The Power of a First Impression Works Both Ways

Those who know say that the first dream a patient has in psychotherapy can be the key to the entire treatment. It may be true, too, for the first meeting with a patient--what occurs (and how it occurs) can drive the rest of the time together.

This patient preceded herself famously. There were piles of prior records from other hospitals, full of the details of her failed treatments, her days and nights in restraints and forced injections for indiscriminate assaultiveness--a symptom hard to sympathize with. The choice of whether to bang her head against walls, hurl furniture or bite an available arm seemed more astrological than reasoned.

Either way, the records were clear: It was violence without vindictiveness. There was never malice--how could there be, when the violence was so impersonal, so democratic? And she was full of apology afterward. In her best moments, the charts said, she was generous, compelling and wickedly witty. She did laundry for patients who were too disorganized to do it for themselves. She bought tonics from the canteen for patients restricted to the unit. She worried about her weight (too heavy) and the weights of her roommates (too thin). But most of the time, she lived by forces that appeared beyond her control.

We met in the quiet room. Her shoelaces had been removed to prevent any risk of hanging. She wore a Daisy Duck sweatshirt. Her eyes were brightly anxious. She seemed interested in the best social efforts and offered her hand.

It reminded me of what my mother had taught us when we were children. “This makes a good first impression,” she had said, grasping each of our hands firmly, “and this”--dangling our fingers as if the weight had slipped the hook--”makes a bad one. Never shake hands like a fish.”

We sat for the routine questions. Chronic hospital patients have heard them so often that they ought to list their answers on mimeo, with copies for each freshly interested interviewer.

Do you hear voices?

Do you have special powers?

Does the radio speak to you?

Are there whole days when you run on speed and don’t need sleep?

Do you weep often?

Do you feel like hurting yourself or anyone else at this minute?

I have always found this last to be a particularly useless question. There is no good reason why anyone should confide their most frightening impulses and plans to a stranger. I was taught never to disclose the personal to anyone I did not know and to suspect all solicitous questions from strangers.

But the chart requires documentation. The question must be put.

I put it. The patient, who had been anxious from the handshake, began to tremble, as if some geological event were rising toward the surface.

“Get the restraints,” she said. “I’m about to lose control.”

Her eyes darted around the room, at me, at the team nurse, at the cinderblock walls. I was taken aback by the suddenness of it. Some important decision hovered, but it seemed all three of us were equally unclear what was going to happen or why.

She picked up a cup of grape juice I had brought in to her. The cup was full. She gazed into it, perhaps for direction, perhaps for guidance from tea leaves, then hurled it at me. Her pitch was poor, and it splashed against the wall. The green cinderblocks turned violet. They looked like digestive enzymes.

I turned to the nurse. As a rule, nurses are more gifted and better equipped than doctors to handle the practical turns of real life. She gazed back at me. There was silence. The walls dripped. The patient waited.

“Perhaps she ought to clean it up, now,” the nurse murmured.

Just what my mother would have said.

I found a towel and gave it to the patient. Immediately, she began to rub the wall down. She worked vigorously, until the enzymes had digested everything. She held the towel out.

“No one’s ever asked me to clean up,” she said. There was surprise and, I thought, some subtle enthusiasm in her voice.

“Perhaps she ought to throw that [towel] in the laundry bin now,” the nurse murmured.

The patient spent a year and a half with us. She required restraints once when she tossed a lamp at a television. We changed her medications and involved her in behavioral programs, but the grand moment of treatment, the moment of practical genius, had already occurred.

All walls were firmly green on the day she left. The team nurse was off duty but spiritually hovering when the patient asked for a glass of grape juice. Then she laughed and shook my hand. It made a good impression.