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A Piece of My Mind
October 8, 2019

Into the Well

Author Affiliations
  • 1Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
JAMA. 2019;322(14):1353-1354. doi:10.1001/jama.2019.15350

I sat in the on-call room of the psychiatry department, wrapping my index finger around the coils in the telephone cord. The sun had just dropped behind the city skyline, marking the end of another day on the general adult inpatient psychiatry unit. I had spent most of the day talking to severely depressed individuals, listening to their hardships, and cataloging their symptoms.

Some took me step-by-step through their plans of suicide, how many pills they would take, where the gun was in their house, where they would hang the rope. For these select few, I had worked hard to keep them in the hospital, building therapeutic alliances and giving my recommendations or removing their civil liberties for a moment in time to ensure their safety. For others, a carefully thought-out regimen of medications caused them to take steps in all different directions. Some lunged forward. Others sidestepped or shuffled back. After completing this dance of psychopharmacology and psychotherapy, I was now in the middle of reaching out to the patients’ families to offer updates and ask for collateral information.

Before making my final call of the evening, I leaned back in my chair and stared at a small, dark fingerprint on an otherwise pristine, white plaster wall. Since starting residency, I had developed a daily closing routine to help cope with the emotional toll of the day’s activities. Every evening, after checking the final box on my patient list, I would stare off into the whitewash paint of the resident workroom and picture an old-fashioned stone well situated in a bright, ivory landscape. My imaginary well was nothing more than a generic, stock photo-esque creation, equipped with a slight covering of green moss and a wooden pail tied to a lever. The well contained a thick mixture of memories, both professional and personal, intermixed with the emotional significance that instilled importance to these past experiences.

Every evening I would walk up to this well, sit on its edge, and review the barely legible notes I had made on my patient list. After I was certain my daily tasks were complete, I would throw my list into the well, allowing my patients’ stories to slowly dissolve into the solution below. Developing this practice had proven essential to maintaining my well-being as an intern, allowing me to separate suicide notes and child abuse from long runs with my wife and evenings with my friends and affording me the ability to enjoy life outside of the hospital. Daily visits to the well also helped keep memories of my own past from entering the hospital doors.

While I envisioned sitting on the well’s edge, I decided to make my final phone call of the day. I dialed the number of the parent of a young adult who had recently quit school and stopped interacting with others. The patient began experiencing auditory hallucinations telling them their roommate was planning to harm them, which ultimately led to inpatient hospitalization. The patient had responded well to antipsychotics and was now ready to transition to outpatient care. My goal was to inform the parent that their child was clinically ready for discharge. I recall the conversation.

“Hello?”

I closed my eyes and leaned back in my chair, pulling the phone base towards the end of the desk with my finger still coiled in its cord. We exchanged pleasantries, followed by a brief synopsis of the past few interactions between the patient and inpatient psychiatry team. Like a dance instructor, I revealed how the patient was now taking steps forward, detailing the changes we had made to restore rhythm to the patient’s previously chaotic thought process. And after discussing follow-up appointments for medication management and upcoming psychotherapy intake, I broached the topic of the patient’s inevitable discharge.

“What?”

With my mind split between the present conversation and my imaginary world, I had left myself emotionally vulnerable. Part of my attention peered over the stone edge of the well, staring down at the memories circling at its basin. The other twisted the phone cord, anchoring me in the present moment. My carefully orchestrated routine, perfected through hundreds of family phone calls before it, was interrupted by an unexpected misstep: I had omitted the parent from the decision-making process. Furthermore, after a full day of emotional strain inflicted by the inpatient unit, I knew my reserves of emotional strength were dwindling.

“How could you let [my child] leave? This just isn’t enough time; there is absolutely no way.”

I tightened the telephone cord around my finger until it began to throb with anoxic injury. Using this secure attachment, I peered deeper into the well. Just under the surface of the water, steeped in the same visceral desperation exhibited by the patient’s parent, I saw the outline of a familiar scene.

The tight coil suffocating my finger loosened, and the telephone cord slipped out of my hand. My chair lurched backward as I fell from my stone perch into the well. The well-known sensation of weightlessness was met by a wave of piloerection, as I splashed into the chilled liquid below. My heart began to race, my stomach turned, and my breathing became shallow and frantic. Soon, I was completely submerged in memories and emotions; the room around me, the chair beneath me, and the phone gripped firmly in my hand felt unreal, as the scene I had glimpsed while peering into the well, a memory that I had not allowed myself to revisit for years, became clearer, finally overwhelming the present moment.

I found myself sitting in my best friend’s living room with my bent knees pressed firmly into my chest. I was 17, and while I carried a stoic demeanor, my emotions and internal sensations were completely derailed. That morning, my mother told me my friend was missing. I rushed to his house to find it filled with multiple police officers, each searching for more details to piece together the puzzle of his disappearance. Where did they keep medications? Was there a gun in their house? Was there an area on the property to hang a rope?

I dropped my head between my knees in an attempt to block additional sensory input from entering my already overwhelmed body; however, I could not stop the stream of recent memories from churning through possible explanations for my friend’s absence. As the sights, sounds, and sensations of this distant living room began to give way to the realities of the workroom—the white wall, the fingerprint, the phone pressed to my ear, the concerned parent at the other end of the phone—my focus remained tethered to a single, haunting question: How could I have let this happen?

I was now loosely grounded in two separate worlds, connected by intense physical emotions and a lingering question rooted in helplessness and guilt. The well I had constructed as a mindfulness routine had become an inescapable tomb, where suddenly I found myself drowning in the viscous mixture of memories and emotions. In this moment, the previously hidden purpose of my imaginary well became patently clear: it was a mechanism to keep the emotionally challenging moments experienced by myself and my patients concealed, allowing me to practice medicine and life without experiencing the emotional variability in which both are deeply rooted.

Yet as I floated in my imaginary well, I began to realize the fortune in my inadvertent plunge. My ability to feel a fraction of what my patients and their families experience provided new weight and meaning to my words of guidance; I was no longer a dance instructor who had learned from observing others, rather one who had experienced some of the same steps in all different directions. My past experiences, however painful, helped me connect beyond the well-orchestrated routines I had spent the past year developing. As I noticed the fear, tension, and anxiety my body exhibited, the final steps became clear. I arrived back in my chair, firmly holding the phone in my hand, equipped with words I had uncovered within the moss-covered well.

“I know how much you love your child and how afraid you must feel. I’m afraid as well.”

The line became silent, followed by muffled sounds of crying. My imaginary well began to drift away, and I found myself again staring at a dark fingerprint on the white plaster wall, wrapping my index finger around the coils in the telephone cord.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Colin Wendt, MD, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Seattle, WA 98195 (wendt126@uw.edu).

Conflict of Interest Disclosures: None reported.

Additional Contributions: I thank Bernard Trappey, MD, for editorial guidance, for which he received no compensation. I also thank the parents of my childhood friend for providing permission to share their son’s story.

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