Abstract

Humane and empathic care are quintessential to the medical profession. In this narrative, a psychiatrist reflects on a difficult patient encounter which highlights the influence of trauma on a patient with psychosis and how the doctor-patient relationship is paramount in the treatment of any illness.

Keywords: psychosis, empathy, doctor-patient relationship, peak experience

The great lesson is that the sacred is in the ordinary, that it is to be found in one’s daily life, in one’s neighbours, friends, and family, in one’s backyard.

— Abraham Maslow [1]

A 34-year-old woman who had delivered three days earlier in a neighbouring hospital was brought to the medical college hospital where she had been treated for the last few years for a mental health ailment. She was clutching her three-day old daughter with a grip that spoke not only of love but of a fear that transcended the ordinary. In her paranoia, she had not allowed anyone to touch her new-born. Her mother and brother were exhausted, persuading her to give the baby into their care, as they worried about the potential harm to the baby in the hands of a mother whose grasp on reality was fragile. She was physically drained, having hardly slept after childbirth, but she clung to the baby as though guarding her from the perils of the world that she had herself endured. I got a frantic call from the resident for help with managing this patient and the events that unfolded left an indelible mark on my understanding of the patient-doctor bond.

When she had first visited the hospital a few years earlier, this woman was a soul adrift, withdrawn from the world, deluded that she was possessed by “Satan”, making her incapable of reciting the holy book. She was diagnosed with schizophrenia, a severe and disabling chronic psychotic disorder. Her mother was not optimistic about her chances of making a recovery having consulted a few psychiatrists over the years. However, they stuck to treatment with whatever last strands of hope and resilience remained.

We navigated the enigmatic labyrinth of her mind over the next year through regular follow up visits. The scars of childhood trauma and fear of abandonment, following her like a shadow all her life, were apparent in our conversations. Her neglectful father was effectively absent from her childhood which meant that her mother was solely responsible for her upbringing.

The patient’s perseverance with the treatment paid off and the dark clouds of psychosis started to recede. Once in a cocoon of despair, she gradually started to emerge like a resilient butterfly spreading its wings and trying to regain her life from the grip of psychosis. She was remarkably improved, but was unable to visit the hospital for consultation after the Covid-19 pandemic lockdown. However, she continued the antipsychotic medications which were instrumental in her recovery during this period. Her family, their confidence reinforced with a new found hope, started contemplating getting her married. They struggled as women are married young in their community and the stigma of mental illness diminished one’s chances of getting married.

Finally, she reluctantly married a man who already had a family. She was unhappy about this, but refusing this offer would have meant spending her life alone which is a taboo in their culture. She became pregnant and decided to see the psychiatrist as she was not sure about continuation of the antipsychotic medications. She was in clinical remission and was nowhere near her past state of desolation. Her medication was tapered off as per her wish.

The next time I heard about the patient was when she landed in our hospital after her delivery. The family informed us that in the weeks leading to the delivery she was easily provoked to anger. The family were unaware of the storm brewing inside her and things took a grim turn after she delivered. Her husband did not visit them in the hospital, and the old wounds of abandonment resurfaced. The hospital room, which should have been filled with the joy of the arrival of a new life, was instead filled with paranoia. She became obsessed with caring for the baby, not letting her baby leave her sight at all times. At night, even when she was utterly exhausted, she would cling to her baby. Her mother had to face her wrath as she was deemed unworthy of childcare. She declared, “You married a man who was unworthy to be a husband and a father. Because of you I had to live a life of suffering. I do not want my daughter to endure the same hardships. I will not come to your home. I will live separately with my daughter. I will earn and bring up my child alone.”

Her mother was distraught by these developments, and they rushed to the psychiatrist who had once helped their daughter. Our resident tried every trick in the book but couldn’t get her admitted. It was clear that this would be an involuntary admission considering her lack of capacity to take treatment decisions and the potential risk of harm to the new-born. Our residents then planned a ruse to admit her. They took her to Casualty from the outpatient department, and under the guise of drawing blood for some tests, planned to give a dose of sedative. The lady was so vigilant that when she noticed a loaded syringe, she grabbed it and threw it away.

The commotion in the casualty was disturbing other patients who were critically ill. The hospital authorities decided that the baby was at risk if they tried to coerce her into taking any treatment. So, they decided to send her to the city hospital where I was seeing patients as part of my evening practice. One of our junior residents accompanied the patient as she was becoming increasingly angry and aggressive towards her family.

As I was kept informed about the developments regarding this patient, a nervous anticipation had risen inside me. I noticed myself running through possible scenarios when I would come face-to-face with the patient, and how I would distil my experience to tackle this challenging patient encounter. As soon as I got the news of the patient coming to the casualty of the hospital, I rushed to see her.

When we came face-to-face, I emotionally attuned myself to her suffering, aware of her tumultuous journey over the years and the chaos that ensued after childbirth. With kindness in my eyes, I said to her “The baby looks adorable. Shall I hold her?” The baby, a symbol of innocence and an embodiment of her hopes and fears, became a conduit for a fragile trust. In the midst of paranoia and anger, an offering unfolded — she handed over the baby to me, a bridge between the realms of sanity and chaos. I have tried hard to put this unforgettable epiphany into words. All I can say is that I was blessed with what Abraham Maslow would call a “peak experience” [1]. A precious moment of transcendent joy. The trust she placed in her doctor surprised everyone. Shrouded in the darkness of psychosis, her relationship with her doctor remained intact. A mirroring of her emotional state by the doctor opened up a chink in the armour she had built to defend herself from the painful reality of her life. As I cradled the baby in my arms and listened to her, a gush of emotions was released. She shared her deepest fears, and it was clear that the events of the last few days had scratched and laid bare childhood traumatic experiences.

She was advised to take a sedative injection as she was drained and sleep-deprived. She agreed and slept after the injection. When I returned to see if everything was fine, the baby was in the grandmother’s arms. The uncle was preparing formula milk to feed the baby. The resident who was there during this time told me that the family’s joy in finally getting to hold the baby was palpable. We admitted her and listened to her fears every day without judgment, and guided her family on how to deal with her behaviours. The family gradually understood why she was antagonistic to them and how her vulnerability fuelled paranoia and pushed her away from the reality that now she was a mother and her family, though not perfect, had backed her through all her ups and downs. She was discharged in a few days, on antipsychotics, and she went to her maternal home.

Our patients impart wisdom which transcends academic textbooks. This challenging patient encounter is a poignant reminder of how trauma can have an enduring influence on an individual’s life experiences and relationships. It highlights the importance of tapping into our human nature to provide empathetic care. It’s a testament to the sacrosanct nature of the doctor-patient relationship and its healing power.