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The Dangerous Language Of “Crazy”: How Stigma And Judgment Affect Patient Care

Discussion in 'Hospital' started by The Good Doctor, Jan 9, 2023.

  1. The Good Doctor

    The Good Doctor Golden Member

    Aug 12, 2020
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    He’s batshit crazy,” fellow physician Karen eagerly confides while describing another colleague, Kevin, in a private office conversation.
    I laugh, assuming intended hyperbole.

    “No. Really. He is,” Karen says. “He’s been hospitalized — several times. And his kids are crazy, too. They’re all crazy.”

    I jolted into an instant somber, “Oh, I’m so sorry to hear that.”

    Karen looks disappointed. Her intended collusion collides with my concern. We stare at each other momentarily and uncomfortably until she awkwardly pivots to another topic.

    But I cannot concentrate. My thoughts linger on our colleague Kevin. He’s not just “crazy,” but “batshit” crazy. I wonder what, exactly, is the difference between the two? When is crazy qualified as “batshit,” and where should “apeshit” fall on that continuum?

    In subsequent days I find myself returning to the conversation like an itch that no scratch can soothe. It irritates me. It unsettles me. It gnaws at me.


    I hurl disappointment in Karen into the universe, and it boomerangs as fear. Fear that I, too, will be judged like Kevin for anything — for everything.

    Karen and I have known each other for almost 20 years — beginning in the roles of senior resident and intern — and I am startled at the thought that I do not honestly know her. Now, she seems indistinguishable from many of our professional peers who dismiss patients with behavioral health struggles.

    No doubt we have all heard, and maybe even initiated, the glib check-out that includes the catch-all disclaimer, “the patient is crazy” or “likely supra-tentorial etiology.” Why do health care providers feel the need to assert this disclaimer? Perhaps as absolution for our inability to understand, diagnose, treat or heal challenging cases. It’s them, not us.

    Carl Jung would disagree and insist it is us, that our professional annoyance is a projection of our own insecurities and foibles. Altogether absent from the dismissive descriptor “crazy” is the recognition that observed behavior rarely arises in a vacuum. There is almost always a back story that contextualizes the conduct. If we providers take a moment or two longer in a clinical encounter to even just begin to try to understand, the seemingly bizarre — and our accompanying unease — may cease to be so.

    I can cite multiple examples of “crazy” in my professional work:
    • The verbally abusive patient hurling offensive epithets at the medical staff
    • The “disruptive” physician defying administrative directives
    • The pediatric patient’s hostile mother conveying her disappointment
    Beyond the travesty of judgment providers harbor lies the missed opportunity for compassion. What if we providers were so grounded, so meta-cognitively aware, that we could look past the superficial behavioral antics and step into our patients’ and colleagues’ worlds for even just a moment?

    That verbally abusive patient? He feels hopeless because he is chronically unemployed, his marriage is failing, and his daughter — born after several miscarriages — has multiple medical problems. The disruptive physician? His professional calling clashes with contemporary medicine’s metric-driven morass, and he’s just been prescribed antidepressants for which he is deeply ashamed. The pediatric patient’s hostile mother? She lashes out at the medical team because it is far easier than confronting her absentee husband, who works long hours and frequently travels for a high-stress, high-visibility job.

    Certainly, understanding does not solve problems. But, it lessens the divide between us and others. It gets us a step closer to helping and healing, which is a main tenet of our profession, no matter our motivation for entering it.

    So, what can providers do to try to understand their patients’ behaviors?
    1. Suspend, or at least conceal, judgment
    2. Make eye contact while listening uninterrupted with occasional nonverbal support
    3. Imagine how it might feel to experience the hardship being described
    4. Stop the behind-the-scenes derision of these patients
    These seemingly simple tools nudge us to pause in the hustle and bustle of overscheduled work days and be present — even if just momentarily — for our patients and colleagues. There is infinite healing for both sides in the pause.

    I use this same approach when I have conversations with my colleague, Kevin. His supposed batshit craziness? It doesn’t phase me. If anything, I am more focused on conversations with him. I try to understand and ease his path in any little way I can as he works through his life’s issues.

    As for my colleague Karen? I’m rooting for her. I know she can evolve. The “Karens” of our profession set our collective orientation towards behavioral health struggles. They are “us.” This is us. De-escalate their discomfort, and we will successfully destigmatize much-needed mental health care for others and ourselves.


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