By Erin Yancey
“I like your shoes!” I said to the teenage girl standing against the wall of the elevator as I stepped in. I had just begun my third-year psychiatry rotation, and I was arriving for my first day of clinic with a child and adolescent psychiatrist, Dr. Wilson. I was particularly interested in both psychiatry and pediatrics, so I had been looking forward to this day for a while. The girl ignored my compliment and continued to stare down at her bright pink Converse sneakers, complete with multicolored laces and a hand-drawn eye on each shoe. Her mother standing next to her asked, “What do you say? Can you tell her thank you?” The girl continued staring down, and her mother smiled a soft apology towards me. The elevator arrived at our floor, and I tried to smile at the girl one last time to no avail. Her gaze was fixed upon the sharpie-eyes on her shoes as if in a staring contest.
Once in Dr. Wilson’s office, I watched him speak with patients with a variety of needs. Although I had performed psychiatric evaluations with adults on my own, he suggested I shadow him for the first few patients of the day to see how interviewing children differed. The first several patients were being seen for follow-up for their anxiety, depression, and ADHD. I noted the close patient-physician relationship—all patients and their families spoke with Dr. Wilson comfortably and honestly, and it was clear they saw him as someone they could deeply trust. Dr. Wilson quickly briefed me on the next patient to be seen as he had done all morning. Her name was Sarah, and he explained that she rarely, if ever, spoke during her visits and had a history of severe depression. She had a difficult past and lived with her adoptive parents. Earlier in the week she attempted suicide by wrapping a shoe lace around her neck, the subject of her visit today. The nurse brought Sarah in, and I immediately recognized the bright pink sneakers from the elevator. She sat down in the chair across from the doctor’s desk and planted her heels firmly on the seat so she could rest her head against her knees. She was around fourteen years old with wild, red hair, and in her right hand she tightly clutched a cell phone and pair of earbuds. Again, she began staring down at the eyes on her shoes. Her parents sat on the couch near the back of the room, and Dr. Wilson began the session.
When Dr. Wilson said that this patient would rarely speak, he was not exaggerating. He spent a few minutes asking her about what had happened, but each question hung in the air unanswered. Eventually, he directed his questions to her parents. They seemed concerned, and equally defeated, as they told him that she would not speak with them about it either. As they spoke, Sarah remained silent, staring at her shoes and methodically winding her earphones around her fingers and palms. Dr. Wilson expressed his concern about her unwillingness to speak to him and offered to find a psychiatrist that the girl felt more comfortable opening up to. Her parents assured him her behavior today was not unusual; she had a long history of selective mutism in the presence of medical professionals. During visits to her primary care physician and even during a recent urgent-care visit for a sprained ankle, she refused to speak to any doctors or nurses. He sat quietly for a moment, thinking. His expression suddenly changed as he stood up and said, “Mom, Dad; let’s take a walk.” Before they left, he said to me, “You’re going to do this.” I was caught off guard, but I nodded, grateful that he was allowing me to conduct the interview. I felt nervous, too, because I knew my prospects of making a breakthrough with the girl were dim. All but me and Sarah left the room, and I walked around the desk to sit in the doctor’s armchair.
I watched her as she wrapped her headphones around her hands again and again while staring at her shoes. I attempted to revisit Dr. Wilson’s earlier questions with her. “Can you tell me what happened this week?” Silence. “Why did you have to go to the hospital?” … “How have you been feeling lately? What is your mood like?” More silence. I began to feel discouraged and acutely aware of how long the others had been gone. I tried one last time, with a slightly different approach. “I know you don’t want to talk. And I know it’s kind of scary being in a doctor’s office. But actually, I’m not a doctor yet! I’m still in school, just like you. If you tell me what happened, it will help us come up with a plan to help you feel better. Can you tell me? Did something happen this week?” As her gaze stayed fixed upon her shoes, she nodded her head.
The movement was so slight, I almost didn’t notice, but she had nodded her head and finally answered one of my questions. Suddenly, my hope was renewed that we may be able to communicate after all. Careful to only ask yes or no questions, I asked about her family, her home, and her school. She nodded and shook her head appropriately, and all the while furiously wound her earphones around her fingers, around her hands, around her knees. I then asked about her friends. She froze. With the cessation of her movements, I noticed the faint horizontal scars on her wrists. I was surprised that I had not noticed them sooner, and then wondered if the systematic winding of her headphones was not absent-minded fidgeting, but perhaps a very intentional distraction. I delved a little deeper and eventually learned that her best friend, her only friend, had moved to another state this week. Her eyes, still fixed on her Converse, began to well up with tears. One escaped and traced an uneven river down her face. She did not move to brush it away. For a moment, she and I both stared at the eyes on her shoes in silence. Her multicolored laces were covered in stars, and I briefly wondered if those were the laces she had turned to in a moment of despair. My stomach turned, and I felt tears spring into the back of my own eyes as I imagined how she must have felt. In that moment I realized that I will never know all the details of her past, or the depths her depression brings her to. I can try to understand, but I never truly will. We carried on, and although her tears would occasionally be too many to be contained by the brim of her eyes, no sound ever escaped from her. Not a sob, not a sniffle, nothing. It was as though she was purposefully refusing to make a sound.
Our communication rested on a delicate balance of safety and trust, and a knock on the office door disrupted the scale and signified that our interview had come to an end. I spoke with Dr. Wilson in the hallway about the information I had gleaned from our near one-sided conversation. We reentered the room, and he and Sarah’s parents spent the rest of the appointment discussing his treatment recommendations. As they talked, Sarah and I sat next to each other near the doctor’s desk. The appointment ended, and I said goodbye to her and watched her unique pink sneakers pace silently out of the room. Dr. Wilson shared his optimism at the small breakthrough we had seemed to make. I, however, felt disheartened as the young girl left, knowing that her illness was severe and her struggle with depression would likely be a lifelong battle. As if sensing my deflation, he said with a smile and a shrug, “Progress is progress.”
As my psychiatry rotation moved forward, I interviewed a diverse cohort of patients with a variety of psychiatric issues including depression, panic disorder, PTSD and schizophrenia, among others. It wasn’t long until I realized that no specialty fascinated me more than psychiatry and its patient population, and I decided what my path in medicine would be. Often, I reflected on my interview with Sarah; the girl with the eyes on her pink sneakers. I interviewed plenty of patients who were somewhat difficult to communicate with, whether they were reluctant to discuss certain aspects of their history, or they were psychotic and required extra patience to complete a psychiatric evaluation, but she remained the only patient I ever interviewed who refused to speak at all. But even without words she had taught me an incredibly important lesson for my future career as a psychiatrist: progress is progress.
I also still had a lot of questions about Sarah. I wondered what her personality would be like if things were going better. I wondered whether her motivation to remain silent came from a place of fear or apathy. The more I contemplated, the more I remembered the vibrancy of her shoes. They almost didn’t match their wearer. But expression is not something that necessarily requires being verbal. Perhaps this girl who was in a very dark place mentally found it easier to express her personality through her choice of foot-wear. She never made eye contact with me throughout our interview, but maybe the eyes drawn on her shoes conveyed that even though her mouth was tightly shut, her eyes were wide open. Or maybe she spent so much time staring at the shoe’s eyes because they made her feel seen. This is all of course speculation, but expression is variable, and oftentimes truly understanding our patients requires paying attention to even the smallest of details.
Towards the end of my rotation, I spent a week at the State Hospital, where the most ill and indigent psychiatric patients in the state received inpatient care. Some patients at this facility had criminal charges against them. On my first day there, I went to the court yard to meet and interview one such patient. As I approached him, I tried to think of what I could say to make a connection with him; to start things off on the right foot. He was sitting in a chair alone, wearing a black hoodie, sweatpants, and a pair of vibrant blue tennis shoes. He looked up at me, and as he did, I smiled warmly and said, “I like your shoes!”
Fictional names were used to preserve confidentiality.
Erin Yancey is a fourth-year medical student in the UAMS College of Medicine.