Courage in the midst of fear
I was born with an insatiable curiosity about people and why they do the things they do. There is always a reason.
In my trip to Beaufort, South Carolina, where Sarah was doing research for her third book in the Ditie Brown Mystery series, I went along for the ride. Naturally, Sarah cannot go anywhere without me, her real-life muse.
What I discovered was a world and a history I knew nothing about. Beaufort, South Carolina is a small town heavy in the history of the Civil War.
Sarah wrote a piece on her Facebook page about a twenty-two year old slave Robert Smalls who risked everything to sail a confederate-owned cotton steamer through Southern waters and into a union blockade with the hope Confederates would not recognize him as a slave and that Yankees would see his white flag of surrender and not fire on him.
He had with him his wife and fifteen other slaves including three children.
What made this man so brave? Would I have been so brave? What drives us to risk everything including life itself for what we want?
Smalls wanted freedom. He was willing to achieve it or die, and he had the drive and intelligence to believe he could achieve it. He had courage, and he succeeded.
When I work with patients, I find it is most often fear that holds them back from living the life they wish to lead. When they can name the fear, it often gives them the courage to risk what they have for what they want.
Are these life and death decisions? Not usually, but an unexamined fear can feel that way.
And it's good to sort out the big issues from the small ones. An unnamed fear can grow to such proportions that it seems insurmountable. If we name it, we shrink it down to size.
When we know what we are afraid of and what we want, we can decide if it's worth the risk. We can find courage in the midst of fear.
It doesn't erase the fear but it does allow us to move on, to move through.
The greatest power fear has is the ability to paralyze us.
That is what I work with patients to overcome. By examining what patients really want in their lives and the fears that hold them back, many find the courage to move ahead.
Humor and Psychotherapy
Humor in therapy is a tricky business. It can be used as a weapon, a defense, or a genuine form of connection.
I hear a joke from a patient in the first days of treatment and ask myself what is this person afraid of. What does he need to defend himself against? The answer of course is everything. Beginning treatment is a hopeful, frightening time. I want you to help me. Maybe you can help me. But I don’t want you to know too much about me. I don’t want to have to change.
I hear a joke towards the end of treatment and I think our work is almost done. My patient trusts me and herself. She is relaxed. She can let me see who she is. The world is no longer such a dangerous place. She can play.
Humor can be used as a test. If I tell you something tragic, make a joke of it, and you laugh, then maybe I can’t trust you with my darkest secrets. Early in treatment, I don’t laugh at patient jokes. I try to understand what they mean. Are they to relieve anxiety? An attempt to deflect the seriousness of our work? An attempt to ingratiate? To not be a bother? To be one with the psychiatrist? To hide anger, hostility, pain? The possibilities are endless.
You may think I make too much of a simple joke. But jokes aren’t simple. Humor can be life saving, but it can also be used to obfuscate, confuse, or deflect the listener. This is particularly true when the listener is a psychiatrist.
I keep an eye on humor as a way to mark the progress of treatment. I had a patient who had learned at her mother’s knee how to use humor as a devastating weapon. People were reduced to caricatures and called by their most distinctive and humiliating characteristics. The barbs were poison darts and deadly. My patient could eviscerate the enemy with a single comment. It didn’t hurt that she was extremely bright, original and a wordsmith. My patient’s humor protected her from getting too close to anyone. Like a porcupine, she could keep everyone at a distance. She was also a lonely and lovely woman. I wondered what would happen to her humor as she got better. Would she lose it altogether? Could she really transform it into a gentler variant?
This was a very witty patient, and while I wanted her to get healthier, I didn’t want her to lose a wonderful part of herself. It was a gradual and amazing transformation. The patient no longer had to rip people to shreds or remain silent to avoid doing that. Her humor did transform. I’m not sure I would have believed it if I hadn’t seen it over time. She was still funny, very funny, but the jokes were no longer at the expense of other human beings. She no longer had to keep people at bay.
There are people who seem to have no sense of humor. I still wonder about this. Is it true? Like people with no sense of rhythm? Can it be learned? Humor softens the edges of life. One of the worst curses in life, it seems to me, would be to live without a drop of humor to lighten the load. Laughter might not be right next to godliness, but it isn’t far behind. The physical act of laughing makes us healthier. The emotional impact lets us have perspective. When people are deeply emotionally sick, it is their humor that fails them. The lack of humor is a sign of their suffering. But what of the person who never sees anything funny in life? I suppose it’s like learning to cope with a missing limb. Perhaps one makes up for it in the same way. One compensates by finding other emotional outlets, other ways to relieve the burdens of the world.
With some patients, I’ve found humor has merely been buried under a mound of suffering and distrust. That’s a happy discovery for both of us—like finding gold in an old, forgotten mine. It must be their humor that we discover, not mine. The psychiatrist who jokes with his patients is a little like the psychiatrist who touches them. The touch, the joke can lead to a misery of misinterpretation. I see what you want from me. I’m to be your friend, your audience. You don’t want us to get too serious in here. I’m supposed to keep it light. You don’t want to know my pain. And the problem is you’ll never know what that joke meant to your patient. He won’t tell you, unless he’s at the healthy end of his treatment. He’ll go along or maybe he’ll leave, dismissing you as someone who doesn’t want to listen to or understand him.
I am like any other caring physician. My goal is to cure. If I can’t cure, then my goal is to relieve suffering. Humor can be a part of the process. Shared humor. And it shows itself after I know the patient well, never before. It comes from my patient, not at her expense. At the end of treatment, humor sits beside sadness and joy. When it’s time to leave, my patient and I reminisce about what we’ve been through, what we’ve accomplished, and yes, even sometimes, the laughs we’ve had.
It’s not a new story. It’s the stuff of fairy tales and too often real life. Most of us have a mother who loved us as best she could. Perhaps not in the perfect way we would have wished but well enough. What about the children who don’t have that? I’m not talking about orphaned children. Their plight is often terrible and offer material for a different essay. I’m talking about the mother who neglects or abuses her child, who doesn’t want her around, who might even wish her dead.
There are such mothers. They are not the stuff of myths although plenty of myths deal with them. They are not relegated to historic royalty, who wish to protect their power at all costs. They can be found anywhere. And the harm they do is extraordinary. It may be trite to say a mother’s love is essential to a vulnerable child, but that is what a child needs to survive and thrive. Unconditional love. Love that puts that child’s welfare above a mother’s self concerns. We are asking a lot of mothers, but biology helps. It’s a hard, imperfect road, and mistakes don’t scar a child. What scars a child is the realization that the one person who should love her doesn’t. The one person who should love her may in fact hate her and wish she were not around.
All children want is to adore their mother and be adored in return. A father’s love is important and can be life saving, but it is the mother who first makes a child feel loved, important, and safe. Love and safety allow her to develop—to find herself, to see it mirrored in the eyes of both parents. She learns there are people in the world who want the best for her.
What happens to that child when that isn’t the case?
A child whose mother doesn’t love her, grows up in an atmosphere of anxiety and despair. No place is safe. No place is comforting. Other human beings can’t provide protection. They are perceived as dangerous. A child in such an environment grows up believing she is the problem. It must be something she did to make her mother resent her, neglect her, abuse her. It must be her fault that she is a burden to her parents. If only she were a better daughter, she’d have the love she seeks.
A child who grows up with such a parent is left with a lifetime of longing and a profound sense of worthlessness. No one has told her she has value, except perhaps in the way she can accommodate her parents, make their lives easier. She is a hollow vessel, meant to serve and stay out of the way.
A child who is unloved by a mother and not rescued by the love of a father or a grandparent or a friend, faces a long and lonely journey. She must find in herself what her mother never saw—a lovable human being worthy of respect and care. She must learn to place responsibility where it belongs, not in her flaws as a daughter, but in her mother’s inability to love her. Huge tasks. She must find a voice—when she was never encouraged to have one.
She must grow herself from the inside out. Not an impossible accomplishment, but a long, painful, and arduous one. And perhaps at the end of the journey, when she realizes she is whole and not broken, she can do the work of forgiving her mother. She can begin to see her mother not as a monster but as a failed human being. When she can see her mother as someone who can no longer harm her, she can begin to let go of the mother she has longed for and will never have. She can make peace with her mother and with herself.
How close should a doctor get to his patient?
The relationship between a psychiatrist and her patient requires a certain distance. For objectivity. For safety. But too much distance is also a danger. You don’t tell your secrets to a stranger. To a person who doesn’t care. It’s a delicate balance, and one of the reasons it takes so long to become a good psychiatrist.
I worked for six years on the Grady Hospital psychiatric unit. Grady is the county hospital in Atlanta, which takes all comers. We saw everything, including third-year medical students scared to death they might catch whatever insanity was roaming the halls. They dealt with their anxiety in a variety of ways. Some questioned why they were on the outside looking in. They seemed to have the same problems and insecurities as their patients. Why weren’t they locked up? Others attempted to remain aloof, viewing their patients as illnesses rather than human beings. They didn’t let themselves get close enough to identify with the people they were treating. Some advocated for their patients. They aren’t as sick as you think. Maybe the bugs they feel crawling on their skin really are bugs. Maybe the solution to their fear they have the devil inside is a simple exorcism. I actually heard that more than once. It doesn’t work, anymore than trying to talk a patient out of his delusions.
It can get a little crazy on a psych ward. The patients provide the fodder and the rest of the staff sometimes run with it. Trouble happens when staff over identify with patients and boundaries are breached. Part of my work as an attending physician was to try to maintain objectivity and help others do the same. A locked psychiatric ward is a microcosm of the world heated up to 500 degrees. Patients can say or do anything. It’s our job as staff to keep them and ourselves safe as we help them get better. It’s essential to find out what’s troubling the patient, not in a psychotherapeutic mode, which comes after discharge, but as a crisis intervention. What is the patient’s diagnosis, what drugs does he need, what do we need to do to keep him from harming himself or anyone else, and what can we do to help him get better? When I was on the wards, we had a couple of weeks, sometimes longer, to stabilize patients. Today, the time may be a few days.
In that time, we need to reach the patient. That may only be possible with the help of drugs. Never is it accomplished by heroics—I can talk to this patient. He’ll listen to me. We hear on the news not infrequently enough about the experienced psychiatrist who believed he could see a deeply disturbed patient on his own, without back-up. The first rule-of- thumb for the young (and old) psychiatrist is never ever interview a patient in a setting that makes you nervous. And never place yourself in a vulnerable situation with a patient who is profoundly ill or unstable. Interview in the middle of the ward if you need to, with plenty of staff on hand. Cut the interview short if you must. Be honest with the patient. "You’re making me a little frightened." Sometimes that settles the patient right down. He’s frightened too.
On an inpatient ward, the distance to be maintained is more rigid than it is in an outpatient setting. You don’t have time to know your patient on a deep level, to develop trust, and some of these patients can never develop secure trust in the people who care for them. They are too fractured, too ill. This is not to say you can’t help them, because you can. But it must be done in a formal, professional way. No jokes, no familiarity. No breaking of the rules to get on their good side. Solid, professional treatment is what they need. Even too much caring can be impossible for them to handle. They can turn that into a paranoid delusion that you mean to take over their lives and harm them.
It’s not a bad training ground for becoming a good psychiatrist. You see a boatload of suffering. You can help but often you can’t fix. You hear tragic, funny, unbelievable stories because the sickest of the sick often don’t have filters on what they tell you. All of this is humbling. You find a distance that lets you care about your patients without drowning in their misery or putting either of you at risk.
In the outside world where people seem to cope, the distance between you and your patient is less. But it is still there. You are not their friend. You cannot trade favors or secrets. It is a one-way intimacy. It is their time, their life, their troubles. While it might seem useful to patients to share your own similar problems, it almost never is. Walking down the path of self-revelation is a slippery slope. People are paying for your expertise, not your life story. You are there to help them—not the other way around.
The right distance isn’t a measurement you can take—like making sure your chairs are placed at just the right angle, a certain number of feet apart. Although physical distance does matter as well. My patients always have a choice of how close or far they sit from me. And I make sure I’m comfortable. Sometimes that physical distance changes over time, and I often see it as a marker of our work, our growing intimacy. It’s something we eventually discuss.
As to psychological distance, there are times when that also fluctuates. As psychiatrists, we use our mind as our tool, the way an internist might use a stethoscope. I tap into what I’m feeling and see to what degree it reflects what the patient is feeling. This always needs to be checked out. Is it ever all right to cry with a patient because you feel his pain so intensely? My response is yes and rarely. I wonder what others would say. If you are too caught up in the emotion, then it’s hard to help the patient. And if you are too unfeeling, then you probably haven’t reached him. Or he is keeping his emotions at bay.
There are times when the balance can shift. At the end of treatment, I allow my patients to ask me the personal questions they have been anxious to ask. I answer them unless I see some reason not to. I allow them to see a little more of who I really am. We don’t become friends—that part of the relationship does not change. Often I wish it could because I like the people I work with. But it can’t. To become friends with even a former patient distorts the relationship and often the work that has been done. It’s not an even playing field, much as we might like it to be. It’s like a teacher-student relationship or priest-practitioner. The patient must be able to trust that we will always have his best interest at heart and not our own, that we will never take advantage of him. And this is an agreement that doesn’t get cancelled at the end of treatment.
It’s a balance that can withstand mistakes and misunderstandings, but one in which the well-being of the patient always comes first. Patient and doctor must know that the distance between them will keep them both safe and connected.