1 Boring Old Man

Unless you’re a race car driver with a manual transmission, you don’t notice the dashboard gauge on the far right. You just glance at the speedometer on the left that tells you how fast you’re going [mph]. The tachometer on the right tells you how fast the motor’s turning [rpm]. It lets the speed demon know to shift before it gets "in the red" or the motor will self destruct.

It was an example I used in a lecture in the 1970’s for new residents called "Crisis Intervention: A Psychotherapy". The thumbnail version goes like this: Anxiety is our built-in early warning system to alert us to danger. If you’re a rabbit in the woods and hear a twig snap, the anxiety system focuses your attention, alerting you that there may be a predator about and mobilizes you to run for your life. It’s the same with bipeds – anxiety mobilizing our attention and emergency coping skills. But if those fight or flight mechanisms don’t work and the danger persists, there may come a point where the problem changes. Instead of the anxiety helping us mobilize to solve our problem, the emotion itself becomes overwhelming and becomes the problem itself. We call it panic, or terror, something dire – it’s a crisis – and all we can think about is escaping the intolerable emotion. We’re running "in the red."

People on the top of a burning building often jump to their deaths even if they see the fireman’s ladder coming up to save them. Panicking soldiers leave their foxholes and go running across the battlefield, becoming sure targets. Crisis emotions really are intolerable, and people do irrational things just to feel better. Worse, instead of learning a new coping skill when faced with a problem they can’t solve, they may develop an avoidant phobia for the situation, or learn a maladaptive pattern that persists. So when you see a person in crisis, it’s a marker that they’re in a situation they have no skill to handle and they are likely to act irrationally. And while it’s a great opportunity for learning something new, there’s a very real danger of acting irrationally and learning something unhelpful.

So the goal as a crisis interventionist isn’t necessarily to solve their problem, nor is it to just get rid of the intolerable feeling. It’s to do something to dial the emotion down into the tolerable range, to help them clearly identify the problem at hand, and if possible figure out why they ended up in a dysfunctional panic state rather than staying in the problem-solving mode. Obviously, if the problem is something that would discombobulate anyone, like a natural disaster or an assault, you will lean way into the patient and help in any way possible. But in many cases, the crisis state has something to do with the patient’s unique life experience.

She was an unusual looking 56 y/o who appeared younger. She was agitated, and complained of having "that feeling" she’d had years before when she’d attempted suicide by shooting herself in the chest. She recalled "that feeling" from two other times in her life resulting in brief psychiatric hospitalizations. She had moved to our area a year or so ago after divorcing her second husband – living alone, supported by a monthly check from her first husband. She knew no one here, and was emphatic that she didn’t want to get to know anyone. She had been depressed for several months and had been tried on several antidepressants by her primary care doctor [currently on Prozac 80mg/day] without much effect. She’d gotten "that feeling" – escalating over the previous week.

Like most people in crisis, she wasn’t at all forthcoming with her history, preferring to talk about needing to get rid of "that feeling" – afraid of what she might do. So at first, getting the history took some real doing. When I inquired about her marriages, she said they’d lasted 28 years and 12 years respectively with 4 kids by the first husband, now grown, "scattered," and doing well. She had initiated both divorces, the first so she could be with the man who became her second husband. One of the things that came later in that lecture about Crisis Intervention was the importance of constructing a timeline. Here, I’d done my math: 56 years [her age] – 28 years [her first marriage] – 12 years [her second marriage] – 2 years ["a year or so"] = 14 years old. So I asked, "Why did you get married so young?" She responded, "I was just barely 15" and finally volunteered her story.

She was adopted and in an unusual way. She was Japanese. Her adoptive father was stationed in Japan and brought her home as an "orphan" to his wife at age two. The adoptive couple had talked about adopting "a boy," but he brought her instead. When she was older, she’d figured out that she was only half Japanese ["unusual looking"] and that he was actually her biological father, but "he’d never admit it." She was mistreated as a child [I’ll omit the details] and consciously married [became pregnant] to escape. While she was grateful to her husband for the rescue, she was never happily married. The three episodes of "that feeling" were marital crises when she "couldn’t stay and she couldn’t leave." After her kids were grown, she met future husband number two and thought she could finally "be happy." When he turned out to have some deal-breaking problems of his own, she "gave up" – defeated. The "depression" she presented to her primary care doctor would be better characterized as an embittered loneliness.

So where was the crisis? A month earlier, she’d signed up on a dating web site and met someone that she really liked. A week ago, he’d begun to press for them to meet in person. Caught between hope and fear, she was overwhelmed with the weight of her biography and experience, and presented in crisis.

Obviously, the case stuck with me. Partly, it was the nostalgia of an old man [me] being reminded of my first job a director of a Crisis Unit, and later teaching crisis intervention techniques to residents and trainees from other disciplines. I really enjoyed working with them as they developed "the knack" of doing this kind of interview. Some were "naturals," some took a lot of work, and a few… well it’s just not for everyone. Crisis Intervention was a vital component of the Community Mental Health Movement [secondary prevention], but now it’s rarely even mentioned. A lot of the cases I see in our clinic are not in full blown crisis, but they still need that same kind of "sorting out" to get anywhere. But I put it here for another reason. I got to thinking about how such a case might be handled now in some of the currently proposed systems.

I suppose some would see this as treatment resistant depression. She had a history of depressions and she’d presented complaining about being depressed. She hadn’t responded to antidepressant drugs – even titrated to a maximum dose. Would she be a Ketamine candidate? Atypical Antipsychotics? CBT? What would’ve happened in Collaborative Care? When she didn’t respond to drugs from the Primary Care Clinician, she would’ve been passed on to the Clinical Coordinator. Would that Clinical Coordinator have known how to evaluate her? had the experience and training to get at the pertinent story? know how to take a focused history? And when the Coordinator presented the case to me as the consultant Psychiatrist, what could I possibly suggest without having that story, without seeing the patient?