therapy

For my weekly outpatient experience for psychiatry, I spend half a day at the women's clinic at the VA. Given that I will have spent three months at the VA by the time I graduate, I thought it would be nice to interact with part of its population to whom I've never really been exposed. None of my patients on my medicine rotation at the VA were women. I was told that two years ago, the number of female veterans surpassed the number of World War II veterans, and women are currently the fastest growing demographic group in the military.

The sessions are essentially talk therapy, in which I have no training or experience. The psychiatrist often leaves me alone with the patients, which is both something I appreciate and something that terrifies me. Conversation I can do, but conversation in the setting of purpose is different, and I'm not sure it's my role to be attaching "therapeutic" to anything I ask or say. If anything, it's felt like much of third year, where we're given more than we give.

But this past week, I learned that that's the point. The psychiatrist explained to me that these sessions are based on logotherapy, a form of psychotherapy developed by Viktor Frankl. Frankl was a Holocaust survivor and psychiatrist who struggled afterwards to derive meaning in a world that had shown itself capable of such injustice, cruelty and suffering--things that these women know so intimately that it seems to sit in their skin. He believed that meaning existed in every existence, even one of pain, and that tragedy could serve as sources of good. Logotherapy focuses on helping people use their tragedies to form meaning in their lives; not to see the negatives as simply barriers to overcome but as means to create value.

The role of the student in these sessions exemplifies this philosophy. By sharing their stories, the patients give us an inexplicable amount of life. The women are tough with how their experiences have grown into them but are generously open with the layers they've developed. Each sentence, each shape their faces take, give texture such that I feel like I could hold the air between us. And this is a small part in acknowledging that their stories of pain have worth, that what's been taken from them doesn't have to perpetuate loss but can further growth.

At the end of the day I'm very tired, drained from absorbing the sadness of their stories. On some days I choose to sleep or listen to music without doing anything else or shower even if I'd already showered, to concentrate on a sole sensation because this is easier. I don't blame myself or anyone for retreating to this numbness for a short while; it's natural. And I like to think that it eventually leads to working to continue what these women started, not just absorbing their experiences but then using them. It's a weight, but not one to be sucked in or erase. It's something to take time to record, remember, share and integrate into how we process and experience our days. I'm a little tired now, but I think that will all come.

birthday

Some people think birthdays are silly, and like most socialized celebrations there is an element of that. But I really enjoy celebrating people's birthdays. I think it's a nice idea to be thankful for someone being born, for existing at a time you can know them, for continuing to be there. This year I felt particularly loved, and knowing what that feeling is like, it's natural to want to give that.

Like first year of med school, this year G. and I celebrated our birthdays together, mine on the 22nd and his on the 23rd, both of us turning 26. I wanted an excuse to eat a lot of sugar, and so we had a desserts & drinks party, in which we baked and guests brought drinks. A dozen girls (and a guy) contributed baked goods: brownies, red velvet cake, macadamia nut & white chocolate (with cookie), oatmeal raisin cookies, three kinds of pie (apple, pecan chocolate, key lime), carrot cake, lemon squares, cheesecake, and pumpkin bread. I baked for three days in a row, the first with one friend, the second with two, and the third with a gaggle. M&A came down from NYC for a morning and part afternoon to help bake, and they brought champagne and orange juice for mimosas. My best friend from high school came from CA by means of NYC and in transit to DC to New Haven, to share. She integrated seamlessly into my day to day life, helping me clean, set up, and clean again. To have people from my sequential periods of my life in my kitchen, making things and sharing cups--it was meant for a polaroid.

A small, close core of our friends came early bearing delicious chicken and chickpeas, and we ate together before the larger crowd trickled in. The party expanded past the kitchen into living room and bedroom, and my bed again became innocent nest to parties of five or six friends. We received wine made from frozen grapes, each one contributing one richly sweet drop. Lots of wine, beer, and milk, and cards and candies tossed in. In the midst, acts of thoughtfulness that spoiled us. Waking up early despite sickness and overwhelmedness to make a beautiful red velvet; introverts arriving to share; cooking for the first or rare time; searching three stores for my favorite sweet; songs sung under pressure and songs sung cause they just can't help it; a piggy back ride despite aching bones.

Then the surprise of something I've so wanted but haven't been able to get myself to give myself, from the people who have made the past three years so good. The sensation of hearing The National flow from a record player encased in a soft brown trunk is ineffable. There's no other way to say that I was incredibly touched. Not only do I get music but it will be forever connected to these people.

I'm glad also that G. ended up really enjoying the big party; we are both more used to more intimate get togethers. It's hard to talk to each person in this atmosphere, but there is something to be said about so many people you enjoy in one space. There are many classmates who I may not see all the time or talk to often but whose characters I value and whose presence make for the fullness of my life here. And to have all my closest simply spending time together is a continual source of gratitude. And in the end that's what it's been all about, a day to remember how lucky I am to have known these people who I admire, respect and love so much. It's hard to describe them without sounding corny, and that's because they are why cheesiness was made. They listen, they pay attention, they see past themselves, they make fun, they hug, they look out, they wash dishes, they take pictures, they seek outdoors, they perceive brokenness and they fix without judging. It's their world that I celebrate being born into.

psychiatry, introductions

I started my first week of psychiatry today. It is the best way to end my third year, which has been a string of glimpses into different realms of experience. My attending physician keeps letting me go right at things, because I'm at the end of this clinical year and should theoretically well-equipped to do so, but in reality I feel more unprepared for this than for any other rotation. It puts me in a place of true beginning, which has been humbling.

For three weeks I am working at the VA. I've worked here before, for one month of my internal medicine rotation, and I love being back. I think there's an element in it that has to do with being sensitive and aware of a specific population (of veterans), in the same way I liked how ob-gyn paid attention to their specific population of women, how pediatrics is concerned with how to treat kids, as opposed to another type of person. I think this is how adult medicine should be: the general population of people is also a specific population that requires certain thoughtfulness and attention, but people don't think of it that way enough. So whenever a particular quality (age, gender, or in this case military service) makes care providers more aware of who they're treating, I find there is a lot to appreciate.

I'm working in the consult service, which means that we see any patients who are admitted to any other part of the hospital (medicine, hospice, surgery) who have psychiatric concerns. They were not admitted to the hospital for psychiatric reasons, but they have psychiatric needs nonetheless, so our team follows them as patients. So far I've had one patient from the ICU, one from the general medicine service, and one patient from hospice. The VA has a wonderful hospice department; it was the first hospice I'd seen (second year of med school) and it was where I had my first end-of-life patient (third year of med school), so besides the other reasons to enjoy the VA, I'm really glad to have this integration.

I had my first one-on-one conversation with schizoaffective disorder today. This means he has both schizophrenia and a mood disorder. He says that someone inserts thoughts into his mind; it's not a voice, it's a thought. These thoughts are pleasant. They keep him company; he's been alone all his life. The television sends him messages, and he finds it a sign of his significance. He's adamant about getting out of the hospital, talks about this with intense fierceness in his eyes and voice, but if you joke with him his eyes give way a bit unsteadily to crinkly amusement...the transition is sweet in its clumsiness. My attending doesn't see the point in changing his medications to decrease his symptoms. He's comfortable in his psychosis. We often see patients in terms of their limitations, but sometimes they own more than we can call ours.

naturing

Spent Sunday's daylight at a waterfall in Woodbridge. A. brought curry he'd cooked, sliced pineapple, and cold clementines. I brought leftover rice recently reheated in the microwave. The short drive was spent becoming acquainted with silence, and living through the open windows and open sunroof. Entering the narrower roads, the fluffy green of spring, so light and nonchalant as the car wheels crunched along, made silence easy. I'd forgotten how green it gets. I'd forgotten the way you forget photographs from last year's trip across the world even though you spent weeks after that trip flipping through the same pictures over and over. Upon arrival, we surveyed the contents of his trunk: two chairs, a cot, a sleeping bag, and a wheelchair. "What do you think we need?" "One chair and a sleeping bag," I decided, for once making a decision.

It's a short walk and a slight descent onto the rocks, where the sleeping bag was spread, the chair placed still folded on another. We ate first, and bites through my fourth or fifth clementine I realized that I'd have to pee at some point in the day (twice, it turned out). He threw the peels into the water. It was still five or six hours until daylight would slip. The first hour was spent meeting feet with water. We saw a couple of frogs, and I looked down the creek for minutes. I cross-legged onto the chair with my book, which I finished late that afternoon; he laid on the rock spread with sleeping bag and hours passed. Somewhere in those hours I slept deliciously, sitting and thinking that it must be raining because the water was streaming by in steady slushes and waking up intermittently to the pleasant surprise of being dry, warm and sunned and closing eyes again. We woke to eat again. I walked along the banks, up on the slopes and down by where water made dirt mud, and spent a full two minutes blowing the fluff off a lone dandelion. I made it back to the parking lot and tried writing into a rock with another stone. When I made it back to our rocks he'd moved, and I took his spot atop the sleeping bag. I was closer to the water here, and it sounded different, just a few feet from where I'd been there before. The police woke me, to ask what we were doing; apparently it is unusual to find people sitting at the base of a waterfall and sleeping on a rock up the bank.

When they left, we began staring at each other. He had suggested this as an activity months before, and it'd recently come up in conversation with a stranger newly met, and I thought of it again, as something I'd now be ready to try. I only laughed for the first couple seconds. From watching him I understood we were allowed to move, so long as we kept eye contact; and the mosquitoes kept us swatting about and the rocks' edges kept us shifting legs and feet. I didn't imagine the activity as meditative; I imagined it as an interaction between people. So for a long time I was frustrated; I felt a barrier more than an entrance; I don't know any better what he was thinking or how he was feeling. I've often thought that not seeing is a result of not trying hard enough to look and see. But this made me feel that you can look and look so long and hard, and still not see. I only felt more strongly how much I didn't know, and once the frustration reached its peak, I slipped into a groove where I felt I could do this for a long, long time. It was then that I felt something give; the barrier remained the same, but I felt patience come. And I felt that the best I could do is be patient, to keep looking without expectation or return, and so a very long time did pass.

The day was slow and languid; when I look back I envision a movie montage with scenes moving from one position to the next, but the experience of it wasn't a series of clips. It was a natural flow of feeling a sense and letting it take its course. It's a little cove of elements, not a postcard or even a picture, but better; a space to fill and then leave, that gives without effort on anyone's part. Maybe it defies laws of physics or whatever, because I really don't think the reaction is equal in force, though its direction may be opposite; it is an insensibly generous thing when you are so still and things envelop you so hard.