A friend posted this on facebook, and I thought it was a charming little article. I remember feeling the same way during my psych rotation: Can I crack a joke? Are the paranoid schizophrenics going to go crazy if I smile at them? Will the demented people take what I say the wrong way and tell my attending I harassed them? In the end, it's a matter of discretion, but it's nice to know that there ARE times to loosen up, and be able to address your patients - even the ones who are supposedly "not all there" - with some semblance of humanity. After all, whoever said that WE were the ones who should control the show?
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In Psychiatry, Can a Punch Line Be a Lifeline?

By BENJAMIN BRODY, M.D

“Has anything changed since the treatments began?” I ask the patient, as he lies down on a stretcher in the ECT suite. The anesthesiologist places an IV line in his arm and checks his vital signs. My attending psychiatrist adjusts the machine that delivers the electric stimulus. I’m a psychiatry intern, and this is my electroconvulsive therapy rotation. I’m here to watch and learn.

“My cellphone always has a great charge,” the patient deadpans.

If this were a friend or colleague, I would laugh easily. But this is a patient I barely know. He has bipolar disorder, a previous suicide attempt and a history of bizarre, impulsive behavior. In that context, his joke just feels inappropriate and overly familiar.

I’m taken aback. Is it O.K. to laugh, I wonder? An intern, with years of experience being inexperienced, I quickly glance around to take stock of the room.

The nursing assistant laughs and the anesthesiologist grins broadly. The attending psychiatrist remains stone-faced, and says, “Clearly he’s improving.” As the anesthesiologist injects a sedative, a telephone rings. Everyone’s hands are occupied; the ringing continues. Just as the patient starts to drift off, he looks over at me and says: “Can you get that? It might be the governor calling to stay my execution.”

A moment later, he’s out. The attending hands me the leads, and I feel slightly uncomfortable as I bring them to the patient’s head. The nurses are still laughing as he begins to convulse.

When I was an intern on the medical service, I often joked with my patients. It’s how I naturally relate, and carefully joking with a frightened patient is a powerful way to establish rapport.

But when I left the internal medicine floors for psychiatry, the humor stopped. On the advice of the attending doctors, I tried to be more concrete and matter of fact with psychotic patients, more empathetic with depressed patients and more authoritarian while working in a volatile emergency room. Not since adolescence had I spent so much time worrying about how I come across.

I had a vague sense that prompting a patient to laugh could sometimes be therapeutic. But when is it safe — let alone useful — to joke with a psychiatric patient? At least in the hospital, the patients seemed to have enough trouble relating to me without having to decode the nuance of humor. It seemed too risky, too ripe for misunderstanding.

Still, there were patients who insisted on joking with me.

Leading a community meeting on the inpatient unit, I asked the patients and staff members to introduce themselves and say something about who they are. “I’m a social work intern!” a staff member said brightly, followed by a patient, who declared, “I’m a chronic bipolar patient.”

This wasn’t what I had in mind; I’d imagined some type of biographical detail, not a recitation of titles and diagnostic labels. I grew uneasy as the patients started describing their personal pathology to the group.

Just as I was getting uncomfortable, one of the patients acknowledged the tension. “I’m a nursing student,” he said, with mock authority. The next patient, someone who had trouble relating to others and often missed social cues, said, “I’m the nursing manager.”

The entire group, myself included, erupted with laughter. The moment was a striking contrast to the unit’s usual sober atmosphere. Not for the first time, I wondered whether it might ever be appropriate for me to lighten up and initiate a joke.

At the end of my internship, I got my answer. I was on call at 1 a.m. on a Thursday, admitting my last patient of the evening. She was a woman in her 60s, brought in by the police for disruptive behavior in her apartment building. After being involuntarily admitted, she hid in her room and refused to talk to the nurses.

When I tried to interview her, she buried her head under a pillow, exclaiming, “I refuse all psychiatric care!” But beneath her refusal, I noticed something playful in her tone.

“That’s O.K.,” I said. “We’re good at treating people who refuse psychiatric care.”

That got a little laugh.

“Can you tell me how you got here?” No response.

Maybe I should try something more concrete? Given her age and the story I got from the senior resident in the E.R., it dawned on me that she might be cognitively impaired. “Who’s running for president right now?” I asked.

That got a response. Three people, she replied, using an epithet I can’t repeat here.

What are their names? I shot back, using the same epithet.

“Clinton, Obama and McCain,” she said. She was looking at me now.

“O.K., so what’s a nice lady like you doing in a place like this?” I asked.

Suddenly, I was in. She started telling me about her paranoid delusions about her landlord and neighbors. I sat down and started writing.

“Tell me more,” I said.