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Introspections   |    
The Holiday Rush
Y. Pritham Raj, M.D.
Am J Psychiatry 2007;164:1803-1804. doi:10.1176/appi.ajp.2007.07020316
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As “November” fell from my clinic calendar like an autumn leaf and the finality of “December” was left emblazoned on my desk, I realized that I was about to give up on her. She was just a name to me. Her particulars had been sent to me several weeks prior with the ever-so-descriptive reason for referral: “evaluate for new symptoms of depression.”

She had missed her two and only scheduled appointments with me, calling at the 11th hour each time to tell me either that she was too sick or that the weather was too prohibitive for her to make it to the office. But with each missed appointment, she had created an hour-long void in my clinic schedule. Chagrined, I sent her a letter stating that she would be given one last chance to keep an appointment before I deleted her from my patient registry. In baseball terms, she was flirting with three strikes and “You’re out!” She finally arrived on the eighth of December…running a few minutes late. Brash and familiar but speaking with a polished English accent that gave her an air of aristocracy, she marched into my office.

“I’m dying of cancer,” she informed me bluntly. “What I want is a special Christmas with my son and daughter.”

It was a request that caught me off guard, one that initially seemed better suited for the ears of Father Christmas, Santa Claus, Père Noel, Kris Kringle—any of the mythological figure’s alter egos—not for the ears of a psychiatrist. I began to wonder if the oncologist who referred her to me did so because of my combined expertise in internal medicine and psychiatry or simply because as junior faculty, I was the guy with the open slots. I had little time to mull, for she quickly launched into a synopsis of her recurring dream.

“I find myself floating in a river and gradually feel my spirit leaving my body. I rise up into the sky. The feeling is actually quite liberating, for I’m not afraid to die.”

Her description left me feeling strangely like Charon, the ferryman of the dead in Greek mythology. But this “passenger” still had unfinished business to attend to—the holidays. She looked at me with expectant eyes—me, her second and likely last psychiatrist. So instead of focusing on death, we focused on life.

She told me about the key players, family members with whom she wished to spend the holidays and others she preferred would remain absent. She painted glorious pictures of favorite holiday pastimes and tasty treats that she hoped to share with her children “one last time.” I let her talk. There was urgency in her voice, and the pace of her dialogue, frenetic. She was like a Christmas Eve department store shopper, a woman on a mission. Against my usual practice, I did not address her penchant for creating nicknames for me along the way. Setting limits with a dying patient proved difficult.

She first tested our therapeutic boundary with what I like to call the colonial India approach, in which she, a British woman, inquired about my heritage. My brief validation of her suspicion that I was of Indian descent was followed by her recitation of a cascade of Hindi greetings and phrases. She was not manic, just trying desperately to connect with me. But I was once again caught off guard when, while processing several unresolved issues with her daughter-in-law, she paused, smiled, and asked, “Do you not agree, Raj? Can I call you Rajee? You are so nice…Rajee Mahal. I bet you get that sometimes. Please do not take offense. I just feel very comfortable with you.”

I’m not sure how I reacted or how I should have reacted. I was interacting with a patient under hospice care for terminal lung cancer. Somehow a more conventional, limit-setting response such as “It would probably be best if you just call me by my given name” did not seem appropriate. Perhaps I was cutting her too much slack. But in therapy, this was all new territory for me.

At the end of the hour, she rose, elated. I was spent. She had generated a plan that ensured that only her wanted guests would be with her during the holidays. She was empowered to enjoy the next few weeks of her life. Unfortunately, her master plan did not include time for a scheduled follow-up visit with me. But a week later, my office phone rang.

“Rajee-Pooh, how are you?”

It could only be her. She called to let me know that she was not sleeping well. I prescribed a different sleep aid and asked her to call me later and let me know how the holidays went.

It was December 28 and she hadn’t called—so I called her. A tired voice answered. She told me what a wonderful Christmas she had with her children. She was fatigued and now taking antibiotics for pneumonia but content. She said that everything was fine and graciously thanked me for my call. It was my last conversation with her, for she died at home that very night.

I used to believe that setting firm limits in psychotherapy was our mandate. But perhaps it is through flexibility, a flexibility that permits a “Rajee-Pooh” every now and then, that we truly discover the art of psychiatry.

+Address correspondence and reprint requests to Dr. Raj, Oregon Health and Science University, Mailcode: L475, 3181 Southwest Sam Jackson Park Rd., Portland, OR 97239-3098; raj00002@mc.duke.edu (e-mail). Introspection accepted for publication September 2007 (doi: 10.1176/appi.ajp.2007.07020316).




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