Unspoken  

By Shlomo Ungar, medical student, New York Medical College

Day one of my psychiatry rotation: “Orientation.” My prediction—this would be boring. As the morning dragged on into the afternoon, I sat with two classmates when our attending’s beeper sounded. “Code green, B1! Code green B1!” This was code for “patient at risk of violence.” Dr. M jumped up and we followed. We arrived at B1, the outpatient therapy unit.  

The patient, Ms. T, had a previous psychiatric diagnosis of borderline personality disorder. She’d been to multiple facilities over the past year, each hospitalization ending with an abrupt discharge or transfer. A pop-up note on her chart warned of violent behavior. Our attending began to engage Ms. T, first by listening calmly and then by asking some basic questions. Although we knew her name, Dr. M asked her name for confirmation. She responded by making up a name, and when questioned, she said, “Why did you ask my name if you knew it? You’re just testing me because you think I’m stupid.” She asked to be released and promised not to harm anyone. She denied any prior suicide attempts and said she wouldn’t harm herself.  

With the strict criteria for involuntary admission, it would have been easiest to let her go. But our attending heard something that others had missed. Although she denied having thoughts of suicide, self-harm, or harm to others, she intermittently peppered our dialogue with statements like “I’ll just go to a motel, and you’ll read about me in the obituary in a few days.” Dr. M heard this not only as a warning that the patient might be a danger to herself, but an unspoken plea for help.  

Concerned for Ms. T’s safety, the attending was preparing to admit her involuntarily. When we returned with the paperwork, she agreed to voluntary admission to the acute inpatient unit. After a few days in the unit, her mood stabilized on medications and her tone softened. Curious to learn more about her, I cautiously approached her and asked if she would share her story with me. Ms. T agreed. We spent hours talking over the next few days. The woman I was getting to know was in tears, talking about her childhood traumas, romantic relationships, and also the recent tragic death of her son. I learned that her son had died in a crash only a few months earlier, and that Ms. T hadn’t had an opportunity to grieve. She clearly needed some time to work through her great loss.  

The medical team wrote a condolence card and had it signed by everyone. With tears in her eyes, she said this was the only card she’d received acknowledging her loss. She was finally able to confront her loss head-on and this allowed her emotions to flow.  

From this experience, I learned two important lessons: look for hidden messages in the patient’s story and explore these messages with curiosity. Sometimes a patient’s cry for help is unspoken.   

In this patient encounter I learned Ms. T’s true chief complaint was her son’s death that played a prominent role in her recent behaviors. Her chief complaint was not one that could be fixed with medications alone. Like all patients, she needed to be treated with empathy, listened to, and heard.  

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.