I bid farewell to four people this month who I’ve been caring for in my outpatient psychiatry practice — all under sensitive circumstances but ultimately moving in positive directions. As I write formal discharge letters, the unique role psychiatrists and other mental health clinicians play in the lives and minds of the people we care for is on my mind.
It is the nature of our healing practice to build trust and for the relationship to go deeply into the mind, heart, and spirit of the people who come to us for help. Even though this mental and emotional vulnerability isn’t a two-way street, it ties a part of us to them in the responsibility we take for their emotional well-being and as keepers of what they share with us.
It is understandable for a person to become attached to the doctor they trust and not want to start over in an unknown circumstance. Referring someone to a higher level of care when it becomes apparent that their needs go beyond what I can provide is one of the hardest things I have to do. This is especially true when it comes down to the need to set deadlines, after which point I must end my involvement in their care.
Continuing to provide care that is less than what they need to stay safe is not a responsible practice. When the crisis that brings things crashing to a halt in both our lives and overwhelms my reserves emotionally, energetically, logistically, and workflow-wise peaks, it isn’t fair to them, me, or to my other patients who rely on me being physically and emotionally present.
I’ve had enough of these “transitioning to a higher level of care” conversations go poorly that it remains a deep pain point, impacting my patients and me on a regular basis. They reach for me as if they are suddenly pushed into a pit of quicksand, even though preparatory conversations have already been had.
“You’re firing me? What did I do wrong?”
“Please don’t give up on me. I have a new lease on life. And I’m taking the medications now — all of them, the whole doses, every day. I’ll do everything you recommend this time.”
“I’ve made calls and screened some therapists, but I can’t work with them, I don’t feel like any of them are right for me.”
“You’ve done so much for me. And the other doctor you recommended, the one with the ‘fellowship training’ or whatever, I didn’t feel comfortable with like I do with you.”
“I can’t start over and tell everyone at a program all the traumatic things you know. I can’t go through all of that with a bunch of strangers.”
“If I want to die, no one has a right to stop me. I’m not waiting here for some ‘crisis team.’ If you call them, I’m leaving and never going to see another psychiatrist since I obviously can’t be honest and have my rights respected.”
Even when we recognize, through our training, how objections like these are part of the conditions they need more intensive treatment for, it is impossible not to feel torn in the face of human beings expressing these perspectives.
Of course, it is painful to rehash a history of trauma with a new, more specialized doctor or therapist or a program group. It’s incredibly disruptive and terrifying to go to a hospital for inpatient psychiatric or addiction treatment.
The trust isn’t there for these new treatment relationships and settings, and it can be easy, even as a doctor, to slip into a patient’s frame of mind that the transition may seem more harmful than continuing inadequate care. I’m the one in the best position to help, aren’t I? I already know their history and triggers and circumstances, so how can someone else help more than me?
I also have found myself doing what is a patient’s responsibility and further enabling the learned helplessness that is part of their illness.
I’ll come out of a daze after researching referrals ad-nauseam, looking for ones that might overcome all the objections that they’ve expressed that are distorted by flawed, rigid perceptions. Or after adding a fifth addendum or supplemental note to the medical record following circular phone conversations about why they absolutely can’t do the things that the evidence-based treatment plan dictates, or negotiating with third parties (family, school, employer) about things that the individual feels unable to manage or face.
How did I get here?
I know what I’m professionally responsible for and what I’m not. I know what the evidence shows to be helpful versus harmful. I know that feeding into rigid narratives and triangulation isn’t constructive. But I’m human. And when someone comes to me with desperation, hopelessness, or hostility that originates in fear, and I see them looking at a void where they hoped to find rescue, how do I not feel the same devastating powerlessness that they feel?
I do feel powerlessness — acutely, poignantly.
But rather than be devastated, I do my best to lean into trusting my own humanity and professionalism, my capacity to help with what they need versus what they want, as well as trusting their humanity and the impulse for growth that comprises.
No one can walk a path on someone else’s behalf. We can only clear the way. When the path I point to is rejected, or I am demonized for not carrying them, I hold onto the knowledge their path isn’t just beginning with their next steps. I have already been a step on their path, whatever course it takes, and it will lead where they are ready to go.
It is a law of nature to follow the path of least resistance. And hopefully, I’ve cleared even a little of the resistance to a path to greater wellness.
Occasionally, people prefer to reject all paths if I am unable to personally provide the level of help they need. In those cases, my heart breaks for them as they seemingly lay down in the dirt which they have come to identify with.
But as I build more positive experiences with helping people into more intensive treatment, with most eventually accepting the professional and personal limits I set and making strides they couldn’t have achieved with me, it gets easier.
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