My computer flashes a message that Lisa checked in, so I go to the waiting area of the college counseling center where I work. At first I do not see her, but then I notice a short, thin woman sitting in the corner, her head bowed with long, wavy blond hair covering her face.
Lisa came in for an appointment at the beginning of the semester and then missed the next appointment. After a few e-mails and phone calls on my part, I get her in for a follow-up visit. I do not always pursue a patient, but I am worried about Lisa. She was hospitalized a few months earlier after becoming paranoid and hitting her mother.
We walk into my office, and she sits and looks at me, pushing her hair from her face so I can see her blue eyes. She starts by telling me: “I ran out of medication, but I know I need to restart it.” I ask her to tell me how she knows.
“Since I stopped taking medication, my friends are getting annoyed with me for talking too much and keeping them awake when I call late at night. My professor spoke with me after class and told me I was being disruptive with all my questions. I think I am too revved up, and it is getting hard to concentrate on my school work.”
I feel a deep sense of relief that Lisa has insight into how her behavior affects others and that medication can help her. This is a major step for her, and I am hopeful that she will continue treatment that helps her achieve her goals. I praise Lisa for listening to feedback from others.
Lisa’s insight has been limited in the past. Her first hospitalization was 1 year ago, her second 2 months ago, both for psychotic episodes following escalating marijuana use. She had been a regular cannabis smoker since coming to college. Did the marijuana cause psychosis, or did she increase use to self-medicate psychosis? This will be debated until the end of time, but I don’t believe marijuana benefits her. She has been in college for 7 years.
I started to see Lisa after her first hospitalization. I was relieved that she subsequently stopped using marijuana and took an antipsychotic. Her mind cleared, and she successfully completed the semester. After 4 months of treatment, she told me she was going to taper her medication and would not need to see me anymore. I was sad, but not surprised, when she returned to my care after the second hospitalization.
Lisa still doubts she has bipolar disorder, a diagnosis she was given in the hospital. Whatever her diagnosis is, I ask her to consider using antipsychotic medication as a tool, along with therapy, friendship, exercise, and healthy eating, to accomplish her goal, graduating from college, which she will do at the end of the semester.
With Lisa, I see more trust with each visit. I also see a rocky road ahead for her, as she still uses marijuana, although not on a daily basis. I have tried to convince her of the benefits of abstinence, without success. I believe the antipsychotic is helping her, so I prescribe it. I schedule a follow-up appointment.
Sitting with patients like Lisa, believing you are slowly making steps toward wellness, is deeply rewarding. My job in a college counseling center allows me to spend 30-45 minutes in follow-up with my patients and meet as often as I need to. Lisa would be lucky in the public health sector to see someone every 3 months for 15 minutes.
I truly feel we as college mental health psychiatrists are often in the role of in loco parentis, and we make a difference. The doctor-patient relationship is the key element in our treatment, enabling patients to trust our recommendations, whether it is for medication, therapy, or exercise. Sometimes, with patients like Lisa, the trust has to be built up over time.
The importance of the doctor-patient relationship has not changed in the last 21 years since I completed my training. Sometimes, it is a battle to maintain this relationship, as I spend an increasing amount of time bent over my computer typing and tapping information into the electronic medical record. My notes have gone from short stories to novellas, as I fill in information to meet insurance, risk management, and psychiatry board requirements. I fear I will soon have a closer relationship with my computer than with my patients. Sometimes I feel like the astronaut in “2001: A Space Odyssey,” and Hal the computer has taken over my life.
Patients like Lisa literally bring me down to earth and help me remember why I became a psychiatrist. As I puzzle over how to strengthen the doctor-patient bond, I try to plant the seeds that will allow Lisa to forego marijuana and other drugs for good. I encourage her to connect with others in her shoes by going to a support group, acknowledging my own deficits in knowing her experience but my desire to understand it as best I can. The connections I form with patients, especially the more challenging ones like Lisa, cannot be measured, and don’t have a reimbursement code, but they are priceless.
Dr. Morris is a psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville and has provided clinical care to University of Florida students for the last 20 years. Her areas of specialty include depression, eating disorders, and anxiety disorders.
