Wednesday, March 20, 2013

Terrifying glimpse of the future

Today I worked with a patient who has borderline personality disorder. Normally I'd be thrilled to be working with an actual patient instead of just reviewing treatment plans and making the counselors do even more paperwork and corrections. But borderline PD is a difficult ailment to treat, even more difficult because we don't have a full-time psychiatrist on staff. We have a psychiatrist a few days a week because our regular doctor is on maternity leave, but the psychiatrist is leaving soon.

The patient is about 9.5 years older than I am. She is taking benzodiazepines -- strong short-term tranquilizers that, if you use them regularly, put you at risk for seizure if you stop abruptly. She won't consider going to detox to get them safely out of her system. And she has been discharged from almost all of the NYC-based clinics and hospitals that treat borderline PD and accept Medicaid. So finding her an appropriate referral has been very difficult. Right now she doesn't even have a psychiatrist; her primary care doctor won't prescribe her benzodiazepines and will probably stop prescribing the antidepressants.

Most psychiatrists with outpatient practices won't prescribe benzos to a person with a history of heroin dependence, and rightly so. Benzos don't provide long-term psychiatric stability; in fact, long-term use just reinforces anxiety, as the body struggles against the benzo to achieve equilibrium and overcompensates for the sedation with frenzy. (Hence the seizures.)

The patient also presents with a host of physical problems. Back and knee pain, digestive woes, vague aches that migrate around her body. She complains that her antidepressants have stopped working, moans that her computer isn't working, and tearfully frets that if she goes to inpatient treatment, her cat will be miserably lonely without her. She frequently states that she thinks she would be better off dead, and regrets that her former boyfriend called 911 when she overdosed on heroin a few years ago, instead of letting her die.

I'm not trying to make fun of her. Although she's challenging to work with, she's reinforcing important principles for me. For example, in motivational interviewing (MI), you're never supposed to say "but." Patients who are considering change are ambivalent. They don't want to hear "but." You need to weight both sides of the issue equally.

I am trying to put my theoretical knowledge of MI into practice. But I don't always get it. For example, today she was complaining that she has been poorly treated at several local hospitals and doesn't want to go inpatient.

"You had a bad experience with inpatient treatment at Hospital X," I said, "but--"

I planned to finish with, "that doesn't mean you'll have a bad experience at Hospital Y." That's cognitive-behavioral therapy (CBT) reasoning: where is the evidence that your next experience will be as bad as the previous? You can't foresee the future.

I've got much more experience with CBT than MI; it's my go-to therapeutic response. But in her case, she's not at a stage where CBT would be effective. I need to use MI with her.

"No BUT!" she wailed. "There are no BUTS!"

She was right. I corrected myself: "You had a bad experience at Hospital X, and you're afraid that if you go to Hospital Y it will be just as bad."

"Yes!" she cried, validated.

So working with her is probably some of the best MI training I could ask for. It's frustrating that I can't offer her psychopharmocological treatment at my clinic, but even though I can't offer much concrete help, I can at least allow her to feel validated. Until she decides that she hates me and I'm a horrible clinician, which is fairly likely to happen, given her condition.

But listening to the poor woman gripe and kvetch, I had an uneasy sense of déjà vu. After all, I have knee pain and back pain. I'm miserable about being alone and frequently complain about it. I frequently opine that I should have died already, or that I'll kill myself when I'm 50. Looking at her is like looking in a cloudy mirror; listening to her is reminiscent of my ruminations. Am I that whiny? Not always, but frequently. Am I that unforgiving? I'm still angry at the hospital whose ambulance charged me $1000 to take me less than 30 blocks.

Will I be that miserable when I'm her age? I surely hope not. If I go through the surgery my rheumatologist has in mind, it should help my knee pain. If I don't have constant pain, will I be able to create a meaningful and satisfying life for myself before I turn 50? Without children, and probably without a husband?
Copyright (c) "Ayelet Survivor"

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