On Not Being Nice

It has only recently dawned on me that my approach to psychiatric therapy is entirely flawed.
This notion came like an epiphany to me yesterday as I watched my resident behave like a complete harda$$ to this woman [a crack addict] who had come to the Mental Health center looking to be enrolled in a substance abuse research study. At first, I found myself utterly annoyed with my resident. The guy displayed absolutely no empathy towards this woman. His interview consisted of reading out loud questions in rapid-fire sequence from an admittance form and scarcely making eye contact with the woman. In the end, when he discovered that she was HIV+, he happily showed her the way out -- you see, her comorbidity disqualified her from recieving the experimental treatment.

I was aghast. I could not believe that the Team was not giving her any sort of rehab treatment for the simple fact that she did not meet their requirements for the research study. The indignity of this all bothered me so much that I managed to get the help of a social worker to find this woman a safe place to stay for the night. But even still, I was livid.

As the woman waited for the Staff to process her discharge papers, I sat quietly next to her trying to understand my own feelings and also trying to find the perfect words to say to her. I failed on both parts. There, in front of me, sat a woman who had hit rock bottom. She had no money, no property, no friends, and no family. The only things she did have was an addiction. And the only thing We offered her was a clean pair of sweatpants [absurd given the fact that it was 85 degrees outside].

As she waited for her papers, I asked her what she looked forward to in her future -- she said the hope of living to see the day when fear and crack did not rule her life. I think I then tried to mumble something about seeking role models and acknowledging how difficult her life has been, but I was really floundering, so after a while I just sat there and silently raged against everything that I felt had gone wrong with this patient.

I was pissed at the world for constructing her history as it turned out to be. I was pissed at my resident for behaving so gruffly with a woman in need. And I was most pissed at myself for being so impotent and so entirely useless.

I am gradually starting to see that my emotions and my desire to empathize with patients need to be controlled before they turn me into a good person who is a bad psychiatrist. You see, according to the dogma that governs Western Psychiatry, a psychiatrist must maintain neutrality at all times. You are supposed to be distant; you are supposed to be cold; you are supposed to be a world class harda$$. So that whole thing about my patients at the VA loving me [yah, I had three old dudes ask me to marry them] ... that was actually a bad thing. You are not supposed to display empathy; you are not supposed to make encouraging statements -- and, according to our Thursday afternoon didactics, if you find yourself rooting for your patient or going beyond your neutral boundaries, there is a likelihood that your patient has Antisocial Personality Disorder. According to Dr. Mundy, these are the patients who wheel you in, who try to make you feel sorry for them, who will play every card in their deck until they get their way. They lack any degree of remorse for the crimes they have committed, but they can still make you fall for them.

I finally got hold of the records of the crack addict I spoke to earlier. The chart was nearly five inches thick and fell on me like a ton of bricks [literally and figuratively]. The woman had basically lied to me and my resident about every aspect of her life. Suffice it to say, this woman has done some very bad things which I can't even bring myself to write [we're talking on the level of internecine warfare]. I found that so confusing because when I had looked at her, the only thing I saw was someone who was fundamentally good but who, thru ill-luck and circumstance, had become slave to an addiction. Perhaps this speaks volumes about my naivete. I want to believe that people are good; I want to believe that people are kind; I understand that we all have our faults and yet still I believe we all carry a spark of the Divine.

I suppose I should be feeling sad and jilted for being completely hoodwinked by this pitiful woman. But really, I don't. Rather, I find myself struck by the complexity of the fabric of our human existance. There is just so much that makes up the story of our lives : things beautiful and bonny amidst terror and tragedy. My, what a world, what a world.