“ALL THE SAME”

(Publshed in the East Bay Psychiatric Association Newsletter, August, 2006)

I recently left my one-half day a week part time job at the Contra Costa County Forensic Mental Health Clinic. My responsibilities there for 14 ½ years had been primarily to provide medication management for some 40 conditionally released offenders who were undergoing mandated treatment in the community after a period of years stabilizing in a state mental hospital. Typically, these patients had committed major felonies while psychotic, had been found “not guilty of reason of insanity”, and were diverted from the prison system to the state mental health system. Their crimes were the worst kind, such as homicide (including infanticide), unprovoked assaults, and arson.

I enjoyed this part time work as a contrast to my own private practice. These two patient populations were about as different as night and day. The forensic patients typically came from minority groups in the inner city, had disadvantaged or abusive backgrounds, and often had psychoses complicated by substance abuse. These were the “throwaways” of the population—the people no one wanted. In contrast, my private patients were drawn mostly from the white, suburban, professional class—the people of privilege.

What surprised me was the impact that my leaving this job had on some of the patients. I had not realized that my relatively brief visit with them monthly for prescriptions and support had had such an impact on many of them. Some simply said polite goodbyes at their last appointment. But others amazingly spoke eloquently about how they felt at a little retirement party. And one of the female patients, with whom I felt very little connection, said something very poignant. She suffered from a major psychosis as well as a personality disorder. At her last visit, she brought me a small bouquet of flowers, an appropriate retirement card, and said, “Dr. Winig, you’re a good doctor. You treat us all the same,” and she started to cry.

I realized then, without having fully appreciated it before, that I was taking care of certain people for whom being taken care of was a very foreign experience. Perhaps no one else in their lives cared very much about them, or certainly never treated them as if they were “the same.” It was natural for me to do this. I was just being their doctor. But for some of these patients, the nature of the human relationship that they had with me may have been qualitatively different from anything else they had ever known.

It is important to keep in mind the powerful impact we may have on our patients. Even brief contacts may bring an individual hope and the sense that they are worth something, in the face of a lifetime of experiences that may have communicated something quite different. Sometimes, what seems so simple may actually be quite profound.