When you think of the word dissociate, it likely conjures up images of someone stumbling up a beach with no recollection of their life before being washed up on shore. Sure, dissociative amnesia is a (rare) phenomenon. But dissociating is not.
In fact, doctors are trained to do it.
When I was in clerkship in Toronto, Canada – I started working night shifts. Learning to ignore my body’s signals that it was tired. It’s yearning for sleep. By the time I began working as a hospitalist, I was able to completely bypass the signals in my body telling me it was exhausted or hungry or thirsty or needed the washroom. I even became desensitized to the incessant beeping of my pager, a tone so shrill that it activates my heart rate to this day.
We learn to maintain professional boundaries, not to care too much or get too involved with the suffering. Not just suffering we witness but pain where we are culpable. Where our skills often mean the difference between wellness and illness. It would break our hearts to admit to the iatrogenic harms of the opioid crisis, to the rampant racism within health care, or the knowing that treatment plan has cost someone their housing stability or employment. We are taught to feel responsible when the problem can’t be fixed, to keep trying even when something is futile. We get so caught up in trying to cure that we forget the most healing response might be to … let go.
I’ve seen dementia patients put on dialysis. Patients with no chance of meaningful recovery after stroke given a feeding tube. There are cases, albeit more common in the United States, where a patient is given a medication that has an abysmally low chance of helping them – like the “number needed to treat” to improve their odds of recovery from cancer might be 1 in 700. This is how doctors dissociate from consensus reality.
The first day that I hugged a patient, I felt tremendous guilt. But it was likely one of the most healing acts I’ve done. I had been taught that my humanity and heart were not one of the tools I should bring into the consultation room. That if I loved my patients, not in a romantic way but in a deep compassion and caring way, it was inappropriate.
I’d argue now that it’s inappropriate not to love them.
After well over a decade of inpatient work, I transitioned into the community full-time. My graduation year tells the story of what I had learned about the root cause of illness – I graduated from medical school in 1999, the same time the study was released about adverse childhood experiences (ACEs). It wasn’t until I began recognizing that my patients had sky-high ACE scores (not a great public health measure, but a useful thing to know) – that I realized why it felt like I was putting out the same fire every week. I wasn’t treating the roots. I hadn’t learned about epigenetics until I started to study again, ferociously, to see what I’d missed. All my CME, my master’s in medical education, and attendance at all the conferences still didn’t point me in the direction of causality.
I have since become a clinical integrated traumatologist. I can treat the three phases of trauma recovery (as described by Judith Herman) – mindful grounding for safety, process, and neuroplasticity to change the associations with traumatic content and reconnect to life with a new identity. It’s become the most rewarding work that I could have imagined, leading me to join TikTok to share mental health content and to write a book: The Modern Trauma Toolkit comes out in May of 2023.
But it wasn’t until I learned this new paradigm that I recognized how much dissociation I saw in patients. Yes, of course, there are the obvious ones with ADHD who daydream out the window all day. But also the ones stuck in a “freeze” response where they can’t get out of bed or off the couch. The ones who don’t trust anyone and who feel nothing is safe. The ones we call non-compliant. It’s often trauma.
Dr. Stephen Porges calls this a “dorsal vagal” state – where their vagus nerve that should be sending efferent messages to the brain dampens their sympathetic tone. It happens when they reach a state of overwhelm. They disconnect, “play possum,” by laying down and feigning death, hoping the predator disappears. Netflix and Doordash for days on end. It can look like the Great Resignation.
And it wasn’t until I learned this new paradigm that I recognized how much dissociation there was in my profession. We call it burnout, compassion fatigue, or countertransference. We pathologize our survival strategies.
Physicians are experts at dissociating because the system demands it from us. If we truly listened to our body’s physical needs, our mind’s psychological distress, and our heart’s desires – we would not be so compliant within a system that causes harm to health care workers and patients alike.
It’s time for a reconnection to our humanity. To our instincts. To our purpose.
While this was an important skill to get us through our challenges, we have paid too high a price. We have lost ourselves. Not crawling on a beach, head empty of memories, lost. But we have lost our sense of interconnection that gives humans our truest meaning.
We can recover too.
Christine Gibson is a family physician and trauma specialist.