The mixed bag of emotions described here should be familiar to any clinician, especially to a psychiatrist.
PORTRAIT OF A PSYCHIATRIST
– Series Editor, H. Steven Moffic, MD
I don't know of any psychiatrist who has a single “uneventful” day. Some are more hectic than others. I do think we become numb to the sensations of happenings throughout the day, especially because of the nature of our work. Being used to scientific writing, this is my first attempt at a self-psychological autopsy. Writing about my experience is forcing me to have a second look at myself. What follows is typical of an “ordinary” day in my professional life. I guess if one really thinks about it, there is no such thing in our line of work.
It is early December. Things are slow at the office. Being a child psychiatrist, this is especially the case. Children are counting down the days until Christmas. Between Thanksgiving and Christmas, the formalities of a few weeks of school are usually routine for most children. Whether it is the “Santa Clause effect,” or parents and teachers more tolerant of their children’s transgressions, I have found that during this time of the year, even in youth with chronic behavioral concerns, children tend to have less trouble. We would like to give credit to our therapeutic interventions but I am sure the reality is somewhere in between.
I received a text from a recently turned 18-year-old male patient informing that he has decided to check into an inpatient psychiatric unit. He has been struggling with intense anxiety and depression but has been resisting admission. We have been meeting almost every other day for the past two weeks and engaging in intense cognitive therapy to assess his core issues and distortions in his thinking. Should his condition deteriorate, he has access to my cell number and email. It has been emotionally draining for me. I had struggled with similar symptoms around the same time in my life when I almost dropped out of medical school. I was working diligently with this patient to avoid an admission and to help him maintain his functioning.
The patient was perilously close to dropping out of high school and failing the semester because of minimal school attendance and not completing his assignments. In such situations, feeling a sense of failure in not preventing an admission into the hospital, is often mixed with relief. This mixed bag of emotions should be familiar to any clinician, especially to a psychiatrist, no matter the level of training or experience in the field. For me, the challenge was to endure those vulnerable days full of self-doubt, frustration, uncertainty, fear, shame, and embarrassment that I was letting down those most important to me, my parents, friends, and teachers-and especially my patient..
His inpatient admission was, in a way, a relief for me. Knowing the unpredictable nature of human beings, it was better he was in a safe environment. There was a sense of urgency and need for new direction in his treatment. I was feeling stressed about the slow pace of improvement. I felt powerless to hasten his recovery. Talking to his parents, I realized I narrated exactly the same sentiments that I would have wanted my parents to know, almost 30 years ago, but I could never tell myself. I could read their facial expressions, full of concern and anxiety for their son-these were reminiscent of my parents when I was young. I wonder how many times as psychiatrists we live by the advice we give our patients. How often do we give advice to others that we don’t implement in our own lives? As it turned out, I am still performing weekly CBT sessions with this now medical student. He is doing much better and about to start law school-one of the rare successes story as a psychiatrist that I cherish!
At the opposite end of the age-spectrum is a 94-year-old patient. Recently widowed, “Mr F” has been my patient for the past five years. He initially came with symptoms of depression and anxiety while caring for his bedridden wife. A World War II veteran, he was an avid reader and collector of old books. He he has the popularity of a rock star with our staff. Armed with a smile and twinkle in his eyes, he has been recently forced to use a cane due to arthritis in his knee. He swings his walking stick like a military batton as he greets each of the staff by their name. He has an amazing memory.
In my office, he points his deep blue eyes at me with a smile. “You know what, President George H. W. Bush was my age, yet he is gone and I am still here!” I suddenly remembered how many similarities they shared. On top of belonging to the same generation, both had served in the US Navy during the War and seen active combat. Both had an unparalleled zest for life. Mr F actively took care of his ailing wife until recently, maintained his household, and stayed awake very late reading his favorite books and bidding on online book auctions. He tells me that in the past month he had spent almost $1700 on rare books with one of them being a medical book published in the early 1800s. The oldest book in his collection, worth a few thousand dollars, is from the 12th century.
Mr F is a strong character with a realistic and optimistic take on life. He reminds me of my father living overseas who is about to turn 91. Being very close to my father, I realized the strong countertransference I have for Mr F. As I live in the US and my father in India, Mr F evokes a strong mixture of several emotions-pleasure, anxiety, and guilt. It is no surprise when I try to allay my guilt of not being with my father to take care of my patient on a daily basis. These sentiments probably resonate with every immigrant who lives away from their parents.
During the session, Mr F remembers his deceased wife and how his life has changed after losing a companion of more than 70 years. We both tear up. He recounts that days of the week don't hold much meaning for him, and he no longer cares what date it is. Indeed, his sense of time has metamorphized into the four seasons.
Mr F has recently become my window of what lies ahead in my own future. He evokes my growing sense of my own aging. As I look at Mr F’s perfect silvery coif, I remember my receding hairline and wonder if I would still have such lush hair if I make it to that age. The expanding waistline and morning crackles of my knee joints remind me of the unrelenting neglect of my health in favor of my years of professional obligations. I wonder if not very far into the future, my residents will make fun of my unmatched socks, just like we did to our professors.
As Mr F leaves, I get another call, this time from my resident to supervise a consult on the medical floor. I am reminded I am on call all week. My day will not be over any time soon.
Dr Jainis Professor and Regional Chair, Texas Tech University Health Sciences Center at the Permian Basin, Department of Psychiatry, in Midland, TX.