Laura Katers practices primary care at an underserved community clinic in Seattle, Wash. This essay was written when she was a student in the University of Washington-Seattle MEDEX PA program. The author has disclosed no potential conflicts of interest, financial or otherwise.
Tanya Gregory, PhD, department editor
There is a penny on the floor of the inpatient psychiatric ward of Harborview Medical Center in Seattle that no one wants to pick up. Not the staff. Not the visitors. Not any of the patients. But several of us know it's there. We've been staring at it all week. It's on the floor next to a blue button and a piece of thread. We're in an infrequently used interview room located off the main ward, so maybe these items fell from someone's pocket and have been overlooked by the cleaning crew. Could a penny in here mean good luck? No one seems to think so. We leave it there, with the thread and the button—the remnants of something that once cost something; that once held something together.
In acute psychiatric distress and illness, not much is held together. Thoughts spiral like wildfire, friendly conversation can be misconstrued as a private attack, and the only option too often appears to be a self-inflicted end to life.
I first experienced this slow burn of mental suffering some years ago when I was working in a large substance abuse facility in metro Denver. People—men and women, some barely adults—would cross the threshold of our facility either of their own volition, with paramedics, or escorted by police. Many were homeless, but many were not. More than half were experiencing co-occurring mental illness and substance abuse.
At first, I took up a mighty internal cheer to help everyone. “We will get you clean,” I would say. “We'll get you on the right meds, off the streets, set you up with your own place!” Over the following 6 months, I changed my rhythm. Some of the people, mostly the men, wanted to be homeless. They didn't want to be saved. They didn't want to stop drinking. The streets were their community. And either way, none of them was ready for the big changes I was thinking of. So I learned to smile at the “frequent flyers,” give a welcome nod every time the same client walked through the door. “So good to see you, sir,” I'd say. “I'm glad you're still alive. Let's get you a warm bed and something to eat.”
When I first met Katherine, I thought she was a lawyer for one of our clients. She was a well-kept woman in her mid-40s with beautiful, strong features and the air of someone important. But she was self-referring for IV drug use. Her story became one I would hear over and over. She was at a party, she decided to try heroin “just once—everyone was doing it.” She was a successful businesswoman and financially independent, but—“just like that”—things turned. Within the span of 9 months, she lost everything. Her job, her children, her husband, her self-respect. She lost nearly 30 lb and became a skeleton of herself, a shadow. But, most importantly, she lost all hope that things would change and that she could dig out of the hole she was in.
Hope is a funny thing. We—each of us—spend many moments thinking of the nice things in store for us. Who we might see when we get home, what activity awaits us on the weekend. We may have a trip coming up that we are saving for and subsequently hit the gym so we can look lithe and sleek on the beach. We might have a simple wish just to get home and make dinner and settle down and relax with a good book. What keeps so many of us going are these simple, flittering ideas about our future. I think these ideas are called hope.
Katherine had lost hers. She had nothing to look forward to. Every day, she thought of killing herself, such was the degree of her despair. She began to teach me what my real job was, and it wasn't to supervise the milieu of a large detox facility on a Friday night. It wasn't to make small talk with the other staff. It wasn't to write up shift reports. It was to create a small reservoir—a receptacle—somewhere (maybe even within myself) for other people's hope, and keep it for them until they were ready to get it back. After all, if I didn't believe in her, who would?
Over the course of the next year, Katherine was in and out of our facility. She would stay long enough to endure the horrendous withdrawal from heroin (often described as “it won't kill you but you'll wish you were dead”), only to leave and use again. She would commit to an inpatient treatment facility, only to leave abruptly in search of another fix. She was burning bridges, and she knew it. The last day she left our facility, I didn't think I would see her alive again.
Then, during an abnormally busy shift change at work, a staff member told me I had a visitor. Oh great, I thought, it's someone's parent or lawyer or someone high or drinking and wanting to lodge a complaint. Ours was a 40-bed lockdown facility. Patients could not leave unless they were sober and stable, and many were mandated by the court to stay against their will. As the shift supervisor, I knew this led to many colorful and disgruntled people showing up at our doors wanting to see me. I finished up what I was doing and went to the front window. Framed by the metal edging was a full-cheeked woman of about 45. She had bright blue eyes and long brown hair. She was wearing a green sweater. At first, I didn't recognize her. Then, all at once, she seemed familiar.
“Laura, it's me,” she said. And I knew.
I launched through our locked doors to see her in person. Katherine was back to a normal weight, and she was glowing. She'd just finished a successful 6-month treatment and felt something she hadn't felt since the first time she used heroin: hope for her own life. During her darkest days, we held onto it for her. We believed in her—I so wanted to believe in her—enough that she could do the hard work of simply surviving. When she was finally ready, she took everything we gave her—all the writings, the group work, the small journal I had encouraged her to keep, even the scars from her past drug abuse, all the things that had come to represent who she was and also who she wasn't anymore—and she changed her own life.
Now, some years later, in the interview room at Harborview Medical Center, I'm talking with a woman who has experienced significant physical and mental abuse. The story sounds familiar. When you work in psychiatry, you hear it often. This woman is crying fast, heavy tears that seem like they could go on forever. Her cheeks are wet, and the front of her shirt is darkening with salty droplets. Then a sob catches in her throat. She sees the penny beneath my feet. The same penny that no one wants. The one lying on the floor for nearly a week, next to the button, next to the thread.
“Can I have that?” she asks sheepishly, but with an edge of excitement. “It's a lucky penny.” Her eyes are as wide as a child's.
“Of course you can,” I say with a smile. “It's been waiting for you all along.”
I watch her gingerly pick it up, flip it over and over, noting it was minted in the same year she was born. Like Katherine, and like so many others, this woman appears to find something that might help keep her together. Her demeanor suddenly shifts. She takes off her right shoe, carefully places the penny in it, and looks up at me.
“Let's do this.” She says. “I'm ready.”
© 2014 American Academy of Physician Assistants.