The mute patient

The mute patient
Saturday August 29, 2009

Dear Alice Miller,

In my work, I am responsible for the care of a 19-year-old male patient who was transferred to the mental hospital by the army authorities soon after his enlistment. His commandants could not understand his behavior: he did not answer when approached, only occasionally mumbled single syllables, and much of the time was staring into space. In the psychiatry ward, he behaves very much the same: he is very quiet, generally mute, only answers with single words or not at all, looking very perplexed and often staring into space when approached. We cannot say for sure whether he is hallucinating or not. When he was admitted, he uttered several words from which it could be understood that he suspected that the food in the army had been poisoned by his mother. But later he denied this. He does not talk to other patients, either, and seems only to care about the vegetation, a fish aquarium that stands in the ward lobby, and the cats in the yard that arouse his intense curiosity. It has not been decided yet if he suffers from schizophrenia simplex, Asperger’s syndrome, or a sever schizoid personality disorder with superimposed depression or PTSD.

Soon after he was hospitalized, I interviewed seperately both of his parents, who are divorced for several years now. They both seem very disturbed and very intrusive. The mother is hysterical and talks incessantly, trying to convince her son to do this or that; the father is a cold and manipulative man who constantly criticizes the patient for “not cooperating” with his doctors, for not being shaved etc etc. Each one of them slanders the other parent in front of their son but they refuse to talk to each other. The mother has told us that the father used to hit the boy in earlier years and that the boy has also had violent outbursts at home, because “he is the same type as his father”. They both state that their son has really not changed very much, he is pretty much the same as he has always been, maybe just a little more depressed. They seem not to grasp at all that there is a serious problem with their son who is obviously suffering.

The patient is now hospitalized for several weeks already, with no change in his condition. Despite my initial efforts, I could not establish any meaningful communication with him. Gradually, I feel I am giving up on him, although I know this isn’t right. But I must admit that this young man’s silence makes me resent him. I did not pressure him to talk to me, and I expected that with time, with a gentle approach, he would open up. I told him several time that it must be difficult for him with parents who treat him like this, trying to find out how he feels, but he did not respond to this.

I am now beginning to ask myself why I hate my patient for his silence and why I want to give up on him, and I am beginning to see that this has to do with my own history. I know from descriptions of my mother and sister that until the age of four or so, I had been almost mute; I know that my silence used to drive my mother crazy. She told me that she tried to make me talk about myself by beginning to talk to me regularly about HERSELF. Obviously, this didn’t work; from her behavior I learned that my job was to listen to my mother, that is all. When I was sixteen she told me with tears in her eyes how hard it was for her to have a son like me, who doesn’t talk to her. She admitted that when I was still a little child, she once became so mad when I did not answer her, that she grasped me by the hair and shook my head in frenzy, screaming at me. I remember vaguely that as a child, I only talked to my parents when it was necessary. I don’t think they wanted to know what I am thinking or feeling. I do remember my father once coming into my room when I was a teenager; he obviously wanted to talk to me but he didn’t know how; he was never much of a talker himself. After a few moments of embarrassed silence he left, leaving me with terrible guilt – which I can still feel now as I am writing about it.

I don’t know why exactly I was mute. Was I imitating my mother who sometimes punished the children with “silent treatment”? Or was I imitating my father who was an aloof, lonely man? Maybe I was simply afraid to say the wrong thing and to be humiliated? Was it a kind of revenge? Or did I know already back then that if I spoke, I would never be understood? And now I am asking myself: how can I give empathy for my mute patient, when I all I received for my own silence as a child was hatred and guilty feelings? How can I understand my patient’s silence when nobody ever understood MY silence? Now I cannot empathize with the silent child I was, and I cannot understand him. N

AM: It is the first time that I hear a physician who clearly feels his hatered toward his patients and dares to make connections with his own childhood. I am sure that in most cases it would make sense and be helpful but there may be cases where even this kind of deepest empathy is not enough to coming in touch with the feelings of the patient. If he feels more sure when he doesn’t speak with you I think that you must respect his decision and send him to another colleague. Otherwise you would repeat what your mother has done when she forced you to speak. Your resistance to talk was however a sign of a strong and (in these circonstances) healthy, protest, wasn’t it? It gave you a bit autonomy however.