I went for a run this morning. It's part of my "self care" that clinicians are supposed to engage in. It's how I process my week, and things that can really get to me, like the kid that was in my office yesterday.
Usually the kids I see have some pretty chaotic upbringings. They've seen mom get beat up. They've seen people get knifed. Maybe they've been beat up. By mom or dad. Others have been sexually abused. As horrifying as it is, I've gotten used to it. I'm not numb, but it no longer haunts me.
But the kid who was in my office yesterday had none of that in her history. She regarded me suspiciously, staring at me intently under heavy-lidded eyes. The receptionist at the front desk later commented to me, disapprovingly, "That kid sure has some attitude. Hostile."
"She's not hostile," I corrected her, "She's severely psychotic, and heavily sedated."
When the kid blinked, she blinked slowly. Her mouth hung open. She would sometimes speak in response to questions, but it took a while, and the answers were hard to understand and usually just one word.
And there was that stare.
She was 17, and would turn 18 in 2 months, the age at which she would drop off the edge. Deemed by society to be an "adult" who was perfectly able to take care of herself, and the benefits of being an ill child would disappear once she became a mentally ill adult.
"Heavily sedated, flat affect, psychomotor retardation," I jotted in my notes.
She has schizophrenia. Out of nowhere, at age 15, she started hearing voices. The many voices provided a running commentary of her thoughts and actions to each other, and sometimes to her. She started mumbling to herself in class, and would say and do things inappropriately sexual. She was convinced she had a chip or wire implanted in her, and prepared 12 pages of single-spaced, typewritten information supporting her theories, which she asked her psychiatrist to get to the government. She believed in a plot by Nazis and the occult to overthrow the US government.
Several different medications had been tried. But the girl she was, well-behaved, straight-A student who never did drugs or got into trouble at school, she was never going to be again.
Most of the medications that they had tried so far caused sudden severe weight gain, or movement disorders, such as dystonia, a kind of twisting motion, and akathasia. Akathasia is what causes the pacing and walking you sometimes see in people who are on antipsychotics. The medication makes their legs feel twitchy and restless, so they walk to get rid of that feeling. Some antidepressants do it, too.
The kid's Mom could barely speak English. Dad couldn't speak any. I could stumble through a tiny bit of Spanish, but not this. How do you say "Treatment resistant psychosis" in Laotian?
I tried not to let my horrified sympathy show through too much when I spoke, to keep my face even, as I read through the case notes from the hospital that they'd brought with me.
They looked so hopeful. I wanted to honor that hope. I wanted to tell them that we had something that would fix their daughter, and that she would be the child they used to know. But we didn't. We don't.
"We don't have a program for you," I finally said, carefully placing the papers on my desk. It was hard to look them in the eye when I said it. Their daughter had no behavior problems that we could remedy, and we only treat kids under 18. I wanted to convey sympathy.
We can fix her, I wanted to tell them. But we can't. She'll need long-term care. This kid has severe, unremitting psychosis that causes her to do stupid, dangerous things, mostly dangerous to herself. Ever seen the scars where a kid has tried to dig out those implanted chips?
She also has a much higher risk than others her age of committing suicide. She's already told one psychiatrist that she didn't believe anything would ever work, and that "this is who I am now." Hopelessness has settled in on a 17-year-old.
She would need a treatment guardian, and a transition plan for adulthood. I assigned her a case manager to start that process, and moved on to the next case.
Stuff like this gets to me. The bright future extinguished, it stays with me longer than the rest. I think about the dreams that we have for our children, and often for ourselves. I wonder about how it would feel for that to be snuffed out, without warning.
In many ways, it would be worse than a death, I think. You have the person in front of you, and they look like the kid you used to know, but that kid is gone.
Occasionally, you would see glimpses of the person they used to be, and you would hope. Then, hope would disappear again.
Sometimes I process these thoughts by writing them out, in my silly little blog. But more often than not, I run.
As I run, I imagine the wind blowing the images in my head--grief-stricken, worried faces; twitchy, nervous kids; staring girl, and angry boys--through me and away.
So, as I said earlier, I went for a run this morning. It was a nice, long run, about 6.5 miles in the cool dawn.
At the end of it was a smiling, handsome man with a cup from Starbucks.
Friday, August 27, 2010