An experience from the Pediatric Inpatient Psychotherapy Squad

Continued

My first therapy patient was a teenager with intellectual disability who had a hematoma leading to right sided hemiplegia. He was thereafter diagnosed with acute lymphoblastic leukemia. By the time I became involved in his care through PIPS, he had been in the hospital 26 days, only half the length of what eventually amounted to a two month stay. I was available to take him on as a therapy case for the remainder of his stay and was unsure what to expect.

When I first evaluated him as part of the pediatric consult-liaison team, he presented with sunny spirits. He was going to be a doctor, a lawyer, or a garbage man. He was going to learn to walk again, help with chores, and help with his younger siblings. His resilience astounded me as I learned further details about his admission. I contacted his father to confirm that his son was allowed to participate in our program. He explained that he could only come visit at night as he worked all day to cover the bills for his family. His mother barely visited as she couldn't stand to see him in this state and had her own problems; ACS was involved somehow.

Shortly after I met him and his contagious optimism, he went into acute liver failure and needed a transfer. When he returned, he needed a PEG tube due to poor oral intake. I continued my services in earnest, wanting to provide another support to this child undergoing quite difficult times. Through this process, I watched him become jaundiced and thinner. He developed a barren, blank stare focusing on the television and iPad that occupied his time. Sometimes he watched classic cartoons, smiling weakly at the antics on the television. At other times he watched news clips on his iPad, on one occasion saying, “How sad, that person died.” This statement struck me especially hard as I watched this child’s health continue to decline. Perhaps these videos were the only way he could process the grim reality of his diagnosis. In between his media moments, I often looked to engage him in therapeutic techniques to see if I could draw out and share whatever burden he was hiding.

One day, he asked for Lego. As we began the first few steps, he became disheartened by his inability to use both hands to build, as he could not firmly put together two pieces without my help. “Maybe another time,” he told me, the reason he stopped remained clear yet unspoken.

Spring 2023

Volume 39, Number 1

An experience from the Pediatric Inpatient Psychotherapy Squad Continued

I offered him the chance to write his stressors down and physically rip the paper apart. I explained that if he wanted, I could write for him and we could work together to destroy everything that made him upset. "What good would that do?" he asked. I had no answer to appease him. I offered him a game of Uno once; he played one round in an attempt to appease me, his cards resting on his chest as he couldn’t hold the cards up. After that round he stated he was tired and requested to be left in peace, terminating our session earlier than expected. Sometimes, other doctors would check in on him during our sessions, peeking through the curtains., He'd say they were visiting the patient in the other bed and not him. I knew they were assessing how much he was eating and waiting for a parent to arrive to discuss next steps.

I felt defeated after three weeks of visiting a few times a week. I was watching a child face an immense task and seemed to be unable to give him aid or relief from these pressures. “How can I help?” I asked my mentors. Our group included the child psychologist who I met with regularly, our child psychiatrists, who were always accessible, and the child life specialists who saw him daily growing weaker, and his medical team. All parties had suggestions, but there was no easy answer to help this boy. What I eventually discovered, as I persisted with my visits, was that he valued the quiet times – the only time she would occasionally express his inner thoughts. Our sessions often began with blank stares at a screen before he eventually looked at me, saying how much he missed his life. He wanted to finally leave the hospital, to go out and learn to walk again, to see his siblings again. He granted me glimpses of his pain for just a few moments before turning his attention back to the lifeless screen. Near the end of his admission, he said, “Thank you.” He told me he was glad I came to see him. Then he went back to his iPad, eyes glazing over as I realized that all he wanted was to be heard and acknowledged, that sometimes for all the dedication that could be poured into offering suggestions and techniques and coping skills, all he needed was the empty space in which to pour and process and speak without fear or judgment.

As I enter my child and adolescent psychiatry fellowship this July, I know that this experience will carry forward in my work. Holding space for him proved helpful for him and invaluable in my own education as an ability I hope will serve other youth with their battles. I want them to speak, scream, whisper, cry, or remain silent if that is what they need. As much as psychiatry is known for using words, the moments without them may be just as, if not more, potent and powerful.

Spring 2023

Volume 39, Number 1

A very small suggestion for a very big problem

Michael Flaum, MD

AACP Immediate Past President Professor of Psychiatry, University of Iowa

The backlash aimed at reversing any progress made over the past few years in recognizing and dismantling structural racism in this country is in full swing. It is well funded, highly strategic, and not limited to a few outlier states or regions. Where I live, it began with legislation in early 2021 that banned the teaching of “CRT” in public schools.Just last month, the Board of Regents declared an immediate halt of all new “DEI” initiatives and a review of all ongoing “DEI”related activities across the state universities. News stories about both included pictures of happy-looking Iowans holding up “NO-CRT” and “NO-DEI” signs during the respective announcement ceremonies.

I couldn’t help wondering how many of the people holding those signs even knew what the acronyms stood for, much less their underlying meaning. What seemed very clear was that they were against something, and pleased that action was being taken.

I’ve been working with rural Iowans for many years now, in counties than voted by 90-10 margins for those that are championing these kinds of actions. I’ve never talked to any of them about how they feel about critical race theory or diversity, equity, and inclusion, but I do know something about what they are against, what they care about, and how they get their information.They are against the downward trajectory they see in their overall quality of life and that of their families.Their communities aren’t thriving, their schools are not what they once were, many have sold their family farms to big agriculture and their children and grandchildren are scattered, and often struggling with diseases of despair. They can’t keep up with their medical bills, etc., etc. I also know something about the news and social media most of them listen to or read, and what they are being told day in and day out:That the reason for their woes last year was at least partly caused by this thing called “CRT”, and when banning that didn’t make anything better, today it is because of this thing called “DEI” or “wokeness” (whatever that means).

Spring 2023

Volume 39, Number 1

A very small solution for a very big problem- Continued

I know many of these people quite well, and my sense is that most of them genuinely embody the values of equity and inclusion. (It’s harder to speculate about their feelings about diversity, as many have limited experience with diversity in their communities.) Yet, most of them, when asked what they think about “DEI” initiatives would probably tell you they are strongly opposed and glad that those in charge are putting an end to all this nonsense.

This brings me to my small and probably unrealistic suggestion: Perhaps we should actively avoid using acronyms like “DEI”. When we are talking about equity, diversity, and inclusion, can we get in the habit of actually using those words? It may seem impractical, especially for those who work directly with these issues and need to use these terms dozens of times each day.But might there be value in modeling the time it takes to say them fully on each occasion? And if someone is talking or writing about their opposition to equity, or to diversity, or to inclusion, wouldn’t we better positioned to ask and expect them to use those words when referring to their reasons for taking that stance, if those of us promoting those values use them ourselves?

We live in Orwellian times, when words are routinely transformed to obfuscate their meaning.One small recourse is to speak slowly and precisely.

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Spring 2023 www.communitypsychiatry.org