Are We Clear? Crystal.

My first patient had me thinking of a number of things at once. The first thought was of one of my first clinical instructors, who described his process of differential diagnosis: "I ask questions, and I keep asking questions until I have a crystal clear image in my mind of what might be wrong with this patient." I also thought of the "clinical tales" of Dr. Irvin Yalom, where he initiates the assessment with the simple words, "What ails?" Questioning. "What brings you here today?" "How can I help you?" And, of course, the ever-poular, "So, what's up?" Now, be sure to read Dinah's interesting take on what people talk about in therapy (before she thinks I have again stolen from her): "I've taken to giving patients fairly specific instructions about what I want to hear, what I think will be helpful to them." This, I believe (and feel free to correct my presumption, ShrinkRap), presumes you have already determined what is wrong; what needs to be "helped."

This patient presents with the textbook affect of major depression: sad face, slow shuffling walk, eyes averted, shoulders hunched. He has a fundamental lack of animation, absent range of emotion, soft and pressured speech. Yet, when he speaks, his vocabulary, thought process, and general "fund of information" suggests that he is quite intelligent. But like a prepared witness, he offers no more than what I specifically ask. Sleep & appetite disturbance, lack of motivation, doesn't seem to enjoy much of anything; about two years ago, when he was especially depressed, he admits to hearing voices. The voices have continued, and now he "sees shadows or ghosts" in his peripheral vision; "When I turn to look, they're gone." "Why are you here to see me?" "I need to re-apply for Social Security Disability." Disability? This is an anomoly among these patients, generally, because to qualify, you must have an actual history of work, "on the books," and have actually paid taxes & FICA. This is only the second request in as many years.

It turns out he has an AA degree, was going to night school to get his BA, and had a "niche" job in a major technology company because he had training in an unique specialization. Until the "accident." "How did you get on disability?" "I got in an accident at work and was injured." "What happened?" Nothing. Silence. He is looking at the floor and remains unresponsive. I wait a reasonable moment and gently say, "Can you tell me about the accident?" Tears begin rolling down his face, but he makes no eye-contact, nor provides a response. He has now dropped his head in his arms onto the table. Again, I wait a reasonable moment and gently say, "In order for me to help you, you have to help me understand." Another silence, and finally, "I'm sorry. I just can't talk about it." Wow. OK.

As I consider the next course of action, I offer him some water, and finally ask if he believes he can continue. Factually, if he is filing for SSDI for a physical disability, I really don't need a psych work-up, and I also realize that under these circumstances, I shouldn't be seeing him in the first place. This fact is made more prominent when he tells me that he has a $50,000 brokerage account and a trust for his children. But equally factual is that applying for disability doesn't take a lot of time or effort, and there is no harm in helping him. He signs the forms, I ask the minimal questions, and we're done.

Lastly, I ask, "What is your controlling case?" (i.e. the crime that brought you to prison). Without a hesitation and with direct eye-contact he casually says, "Forced oral copulation of a minor with violence, and possession of a controlled substance." WTF! I am shocked at the bluntness of his statement; like he had just told me the Padre's score. After he leaves I get his chart: First-time offender. Depression NOS, Mirtazapine 45 mg. q hs. Axis III, "lower back pain." Report of radiology consult of the lower back: no evidence of trauma or derangement, inconclusive. Absolutely no reference, not one, to any accident.

"You can't handle the truth!"