Countertransference

So far, my Psychiatry clerkship has been a boon for several reasons:

(1) Psychiatry has given me the opportunity to explore the complexities of the mind and its potential dysfunctional behaviors. Accordingly, it has given me a chance to scrutinize my own thought processes, including, most recently, my rapid growing passion for Neurology. Additionally, it has given me an acute awareness of my impressions and attitudes toward my patients.

(2) Although I had equal intellectual interest in both Neurology and Psychiatry from my second year Neuropathology and Human Behavior coursework, my Psychiatry rotation has offered me clarity: I now know that it is possible for me to find a subject interesting without wanting to work in the field. By contrast, my feelings for Psychiatry have accentuated my interest in Neurology as a possible career pathway with the knowledge that I won’t fall in love with every field through which I rotate. Prior to my rotations, I had equal magnitudes of bias against both Neurology and Psychiatry, but my bias against Neurology dissolved with new knowledge, familiarity, and experience (unlike my bias against Psychiatry, which has largely been confirmed and solidified despite my increasing respect for those practicing in the field).

(3) Psychiatry has not only given me the intellectual opportunity to think about my thought processes and career planning… it has also offered me the time to do so! The days have been considerably shorter than those on Neurology, giving me time to do extra reading in Neurology and Medicine.

However, despite these benefits, this Psychiatry clerkship has been a twisted journey through the dark side of medicine. For a number of reasons, I cannot see myself pursuing a career in this field under any circumstance:

(1) By necessity, Psychiatry is far more paternalistic than any other field of medicine. In other fields, the physician and the patient can be partners with equal input into the relationship and effort. The physician can use reason and knowledge to convince a patient that a particular therapeutic regimen is the best option, and the patient can use her intellectual capabilities and logic to navigate the medical reasoning and adhere to the treatment plan. For the most part, gone are the days when doctors would simply say, “Do this, and you will get better” without further explanation; patient education is an essential part of medical treatment. However, in inpatient Psychiatry, this equal relationship does not and cannot exist. Mental illnesses are only problems when they impair an individual’s functioning in activities of daily life (work, family life, social interactions, following basic legal standards, etc.). In order for a patient to be admitted to an inpatient psychiatric ward, there is almost always a legal issue: threatening suicide or homicide, violent or aggressive behavior, disturbing the peace with psychotic behavior, etc. In treating a patient with poor judgment and insight, the likelihood of actively engaging a patient’s reasoning or logic is very low. Accordingly, the patient’s role in treatment planning is often minimal, at least initially, leaving the physician in the position of “always being right.” This creates great potential for antagonism in the patient-doctor relationship.

Would I find much personal reward in a field where one is frequently arguing with patients who express their hatred of you? No. From my observations, when confronting oppositional behavior, I suspect that many inpatient psychiatrists find purpose in keeping the world safe from the dangerous and volatile minds and behaviors of their more psychotic and delusional patients. But that would not be a powerful enough motivator for me.

(2) Countertransference refers to the emotions a physician feels for his or her patient (sometimes displaced from another person to the patient who is reminiscent of the former). By my nature and commitment, I have sought not to lay judgments upon my patients. Nonetheless, this has not restricted me from developing friendly interactions with all but three: two of the patients were comatose, and the third is a chronic paranoid schizophrenic (CPS) who is currently floridly delusional. I have had several CPS patients so far, all of whom were relatively easy to manage and talk to without argument or the development of negative countertransference. Furthermore, until my most recent patient, I have not triggered or encountered significant paranoid delusions extending to myself and the treatment team. I have generally served as the “patient advocate” to voice their concerns. Nonetheless, I now have the opportunity to work with an openly oppositional and confrontational patient who, despite my reassurances and explanations, now thinks I’m “racist” and “trying to single (him) out.” I would like to talk to him about another of my CPS patients of the same race, size, gender, and difficult legal background (homicide), and my friendly and professional interactions with him, but it is clear that logic and reasoning will not work for this patient.

The difficult part for me is that I have been willing and perhaps even eager to give this patient the benefit of the doubt (considering he was committed by a family member who provided the opposite, guilt-assigning story to his own). I was even surprised when my attending remarked this morning that this patient is very sick, as he otherwise appears reasonably high functioning. However, I now understand my attending’s astute assessment: his thoughts are truly, extensively delusional with little or no grounding in reality. In some ways, I feel very sad for him: his delusions of victimization may prove self-fulfilling, as his confrontational behavior might prolong his hospital stay or get him committed to a more high-security facility. On the other hand, my sympathy has faded with the rapid surfacing of his delusional and confrontational behavior, making the allegations of his wife-beating, treatment noncompliance, and poor outpatient functioning much more believable.

In this situation, it is requiring some effort on my part to constantly remove myself from the position of judge, and the result is that I have a painstakingly neutral attitude toward this patient. For me, this position is far from ideal: I would like to encourage and contribute to the betterment of the lives and health of my patients. In this case, it is more likely that I will be in the position of cooly watching this patient’s descent, indifferent to his fate, but rather, more concerned with the fate of those he might harm.

I feel the numbness I observed in our psychiatrists toward many of the patients. I look forward to the end of this rotation.

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