Personal Accounts: A Touch of Dynamic Psychiatry

I thought I was all caught up with the day's schedule. As a hospital staff psychiatrist, I had typed my electronic clinical notes, checked my patients' outstanding laboratory values, and completed their multidisciplinary treatment plans. Now, at 4:30 p.m., just as the thought of reading some recent psychiatric literature passed through my mind, I was paged for a code purple—a psychiatric emergency.

The patient, a 29-year-old man, was in the emergency room—handcuffed, attended by a police officer, and accompanied by his wife, his two older twin brothers, and his grandmother. Earlier that day, the patient, Mr. L, called Jimmy, had shot several newly planted trees in his neighbor's front yard with a BB gun. The neighbor and all of Mr. L's family members had failed to persuade him to stop this irrational behavior. The police were called, and Mr. L was handcuffed and brought to the emergency room. According to the family, there was no precedent for such an action, and Mr. L had no history of psychiatric or substance use conditions. His family history was also negative for psychiatric disorders.

Mr. L was calm and appeared to be unconcerned about the day's events. He countered my attempts to interview him with absolute silence. He kept gesturing to the police officer that he wanted the handcuffs to be removed. I saw his request as a golden opportunity to show empathy. My request to fulfill his wishes was answered by a clear and loud "No" from the police officer, Mr. L's family, and the emergency room nursing staff.

My mind went numb as I attempted to review the DSM-IV diagnostic criteria that Mr. L's condition met. All I could think of was to rule out "not otherwise specified" diagnoses. Mr. L's grandmother kept asking, "What are you going to do to my baby?" His wife was enraged by that statement and shouted, "Jimmy is not a baby; we are expecting our first baby soon!" His brothers joined the debate and confirmed that Mr. L had always been "Grandma's baby."

I was at a loss how to intervene, and the police officer, seeming to lose his patience, asked in a clear, firm, and raspy tone of voice, "What's your recommendation, Doc?"

I was overwhelmed with anxiety and felt that I myself could meet DSM-IV criteria for an adjustment disorder with anxiety. I suddenly recalled a psychotherapy intervention: "Be courteous and considerate, and intervene with several options without escalating anxiety and fears." So I came closer to Mr. L and in a soft voice asked, "Could you tell me what you were doing with that wee wee gun?"

A burst of laughter engulfed everyone present, including Mr. L, who also became teary eyed. He then asked his wife to hold him. She hugged and kissed him. Mr. L told her, "Honey, I'm so glad you're going to be our baby's mom." The grandmother and the twin brothers showered the couple with hugs and kisses. The police officer smoothly and quietly removed the handcuffs.

Mr. L told me that I "did pull a fast one" on him and that the words "wee wee gun" pulled him out of his confusion. Only then did I realize that because of my anxiety, I had said "wee wee" instead of "BB" gun. Mr. L's wife, his grandmother, and his twin brothers tearfully thanked me for bringing Mr. L back to reality. The police officer and the emergency room nursing staff congratulated me for handling this potentially violent patient.

I wanted to clarify my mistake and explain that saying "wee wee" was not intentional. Then I recalled that in psychotherapy, affirmation is a simple intervention that involves supportive comments like yes, no, or uh-huh, so I said "uh-huh." Immediately Mr. L proceeded to tell me that when he was six years old, his father promised to buy him a BB gun when he reached his 18th birthday. Unfortunately, his father lost his job a month before that birthday, and Mr. L never got the promised BB gun. Although he did not harbor any resentment toward his father, he felt disappointed and "betrayed." He also made a conscious determination that when he became a father, he would never promise his children any gifts unless he had already purchased them.

So when Mr. L found out a few days before the shooting incident that he and his wife were going to have a baby, he felt numb. He could not remember the reason that led to the purchase of the BB gun or the antecedents of his emergency room visit.

By then I felt calm and collected and thought that this was the opportunity to obtain a detailed history and a mental status examination, to help confirm the probable DSM-IV diagnosis of psychogenic amnesia. Neither Mr. L nor his family were interested in such an endeavor. They agreed to come for a follow-up appointment, they thanked me for my help, and they all left in a joyful mood. I was left alone with the police officer, who suddenly stood up, shook my hand, and said I was a "great psych doc." However, the emergency room nursing staff expressed their dismay at the ending of the intervention, as no medications had been prescribed.

I concluded Mr. L's clinical note with the statement that the source of his apparently irrational and otherwise inexplicable behavior seemed to be in a part of his mind of which he was not consciously aware. I then realized that Mr. L's behaviors and my reactions to them were expressions of interacting conscious and unconscious processes. My situational anxiety had led to the unconscious use of "wee wee," and that humorous term apparently evoked conscious and unconscious memories from Mr. L's childhood that were related to his expected fatherhood. At that moment my enthusiasm for dynamic psychiatry was rekindled.

I then also realized that considerable time had passed, and that according to mandated clinical guidelines for seeing patients, my clinical intervention would be categorized as "disproportionately costly." Over the past four years the introduction of managed care practices has pushed me to squeeze more patients into increasingly shorter time slots. Under the banner of cost-effectiveness, I have been urged, and at times pressured, to limit my interactions with patients to the task of prescribing psychotropic medications and to refer them to other mental health professionals if they need psychotherapy.

I went back to my office and looked for my textbooks on dynamic psychiatry. They were at the bottom of a cardboard box that I had not opened for four years. They now stand clean, tall, and proud, with DSM-IV on one side and my psychopharmacology textbooks on the other. I am thankful to Mr. L and his family. Their emergency galvanized me to take a conscious step to reintegrate dynamic psychiatry into the treatment of all my patients.

Acknowledgment

The author thanks Paul Emery, M.D., for his clinical guidance.

Dr. Khouzam is a staff psychiatrist at the Veterans Affairs Medical Center, 718 Smyth Road, Manchester, New Hampshire 03104-4098 (e-mail, [email protected]). He is also adjunct associate professor of psychiatry at Dartmouth Medical School in Lebanon, New Hampshire. Jeffrey L. Geller, M.D., M.P.H., is editor of this column.