The Re-Wounding of the Wounded Healer
I walk onto the inpatient unit on a Monday morning. The feeling of discomfort begins to overwhelm me. I must be honest; I did not want to return to inpatient work and but was forced to due to staffing shortages. My discomfort could just be connected with my wish not to be there, but there might be a deeper struggle.
I started my training at a time where therapy was a central part of education. Understanding even the most psychotic patients was a key element of our field. I do not recall the vast number of court cases that we have today. I do not recall the regulatory demands being as onerous.
One of the first books I read during my training was Harry Stack Sullivan’s “Schizophrenia as a Human Process”. The ideal was to provide multiple modalities of treatment with a psychotherapy, group therapy and family therapy. Today we remand to the hospital, medicate over objection, and force outpatient care. We complete multiple forms to ensure patient “safety” and maintain compliance with regulatory affairs, but few of my clinicians “know” their patients in the way that Sullivan thought we should.
Therefore, I go through the motions of covering my team; rounding, trying to talk to staff and patient alike, but feel mentally exhausted. My lessons to students and residents feel completely out of date. I feel that my experience adds little value to the provision of care in 2022. I think about one of my favorite songs, “Old and In the Way”, with the following lyrics
Old and in the way, that’s what I heard them say
They used to heed the words he said but that was yesterday.
Rounds being over I have the ability to reflect on my day and my internal state and thing about the archetype of the wounded healer. I am the first to admit that my wounds have an important role in my development as a physician, psychiatrist and person. The work that I have done has been immensely helpful in my becoming a therapist. However, the literature does not speak to this wound having much to do with my feeling of exhaustion. I am burnt out. That is all. Nothing that a good session at the gym, deep breathing and puppy petting could not cure. However, this does not ring true to me. To begin with, I pet dogs every day and a cat. I deep breathe. The gym of course is not in my repertoire, but I think 2 out of 3 “ain’t bad”.
I believe this discomfort stems from my own personal wound. Although the wound allows me to be empathic and understanding, the system does not allow me to do what I am driven to do. I must neglect my needs entirely and go through motions that “re-wound” me.
My desire to go into psychiatry is a complex one, and a number of “wounds” were involved in my becoming one. One of my issues has always been the hating of confrontation, noise and threats. My background was a loud one to say the least, and entering into a loud and confrontational situation continues to trigger me. I have always tended to be quiet concerning my needs. I had two roles in my family system, one of which was the “hero” who would achieve all the things that family wanted me to achieve, and the “joker” who would use humor to de-escalate confrontations. Using my time in therapy, I was able to see my own needs, and rather than blindly remaining the “hero”, I decided to embrace my own path. My central theme was developing autonomy. My inner world was quiet. Words were used and those were calmly delivered. Being a therapist fit perfectly into my picture of self. It has the elements that allow me to use the wound in a productive manner and help others. The setting of therapy is one of a mutual recognition of the other as being human and the need to have this human connection to achieve some sort of healing.
Inpatient psychiatry is different. It is loud, violent and confrontational. None of my patients voluntarily seeks care. A third of my patients refuse treatment and their case ends in court. In truth, I do not want to force treatment on a person. I understand that I have the right (and responsibility) to do so, but it does not sit well with me in general. The patients wants to leave, and they do what they can to convince us that it is safe. We spend little time on the process of healing, acting more like a stabilization service. We cannot wait for the therapeutic relationship, since the insurance companies want them medicated and out.
I feel the need to protect myself, physically and mentally. I enter the unit alert for potential physical dangers. I then try to engage with people, but they for the most part just want to leave. I want to leave as well, but neither of us have that ability. There is a “system” that includes government, regulatory affairs, and third party payers’, CFO’s, legal systems and family. There is the constant need to satisfy this “system”, but that usually entails committing people and keeping them until they are “safe”. Of course the elements of the “system” cannot all agree as to what is meant by safe, what is meant by least restrictive, most cost effective, so the patient and provider are responding to multiple layers of rules that are provided by the “system”. We are always going to upset some part of this group. The civil libertarians want maximum freedom, family often want tightest control, finance people want whatever costs less, and in the end there is a lack of consensus. How do I explain this to my patient?
“We need to develop a safe discharge”, I will say
“Send me home”
“Your parents cannot take you back”
“You’re lying, I just called them and they said they are ready to get me”
As I try to explain, further the anger only increases. The idea of a therapeutic alliance is lost and we now enter into the world of conflict. I know my patient dislikes this conflict, as do I. There is no other option however. I must take this person to court. I must learn to embrace the conflict. After all, it is for their own good. Or is it? After so many years of practice I am not sure that treatment will work or now. I have no ability to predict that the treatment will work or that the lack of treatment will be detrimental. I am making a well educated guess. In the end, I am colluding with the removal of an individual’s rights based on an inexact science. The only thing that I do know is that no treatment is obviously not working for this person. I move forward with at least this fact in hand.
I swear to tell the truth. I try my best not to deviate from the truth. I do not put words in the patient’s mouth. At the very end, I am asked if I feel that this is the best treatment available, and I can truthfully say yes. It is the best available. More often than not, the order is granted. We must tell the person that if they do not take the pill by mouth we will inject them. Some continue to refuse, and insist on the injection. Others passively take the medication. Staff talks about winning the case, but there is no real winner. I did not go into this work to deny people their rights and inject them over their objections. I lose a part of the human connection that I had hoped for. The patient has lost. They have to take the medication and in a court of law, they are now considered mentally ill. The label will follow them for the rest of their lives.
Thomas Szasz would speak about this inherent difference between psychiatry and other fields of medicine. If I have chest pain, I come to see the doctor and hope that they can help me. I am offered options, and I must consent to the treatment. In Psychiatry, it is different. Consent is a term we use but in the end is not needed. The reason the individual is brought to the hospital is for behavior that is not acceptable in the community. I can be ill and at home as long as I do not bother anyone. One of my old teachers once told me “psychiatrists are called when people do not behave. We get called in if someone wants to kill themselves, kill others or smells bad”. I often wondered about smelling bad, but it is a poignant example of locking someone up because his or her behavior is not acceptable.
I do not believe much will change in my lifetime. In the meantime, I guess I will go home, take a deep breath and pet some animals. It might not cure the wound but it cannot hurt.
