The Haunting Smile

Frozen flower_Behdad Bozorgnia“Frozen Flower” by Behdad Bozorgnia, MD

P4_HauntingSmile_title

“I just want to kill myself,” she said with a beauty pageant smile, sitting on a cot in the hallway of a busy ER.

She was a thin, pretty teenager with a 4.0 GPA and long, straight hair. Tesla keys rested on her designer bag, which cost more than my monthly rent. She could have been Asian, Hispanic, or Middle Eastern. I’ve been called to the ER for identical consultations for teens from all of these immigrant groups, and surprised to find that the culture of Silicon Valley is always the loudest in the room.  Pressure. Perfectionism. Tech. Work hard and get rich quick, or you’ll never survive here if you don’t.

Her clothes, environment, and stressors felt foreign to me coming from training in inner-city Philadelphia. I had no idea what to say. She was staring at me expectantly. She wouldn’t stop smiling. I felt the urge to smile back, but couldn’t. Smiling felt perverse.

Most of my psychiatry training was with inner-city patients whose despair had obvious sources: they saw gunshots, were homeless, raped, abused, and abandoned. Their parents were addicted to crack or beat them or never gave a shit at all.

“Who wouldn’t be anxious or depressed in your circumstances?” I’d often ask. It provided them some relief, knowing they were having common reactions to extraordinary stressors.

I couldn’t ask that now, in sunny Silicon Valley, to this beautiful, wealthy, smiling girl.

“Why are you smiling?” I finally asked, mostly because it was the only thing I could think about. I was getting nervous, thinking I was operating off-road as a psychiatrist. I hadn’t seen many patients like her before.

“I don’t know,” she said.

“It must be tiring,” I said, desperately trying not to divert my eyes from her haunting smile. It was making my skin crawl.

“It is,” she said.

“Why not stop for a minute?” I asked.

“I just can’t,” she said.

My biggest fear in choosing psychiatry was that the emotional burden would be too much. As a medical student, my patients occupied my thoughts and dreams. Older psychiatrists said I’d become desensitized, not to worry for a second that I wouldn’t! They insisted that sitting with people on the worst days of their lives would become routine. I didn’t believe them.

They were right. During my training, the emotional pull lightened as patients’ desperate stories of grief and violence replaced polite chatter as the bread and butter of my daily existence. By the end of my residency, I could go home after seeing 15 suicidal patients in a 14-hour shift and leave it all behind.

I couldn’t leave her smile behind. Why was she smiling? Why did she want to die when she had access to so many of life’s great gifts – youth, beauty, intelligence, and wealth? I didn’t get it. I discharged her home to the care of her parents, psychiatrist, psychologist, nutritionist, and tutors. She had suicidal thoughts for years and had never made an attempt. Her family seemed supportive. I didn’t think a week in a locked psychiatric unit would help her, but I felt uncharacteristically uneasy about sending her home.

A few months later, she was back in the ER, still smiling. This time, she had cut her wrists.

“Remember me?” I asked.

“Yes. You’re the only one who ever noticed that I smile all the time,” she said, and after a long pause added, “I hate that.”

“Who wouldn’t hate that?” I blurted out, rejoicing I had found something to normalize though I wasn’t even sure exactly what she was referring to hating.

“I should be smiling,” she explained,  “I have no reason to be depressed.”

Her argument was about privilege. Her parents were immigrants who hadn’t had easy lives. She was raised on tales of how lucky she was compared to other kids, other generations, those who hadn’t made it to America, and basically everyone.

I finally got it because I heard the same script growing up. My great-grandfather was in a concentration camp and my grandmother, as a teenager, brokered a deal with her Nazi piano teacher to bribe the guards to get him out. They left their house, business, possessions, and beloved country, Germany, to flee with nothing. Those were real problems! My life was easy and I was privileged. I was told this again and again and I believed it to the depths of my soul.

I spent much of my teens and 20s wondering what I could possibly do with my life to justify their suffering and bravery and the fact my family had survived only by virtue of our wealth and connections while so many others had perished. I felt like I didn’t deserve to be depressed, anxious, or anything short of joyful and grateful to be alive, which is the most invalidating position in the world.

“That’s bullshit,” I said. She smirked. It was the first expression that felt authentic.

She told me the real story this time and it was about a life no child would covet. Her parents worked all the time. They said they did it for her, to give her opportunities they never had. She studied for six hours a night while they went to business dinners and told her to order take out. She rarely ate. They rarely noticed. She tried to get their attention: she drank their liquor, left a bong in the living room, skipped school, and bought $2,000 purses online.

“They only noticed because all the blood in my bathroom worried the maid,” she explained. Still, she defended them, “They’re doing the best they can. I know they love me. They’re working hard so I can have a good life.”

The only problem was that it wasn’t a good life. When she said, “It doesn’t feel like a life worth living,” she finally stopped smiling.

A mentor once told me that the problems of the rich mimic the problems of the poor: broken families, underemployment, substance abuse, and neglect. Her problems, which seemed foreign to me initially, are actually universal – yearning for parents’ attention and approval, loneliness, guilt, self-doubt, and fear. They were my problems, too.

Lisa Jacobs is a Child & Adolescent Psychiatry Fellow at Stanford University and the founding editor of The Penndulum.

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