Mary (identifying information changed) was extremely pleasant, to say the least.

By the time I met her on the senior unit, she had seemingly befriended even the orneriest of our geriatric patients. She wandered and danced about the unit, speaking with each fellow patient she encountered in a style one nurse called “cheerfully mad.”

Her strategy, maximalist and crude but stunningly effective, was to talk your ear off in a joyful stream of consciousness, delivering an overwhelming rush of discourse punctuated by a few sonorous laughs for good measure and general jocularity. “Why nice to meet you ‘student doctor’ Tie!/the weather’s glorious today/even though we’re all trapped in here/what are you gonna do? (laughs)/I guess it’s time for me to break in my new psychiatrist/I can tell you how everyone around me has died/you seem like great fun/we’ll be the best of friends!”

She was manic. She hadn’t slept for five days. To be clear, she was suffering — the human mind isn’t meant to sustain the exertions, the rushed performances, demanded by mania. Yet from afar, she radiated pure joy, an avatar of good cheer bestowing her blessings upon on our normally staid, relatively sedate unit.

I was taught that the therapeutic relationship between psychiatrist and patient cannot proceed without some prerequisites: the essential foundations of rapport-building, successful engagement with the patient, and the engendering of mutual trust.

If, with some patients, this is an incremental process of accumulating empathic connection and gradual respect — a slow accretion over days, weeks, months, and years — with Mary, I felt that I had been inducted instantly into her inner circle of friends within seconds of meeting her. I was being yanked into intimacy. She spoke to me with a friendly familiarity that seemed undeserved and, at times, eerie.

If at first I found Mary fascinating in her constant output of effervescent, positive energy, that feeling soon soured into frustration.

That jocularity of hers, the warmth Mary exuded — it wasn’t a deliberate deception, but it made things difficult. It was an agreeable veneer, a trapwork of affect layered over a profound inner despondency. She had lost five loved ones in quick succession over two months during the COVID-19 pandemic. It was an incalculable loss. To even begin to plumb the depths of her grief in the midst of a manic syndrome would be impossible.

Indeed, I wasn’t even sure I could engage her effectively. The word count she produced as she spoke — for example, “Ed I’ve had 10 psychiatrists in ten years/can you believe that/guess they couldn’t crack me/lunch was INCREDIBLE/but you know what’s the opposite of an incredible lunch/the answer’s LITHIUM cause it numbed me and wrecked my kidneys/but I’m manic anyway so …” — ran roughshod over any response I had feebly cobbled together moments before.

My instinct with Mary over our first conversations was to tame our interactions — to set down boundaries, to discipline and establish rules, to somehow hold back the tide of excess and loquaciousness by offering a kind yet stoic demeanor, responding with silence when appropriate, gently challenging her particularly delusional statements, and prompting her to slow down.
This was a disaster.

In my attempts to micro-manage the interview, I displaced myself from it. Here I was conducting a psychiatric interview from a far-off place, a remote mindscape where my chief concern was triangulation — when to jump in the conversation, when to pull back, when to nudge. I felt an almost atavistic drive within me to wage battle on her mania. I busied myself with reining in the conversation, attempting to suppress and sublimate its swerving chaos into meaning, linearity, and healing by engineering the perfect response to whatever Mary was spouting out.

It went like this: Mary would say something absolutely divorced from reality, for example, a pontification on her messianic delusion. “You know Jesus, the son of god?/well I’m his daughter/and I’m pregnant in a divine conception.” By the time my brain processed a possible response (maybe a gentle challenge to her delusion, “Mary, I’m not sure how many people would believe you on that; that sounds a little too good to be true.”), Mary would be speaking on something else entirely.

So much for wrangling all of it through clever phrases. Ironically, I, the budding psychiatrist, was too in my own head. Mary, of course, immediately noticed: “You aren’t even listening, are you Dr. Ed?”

She was right — I wasn’t listening in any real way.

In my time with Mary, my mind perseverated on a fundamental question that encircles the whole practice of psychiatry — how do we meet our most psychiatrically ill patients, the floridly manic and psychotic, where they are? How do we as psychiatrists sit with them in the depths of their madness and suffering, engage empathetically, and trudge with them towards mental health?

I wish I could say I figured it out with Mary. The truth is I didn’t. Each day I allotted 30 minutes for Mary — I spent that time fully present, listening to whatever she said, trying to glean some kind of emotional truth.

As I worked with Mary, I thought frequently of Michel Foucault and the figure of the “Madman” he writes of in Madness and Civilization. The Madman, also derided as the “Fool,” the “Simpleton,” at once emblematizes ridiculousness, unreason, inscrutability, and madness incarnate, yet simultaneously has privileged access to a divine truth others cannot possess or understand by reason of his madness.

With Mary, I took this to mean that even if her mania seemed impenetrable to my attempts to understand, operating within its own inescapable, internal logic, I could still stand witness to her voice, listen attentively, and offer a therapeutic presence if nothing else.

I thought too of the physicians of old, uncomfortably pressing their ears into a patient’s chest to capture the echoing thumps of their beating heart, listening intently for the rhythms of health. Wasn’t I attempting the same — standing in the swirling, raucous symphony of Mary’s mania, trying to hear Mary beneath the din.

Edward Kai Yan Tie is a medical student.

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