What no one tells you in PT school

painI glanced at my clock. Midnight. I knew I should be asleep – the alarm was going off in less than five hours. But I couldn’t get the image out of my head of the woman sitting on my treatment table today telling me her life was hopeless.

Rachel (not her real name) was living the dream. A year and a half ago, she was single, 38, with a masters in public health and a high-profile public health job. Her apartment in a trendy neighborhood near her favorite bars and restaurants. She traveled. Her family of origin lived close by and, though they had conflict, she remained close with her mother and sister.

She had experienced frequent bouts of severe depression, anxiety and suicidal thoughts since she was a teenager. She believes this was responsible for her being unable to maintain a relationship longer than a year or two. “I just used to chase people away,” she told me. Since her mid-30s, however, she had finally found a cocktail of drugs, meditation, yoga and therapy that allowed her to escape “the beast,” as she named depression, for the first time in her life.

When she walked in the first time six weeks ago, she walked in slowly and stiffly using crutches to take weight off both knees, but her swollen wrists made it difficult to use them.

After a trip to a developing country last year, she got a bacterial infection, began to have knee pain. She underwent a “simple” knee scope (don’t get me started), and several weeks later had intense swelling and pain in her knees, wrists, elbows and ankles. Five infections disease doctors and two rheumatologists had yet to give her a diagnosis. She was taking a cocktail of prednisone and methotrexate, and only seemed to be getting worse.

For the past six weeks we have worked on range of motion, fitting assistive devices, compression garments, etc. She gets relief from joint mobilizations, and makes sarcastic, dark jokes throughout every session.

Her rheumatologist is a caring, brilliant woman. She assured Rachel that there were “lots of options” depending on what happened with this drug cocktail. But Rachel, being an MPH, had done her research and was very anxious about the side effects of biologics and other drugs used to treat inflammatory arthritises. (This anxiety about side effects is a very common symptom of anxiety.)

So yesterday, she sits on my table and says she’s not quite ready to do it, but she’s feeling like there is no hope and wants to die. The tears start to flow. Big fat tears fall out of her eyes and splash in her lap.

“I want to do it, but I’m too chicken shit to do it. I’ve done all the research. If I decide to do it, I’m going overseas where I can get a painless drug cocktail.” She tells me quietly. “I’ve felt suicidal so many times, I almost feel glad that now I at least have a good reason.”

I told her I understood, and I would probably feel the same way if I were in her position. She was shocked that I didn’t panic or tell her some version of “life is always worth living.”

She has lost all her friends. Her caring family, in their eagerness to help, has become overbearing and she has largely isolated herself from them. Her work has suffered, and she will likely lose her job. She has spent her small savings and has gone into debt to cover medical bills. She can’t climb the stairs to float in her apartment pool. She can’t go out to a restaurant without careful planning. Her usually neat apartment is a “trash heap.”

No one knows what’s causing the swelling and pain. No one knows the next step. No one has an answer.

At this point my next two clients were sitting in the open waiting area. I pulled the curtain and put my arm around her and said, “I’m so sorry. This is so hard. I’m so sorry. So sorry.” I let her emotional pain and fear surge through me and cried with her. Then I sat in front of her, made her look me in the eye and commit to at least tell one person her plans if she decided to go through with it. At first she says, “Yeah, sure,” and looked down. And then realized I was serious. She said the words, “I commit to you, Ingrid Anderson, that I will speak to someone about my plans before killing myself.”

I got the name, number and email of her therapist (whom she was scheduled to see that day), along with permission to contact her.

Right now, there’s nothing more I can do for Rachel’s pain beyond some joint mobilizations and strategizing movement.

There are many versions of this woman’s story in our work. Chronic pain. A fibromyalgia diagnosis. “Failed back” syndrome. Massive stroke. ALS. Phantom limb pain.

No hope. No hope. No hope. No hope.

Sometimes it’s our job to give hope. Sometimes to manage expectations.

Sometimes all we can offer is to be quiet and present, and tell the client, “I hear you.”

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