On kids.

It's been a whirlwind of a month and I've loved psych more and more with each day. I never believed the doctors at the interest group dinners who were like "Just go on rotations, cause once you fall in love with something, you'll know it." Well it happened, and I guess they were right, with all their experience or whatever.

I've especially come to love adolescent psychiatry. There are some kids, yes, that are difficult cases but they are almost always a product of their environment. Sometimes it's a sad, sad environment with stories that suffocate me and make my chest hurt with their tragedy. Like the 15 year old girl who grew up with a mother with schizophrenia, and was repeatedly raped by her mother's continuous conveyor belt of deadbeat boyfriends. She told us that two years ago, she got pregnant from her mother's boyfriend, carried the baby to term, gave birth secretly at home and then her mother "threw it away." Hearing that story, my heart broke into many pieces that still haven't fit back together quite the same as before. The girl ended up going to a more long term facility. But then there's the kid who came in two months ago, floridly manic, leaping from table to chair to bed to table, rattling off Eminem lyrics for no reason, picking fights with kids without even knowing why. After months of tweaking drugs, and an extensive (but ultimately negative) neurology workup, the anti-psychotics and mood stabilizers kicked in and he went home to a loving, concerned, but ever supportive family. There are happy stories in psych too, that give me hope for these kids, which by default give me hope for the future.

What draws me most to adolescents is how sometimes I see myself in them. I've felt their hurts before, I've sat in their chairs listening to the same lecture that I heard not too long ago myself. I saw myself in the cynical emo kid who found all his classmates achingly shallow and dull. I saw myself in his consciously "stick it to the man", "go against the flow", opposite of mainstream attitude. He was exploring his gender identity and wanted to cross dress, but his parents wouldn't let him due to their living in a white, conservative, small area where he would almost certainly be a negative target for both kids and teachers at school. He also struggled with these struggles themselves; he felt like a burden to his family and friends. He said he "leeched from their happiness, but never added to his own in the process." He told me when I asked if he was happy or unhappy that "happiness is an unsustainable state of mind" and he brings people down. He should major in philosophy in college. His parents were also supportive, telling him they loved him but that sometimes the world isn't fair, accepting or easy sometimes. They compromised by letting him cross dress on weekends, and at the upcoming Comic Con. He was the splitting image of his mother, both with striking, bright blue eyes and a very distinct smile. He's a kid I don't see coming back to the hospital, a kid who will use this experience to learn, grow, and go to far away places where he can be a she if he/she wants.

Today I had a family meeting with a mother I was afraid to meet. Her daughter threw herself into traffic after a counseling session last week in a suicide attempt and was brought to the hospital. Their history is a difficult one, as the mother has HIV and is in end stage kidney failure and waiting for a new kidney. She is an African American single mom who has had serious health issues all her life. Her daughter, this bright, bubbly, though very dramatic 14 year old girl stole my heart despite my best attempts for her not to. During our first interview, she cracked jokes, playfully called me "Ms. Crystal", and asked the resident where he got his shoes. She told me about her difficult life, how she was raised half the time by a family friend while her mom was in and out of the hospital, how when she lived with her dad he "beat her and burned her." She was also raped by the family friend's husband two years ago, after which she felt so alone and confused that she started seeing an imaginary friend who has been with her ever since. My heart went out to this poor girl and her tumultuous upbringing, bouncing around homes, never a stable life.

One problem was that after being in the hospital for three days, her mother never visited once. She told me that her mother would tell her she'd visit, but then she wouldn't. Her mother told the doctors that "she's just seeking attention" and she refused to visit. I was appalled, and so sympathetic toward this girl who just wanted to know if her mom cared. And when her mother met with us today, her first words were "My daughter did this to herself, and I'm just about done with her." My first reaction was fury and judgment. This girl needs you!, I wanted to say. She's hurting, she's confused, she needs guidance, but mostly she needs support from you!
Then she broke down. She explained that they're financially struggling, that she hopes to get a kidney by June but needs to keep her stress/blood pressure low for that to happen. She just moved into an unfurnished house with no refrigerator but she just bought a microwave and is working on getting it furnished. She is looking for a job but it's hard to find one that will accommodate her need for dialysis twice a week. She's working on pressing charges against the man who raped her daughter. She dabbed at her eyes as she explained how everything she does, she does for her kids, and her daughter doesn't understand that she has to meet her half way. That her daughter doesn't come talk to her civilly with her problems, but instead does these dramatic, self injurious gestures to garner attention and sympathy all the time. "I have a son to think about, and he's getting neglected because I'm always dealing with her." And as we spoke for close to two hours, with her son sitting alone in the hallway waiting area, I understood her frustration, her deep love for her kids, and her guilt for not being able to provide more. I also understood why she did what she did. "I didn't come on purpose," she explained, "I cannot enable this behavior. I would do anything for my kids, but she needs to understand that her actions bear consequences, and I won't tolerate this behavior. I'm almost at my limit as it is." And I heard her, I believed her.

When we brought her daughter in, the first thing she did was squeal, "Mommy!" and jump into her mother's lap, hugging her for a long time. But as we talked more, she slowly shut down. "Talk to me!", her mother would plead. "Be open with me!" The patient stated that she was worried that her mother's health was failing, and what would she do if she died? The mother reassured her that she wasn't dying. The patient brought up how whenever she talks about her feelings, it always ends up in an argument. The mother responded that it doesn't have to be that way, but that her mother would not sugar coat things, or treat her with comforting sympathetic nothings if that wasn't how she really felt. "The real world out there doesn't care about your feelings. I do, and I'm here right now, and I'll be here legally at least till you're 18, and probably even after. But I'm going to tell you like it is, even if you may not like it." Throughout this, the patient nodded but became silent, making less and less eye contact, and eventually left the room without a word. We were confused, and I felt that there was something missing.

I followed her and asked her what happened. She told me that she was mad that her mother lied to her, told her she'd visit but she didn't. She told me that her mother often doesn't let her finish her thought before interrupting her and jumping in. When she tries to get her to stop and listen, her mother "thinks I'm being smart with her" and it escalates into an argument. She is also struggling with the conflicting feelings that 1) she doesn't want to be a burden to her mother in this difficult time, but 2) she needs her mother's support and that means to be a burden to some extent. Her mother sends conflicting messages like "my health is fragile so do your best to help me and not cause trouble", but "always be open with me with your thoughts, good and bad ones." I can see how she's struggling, how to behave with her mother's best interests in mind, and when to listen to her own needs. It sounded like she would bottle up her own needs in order to help her mother until she wouldn't anymore, and it all just explodes and her mother sees her as a volatile, dramatic, unpredictable and immature child. Her mother reminded me of my own mother. There are times when I just need support, I need to vent, I need a sympathetic shoulder to lean on. However these strong, independent women, in their need to raise strong, independent daughters have trouble playing into this role. "I'm the only one who will tell you the harsh truth," my mother would tell me, "if you want fluffy support and nice words, you have friends for that." It's frustrating, and I totally get it. But we can't change who they are, we can't demand emotional resources that they don't really have/aren't willing to give. We have to live with what we've got, and coming to terms with the fact that your mother isn't a soft, downy comforter but more like a solid, hard floor is a difficult journey that I, myself am still navigating.

I convinced the patient to return and tell her mother what she just told me. I prodded her to explain how she was mad that her mother lied about visiting, and her mother apologized, saying she didn't mean for it to hurt her, she just needed her to understand that this is not OK. The patient also explained how she didn't feel heard, (granted she was interrupted twice during this exchange so I see where she's coming from), and we agreed it's something her mother can work on. At the end, it was a positive meeting, and we will be referring them to services that provides in-home family therapy.

I learned from this whole ordeal so many things. I learned that a patient will only ever paint one picture of a person, and to never make judgments until you sit down and talk with the other party yourself. I learned that communication is still always so, so important. It's the first step to say to your daughter, "be open with me, I'm here for you." But it's harder with a teenage daughter to stop, shut up, listen to all her thoughts and feelings. Feeling like you are heard and respected is almost as important as actually being heard and respected. I learned that mothers with older daughters have a tough time too. Your kids are your kids, you still tell them what to do and want to teach and prepare them for the world. But you need them now, they can be your confidante and support as well, and it's a weird change in dynamic. I think this patient and her mother have a long road ahead, learning to communicate and facing their difficult social situation. But I felt so much better that I wasn't really meeting with an apathetic, abandoning mother, but a brave woman struggling with the difficult hand she's been dealt. I think they'll be OK, and I felt like I made a difference, showing the patient what it's like to have this first conversation where her side is heard, but there wasn't a fight. I showed her that she doesn't have to shut down, that her mother can work with her. I love psych even more after this experience, and I can't wait to help more kids figure out this confusing and scary journey that is growing up.