A View From Inside A Behavioral Health Team
By Tai Mendenhall
I'm a medical family therapist working with other medical professionals in family medicine and emergency settings. My "office" is just as likely to be an emergency room, trauma unit, or hospital ward as my quiet consulting room. In the large metropolitan hospital system where I work, I deal with interpersonal violence, sexual abuse, attempted suicide, death, and every imaginable emergency—often while the emergency is unfolding. My job is to stabilize these crises, help patients calm down enough to ensure their short-term safety, and set up a counseling schedule with them if possible. If I do end up counseling them, I usually see them for from six weeks to six months. Every day in "crisis land" brings its share of jolts to the nervous system, and often I'm pushed beyond the boundaries of my baseline clinical training and personal comfort zone. A day almost never unfolds exactly according to schedule, and there aren't many days when I don't feel like I'm walking on a swaying tightrope without a net.
My cell phone rang as I was driving to work. "When are you going to get here, Dr. Mendenhall?" one of my nurses asked anxiously.
"I'm on my way." I always arrive about 30 minutes early, so I can raid the coffee machine and look through my first few patients' charts.
"We cancelled out your morning appointments. Heather Shutters is in the ER with her son, Adam. The police said he could come here and see you or go to Juvenile Detention. He said he'd see you, but hasn't said anything since."
"All I know is that he freaked out last night and tried to kill his mom, himself, and some cops."
I'd seen Adam's mother in therapy for depression a couple of years before. About eight months back, she returned for family therapy because she and Adam were fighting a lot over normal teenage stuff. We worked on laying out household rules and expectations consistently, negotiating age-appropriate rewards and consequences—the usual. And then we were done (I thought).
Two uniformed police officers met me at the door. "Are you Dr. Tai?" one asked. He sounded huffy, and had the physique to back it up.
"Yeah. Well, Dr. Mendenhall. A lot of my patients call me 'Dr. Tai' or just 'Tai.'"
"Whatever. Are you willing to take Adam Shutters into your care at this facility? If you are, we'll leave him and not press criminal charges. It's your call."
"We'll take him."
I opened the door to S-21 and found Adam sitting in a chair with his hands cuffed behind his back. His wrists were bandaged. They looked wet and bloody. Heather was standing in a corner, her expression flat. Without a word, the officer uncuffed Adam and walked out.
"What's going on?" I said to nobody in particular.
"He went crazy." Heather's voice was trembling. "These last few weeks, he's been so sullen. He won't talk. And last night, he just went crazy."
Adam said nothing, staring at the floor.
"Crazy, how?" I asked.
"I woke up about 3:15 in the morning to use the bathroom. I saw that Adam's light was on and heard music playing. I knocked, but got no answer, so I opened the door and found him sitting there turning this knife over and over in his hands. I started yelling at him, but he never even looked up. It was like he was somewhere else. I reached for the knife, but he started screaming and pushed me into the wall. Then he charged me. I was so scared."
Heather burst into tears. "He chased me through the house. I locked myself in my bedroom and called the police. When they got there, we found Adam in his bedroom again. He was sitting in the same spot, but there was blood everywhere. He'd cut his wrists. When the police jumped him, he tried to cut them, too. It was awful."
Finally Adam looked up at me. We stared at each other for a moment. I could see pain in his eyes that was almost palpable.
I asked Heather if I could talk to Adam by myself. As she shut the door, Adam closed his eyes.
"Jesus," I said. "What's up, man?"
Silence. Five minutes, maybe ten. Finally, he spoke. "Did you know that 3:00 in the morning is a witching hour?"
"Yes," I said. Lots of my patients talk about 3:00 a.m. "Three o'clock in the daytime is a holy hour, according to some versions of Christianity. The Father, the Son, and the Holy Ghost. Three. The antithesis of three o'clock in the daytime is three o'clock at night. A dark time. A witching hour." It's also a common time for suicide attempts.
"That's cool," Adam said quietly. "That you knew that." A tear rolled down his cheek.
"Why do you want to die, Adam?" I didn't say "did." I could see in Adam's face that we weren't out of the woods yet. Suicidal patients brought to the hospital may try to kill themselves again as soon as nobody is looking. In the last year, two patients had tried to hang themselves on the door to their in-patient rooms, one ingested cleaning supplies from a janitor's cart, and several cut their wrists with anything they could get their hands on—paperclips, pens, anything.
We talked for the next five hours. Adam's world was falling apart, and his ferocity toward his mother and the police was founded in a profound despair. He was sorry for scaring his mom, and he later told her that as we arranged a stay at the hospital for a few days. He also agreed, finally, to not harm himself as we worked through some of the things he was struggling with. I checked my watch—12:38 p.m. A fully-scheduled afternoon would start for me in 22 minutes.
In addition to having placements for doctoral-level medical family therapy interns, our clinic set up an undergraduate internship to introduce students to the helping professions by facilitating their actual participation in care. Our current intern, Kendra, shadows me on Tuesdays.
As she perused the day's schedule, she read each respective patient's problem-description. "Chronic headaches. Depression. Stress. GI trouble. Diabetes." She paused. "Depression again. Anger problems. Chronic back pain."
"Ethnicities?" I asked. Chronic pain, gastrointestinal troubles, or poor metabolic control are often influenced by patients' cultural and ethnic backgrounds. Social class can be just as relevant, but the daily schedules don't say anything about that.
"Three Hmong. Two Caucasian. One doesn't say. One Hispanic. One Italian. Italian? We've never had any Italians before."
Our first patient was Lee Vang, a 35-year-old Hmong woman with eight children. Referred by her physician for chronic headaches, she'd been prescribed just about every medication in the book. She was nicely dressed. Our Hmong patients often view coming to the doctor as a big deal, and they dress accordingly. Her tight-fitting hat reminded me of movies set in the Roaring Twenties. Our clinic interpreter sat next to her on the couch.
"I understand that you're having a lot of trouble with headaches," I said, "but I don't know much more than that. How about we get started by asking you what brings you in to see us today?" I always say "us" and "we" when I'm working with interns, because it engages them and recognizes that they're part of the therapeutic team, rather than passive observers.
"My head is always hurting, and I do not know what to do," Mrs. Vang said through the interpreter. "The doctor told me that I should see you because nothing he has tried is working." She began to cry. "I cannot afford to see the shaman. I have tried herbal medications. And I have tried to let the pain out, but that doesn't work either."
Let the pain out? Oh god, the hat.
"Can I see your head, and how you've tried to let the pain out?"
Kendra looked at me, confused. Mrs. Vang slowly removed her hat, revealing small puncture wounds all over her scalp. I wondered what her physician would think about this.
"Your pain sounds so awful, Mrs. Vang," I said. "I can't imagine how exasperating it must be for you to try so many things, and still not have it go away."
"What have you used to try to let the pain out?"
"Sewing needles," she replied.
"Do you clean them first? Like with rubbing alcohol?"
"Yes. My brother told me to do that."
"That's very good. If you poke your skin with a dirty needle, it could get infected and then you might feel even worse. Do you know what I mean when I say •infected?'"
"Yes," she replied. "Germs."
"What's going on in your life that's making you so stressed?" I didn't think that I needed to ask her whether she was stressed, given that she had eight kids at home, can't speak English, and has chronic headaches. "I want to know because I think that your stress might be causing your headaches. Lots of times, when we're stressed, our bodies hurt."
Mrs. Vang spoke, slowly at first, then with more animation, about her struggles with her ailing and much-older husband who was expected to die soon. She talked about the ongoing and exhausting conflict with her two oldest sons, who refused to follow household rules and called her "dumb" because she can't speak English or find work. She explained her worries about the broader implications of their conflicts, insofar as many Hmong parents believe that they can't ascend into heaven unless their children perform ceremonial rites. She was afraid her sons wouldn't perform those rites when the time came.
Toward the end of our session, I reflected back all of the things that Mrs. Vang had shared with us.
"I'd have headaches, too," Kendra added. "Jesus!"
"I think that if we make you less stressed about the things you're dealing with, your headaches will get better," I said. "Are you willing to come and see us for awhile to figure out ways to do this?"
"Yes," Mrs. Vang said. "I will come."
Poking needles into one's head to relieve a headache or the idea of that children affect whether a parent goes to heaven may be outside of many Western experiences or understandings, but the culturally-driven contexts and nuances of this case aren't uncommon. Conventional healing practices throughout the world employ cures that may seem odd to us, or at best contraindicated. Puncturing the skin to release badness (however defined), bringing the blood to the surface through suction cups and bruising, and a myriad of other techniques are commonplace with many of our patients. And they tend not to discuss these things with those providing Western care, unless they're asked.
I'd barely finished with my first patient when David, one of my residents, approached looking worried.
"Dr. Mendenhall? I need your help. I have a patient and her mom in E-24."
"A little girl. She's 3." He opened her chart. "Increasing difficulty over the last few months. Irritable. Temper tantrums."
"She developed what her mom described as •sores' in her genital area. Mom presumed it was related to bed-wetting. The girl was potty-trained a year ago, but now she's wetting the bed again." I already knew what David was going to say next. "She's got genital herpes."
"What's the girl's name?" I asked.
"Allison. Goes by Ali."
"Debbie. She's one of my patients, too."
"Is Dad in the picture?"
"No. They split up before Ali was born—which is good, because he beat the hell out of her. Doesn't know where he is now."
"Is Debbie seeing anyone?"
"No. Doesn't want to until Ali is older."
"Does Debbie have herpes?"
"Jesus," David said. "She's only 3 years old."
"Tell Nursing-3 to roll your next few patients to Urgent Care."
We went to E-24. David knocked softly on the door, and then opened it. Debbie looked like she was in her mid-thirties, casually dressed in jeans and a sweatshirt. Allison was playing on the floor with a couple of stuffed animals.
"Hi, Debbie," David said. "I'm sorry that it took a while."
"That's alright." She looked tired.
"That's alright," Allison repeated. She was pushing stuffed animals' heads together, making "grrrr" noises.
"This is Dr. Mendenhall, one of our faculty here. Is it alright if he joins us?" Our patients are usually familiar with the drill—having faculty come in with residents to meet with them at some point during a visit.
David sat down on the stool in front of Debbie. "I ran several tests for Ali, and we figured out what the problem is."
"Good," she said. "Let's get this thing fixed."
"This is very hard for me to say," David added. He looked at me. I nodded to go ahead. He said quietly, "Allison has genital herpes."
Debbie stared at him for a moment. "What?" she whispered. Ali wasn't paying attention to any of us. She was using the step in front of the exam table as a cliff in her imaginary world of play.
"My little girl has herpes?" Debbie asked, covering her mouth. "How?"
"I don't know," David said. "I'm so sorry."
I said, "Debbie, I'd like to take Allison out to our nursing station for a bit, right around the corner from this room, and have one of our medical assistants watch over her there. Is that okay with you?"
She nodded. Her hands were still over her mouth. When I returned, Debbie was sobbing. David looked like he might start crying, too.
"How could this have happened? What kind of monster would do this to my little girl?"
"I don't know," David said. "Who has access to her—in your home, day care, wherever?"
"Lots of people, but they're family. I work a lot. I have to. So they help me. My parents, my aunt, my Uncle Jim and his kids. I don't know who it could be."
It always amazes me that we warn our kids to beware of strangers, when more than 90 percent of sexual abuse is perpetrated by family members.
"My hope is that Ali will tell us," I said. "But we're going to have to be careful about how we talk to her. It's important that she feel safe, and that she understand that none of us is mad at her for what's happened."
"Oh my God, who hurt my little girl?" Debbie sobbed. "Who hurt my little girl?" She was escalating.
"Debbie," I said, "listen to me."
She screamed. A long, guttural scream. Nonabusing parents, at times like this, can become almost crazy with rage. "I want to know who the bastard is, and I want to cut his balls off!"
Most people have never screamed Debbie's scream, or felt her fury. And most people are against the idea of savagery or murder—until somebody rapes their 3-year-old.
We sat with Debbie for a while. As her cries subsided, I tried again.
"Debbie, I can't imagine how much you're hurting right now, but I need you to listen to me."
"Okay," she finally managed.
"It's really important that we make sure Ali is safe. Right now, we don't know if she was abused once or if it's still going on. We need to talk with her, and I want you to play a big role in this. You can do anything you need to right now, but you need to hold yourself together when we're talking to Ali. She needs to understand that you aren't mad at her, and that it isn't her fault. She needs to understand that you'll protect her, and that this isn't going to happen anymore."
"Oh my God, I don't want her to think that I'm mad at her!"
We talked for more than two hours. David helped get all the information for Child Protective Services, while I explained that the report would facilitate an investigation. We talked about ways to ensure Allison's safety, and scheduled family therapy. We'd later find out that Debbie's uncle was the abuser, that it'd begun six months earlier, and that it was still going on—up until the day before our visit. Debbie's uncle was incarcerated, and Debbie, Ali, and several other family members have been participating in family therapy ever since. They're doing a great job, overall, but are still struggling over how to raise a child into adolescence and adulthood who's contracted a sexually transmitted disease that'll never go away.
Stacy was referred by a psychiatry resident. She had case notes from the ER and one of our in-patient units. Neighbors had called the police when they saw her pacing back and forth in her front yard in the rain, wearing only a nightgown, screaming unintelligibly toward her front porch. Her boyfriend, Rick, was still in the house, and had called the police as well. ER personnel stabilized her pharmacologically, and she'd been admitted for a 72-hour hold. After a provisional diagnosis of borderline personality disorder had been made, she was referred to me as part of a larger treatment plan. She was to see me for individual and couples therapy, continue to receive psychopharmacological medication, and participate in a Dialectic Behavior Therapy (DBT) group. Meetings with my medical and group therapy colleagues were scheduled later that day to discuss the case.
"I'm really glad that you're seeing us," Stacy said, as the couple settled into my office. Then she giggled. Rick didn't say anything. His eyes looked flat.
"We had a really bad fight, didn't we?" she asked, looking at Rick. "A reeeeally bad fight." She was baby-talking and batting her eyes. Rick smiled weakly. They looked at each other for a moment, and then their heads turned toward me in unison. Now they both looked flat.
This is a bit strange, I thought.
"When I first meet with people I often kind of have to play 'sponge' and ask a lot of questions," I said. "Can we start with me asking you both some questions?"
Stacy sat straight up. "Yep." Now her composure was almost businesslike.
"I understand that you were brought into the hospital a couple of nights ago because the police were worried that you were going to hurt yourself."
"She was going to do a lot more than hurt herself!" Rick exclaimed. "We got into a fight because I wasn't in the mood, and she went ballistic—screaming that I don't love her, that I don't care about her, that I think she's fat, and that I'm an asshole. Then she started scratching her wrists, and making these awful animal noises. She was bleeding, and I tried to stop her."
Stacy was still sitting there, businesslike, listening to Rick as somebody would listen to a weather report. She was staring into space somewhere beyond me.
"Finally, she ran into the kitchen, and I let her. I just couldn't handle it!" Rick looked at Stacy, but she continued to stare forward.
"After she'd been quiet for awhile, I went into the kitchen to see what she was doing. She was . . . ." Rick's voice cracked. He was blinking really fast.
Stacy finally moved—her eyes, anyway. They closed very slightly and looked over at Rick. She looked like a cat watching a bird on a windowsill.
"She was sitting on the floor, cross-legged, leaning back a little bit. She was running a pair of scissors through her, um, pubic hair. But she wasn't cutting her pubic hair. She always keeps that short, anyway. But she was . . . and then she said . . . ." Rick was getting flustered. He looked horrified.
"I told him that I was going to cut off my clit," Stacy said simply. "And I said that someday he'd feel really bad about it. That he would regret forever not wanting me, and he'd know that he could never please me again in the ways that I can please him."
I realized that I wasn't breathing. I started to exhale slowly, not wanting to look as genuinely alarmed as I was feeling. You wanted to cut off your own clitoris?! I thought.
"I started chasing her around the kitchen," Rick said, "but then she ran outside, screaming again. So I called the cops."
Nobody spoke for a few minutes.
"Stacy?" I asked. "What was going on with you?"
"He was being a jerk."
"It sounds like he was really scared."
"Scared shitless," Rick said.
"Scared shitless," I repeated.
"Good," she said.
"Why is that good?" I asked.
She was quiet for a moment. "Because I don't . . . ." Her voice trailed off. She looked away.
"You don't what?"
"I don't want him to leave me. Everybody leaves me." Her eyes were wet.
"Because he didn't want to have sex with you?"
She was silent for a moment. Then lightning flashed in her eyes. Talk about mood lability.
"Do you think I'm sexy, Dr. Tai?" Her voice was tense.
"Do you think that I'm sexy?" This time, more urgent. Angry.
"It doesn't matter what I think, Stacy. What matters is what's going on with you, and with Rick."
"You're not answering my question."
Stacy's hypervigilant response to perceived rejection in the bedroom and her frantic attempts to avoid abandonment were certainly consistent with borderline personality disorder, as were her attempts to test my boundaries.
"I said it doesn't matter."
"Why not?" she demanded.
"Because you're my patient."
"Why should that matter?" she responded with a piercing stare.
I stared back and responded. "Look, you could be a Playboy centerfold or weigh 1,000 pounds. It wouldn't matter. I'll work with you as a therapist, if you'll work with me." I didn't look away. It's a primitive thing, staring. Whoever looks away first loses.
Still staring. "My therapist," she said.
Still staring. "Your therapist."
Still staring. Jesus, how long are we going to do this?
"I can't imagine how awful it must feel to think that nobody loves you or desires you, or that anybody you ever love will ultimately hurt you or leave you," I said. "But you're here, and that's a good sign. And Rick's here, which says to me that you haven't lost this one yet."
"You haven't," Rick said.
Finally, she looked down.
I pushed forward my chair and leaned over, elbows on my knees. "Can I see your arms?"
She pulled back her sleeves, revealing old and new scars from her wrists to her elbows. Scabs were forming where she'd so viciously scratched herself in her most recent rage.
"Your scars show your pain."
"Yes," she said softly.
"If you want to, I'll work with you, and Rick, to help you better control your life and your pain. But it's up to you, and it's going to be a lot of work. I'll tell you, though, that I don't think you'd be here if you didn't want to do the work, and stop your pain."
"Let's work, Baby," Rick said. "Let's work."
"Yeah," she said, looking down at her arms. "Let's work."
I explained that Stacy's treatment would be intense, long (provided she didn't drop out), and likely marked by a series of ups and downs. We talked about how her providers would coordinate their efforts, involving her actively, over the course of her therapeutic journey. We arranged our next visit.
It was late afternoon, and my next patient was a young woman who'd been coerced into a child pornography and prostitution ring when she was 4. Her name was Emily, and she's now 17.
Over the dozen years her abuse continued, Emily had tried to kill herself on several occasions, and the most recent attempt had led her to the ER. This event began a process whereby her abuse was uncovered. She was placed in foster care and then connected with me by the state. After several months of remarkably intense work together, this young girl's resolve and spirit were burgeoning in ways that can only speak to the powers of the human spirit.
This was our last session. We talked about how well she was getting along with her foster parents, and about their plans to adopt her. We celebrated the fact that she was back at school and doing well for the first time.
"I'm a couple of years behind the other kids, but Ms. Little says she thinks I can be caught up in a year, if I work really hard." She almost glowed with pride.
"You're doing awesome, Emily. I'm so proud of you."
"Thanks." She beamed. "And I made the track team!"
"That's fantastic!" Emily had wanted to be on the track team for a long time.
"And I'm making a lot of friends. They know that I'm behind in my classes, but they just think it's because I moved from a different school, so they don't give me a hard time about it. And there are two girls—Ivy and Sarah—who are really cool. We sit at lunch together, and we're hanging out a lot."
We talked some more, and I applauded her for all she was doing. I explained that the door is open if she ever needed to come back, but that I didn't really think that she'd need to.
"Take care of you," I said in farewell.
"Take care of you," she responded.
As she walked away, Emily stopped and turned around. She looked at me for a moment, and then said, "You know, when I first met you, I thought you were a real asshole. And there've been a lot of times that I've thought that as we talked, sat in silence forever, and even screamed at each other." She paused. "But you're the first man who hasn't hurt me. You're the first person who's ever stood up for me. You're the first person who's ever respected me, and not just seen me as some easy fuck or a total loser. You're the first person who's ever believed in me, even when I didn't believe in me."
I didn't know what to say. Emily's eyes looked thoughtful and reflective. "I used to think about the future and I didn't want to go there. That's why I have all of these gross scars now." She paused again. "But now I do want to go there."
I started to speak, but she held her hand up and stopped me. "And I already know what you're going to say, so don't say it! You're going to say that it's me who deserves all the credit."
She was right. That was what I was going to say.
"I'll take some," she said, "but only if you do, too."
She took a step back. In her eyes I saw a combination of youthful innocence and aged wisdom.
"Peace to you. Thank you for doing all of the things that you've done, even when I was being a real bitch to you. Thanks for not hurting me, and for making others—even myself—stop. I don't know what's going to happen now, but I want to find out." She smiled. "Peace to me, right?"
I smiled a small smile.
"Yeah," she said. "Peace to me."
Then she walked away, and I cried.
Tai Mendenhall, Ph.D., is assistant professor in the University of Minnesota Medical School Department of Family Medicine and Community Health. His publications include Action Research Methods in Family Therapy, 2nd edition, and "Key Barriers to the Delivery of Optimal Diabetes Management in Primary Care." Contact: firstname.lastname@example.org. Letters to the Editor about this article may be e-mailed to email@example.com.