October 25, 2010



A couple of weeks ago, I got a call from the mother of one of my teenage patients, a 14 year old Chinese-american boy who initially saw me at the start of the summer for a sports physical. At that time, I became alarmed when he and his father (who was present then) told me that he had been hearing voices in his head and socially withdrawing from his friends. With further questioning, he told me the voices sometimes told him to hurt himself. He was consciously aware that they were not real and said he would never act on them. At first sight, his demeanor seemed somewhat reticent, though not atypical for a teenage boy, and as I broke the ice with him, chatting about football and school, he became more than willing to open up about these voices. In short order, I felt disinclined to believe that the voices were part of a real psychotic phenomenon, because he was too objective about them and had a normal emotional interface with me. I just listened and let this story unfold. His dad wasn’t buying the voices bit either, but reported that the boy’s mother, who wasn’t present, was very disturbed by it. The expanded context here is that the parents are divorced and not on good terms, and the boy splits time between their homes. Worse, this last spring, the boy was at a middle school when a schizophrenic man walked onto the school grounds and shot two of his classmates with a rifle–you may have heard about this as it made national news. The newspapers here have been full of details about the arrest and trial of this deranged man, who was hearing voices telling him to shoot the kids.

With all of that context, and with his fairly objective and rational affect, I felt that this boy was most likely exhibiting some sort of adjustment disorder, in some way internalizing the inner turmoil of his parent’s divorce, his terrifying school shooting experience, not to mention some underlying identity angst. He is a teenage boy, after all, and one of the only Chinese-american kids at his otherwise white suburban school. To me, it seemed that he was projecting this stress into the semi-conjured symptom of “hearing voices.” Perhaps it was not a conscious fabrication of symptoms on his part, but it did not have the flavor of any real psychosis, more like a confused boy crying out for help. But what was I to do? I was wary of sending him to a psychiatrist, because I could envision a snap judgment, a label as a schizophrenic, a heavy duty antipsychotic, and a fast track to a lifetime of mental disability, all as an exaggerated response to an embellished symptom that was really a part of a coping mechanism. He had Medicaid and so his options for child psychiatry/psychology services were very limited. Lacking other resources, I called the The Children’s Hospital psych unit to see if I could arrange a timely outpatient psychology referral, only to be told that the waiting list was twelve weeks long. I spoke to a by-the-book psychiatric nurse practitioner, who, confirming my fears, said instantly upon learning that he was hearing voices, “You have to have him come to the ER by ambulance. He’s a danger to himself.” I told her that he was not and that I was willing to make that call, and could we just get him to see a psychologist within the week? I was confident that this situation needed a quiet, gentle approach, not fire alarms and inpatient evaluation. The nurse practitioner became miffed and told me that she couldn’t be responsible for what happened if he didn’t come via ambulance. I told her thank you very much, and went back and told the dad and the son that I needed some more time to figure out how best to help him, and did they think he would be safe at home for a few days until they could follow up with me again? They said yes, and we adjourned for the day. At present, he is still on a waiting list to see a teen psychologist who accepts Medicaid.

His mother called a few weeks ago, saying that he needed his sports physical form completed so he could play football. I asked how he was doing, is he hearing any more voices? She replied, “Oh, that? No, no more voices. He’s doing great, actually. I think he was just going through a phase.” Who knows how this will play out in the end? But I’m hopeful that, by showing some restraint and keeping him out of the psychiatry unit, we may have prevented a snap judgment, a heavy medication regimen, and an inexorable descent into a lifetime of psychiatric labeling and mental disability.

Of course, it could all turn out badly, I guess. But I don’t think so, not in this case. He’s a good kid, with a bright future. What would have happened if we had interrupted a normal psychological healing process by intervening with psychoactive medications? In this case, he didn’t need any intervention at all, not counseling or exercise or medication. He just needed time, and his brain and mind healed itself. Sort of like the advice I gave him about the mild thigh bruise I saw him for today: ice it, take some ibuprofen, and give it some time. It will get better.

So good to see him out on the football field, instead of in a psychiatric unit.



Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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Mark Foster, DO
Letters from the Front Lines: A family physician, after having read Anatomy of an Epidemic, writes of his struggles to prescribe psychiatric medications in a thoughtful way . . . and help some patients wean from the medications.