start over are those who have hope. They are the ones who believe that they could feel better, they could do better. They could find a way out. These are the ones who believe that they could create better relationships with their parents, they could grow up and leave the households full of conflict, and they could survive the cruel words of peers. Even when they don’t feel happy or strong enough to survive, they have hope that they will one day.
Hope is the greatest prognostic factor
I have a good friend who once described his own outlook on life to me this way: “I’ve done a lot of stupid and dangerous shit in my life. I’m still here. So I’m going to keep doing it.”
That’s the kind of hope I have.
I have come through every bad thing in my life. I have survived them all. That doesn’t mean that all of them have been pretty. Simply that I survived. I have survived the fear and the hurtles and the stumbles and the flat on my face falls.
It has made me a good sailor in a storm.
I don’t think hope is about believing that everything will be perfect, better, ideal. Instead, I think it only has to be hope in ourselves. Belief in ourselves. We are all exactly where we are because we have survived everything to this point. We may not have done perfectly. We may not have excelled. But we have survived.
And that is something to give us hope.
When we find ourselves losing hope, I think we often have to wonder if it is because we cannot have it, will not chose it, or we have made a mistake in losing it.
This piece is
- Not representative of any of the organizations, schools, hospitals, etc. I am affiliated with.
- For entertainment, discussion, and amusement purposes only and any much of my writing is very tongue in cheek. Consider this when reading.
- ALL names (including those of physicians) have been changed to protect the identities of people I write about.
- Some details of locations, times, cases , etc have been altered. In every case to protect the details of the people involved and never to embellish or alter the telling of my experience. What you find here is the true account, as true as flawed human memory can tell, of my experience.
- This piece is subject to all other disclaimers that occur on this blog.