rearrangement

[October 20 & 26]

In the same way they teach us how to derive a differential diagnosis from a history and physical, they teach us how to interact with patients, in patterns and algorithms. I have a lot of respect for the critical thought that the development of these structures entail, and a lot of admiration for the beauty of the forms they produce. But they would feel a little suffocating, get a little boring, if not for the fact that they’re applied to people who aren’t static, who move, who each move with different fluidity even if in the same space as everyone else, and so who make you move too. In a place in the country that feels like another country, you instinctively let go of some of your ground, and become more open to continual rearrangement.

And even without the backdrop of an entirely different culture, there are characteristics that inherently place distance between people. There is a lot of stretching to be done, to talk to people at different poles of age and experience and expressiveness.

I spent one morning at the teen clinic at Chinle High School, where teenagers can make their own appointments and see primary care doctors during the school day. There is a security guard both at the parking lot and within the entrance of the school. Not unusually, they mistook me for a high school student. Despite looking so much like a sixteen year old, the clinic made clear how far from those years I am, how much intangible can happen in ten years’ time. I spent most of my time talking to the patients about sex, depression, and sports—many of them came for physical exams required to play sports; these were often the same patients with whom I ended up talking about sex and depression.

For me, it’s hard to assess what teenagers absorb from their surroundings, because I think their capacity to feel progresses more quickly than their capacity to express, or maybe their desire to express. They’re so different from people just a few years younger or older, making this period of time feel rare and fragile. The subtle changes we all experience from moment to moment are more pronounced in them, but with perhaps less self-awareness. All of this can be frustrating if you try to tackle things too quickly, and so they almost therapeutically push you to take time and care to read them. And if they open just a fraction, they can be in different phases of so many processes at once, many that lack obvious linearity. If you want to do anything with that, you have to be okay working in rough pieces without knowing their sources or trajectories, not immediately and often not in the near or distant future either.

It’s a challenge for me to speak to the quiet girl with skinny jeans, converse sneakers, black glasses and thick black eyeliner, and a short boycut with all the hairs angled to the left of her face, making her face look strikingly straight in comparison. She is one of the students who’s here for a sports physical; she’s playing softball in the spring. She pauses before answering any question, then answers with as few words and movement of her face as possible. The stillness isn’t effortful; it’s without thought, as though the moment her eyes and lips move out of place they naturally fall back to their original state of clear and mute.

All adolescents are asked to fill out a screening form before their visit, which asks them about school, diet, exercise, sexuality, mood, home life, and so on. On her screening form, the girl indicates that she has felt down for more than two weeks and has once thought about killing herself. Talking to her more, she has almost all the symptoms of major depression: decreased appetite, poor concentration, interest in activities she’d enjoyed before, bad sleep, and of course depressed mood. Her mother moved to New Mexico five months earlier, and she misses her a lot. She isn’t at all interested in talking to anyone about these things.

The screening form also asks if the patient has any questions about any of the following: diet, exercise, sexuality, school, relationships. She had circled exercise, and when I asked her what her questions were, she said that I’d already answered all of her questions during the visit. I asked her what kind of questions she had that I’d answered. She responded, “Oh about being bisexual.”

It took me a moment to go with that. I’m already too far removed from high school to understand how teenagers process their environment and relay what’s internal. And I think sometimes we try too hard to really understand; I respect the effort, but I think the subsequent discouragement that comes with failure can be harmful. We get tired and closed. Maybe we can just accept that we don’t know how a person gets from one place to another; maybe we’re closed off from that hallway, but once they’ve gotten to a place we can try to enter that.

So even though I wasn’t sure how we got to this point in the conversation, I took this comment as a gift from the guarded 14 year old. She then looked at me straight in the face, with eyes finally visible behind her glasses and hair even though neither had shifted position, and asked with such earnestness that the numbness of all her past sentences struck me: Is it okay to be bisexual?

I’m not at all equipped to answer this with the sensitivity and exactness that a fragile person deserves; I’ve never been asked that before. All I can do is hope to reciprocate her earnestness. She talks about having told a friend, who then told everyone, who then treated her badly. They tell her to go back from where she came from, and as she describes this, she looks genuinely confused; strange how her strongest expression of emotion is one of not knowing how to feel.

The doctor knocks on our door to retrieve us so that we can complete the visit together. I welcome this reminder that I’m a student, that learning is an explicit part of my role, but I wonder what to do with what I’ve learned. At first the girl doesn’t want me to tell the doctor about anything we talked about. When I talk to her privately about the reasons for speaking to her primary doctor about our conversation, she nods. When we are all in the room together, I tell her that I’m going to tell the doctor a little about what we talked about, that I know it’s personal, and that if she wants to tell the doctor herself that would be all right too; again she nods.

The girl refuses any sort of resource offered, and it’s hard to see her go without much more than she came with, and knowing I won’t see her again. It’s really hard. The doctor feels it too, but she makes the point that now it’s known somewhere whereas before it was only in the girl, and she knows she can come back. It’s one step; it’s a different place, even if a lot of doors are still closed to us.

The transition between places can be jarring even when elicited and anticipated. It can feel sudden when traveled gradually by this quiet teenage girl, or when it pours forth from the outgoing middle-aged woman whose slight change in the folds of her face make me lean forward and ask, precipitating a complete reworking of her face. This woman with strong features and build, a carpenter who can’t imagine not working with her hands, who has gone through rehab for alcohol use, who had her first cigarette in a long time yesterday because that was “just how I was feeling,” who comes to us with questions about a colonscopy that a woman at forty years old does not need, begins to cry. This time again I’m unsure how we arrived here; this time not because the concrete steps were unlinked, but because she moves so steadily on a new path that I lose track of the steps that initially brought her there, and again it seems more important to just continue.

She talks about how she has just moved here last night from her hometown of Ganado, how she doesn’t know if she can go back; she wants to go back but things won’t be the same; she needs work but she can’t go back to pick up her tools; it is hard to find work in a new place; her partner is a woman who abuses her verbally and physically; her family tells her to leave her; she thought she’d been strong; she hasn’t talked to anyone. We spoke for some time. When the doctor saw her a little while later, he provides her with some resources that she seems interested in pursuing and schedules her for a follow-up appointment, a streamlined process that seems a blur compared to what came before.

Watching her leave with an effortful smile and half of the demeanor she’d carried into the room, I’m reminded of something a resident told me on my psychiatry rotation. He’d said that after you’ve helped a person break down part of their exterior to expose other coves, and have dwelled there for awhile, you need to help build them back up before you leave them. With this woman I felt she left more exposed, without much protection for open patches, and so I feel that it’s not just closed spaces that are tenuous. These interactions can be difficult, and so when there’s movement there’s fulfillment, but no guarantee of safety. But to be so lucky as to be given a choice, it seems to me worth the risk.