Washington Baltimore Center for Psychoanalysis

Beyond the COuch


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By Elia Margarita (Maggie) Valladares Juarez, MD

Joe was one of the first patients I met when I joined the outreach assertive community treatment (ACT) team. As a member of this team, I have learned the importance of building trust over time. Human relationships are everything.

Joe is a chronically homeless alcoholic and bipolar individual in his sixties, well known in the community for multiple incarcerations and hospitalizations in his youth. With the dedication of several team members over several months, Joe was finally “housed”—although, in spite of this apparent success, we were all over-functioning to help

him maintain housing, access to food and good nutrition. Daily visits were the only way to ensure he could keep his apartment clean and his clothes unsoiled. Of late, the situation had declined. As we walked down the hallway to his unit, we could detect a potent blend of cigarettes, alcohol, and urine.

Last Sunday I had walked into his apartment to find him intoxicated beyond belief. I wanted to see him and remind him to take his medications. But when I arrived, Joe was unable to walk straight. He stumbled around his living room, trying to make his way towards me to “take his medications”. He looked as if he was about to be sick.

I was shaken and disheartened, watching him weave his way around the room I quickly said to him “Forget it, don’t take them.” I felt like I wanted to rush out of there as fast as I could. The whole situation felt pointless. My presence there, our daily visits, the frozen meal deliveries, all the daily team effort. We had seen this man overcome homelessness, several rounds of rehab, prostate cancer, manic episodes, numerous stays in shelters. Yet here he was, unable to stand or even speak – let alone take the medications that were supposed to help him remain stable. I told him we would be back tomorrow.

“Joe,” I told him, “we need to do something different.”

During our daily staff meeting the next day we discussed our concern that Joe’s health was rapidly declining. Neighbors had begun to complain. We had been trying to find resources. Services that had previously been available for those with substance abuse had been closed or lost during the pandemic. Finally, after a week of effort, we were able to secure a bed in an in-patient substance abuse unit outside the city. Could we get Joe to “buy in?” There wouldn’t even be time to meet face-to-face with him.

The following Friday afternoon, I was getting ready to travel abroad to visit family for the first time in two years, due to the pandemic. In the midst of packing my suitcase, I received a call from one of my team members. J was refusing to go to detox.

I sank onto a chair, awash in the powerlessness of knowing that after all our daily visits, efforts, advocacy, “Not today” was Joe’s answer. He was about to get his check on Saturday and there seemed to be no way this man would agree to get help. He said he would do it after the weekend – a weekend we knew would lead only to another binge.

I had no time to go to his house to “orchestrate” a face-to-face intervention. A phone call would have to do.

I held my breath as I picked up the call. It was from his long-term advocate nurse Hubb, who was at Joe’s apartment with him. She put Joe on the phone, and I began to plead with him to accept the recommendation of the treatment team.

“Joe,” I told him, “in our time together this is the worst it’s been.

Things have reached a low point. Will you take the bed on the unit?”

He hesitated and was silent. I feared he would once more say “Not today.” So I tried to balance hope and despair, allowing myself to feel the full force of my worry and powerlessness.

“Joe, no matter what you choose, we will be there. I hope you do, but I cannot make you. We cannot make you. But seeing you like this is terrifying.”

A long silence ensued. The other nurse and I took turns speaking to him into the silence.

“What do you say, Joe?”

“It’s a great opportunity for you.”

“It’ll just be a few days.”

I was due to leave for the airport in less than an hour. Is this how I would have to leave him?

Sudden laughter broke the silence.

“So sorry, we must have muted you!” I heard. “Joe has been saying yes for the last minute. He says that he will go.”

Unable or rather unwilling to hide my joy I said loudly “Thank God!”. And while we all laughed together, an inner “yes!” in my heart gave me chills as I registered gratitude.

Yet, I know that once again I must release my hopes and wishes for him. This is his journey, it is not up to me. I steeled myself, recognizing that he could check himself out any time and start to drink again.

Community mental health is a balancing act of hope, fear, love, powerlessness, and joy again. Do not hold too tightly to any of those states. Respond moment to moment as life demands and unfolds. Try, fail, regroup, try again. Maintain an unrelenting enthusiasm for life, regardless of the outcome. In reality, this is slow work, filled with heartbreak, loss but also small victories, humor, joy, creativity, spontaneity and healing. For now, we will hold steady and see what the future will bring. You never know. 

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