People warned me that becoming a psychiatrist would be emotionally challenging. Knowing that I would hear personal stories of trauma and resiliency, of sadness and fear, and of death and wanting to die, that concept made complete sense to me. When I chose to enter this field, I knew I had made an informed decision that I could sit with, tolerate, and empathize with other people’s emotions.
I also understood that other people’s stories might bring up my own feelings or experiences. Freud called this counter-transference and described it as a concept in which my own unconscious reactions as a therapist towards a patient might be determined by my own life history and feelings. That is to imply that, for example, if a patient reminded me of my mother that might make me feel a certain way, or if a patient had a story that reminded me of mine, I might feel another. We take classes to understand this and we spend time discussing “what it was like in the room” and “what we were feeling” to learn how those reactions might affect the psychiatrist-patient relationship. Many of us also work in our own therapy to understand ourselves so that we can be better caretakers for others. Being aware of my own emotional reactions to a patient or their story was part of the deal.
Yet, here is something that isn’t said enough: Your therapist and for that matter, all of your doctors, are human beings. We have break ups and make ups and deaths and births. We have unexpected catastrophes that seem unbearable to manage. We have political and personal beliefs that can feel in danger. Sometimes we don’t sleep the night before, or we cry in the bathroom (or in the office with the door closed) before an appointment. We also get the flu, laryngitis, and that “awful stomach virus” going around. But, when you arrive, we put on a “doctor face” and do the very best we can.
There are times when I look at the patient across from me and wonder if she can tell I am not myself today. I wonder if he notices the number of deep breaths I take, or the number of times I drink out of my water bottle. I wonder if I am less present, less engaged, less inquisitive about their stories because my brain is so focused on mine. I worry they think my emotional distance is about them. I wonder if I should have stayed home, let myself emotionally heal…take a “personal day”.
But, that is not the culture of medicine. I have seen friends work through pneumonia with a mask on to see their patients, residents get up from passing out to then go on to stand for four hours to perform surgery, and others who go to work while family and friends are dying or have died. These examples might seem shocking, but they are unfortunately commonplace in medicine. We are taught to put patients first. If we do not come to work---the potential risk to patients (or burden on our colleagues) weighs heavily on our minds. It is not surprising, therefore, that physicians and physicians-in-training have high rates of depression, suicidality, and burnout, significantly higher than aged-matched samples and even the general population.
Maybe no one could tell me how hard this job would be when we are not our best selves because they did not want to admit that they were ever not their best. It is far easier to think of a patient’s emotions and narratives causing reactions in us than the concept that we could be affecting patients. Even Freud saw counter-transference as a personal problem for a therapist, best handled behind closed doors. I wonder what he would think of this.
As a psychiatrist-in-training, I am not operating on a patient and my emotionally distorted focus does not physically damage someone in a tangible way. But, could I do emotional damage by not being not fully present with my patient? Is it my job to work and just be there, or is it my job to only be there when I am my best self? Do I need to be at 100% to be a good psychiatrist, or am I helpful even at 50%? Even still, would cancelling on my patients be worse than me being “sort-of” present?
While these questions continue to echo in my mind seemingly devoid of a “correct answer”, ultimately, I think the first step is just talking about it.