Broken Boundaries

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Working in the psychiatric emergency room, I’ve had quite a few indescribable experiences, to say the least.  The emotions and thoughts that arise in the flood of activity when police bring in involuntary patients necessitating the application of quick restraints are colored by dread and determination.  These experiences are often indescribable and sometimes unspeakable. But, what about those experiences is best defined as taboo?

Miranda was a 26-year-old Hispanic woman who wrote “evaluation” as the reason for her ER visit on the triage form.  Annoyance at her vagueness washed over me. I couldn’t prepare myself for what to expect.  

I sucked it up, called her name, and told her to follow me. I asked, “How can we help you today?”

“I-I don’t know,” she replied, hesitantly.  

I waited.  Sometimes, not speaking elicits a more complete response from patients. The silence weighs on them and works well most times.  This time, it didn’t.  She wasn’t forthcoming.

“Well, can you tell me the nature of what brings you here?” I persisted.  

I was losing patience. Our busy psychiatric ER gets many visits for non-emergent reasons. Some people are seeking secondary gains, like a turkey sandwich, or a way out of the rain or out of the shelter system, since hospitalization means meals and a clean bed: or “three hots and a cot.” Miranda didn’t appear to be malingering.  She was dressed meticulously.

“I left my job today.  I just couldn’t do it anymore. I’ve been depressed,” she said and then paused. “I don’t have any reason to live.”

I became suspicious. “I don’t have any reason to live,” sounded like a catchphrase and a little over-the-top at that.  Catchphrases like “suicidal” or “homicidal” are commonly seen as magic words to get admitted to the hospital.  

I persisted. Does she have a personality disorder, I wondered?  Is she trying to manipulate me into feeling overly sympathetic for her?

I pushed on, “How long have you been feeling this way?”

“For a couple of days…” she stalled, looking about the room.

“And what happened a couple of days ago?” I asked.  Now she was really being evasive.  What was she so reluctant to say? There was a long pause.

“I found out I’m HIV-positive,” she blurted out.  Shaking her head, she said, “What’s the point?”

Shit.  I wasn’t prepared for this.  Shame and regret for the thoughts I had secretly harbored washed over me like a tidal wave over an unprotected shore.  I reprimanded myself. My voice softened empathetically. I began to explore her support system.

“There’s no one I could share this with,” she insisted when I challenged her that people might be more sympathetic than she predicted.  “It’s just me and…this.”

She saw no future for herself, no reason to live. I felt the emotional undertow pulling me in a direction I did not want to go.  As she went on, tears filling her eyes, I felt the tug to cross a line not meant to be broken.  I desperately did not want to submit but, finally, I realized I had to break a rule I was holding onto with all my might: the boundary.

“Being HIV-positive doesn’t mean there is no reason to live. It doesn’t mean life is over,” I said.

She looked at me like I was delusional.  I saw fire in her eyes. “You have no idea what it’s like!  How would you know?”  

My thoughts were racing, blinding.  Panic rose inside me. Should I or shouldn’t I? I dove right in.

“I’m HIV-positive, too,” I said.  “I know what it’s like to feel like you have nowhere to turn.”  

I related to how Miranda felt alone in her diagnosis and was reminded of the primal need I felt to be with my mother when I was diagnosed in 1991.

My mother was living with a recurrence of cancer so I knew the timing of this unwelcome news may not be right. She was dealing with her own death-and-dying issues and this was before there was effective HIV treatment, when life expectancy was less than a year.

I was met with a seemingly endless silence when I told her on the phone. When my mother spoke, she asked me to let her be and to not call her again. She was never one to deal well with death and didn’t know which one of us would go first. I understood.

As I watched Miranda consider my revelation, I could practically hear a wall crumbling –– the wall between patient and provider.  Removing this wall was taboo. I felt the ground shifting in the room and within myself.  I felt warmth on my face as I started to flush and tear up.

Remembering how my therapist cried with me when I was first diagnosed, I continued on without shame or embarrassment.

“You can live a long productive life,” I said as I cried, hearing forcefulness in my voice now.  “Yes, HIV will change your life, but who knows?  Maybe for the better.  It could give you purpose.  Look at me ––I’ve got HIV, yet I’m able to work and I have purpose. HIV may be an opportunity to find a new direction for yourself.  Don’t give up, use HIV for change.”  

Miranda dabbed her eyes, sucked in a breath, and nodded.  I took her vital signs and the rest of her history.  I presented her case (minus our tête-à-tête) to the physician and we discharged her with an outpatient referral.

I’m not sure whether crossing the boundary helped Miranda in the long run.  All I know is that day, it seemed to make a difference for her and for me as well.  I learned that sometimes you have to challenge the taboo, break rules, remove boundaries, and submit to the undertow; so you and the client don’t drown. The experience can be one that words cannot define.  It can be ineffable.

Lary Campbell, BSN, RN-BC works in the psychiatric emergency room at Pennsylvania Hospital and specializes in LGBT healthcare.

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