Pride Goes Before The Fall

Pride goeth before destruction, and an haughty spirit before a fall.
Better it is to be of an humble spirit with the lowly, than to divide the spoil with the proud.
– Proverbs 16: 18-19

One of the redeeming experiences on my Psychiatry rotation is the time I spend with the Veteran’s Affairs Substance Abuse clinic in Alcoholics/Narcotics Anonymous groups. Unlike most of my Psychiatry experiences, the AA/NA groups have been universally encouraging and insightful. Insight is a rare trait to find on the inpatient closed psychiatric ward, and it is refreshing to be with addicts who help one another gain clarity in evaluating their condition, relapse triggers, and positive development. Today, I had the privilege of sharing some of my thoughts with one group of veterans about Step 1. In recognizing one’s powerlessness to alcohol/drugs and understanding the uncontrollable consequences of substance abuse, I noted that there is a subtle but important distinction between pride and strength. For the sickest patients I have seen during my clerkship, pride is one of the greatest and most common flaws: to me, it is the delusion that one is in control when one is not in control. It is the delusion that you can skip taking your antipsychotic and mood stabilizing medications and still regulate mood and not resort to violence. It is the delusion that the world is somehow always against you, and that you have no role in causing your problems. It is the delusion that your suffering is unique and entitles you to special treatment. On the other hand, the ones that have the best chances of recovery (like the AA/NA veterans) are the patients who have the strength to be humble, to recognize their diseases, and to make the commitment to take ownership of their problems and be guided through the treatment process by another. Inner strength gives confidence, not pride, for strength is accompanied by clarity while pride and arrogance are blinded without insight.

Notably, AA and NA have a strong spiritual theme underlying the treatment process. Many people think that spirituality and religion have few meaningful roles in the practice of medicine, but now that I have been exposed to inpatient Psychiatry, I beg to differ. I am not a religious man, but I do express spirituality through a belief in a higher power that, for convenience when sharing, I call God. When people truly believe in a higher power, that belief supports a measure of humility that encourages them to take time to step back and reevaluate their situations. Many of the patients I have encountered on the inpatient psychiatric ward, with their grandiose and persecutory delusions, lack or abandon this sort of belief. I hesitate to think of them as “God-less,” but it is apparent when some individuals lose the grounding that allows most people to interact and participate in shared communities. They do not share, because everything, whether praise or persecution, must be about them in their minds, leaving no room for a God (unless the delusion involves hyperreligiosity, which may sometimes be a delusion of grandeur) or for anyone else. Since they believe everyone else has a problem but not them, they are unable to heal. On the other hand, those patients with some spirituality or at least the capacity for self-reflection and self-evaluation are better able to understand how their diseases are affecting their lives and what steps they must take to allow for a process of healing.

Though there may not always be the time or reason, I hope my patients will be comfortable expressing their spirituality with me (regardless of religion or lack thereof). If nothing else, I hope to take from this Psychiatry clerkship this message, the opening prayer from each AA/NA meeting:

“God, grant me serenity to accept the things I cannot change,
courage to change the things I can,
and wisdom to know the difference.”

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