Mental Bootcamp: Today Is the First Day of Your Retirement!

PrologueIn this strange labyrinth how shall I turn?Ways are on all sides, while the way I miss
-Lady Mary Wroth, In This Strange Labyrinth

Most people are familiar with the saying, “Today is the first day of the rest of your life.” It seems meant to keep up optimism, as well as to take each day seriously and gratefully.

That saying could be also adapted to today being the first day of your retirement life. And I mean you! Whether you are 30 or 70. A psychiatrist or a psychologist. A therapist or a risk manager. A CEO or a case manager. A religious leader or a homemaker. An editor or a writer. And me.

But what could retirement, usually thought of as a milepost in life, mean for everybody every day? It is likely that no one reading this is actually retiring from work today. Not even me, although I will be retiring from my clinical work soon, on June 30th.

The paradox is this. What I found out as I approached my decision is that it helps immensely to prepare psychologically for retirement-even if you never retire-as early as possible. Like right now. Here’s why.

Preparing for retirement
Retirement is like the global warming of our personal lives. If you don’t prepare, you are likely to be burned. Retirement usually won’t be prepared adequately for you. Pensions are rare nowadays, and saving difficult, especially in a poor economy. Loyalty at work is much less on each side. Sometimes, one has to retire unexpectedly well before anticipated. The very rich can afford to ignore financial planning, but not the other aspects of retirement planning.

Psychologically, we know that it is usually easier to focus on the next day rather than an unknown future. Our brain has been hard-wired to be concerned with immediate problems or dangers via the fight-or-flight response. It takes continued higher brain cognition and focus to plan for an unknown future. This is one explanation for why so many people have trouble financially planning for the future, even when they have adequate funds to save and invest.

Moreover, as Dylan Evans discusses in his recent book, even if we are able to persist with future planning, most of us aren’t very good at estimating risks.¹ We often overestimate our future good fortune, say in the lottery, while underestimating bad fortune, such as getting a divorce.

The journal American Psychologist has been on the cutting edge in addressing this concern. The April 2011 issue was a special one devoted to the changing nature of retirement and the psychological challenges involved.² Among the many messages that seemed valuable to me were:

• An individual’s marital relationship has a very strong correlation with retirement outcome
• For couples who do not have a compatible vision of retirement, which my wife has discovered is quite common, strongly consider pre-retirement relationship counseling
• Those who engage longer in retirement planning tend to report less anxiety and depression before and after retirement
• Be able to revise expectations and actions as needed before and after retirement
• Plan how to replace financial, personal, social, and generative needs that work has fulfilled
• Find ways to maintain your self-image without your current work

All of these make planning for retirement right now and hereafter important, don’t they?

Turning from the psychological to the more spiritual, retirement planning can also re-focus us on what gives our life the most meaning. If we are fortunate, we have been working at a job, or at home, that fulfills our own particular sense of destiny. The psychologist James Hillman calls it the “acorn theory.”³ He posits that you can often see a child’s destiny and calling in his or her early likes, skills, and even troubles within a family and cultural context. For me, early on, I had a sense I was to be a replacement for my mother’s beloved brother, who died very early in his medical career. Adding the psychological ramifications to medicine equaled the psychiatrist I became.

Now many people feel that their work has been more drudgery and practical than fulfilling a calling. Thinking about retirement allows for a reassessment of that concern, possibly even to changing jobs. Retirement itself offers other ways to achieve that fulfillment, including volunteerism.

The retirement of psychiatrists
As for psychiatrists in particular, the literature is even more scanty. In part, this may be due to the image and reality of Freud and Freudian psychotherapists-if healthy enough, being able to conduct psychotherapy to the end of their lives, and deciding to do so, at least part-time. Life experiences and accumulating wisdom might even make them better over time. However, as psychiatrists turn more and more to fast-paced medication reviews, with more rapid knowledge change, aging may be more of a detriment to work success, like it often is in other medical specialties.⁴ Those working in organizations with financial pressure are often forced toward retirement, to be replaced by younger and cheaper colleagues.

The first-and perhaps only-survey to assess the attitudes and experiences of older psychiatrists during the process of retiring was done in 1997 in Australia and New Zealand.⁵ In their 60s, about half had begun retirement. Some reported fatigue and memory impairment that were possibly affecting work competence.

Some personal reflections of individual psychiatrists exist. Locally, Barry Blackwell described his retirement in 1998.⁶ At age 64, he decided to retire “before I die with my boots on,” knowing that ours is a hard profession to leave. He felt we often need to continue to care for others in ways we did not receive ourselves. He anticipated not missing night call and professional hubris.

As a sign of my time, I definitely won’t miss EMRs, which take precious face-to-face time away from patient interaction, and won’t miss collegial conflict. But there is a follow-up. Dr Blackwell returned to work part-time. Maybe the reasons were practical. Or, maybe it was as Benjamin Rush said over 200 years ago to the managers of the Pennsylvania Hospital:

There is a great pleasure in combating with success a violent bodily disease, but what is this pleasure compared with that of restoring a fellow creature from the anguish and folly of madness and of reviving in him the knowledge of himself, his family, his friends, and his God!

More recently, the psychiatrist Norman Clemens provided another case study.⁷ He notes that the previous reluctance of the profession to retire seems to be changing. Many factors need to be considered with much thought and preparation: one’s own psychology, attachment to patients, particular kind of practice, health, family, finances, and other interests, among them. Dr Clemens discussed how these factors related to the closing of his solo psychotherapeutic practice.⁸

The retirement of physicians
Given this relative lack of research and role models in psychiatry, I had turned to one in another medical specialty who came from my alma mater, Yale. This is the well-known surgeon and writer, Sherwin Nuland, MD. He emphasizes that doctors who retire must accept the painful fact that they will “no longer be seen as anybody’s healer.”⁹

Despite feeling that caring for the ill was “the most important thing I did in my life,” he decided in his late 50s that he ought to start rediscovering who he was before he went to medical school. (And I don’t think he was familiar with the similar viewpoint of James Hillman.) As part of that renewal process, he came to advocate writing, in part because it helps synthesize what one has learned in life. He also noted the pleasure of his (like mine) 4 grandchildren. As he said:

It’s a question of what my children have brought to their own lives, which is a great source of pleasure and wonder to me.

My retirement
That was it for me! Exploring Dr Nuland’s ideas and experiences confirmed mine. In introspecting about what gave me the most pleasure and where I was needed most right now, it was my wife, the rest of my family, and writing. I had begun to feel more like a replaceable cog in a wheel of a bandwagon racing to treat patients as fast as possible. Even so, two clinics thought my quality of care was superb and asked me to stay on; one did not. I didn’t have the energy or desire to try to find better settings.

So I began the retirement process. Some aspects of terminating with patients on retirement seemed similar to other termination situations, from changes in jobs to changes in location. However, this also adds a finality and different meaning to both sides. For me, the finality was emotionally excruciating. The pain became more tolerable when “sacred moments” took place that would not have occurred otherwise. A rough, tough prison inmate told me, “Have a good life, Doc.”

Another inmate from Mexico offered recommendations of where to travel in Mexico, especially to avoid the drug cartels and crime. He should know, I chuckled to myself. Many patients seemed genuinely pleased that I was retiring, and not because they would get a new psychiatrist! Psychiatrists usually don’t get gifts from patients, nor should they, but this felt like their gift of thanks to me.

As I began packing up my office, I felt so fortunate that I had saved important papers. Shuffling through them evoked memories and connections that I had forgotten. As James Hillman (there he is again) closed an interview:

There’s a strange pleasure in going back over things. And it isn’t just that you go back over them, but they come back to you. You can’t believe it. Where did all this come from? They aren’t just memories, but scenes you can reenter and in them rediscover things you once lived.¹⁰

I’d now recommend doing this periodically over one’s career and parenting.

Endings-and beginning again
Just in time, I also discovered another book that helped prepare the way.¹¹ By now, I was beginning to feel like for some reason I was receiving intellectual manna from heaven to sustain me until I reached the hoped-for promised land. This book discussed how endings can lead to liberation. What Dr Lawrence-Lightfoot said in her Introduction seemed especially apropos to psychiatrists, who process small and larger good-byes most every day of their career:

“I certainly believe that the art of attending to, practicing, ritualizing, and developing a language for leave-taking in the most ordinary moments and settings augers well for taking on the most extraordinary exits that life is sure to serve up.”

Her description of her personal experience also resonated for me:

 .  .  . I have known such moments and they stand as signposts to courage and treachery in my life, those moments when I said to myself-after months of deliberation, indecision, and ambivalence-‘I’m out of here’! I was out of here for my own organization on May 3, when it was clear to me that not only would my academic and scholarly interests no longer be supported, but in fact discouraged. “How do you have time to do all that writing, Steve?” “You have no time left to go to any conference, even if you are presenting.” Well, I certainly would have more time to write and present if I retired.

Planning for retirement can also be likened to planning a vacation. The planning and anticipation in itself can sometimes bring even more happiness than the vacation itself. So, if you already haven’t, begin your retirement planning now, even if you never retire!

For me, the retirement is now set in writing, and like Dr Nuland, I intend to write more. By writing more, I hope to understand psychiatry better. Maybe that will help make up for not serving patients. The life of one of my admired forebears, Maimonides, was reviewed by Dr Nuland.¹² What the physician, philosopher, and Rabbi Maimonides wrote in 1168 might make any physician cautious about retiring:

From this point of view, the study of medicine has a very great influence in the acquisition of virtues . . . then, not only consists of keeping the body healthy, but is a way to understand and serve the “divine.”

Dr Ron Pies recognized that Maimonides should be considered one of the modern-day “fathers” of psychiatry.¹³ Maimonides long ago recommended the integration of mental and healthcare, which we are re-emphasizing once again. He posited early ideas on psychosomatic medicine, cognitive therapy, and exposure behavior therapy.

Right now, I probably need a break to recuperate. As Jung once wrote in reviewing his life as he aged:

"I am astonished, disappointed, pleased with myself. I am distressed, depressed, rapturous. I am all these things at once, and cannot add up the sum. I am incapable of determining ultimate worth or worthiness.”¹⁴

The past-even the distant past-seems prologue to my (and my soul’s) future. I anticipate returning after a couple of months to explore the Old Testament life of Joseph in a series tentatively titled, The Biblical Joseph for Our Psychiatric Times. I am concluding that although there were-and are-shamans, Joseph may have fit the description of being the first psychiatrist. Sibling rivalry, dream interpretation, trauma, cross-cultural competence, professional ethical temptations, prison rehabilitation, and forgiveness. It’s all there, and more.

Stay tuned and enjoy your summer.

Epilogue. . . Yet that which most my troubled sense doth moveIs to leave all, and take the thread of love
-Lady Mary Wroth

References:

References1. Evans D. Risk Intelligence: How to Live With Uncertainty. New York: Free Press; 2012.
2. American Psychological Association. American Psychologist. 2011;66(3).
3. Hillman J. The Soul’s Code: In Search of Character and Calling. New York: Warner Books; 1996.
4. Weinberger S, Duffy FD, Cassel C. Practice makes perfect . . . Or does it? Ann Intern Med. 2005;142:302-303.
5. Draper B, Winfield S, Luscombe G. The older psychiatrist and retirement. Int J Geriatr Psychiatry. 1997;12:233-239.
6. Blackwell B. Taking down my shingle. Wisc Psychiatrist. 1998;Spring:17.
7. Clemens NA. A psychiatrist retires: an oxymoron? J Psychiatr Pract. 2011;17:351-354.
8. Clemens NA. A psychiatrist retires: the happening. J Psychiatr Pract. 2011;17:425-428.
9. Shuto C. Reeling in the years. Yale Med. 2007;Autumn:12.
10. Safransky S, London S, Zeiger G. Conversation with a remarkable man: honoring the late James Hillman. The Sun. July 2012:4-13.
11. Lawrence-Lightfoot S. Exit: The Endings That Set Us Free. New York: Sarah Crichton Books; 2012.
12. Nuland SB. Maimonides. New York: Schocken Books; 2005.
13. Pies R. Wisdom from the 12th century. Psychiatr News. 2007;42(2):30.
14. Jung CG. Memories, Dreams, Reflections. New York: Random House; 1961.