For 10 years after medical school, I was a mother of three young children and worked as a public health physician in Boston and Washington, D.C. When I resumed training in psychiatry, I became fast friends with Marie Z., the head nurse on the hospital's inpatient unit. We both loved clinical psychiatry, and we shared a particular affection for the older patients and the troubled adolescents. We shared a dream that someday we would together go to work with the Indians. This dream was a condensation of shared interest in Native Americans, but mostly it was shorthand for an affinity for a more direct and active mode of psychiatry.
Many years passed; I pursued my fascination with psychodynamic psychiatry and completed psychoanalytic training. In 1989–90 my husband and I were on sabbatical in Israel, where he was the Freud Professor at Hebrew University and I taught at Hadassah Medical Center's Department of Psychiatry. Together we organized and directed a conference on Children in War [see “From Clinical to Political: Working With Children in War,” TAP 31/3] and were active in the peace movement.
When we returned to Boston, I was rebuilding my practice when a call came from Marie Z: 'Remember our promise to work with the Indians? Come and work with me on a home care grant. We need a psychiatric consultant to work with the families of AIDS patients, many of whom are now young mothers.“ So Marie introduced me to an area of the inner city where I had not been for many years while I had been practicing in the suburbs and teaching at hospitals.
I have spent half a day a week there for the past seven years, and I continue to find this work inspiring, enriching, and moving. Every week I am amazed as I continue to learn much from the people I encounter as patients and colleagues in the home care service. It is clear that a psychoanalyst can contribute a great deal in settings out of the ordinary consultation-room framework. What is less well recognized, and more humbling, is how much we have to learn and how much simple, old, sick, poor, immigrant people can teach us. I also learn from the nurses and social workers I consult to; many of them are close to angels in their behavior — caring, genuine, humane, dedicated. They are intrigued to learn from me about the darker side of people — ourselves and our patients. In our continuing dialogues, I am reminded a lot of the better and more altruistic side of human nature.
In my office practice I continue to see more affluent and better educated patients, but I do not see people who have better character, in the old-fashioned sense of the word. It is a useful lesson that people who have survived great adversity, and live in much-reduced circumstances, can have fine personal values and admirable integrity. These are not always qualities we can presume in our neighbors and colleagues.
Perhaps there is a selection: Those who seek out medical care at home may have more interest in developing and/or capacity to develop long-term relationships with the staff and their communities. In a place where I had feared to go because of the widely reported dangers, I am repeatedly amazed by the quality of the individuals, their concern for their families and friends and caretakers. I realize that just as in war zones, an area of the city with too many murders and robberies is also a place where most people live and work and go to school.
In the course of this work I have met Native Americans (Narragansett Indians), African-Americans, patients from many Latin American countries and Cape Verde, and survivors from Lithuania and Hungary, Cambodia and Viet Nam. The ethnic diversity and language of the patients and the bicultural workers is mind-boggling. This mix of people, backgrounds, food shops, and religious practices, only 20 minutes from my home, gives me an exotic travel destination each week.
One young African-American woman, a high school graduate who came to work at the agency as an aide, seemed to have a real flair for languages. She realized this early in life when talking with the Polish superintendent of her building; she later enjoyed learning Spanish and Portuguese and the various dialects and accents of people in her immediate neighborhood. She took a job at a 24-hour convenience store in Chinatown and started to pick up Chinese. Her talent was identified and reinforced in the agency by me and other professionals on the staff; she has started university studies.
It is a real privilege to be invited into the homes of our patients. There we see the range of possibilities: the hovels that are rotten and dirty and crowded beyond belief, the wee personal castles that some people can create, and everything in between. There we see a fuller life, a context of life, relationships in action, that remind us how narrow a piece of a patient's life we see in our consulting rooms. We tend to judge a great deal from the depth of the patient's relationship with ourselves as it plays out in psychoanalytic therapy and psychoanalysis. My home care experience has made me more aware of home and who is there, and more curious about that personal social space as I explore the inner psychic space.
My consulting practice is quite varied. The original group of AIDS patients has passed on. For some unknown reason — perhaps better awareness and prevention, perhaps other services available — there are fewer young women with AIDS. As I followed some of them through their terminal illnesses, I was impressed with their capacity to change lifestyles and priorities. After they were diagnosed with HIV, they intensified their focus on children and child care and stopped their illicit drug usage; reconciliation with family who could provide ongoing care for the children became paramount. As terribly sad as each of these situations was, I found it also refreshing to see how much change could take place in dire circumstances. In my office practice, by contrast, change often comes slowly and less dramatically.
I also see many homebound elderly and disabled folks. I am constantly learning about their stories of life and survival, about their losses past and present. Merely listening with interest, and thereby demonstrating to the visiting nurse and family member the importance of listening, serves to ennoble the stories and the narrators. There is a true wealth of human wisdom among these quiet old people: a woman who was a young leader of the Civil Rights movement in Alabama, the daughter of freed slaves who recalls her parents' tales of the Civil War, a man who started urban gardening with victory gardens in Boston that caught on nationwide.
Consumed by a particular disability, presenting a particular complaint, a person can easily become dehumanized. Reminding others — and the patient herself or himself—of more of the patient's humanity can restore a significant loss. That is often the intervention that helps the most, the one which most
Roberta J. Apfel, M.D., M.P.H., is a psychiatrist and psychoanalyst practicing in Boston; she has a public health background (maternal and child health). She serves on the faculty of the Boston Psychoanalytic Society and Institute and is a clinical associate professor of psychiatry at Harvard Medical School, Cambridge Hospital.
impresses the medical staff, who may start out asking for a medication. Prescribing medication is an important and useful part of my role; getting to know the meaning of the medication, and of the relationship between patient and caretaker, is an even greater gift we can bestow. In many situations, not much can actually be done; it is important to learn and teach that a little can go a long way.
I follow a number of young people with major mental illness. I provide medication; I back up the visiting nurse in helping patients, along with their families and neighbors, to cope. Some of the younger patients have presented with frightening symptoms, such as violent ideas, that must be assessed psychiatrically. Several times I have gone into a home with trepidation, based on scant advance information, backed by another staff member and even a crisis team and police alert. We are fortunate to have an excellent city-wide emergency intervention/hospitalization program, but I have almost never had to use it. More often I am amazed to discover that talking with the patient uncovers fears or losses or problems in the system that contributed to the decompensation or symptoms. Eliciting this information enables everyone to understand and calm down. Here, my psychoanalytic training helps. I am able to listen and to bear negative affect pretty well. I trust my own sense of who and what is truly dangerous, and I never feel totally alone with these judgments.
It is fun to work with a team of nurses and social workers among whom there is much mutual respect and discussion. My colleagues have expressed disdain, confusion, and admiration that I do this work. I have not succeeded in recruiting others from our analytic community to participate. (One candidate sought a job in home care independently.) I wish that I could better convey the pleasures and positives of this community mental health work so that others could offer their services and gain similar rewards. This “work with the Indians” for me is a continuing fulfillment of one of my dreams and a most enriching part of my career.