Ghosts of patients past

I recently learned the term 'ellipsism' which, according to Koenig's (2019) Dictionary of Obscure Sorrows, means 'the sadness that you will never know how history will turn out'. While perhaps not as grand as history itself, the sensation of ellipsism on an individual level is perhaps something we are all familiar with. The child you taught who moved on to a different school. Your friend who dropped out of university and vanished from social media. The person you delivered first aid to before the ambulance arrived. A chance encounter with someone you never saw again. We are left with a feeling of things unfinished, a lack of closure or resolution, and while we're minding our own business we suddenly find ourselves wondering 'what happened to them?'.

As a trainee clinical psychologist, this is a sensation that I have unfortunately become familiar with. The nature of the training means that there is rarely the opportunity to remain in one place for more than six months. While this may sound like a reasonable length of time, in reality it is often only just long enough to build up a caseload, deliver a psychological intervention, and discharge the patients. These endings are planned for, discussed in advance, and scheduled by mutual agreement. Both patient and practitioner achieve a sense of closure, of goals achieved, of a path laid out ahead for the weeks and months following conclusion of the work together.

However, this experience is one that uniquely predisposes trainees to encountering unplanned endings far more often than expected – or perhaps they are just felt more keenly. There are cases that leave a sense of unease at not knowing how things turned out. Sometimes this happens when a patient suddenly enters crisis at the end of a placement: out of time to support them to resolve their crisis, the case is passed on to someone else and the trainee loses any right to access their notes to discover if, in the end, they were alright. At other times the feeling of ellipsism stems from a patient simply never returning to the clinic. It can be hard to know why. Perhaps a breakthrough caused some distress. Perhaps the patient revealed more than they meant to. Perhaps on some level, a connection was made (explicitly or internally) and the feeling of vulnerability became too intense to tolerate returning. Maybe the patient just didn't like the practitioner and didn't feel able to say.

Patient and practitioner have the 'confidentiality chat' – the agreement made before work begins that describes the clinician's duty of care and circumstances that would require breaking confidentiality. Most of the time, the chat ends there. It is agreed, and discussions move on. In some cases, confidentiality must be broken, and support must be sought from other services to keep the patient safe. The disquiet such situations elicit is amplified in these cases, since clinicians are aware they likely had a hand in provoking a relationship breakdown.

Sometimes breaking confidentiality results in a positive outcome: the patient is a participant in the disclosure, remaining with the therapist while crisis teams are contacted, and engaging in the subsequent care plan that helps recover emotional stability. At other times, practitioners must act against a patient's explicit wishes: emergency services are involved, the Mental Health Act is invoked, and a patient is detained against their will in order to preserve life. The therapeutic relationship is sacrificed to keep the patient safe.

The patient may eventually understand and accept why those choices were made. Sadly, such experiences can negatively colour an individual's views of mental health services indefinitely. Therapists are not immune to the discomfort that comes from having to make a decision that is right but feels wrong. The decision is made knowing that there will be no repair, that the patient may disengage from services despite a clear need for help, and that it is their right to do so. The decision is made despite the possibility of never discovering what happened to the patient; if they ever got help, if they participated in later treatment, if they forgave the practitioner for making that call.

It is perhaps a truism of the human experience that we can't get all the answers. Tolerating uncertainty is a tricky but valuable skill. But this scaled-down version of ellipsism is a two-sided coin. The weight of wondering what happened is countered by knowing this comes from our ability to connect with others. By making links and working collaboratively, by creating a place of safety that is free from judgement, our empathy helps us to build relationships with the people around us. Those experiences that leave us wondering are the ones that help us to grow and learn. Reflecting on what happened allows us to recognise what might have been done differently, to consider how we could have supported relationship repair, and to build our own resilience in coping with never knowing. We might never learn how that experience changed that patient's trajectory, but we can reflect on how it might have changed our own.

And just in case anyone had some unresolved worry about me, I'm doing okay.

- Dr Katy Mitchell is a Clinical Psychologist in Dundee Health and Social Care Partnership

Key sources
Gerhardt, S. (2015). Why love matters: How affection shapes a baby's brain (2nd ed.). Sussex, UK: Routledge.
Koenig, J. (2019). The Dictionary of Obscure Sorrows. Retrieved from: https://www.dictionaryofobscuresorrows.com/

Illustration: Ana Rosa Louis