Unholy Alliance

The term “unholy alliance” was used today by a psychiatrist I am working with who has a number of patients who are nurses recovering from addiction and substance abuse. The question he always asks is “How can you use and not get caught?” In some cases, a health care professional might find himself or herself in a position where only one sympathetic person is overseeing the acquisition and distribution of medications by the individual. An arrangement might form where the supervisor might turn a blind eye toward the individual administering medications and fail to notice patterns of abuse. Although this problem can also affect doctors, techs, and other members of medical teams, this problem seems to be especially pronounced in nurses, the frontline health workers who are usually the ones acquiring medications from the pharmacy and delivering them to patients. In the cases I have seen, several of the nurses are highly competent and excellent caretakers, and great effort is expended to rehabilitate them and return them to work.

Nonetheless, my work on an inpatient psychiatric ward (particularly with substance abuse patients) has troubled my thoughts when combined with this knowledge of the “unholy alliance.” Health care is a very difficult and challenging environment in which to work with countless stressors and sources of frustration. I was recently reminded of the classic Akira Kurosawa film “Seven Samurai” in which a village of peasants, harried and oppressed by bandits, enlist the aid of seven samurai to protect them. In the end, the samurai are able to defeat the bandits at the cost of several of their lives. The film concludes with a celebration by the peasants that excludes the battle-bound samurai: they fight hard to save life that they cannot participate in. Increasingly, as the insertion of third parties continues to expand the rift between patients and their caretakers, health care and medicine have often become less rewarding for those taking care of the sick with the shortness of time and emotional commitment. I think there is an unspoken understanding among health care workers about their daily trials that was best summarized by a nurse who was relating to me and my resident a story about her pounding on the ceiling of her apartment to quiet down a loud neighbor: “Normally I wouldn’t bother, but somebody has to come here every morning and take care of people.” Like Kurosawa’s samurai, there is an almost divine or god-given ability and directive given to the people who work in hospitals that confers upon them solace and strength, even in the absence of gratitude or participation in the lives they save. Nonetheless, this divinity that separates patients and caretakers, which some patients might complain about in the hospital or clinic setting, is even more exacerbated and resented on the inpatient psychiatry ward: by definition, the doctors, nurses, and psychiatric aides are supposed to be even better and more capable than normal individuals (for their roles as caretakers) determining the fate of deviants. How disturbing, then, it is to have patients who are former nurses who have fallen from the position of caretaker to psychotic, depressed substance abuser. How easy is it, how slippery a slope it is to self-medicate against the unaddressed frustrations and stresses of working in the hospital?

As I lay in bed last night at 10pm with my neighbors upstairs blaring their television set, I thought about what the nurse had told me about pounding her ceiling to get her neighbors to quiet down. I thought about last summer when I had a similar problem: a neighbor was watching TV all throughout the night and was keeping me awake. And then, as I thought about my patients on the inpatient psychiatry ward, I realized what kept me awake all those nights: it was my inability to let it go. It was the anger and frustration I felt about another person’s inconsideration. It was my belief that my daytime research work in disease treatment and management was more important than someone’s need to watch TV at 3 AM. It was annoyance at myself for not being able to sleep more deeply. Those feelings and thoughts were seeds of anger, paranoia, depression, and anxiety peppering my mind with agitation. The simple beginnings to the tumultuous and convoluted psychological and emotional messes I address daily on the psychiatry ward. With a little bit of that in every aspect of life, it’s not hard to feel a need to reach for a beer or a cigarette. Something to take off the edge. To self-medicate. The need for an acceptable way to release, until the point that the acceptable method is abused. Knowing this, I thought to myself, “Well, why not just let go?” And so I did and slept well last night.

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