What Psychiatry Has Taught Me

A Reflection on Loss

As always, some details may be changed to preserve patient confidentiality.

Recently, I’ve been thinking about how I would respond if, in some hypothetical future non-psychiatric job interview, I were asked, “What have you learned in your time as a psychiatrist?”

I’ve come up with two different answers.

On the one hand, I’ve learned a lot about diagnosing and treating mental illness. If, for example, you happen to be a previously healthy 29 year-old woman who’s an up-and-coming lawyer at a local firm, engaged to the love of your life, and then over the course of 9-ish months you become progressively reclusive, then start planting GPS trackers in your fiance’s and friends’ cars because you suspect they are stealing unborn babies from your womb in the night, I will diagnose you with schizophrenia and prescribe the best treatments available, leading to the resolution of your acute psychotic episode. If you happen to be a 55 year-old man who becomes increasingly depressed over the course of a few months, consumed with worsening guilty ruminations, eventually coming to the delusional conclusion that you have somehow bankrupted your family business and murdered your own children, now intent on hanging yourself for your crimes, I will diagnose you with psychotic depression, treat you with medications and electroconvulsive therapy, and get you better. Or, if you happen to be a 62 year-old man with cerebral palsy hospitalized for another bout of mysteriously recurring psychosis and catatonia, I will see you as part of the psychiatric consult team, determine based on the timing of your symptoms and periodic urinary incontinence that you need long-term video EEG monitoring, and then diagnose you with inter-ictal (between-seizures) psychosis and catatonia, with your symptoms quickly resolving once you’ve started antiepileptic medication. &c. &c.

More generally, I’ve learned to diagnose and treat a wide range of psychiatric problems, how to relate to the mentally ill in a natural manner without fear or excessive affectation, how to manage and de-escalate aggression and other dangerous situations, and (some of) the ins and outs of an increasingly byzantine medical system. I have refined my theories and intuitions about the workings of the human mind. By seeing the myriad ways it can malfunction, I’ve come to appreciate the physical nature of the mind in far more immediate and dramatic fashion than any philosophical reasoning could demonstrate. But that’s just a more pleasant way of saying that I’ve thought a lot about what’s really going on in the brain of someone who is in the midst of catastrophic psychological disintegration right in front of me.

But…I have also learned something else. If you happen to be that 29 year-old former lawyer, your new life will be quite different than what you had once imagined. You are no longer engaged. You are back living with your parents. You are still employed, but are no longer litigating cases. Luckily, the senior partners are decent people and, understanding your new disability, have given you a minimally demanding position shuffling paperwork so that you can keep your health insurance. But you know they’re doing it out of pity, and that it won’t last forever. If you happen to be the 55 year-old gentleman who has recovered from psychotic depression, your next task is to to make some sense out of your repeated and violent attempts to kill yourself, not to mention coming up with something to say to your teenage son who found you hanging from the ceiling half-dead and can now barely bring himself to talk to you. And then there is the fear of a recurrence. If you happen to be the 62 year-old man with recently resolved psychosis and catatonia, you are now faced with the terrifying prospect that the underlying cause of your now-cured psychiatric problems may be a gradually progressive dementing illness for which there are no treatments.

So, again, “What have I learned in my time as a psychiatrist?” The longer I think through this exercise, the more my memory is drawn to one encounter that predates my starting psychiatry residency, one which I will never forget. I don’t exactly know why it had the effect it did, but the salience has only increased as I’ve gotten older (which is explained in part because my perspective on it changed after I had children of my own). Despite occurring outside of the specified psychiatry timeframe, this is the time in my medical career as a whole that I really started to learn, and most importantly feel, the second and most important lesson in a meaningful way.

This was a night during my final year of medical school. I was rotating in the pediatric ER when we were alerted to an incoming trauma case: a 7 year-old girl was being airlifted by helicopter from a massive car crash out of state. The first things I saw were the x-ray and CT scan images. The ED attending scrolled to images of her pelvis. The only thing I remember clearly in that moment was the way she said “shattered”. Then details about the crash came in. Her entire family was packed into a minivan; she was the only survivor, unaware everyone else had died in the crash. Given the acuity I never got the chance to evaluate her, but as they were moving her out of the ER into the main hospital, I briefly glimpsed a bewildered and terrified little face. As she was being wheeled down the hall, her screams of “Mama! Mama! Please, please, where’s my mama?” etched themselves somewhere deep inside me.

The most important thing I’ve learned as a psychiatrist so far is this: that we are, in so many ways, extraordinarily frail creatures. Yes, we are also capable of awe-inspiring strength and resilience, and can achieve heights of true greatness. We can marshal our noble philosophies and faiths to buttress against hardship and for comfort amid failures. But at the end of the day, the hard truth is that there is often precious little one can do when the universe decides to crush you. Loss is real, tragedy is real, unmitigated disaster is real, and no amount of rationalization, or anything else, can prevent it or make it go away. I suppose this is one of those lessons that comes with maturity, and I just happen to have learned it through psychiatric experience.

I don’t mean for this to be a counsel of despair. After all, there’s a reason for the old trope that understanding the fragility of life is a prerequisite to being able to fully appreciate it, and I think this is correct. Authentic compassion and love are only possible when the reality of loss is acknowledged and felt. It is the possibility of genuine loss that opens the door to genuine gratitude. One can’t be a a real person without having experienced some kind of genuine loss.

I wish I had a nice concluding lesson to draw from all of this, something pragmatic and “actionable”, but that’s probably a lifelong work in progress. For now, I’ll say that whenever I dwell on this subject I find myself becoming a bit more patient—more patient with myself and my own weaknesses, more patient with others and theirs, more patient with the whole frustrating process of it all. With that bit of patience I can take more time to tuck my kids in at night, spend more time with the people I love, or just take a moment to tell a friend I’ve been thinking about him, and then to thank my lucky stars for this brief time I’ve been given on Earth.