Illustration by Jackie Hoving
“We got the best drugs.” That was my answer when asked why I chose psychiatry as my specialty. Between the psychopharmacologic art of finding the right antidepressant (hint: it's always bupropion), the transformative magic of panic-blocking benzos, writing ADHD scrips to stimulate students, treating bipolar disorder with all-natural lithium, and calming voices with clozapine, you name it, we got it. I read textbook chapters on mechanisms of actions of antipsychotics and built a mental framework for organizing medications by side-effect profile, potency, and metabolism. I planned whiteboard lectures that I taught to medical students and co-residents because I was so pumped to talk about psychopharmacology.
I had little interest in psychotherapy and psychodynamics. Don't get me wrong, I was all about building the therapeutic alliance, but for me that was just the means to the antipsychotic end. I did learn some motivational interviewing techniques and cognitive behavioral talking points that could inspire change, with few to no side effects. But it wasn't until halfway through my second year that an attending physician displayed psychodynamic interviewing techniques in short interactions with patients that I started to think about what it meant to really understand patients and help patients understand themselves. I began to grasp the difference between medications that can treat and words that can heal.
A case I encountered while on call in the emergency department illustrates the difference well. AJ was a twenty-seven-year-old black female who was in a six-month relationship, had no kids, lived with her twin sister in an apartment, and supported herself by working as a receptionist in an optometrist's office. She had a history of major depressive disorder with psychotic features and had just been discharged from our inpatient psych unit the day prior after a twelve-day stay. In fact, she had been inpatient for twenty-three days over the prior month with two nearly back-to-back admissions. During those stays she had received an aripiprazole 300-mg long-acting injection with the next dose due in a few weeks.
On the evening of my call she was brought voluntarily to the emergency department by her twin sister, and psychiatry was consulted for “hallucinations at home, worsening anxiety.”
“My practice has become a blend of medicine and the dynamic mind, coiled together in a double helix.”
I was not familiar with the patient and did not have adequate time to review her chart in-depth. I was not concerned about nonadherence to medication given her recent long-acting injection. My thought process was linear and goal-directed. Psychosis secondary to substance abuse, treatment-resistant psychosis, and psychosis secondary to unmanaged anxiety were high on my list of differential diagnoses. But instead of preemptively diagnosing her, I sat and asked if we could review the past twenty-four hours since her discharge.
AJ told me her dad picked her up from the hospital and drove her to the family home with almost no conversation on the car ride home. When she arrived, her mom was busy with the phone and didn't greet her, and her twin sister was out on errands. While she was in the hospital, she was deprived of family contact due to COVID restrictions, so this would have been the first time she had seen their faces in two weeks. I pointed out that it would have been natural to feel disappointed that the family she hadn't seen in two weeks didn't seem excited to have her back. We explored these thoughts and the feelings they stirred, until I asked her to fantasize about the ideal welcome. She dreamt up an extended family waiting for her, and her sister greeting her in the car. She wanted to feel supported, like they were in it together.
She told me about the rest of that day. Within a few hours of coming home she felt light-headed and became worried that she was going to faint, so she started pacing. Bio-brain interrupted my thoughts. Was this antipsychotic-induced akathisia? Aripiprazole is a known offender, and the skin-crawling restlessness that comes with akathisia can be described as anxiety with pacing. If so, prescribe propranolol 10 mg twice a day and have her follow up outpatient. But maybe it was something deeper than cellular signaling. I asked if it was easier for her to feel anxious than for her to feel disappointed by her family. She agreed with my interpretation, and I could sense a smile of self-recognition underneath her facemask.
She told me that after a few hours of pacing at home she called EMS herself and was brought to a different hospital where she sat in the waiting room for two hours. While she waited, her anxiety subsided, so she felt ready to return home without being seen. We briefly touched upon what she thought the waiting room offered her that was lacking at home. We concluded that she had been taken care of by doctors and nurses before, and that therefore she associated the hospital with the calm it gave her.
We didn't continue the conversation much further; she said she felt much better and thanked me. She said no one had taken the time to speak to her like this before. I gave her the number to our clinic and to several resources for community care. While in the emergency room she was able to eat, nap, and call her sister, who agreed to take her home and help her follow up outpatient. I called AJ eight months after our initial encounter, and she had not returned to the hospital since. From the time of her first hospitalization, this was the longest she had gone without an inpatient psychiatric stay.
I am not sure where my career will take me, but I want to hone every tool at my disposal so that the future me can best serve his patients and himself. I realized that I initially felt biased toward the biological approach after coming from years of medical school and undergraduate study of the natural sciences. The further I transitioned from the theoretical and the closer I got to the actual patient, the more I saw the intangibles at play. My practice has become a blend of medicine and the dynamic mind, coiled together in a double helix. The more I grow, the tighter these strands twist, and I catch brief moments when they blend into one cohesive art.
Abram Davidov is a third-year psychiatry resident in Detroit. He studied neuroscience and creative writing as an undergraduate. When not walking his dog Moose, playing chess, or reading comics, he likes to practice psychiatry.