I walk onto the inpatient unit on a Monday morning. The feeling of discomfort begins to overwhelm me. Perhaps this was due to being forced back to inpatient, but I felt it had to do with changes in the process. I started my training at a time when 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. The ideal during my training was to provide multiple treatment modalities with 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 patients but feeling 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 My lessons to students and residents feel completely out of date.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. Rounds being over, I have the ability to reflect on my day and my internal state and think 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. It is all about burnout. Gyms and pet therapy are all that I need. 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 want 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 my 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. 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. Inpatient psychiatry is different. It is loud, violent and confrontational. None of my patients voluntarily seek 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 want 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 has that ability. There is a “system” that includes government, regulatory affairs, third-party payers, CFOs, 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. Civil libertarians want maximum freedom. Families often want the tightest control. Finance people want whatever costs less. In the end, there is a lack of consensus. As I try to explain, the anger only increases. The idea of a therapeutic alliance is lost, and we now enter into the world of conflict. 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 whether treatment will work or not. I have no ability to predict whether the treatment will work or whether 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 lost 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.” 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. Source
