A Patient Reads His Psychiatrist
By the morning of November 23, 2013, I went through another sleepless night. The last few nights had been particularly bad as I had been tossing and turning with sweat pouring from me. Whatever brief moments of sleep I was getting were tormented by the violent images of my dreams. My night terrors were a perfect expression of my traumatized mind. My focus had narrowed to the Shakespearean question, “to be or not to be.”
I felt terribly ashamed and guilty for losing my job and jeopardizing my wife’s well-being. She was blaming me for not being able to keep my job. I thought my only chance of making it up to her was by killing myself. I told her that if I died, she could live off my death and social security benefits which would have allowed her to remain in our beloved house. I told her that I thought sacrificing my life for her benefit was a loving thing to do.
That morning, I called our longtime family doctor, to tell her I needed to go to the hospital as I was desperate for sleep. Not getting restful sleep for days was unbearable. By going to the hospital, I thought I would be able to get medicine to break the many nights of sleeplessness. I assumed I would be on a medical unit where I would have a quiet room. I knew from my experience as a mental health therapist that sleep deprivation is potentially quite dangerous.
My wife drove me to the hospital and sat with me as I was interviewed by the emergency room doctor. The note from the ER doctor read that I was a “patient experiencing major depression, suicidal thoughts, constant anxiety, hallucinations, and possibly delusions. He cannot clearly contract for safety, stating, ‘if something terrible happened, I would not be surprised.’ The ER doctor recommends inpatient hospitalization at this time for stabilization and further evaluation. The patient is voluntary and wants to be admitted.”
After a bit of a wait in the ER, I was admitted to a locked psychiatric ward. As I was wheeled onto the ward, the door locked behind me, and my life would never be the same. As I entered what felt like Dante’s Inferno — a house of horrors — my high anxiety morphed rapidly into absolute terror when I was assigned a shared room with a psychotic man who upon meeting me said, “So you’re here to sleep. I’m here to talk to you.” Fear and terror ravaged every cell of my mind and body in an environment that was anything but calm and quiet.
The noise and chaos in the unit were unbearable. Terrified of being confined in the hospital, I was desperate to go home as soon as possible. Dr. W. wrote in my medical chart, “Unfortunately, he has had severe insomnia due to anxiety and has not slept well, or perhaps at all for 2-3 days. Also unfortunately, the only bed available here was on our intensive care unit, where there are currently multiple patients with severe MI who are psychotic, loud, and disruptive, which is about the worst environment for this patient one could imagine.”
By the time Dr. W. was ready to see me, I was severely agitated and feared losing my mind. Within seconds of meeting him, I could sense Dr. W.’s dis-ease and discomfort. I suspected he was told before he saw me that I was agitated and demanding to be discharged. When he introduced himself, his affect was dull and he seemed irritated that I had been begging to be seen by him. He was very impatient with my impatience to leave the hospital as soon as possible. I was on the edge of a nervous breakdown, but there was nothing calming or reassuring in my doctor’s presence. This hospitalist was anything but hospitable.
Dr. W. seemed unaware that the manner in which he presented himself had real-life consequences. Being a seasoned therapist myself, and being exquisitely sensitive, his negative affect frightened me and served as a warning sign that I was in trouble. I felt trapped behind the locked doors of the hospital unit. I resented that he acted as if it was unreasonable for me to expect that he would be kind, patient, and considerate. He had no ability to form a therapeutic alliance with me.
Dr. W. quickly ushered me through a perfunctory suicide screening assessment he had committed to memory. He was trying to determine if I had the desire, intention, and means to kill myself. The way he asked me questions put me in a defensive mindset. To each question I answered, “I am not suicidal, I just want to go home to sleep.”
In a state of panic, I knew I needed to do something to appease his dislike for me so he would release me from his control. I thought I would appeal to his sense that I was a capable mental health therapist who knew what I needed. I told him that for seven years, I had been a behavioral scientist in a family medicine residency program. As a medical educator, I had taught that how a doctor feels about a patient is of great importance and makes a substantial difference in patient satisfaction and positive outcomes. Simply put, no physician can take care of a patient without caring about them as a person. When a physician does not like a patient, they are more likely to be dismissive, inattentive, abrupt, and impatient.
After telling him about my clinical experience in teaching family medicine residents, I said, “I don’t think you like me.” Dr. W. stared back at me impassively and said, “You’re right, I don’t like you. You’re making my job difficult.” His words were said without insight, self-awareness or compassion. His glib response was thoughtless but he did have the presence of mind to not document his caustic words — “I don’t like you” — in my medical chart. By doing so, he buried the moral significance of his cruel words and presented my alleged “lack of cooperation” as completely unwarranted.
The crucible in which we met was a cauldron of mistrust. I didn’t trust him and he didn’t trust me, which distorted the perceptions and inferences we made about each other. I was agitated, sleep deprived, and fearful; he was annoyed, impatient, and irritated. I didn’t trust him because he didn’t like me and I didn’t think he had my best interests at heart. He felt insulted that I was aware of his negative countertransference.
My medical chart was mostly focused on how he felt insulted and offended by my presence. I quote from the discharge summary: “He was extremely irritable, and was personally insulting to this examiner, repeatedly seeing himself as trying to teach me how to conduct a decent examination, and was very critical of my attempts to do so, while at the same time refusing to cooperate with even a rudimentary evaluation until I could finally convince him unless I was able to do so, I would be forced to place a hold on him because I couldn’t draw any conclusions about his diagnosis and safety. He interpreted that as a “threat.”
Dr. W. was most likely unaware of the large percent of suicidal patients who deny being suicidal when seen by mental health professionals. According to one study in General Hospital Psychiatry, roughly one half of people who have suicidal ideation will deny it if a mental health professional or researcher asks them about it. In addition, about one-third of people who attempt suicide do so in the first couple of weeks following a psychiatric evaluation and hospital discharge.
Dr. W. acted as if mentioning my perception of his affect violated the sanctity of the doctor/patient relationship. His quick dismissal of my words about his affect showed a subtle but important form of unconscious bias. While he complained that I was arrogant, a more reasonable assessment would have considered that I was highly intelligent, well-educated, and insightful, and in that regard, I might have been an atypical or unusual patient for him.
From what I experienced over my 40 years in the mental health field, such attitudes toward distressed patients are anything but rare and unusual. Nonetheless, how Dr. W. wrote about my pain was deeply flawed. He believed my pain was endogenous, a product of my presumed personality disorder. He didn’t seem to have any interest or ability to link my symptoms of despair to the rapidly deteriorating circumstances of my life. In my medical chart, he made no mention of my being unemployed, or my fear that at age 63, I would never find another suitable job.
The story of my suicide attempt exposes the ease with which a well-regarded psychiatrist can inure himself from a sense of responsibility when a distraught person is suffering. My story also exposes the ease with which some mental health professionals are able to suppress their own capacity for empathy and compassion. Dr. W.’s attitude of knowingness, that he knew what he needed to know, was reflected in his repeated claim that he was a “pretty good doctor.” He was more concerned with protecting his professional identity rather than being a good doctor for me.
Dr. W. was unable to accept the fact that he and I were not a “good fit.” Conscious awareness of the autonomy of negative countertransference is not something promoted in modern day psychiatry. In fact, the way that countertransference is typically conceptualized is that it is evoked primarily by the assumed pathology of the patient. This gives clinicians great power and allows them to avoid responsibility for their unkind and impatient reactions to patients.
Unbeknownst to Dr. W., his biomedical orientation to medical interviewing was evident in everything he said to me. The “self-assured” psychiatrist seemed to be completely unaware of why I did not trust him. He never acknowledged that I might have “insight” into what was happening between us. He never considered that I might have reason to mistrust what he had to say to me and about me, especially given the fact that we never established a therapeutic alliance. The only common perspective we shared was that he didn’t like me. His power over me left me feeling exquisitely vulnerable.
Dr. W. wrote his diagnostic assessment as if it was the definitive truth about what happened between us. Though he had been “trained” in psychiatric interviewing, he seemed to be unaware that there are many in the healing professions who have legitimate concerns about his particular biomedical style of psychiatry. I doubt that he had much training in motivational interviewing, reflective listening, and the importance of listening with an open mind to what a desperate patient like myself had to say. He showed no understanding of the intersubjective nature of medical interviewing and that his emotions had any bearing on the quality of our relationship. It was clear that he was annoyed and irritated that I was not a more passive and deferential patient.
Ironically, my estimation of Dr. W.’s core affect (that he didn’t like me) was completely accurate. In a curious twist of fate, I was more in sync with him than he was with me. He was confident but not correct in his assessment of me. He acted as if I had no legitimate right to feel frightened by his words and behavior. To me, this shows an utter lack of understanding of my lived experience as a depressed and potentially suicidal patient. It never dawned on Dr. W. that I might be insightful while still being distraught and desperate.
After he made clear that he would not release me until he “completed” his evaluation, I then focused on saying what he “wanted to hear.” I knew from experience that if I insisted that I was not suicidal, he would be more likely to discharge me. I repeatedly said, “I am not suicidal, I just want to go home to sleep.” That was my standard response to any of his questions. From this, he said that I “contracted for safety.” He took my denial of suicidal ideation as factual when it was not.
He also wrote in my medical chart that my then-wife was not “concerned about my safety” if I was to be discharged. He accepted her statement at face value, without considering its irony, but he never documented what she meant. By the time he discharged me, I was certain that he didn’t care if I lived or died. The same can be said for my now ex-wife. On the day of my suicide attempt (November 27, 2013), she told a common friend, “I can’t believe Michael ‘messed up’ his suicide attempt, I would have been able to keep the house.”
Dr. W. complained that I was uncooperative because I was agitated without understanding that agitation is a significant risk factor for suicide. The late suicidologist John Maltzenberger wrote, “Intense desperation is a mental health emergency.” But for Dr. W., all he could see was an “uncooperative patient” who had the audacity to notice his dislike of me. Dr W. went on to write that he had never met someone so inclined to blame others for his own problems. It seems evident that he was not used to a patient being able to read his implicit bias and negative countertransference.
Dr. W.’s conclusions were neither apt or meaningful. There is extensive research on the high rates of suicide in the weeks following a discharge from a psychiatric hospital. His problem was that he was unable to keep what he felt about me from influencing what he claimed to know about me. In psychological terms, Dr. W. was a naïve realist who believed that he saw me just as I was. In an instant, his solipsism transformed me from an intelligent, caring, and distraught person to a non-person, an unlikable person, unworthy of receiving kindness, compassion, and professional consideration.
His claim that he didn’t like me was absolutely truthful, but his insinuation that I insulted him was completely self-serving. In the midst of my woes, he used professional jargon to isolate and insulate himself from self-examination. Much of his verbal and written discourse consisted of hyperbole, accusations, and distortions. In his defensive state of mind, Dr W. was too jejune to ask himself, “What is going on with me that I am being so unkind to this vulnerable man?”
I felt that Dr. W. did not understand the depth of my despair. He neglected the context and specificity of why I was having the problems I had. It was not possible for me to reorient my psychiatrist so he would become more compassionate to me. He thought it was preposterous that I didn’t think he was empathic.
From my perspective, his problem was that he couldn’t admit to himself that he had no idea how to form a therapeutic alliance with me. For him, that kind of awareness would have been humiliating rather than humbling. I would have had more respect for him if he had paused and asked me with an open mind, “Why do you feel I don’t like you?” I would have also appreciated being referred to another doctor to complete the evaluation. But that would have taken courage and humility that Dr. W. didn’t seem to have.
It is well established in the mental health literature that psychiatric diagnoses are often misused to create an arbitrary and stigmatizing distance between the doctor and the patient. Dr. W.’s description of me, that I was agitated, insulting, uncooperative, did not match the emotions I was feeling. I felt distraught, hopeless, terrified, and desperate, a derivative of the word despair. He showed no understanding that his affective response to my despair made my situation worse.
Dr. W. did not listen with the intent to understand, he listened with the intent to categorize and label; for he made it clear that unless he could give me an appropriate diagnosis, he would put a hold on me. Psychiatric diagnostic categories are intended to reduce the complexity of lived experience for the purpose of insurance reimbursement. Dr. W. would not have been paid for his time without giving me the label he did. Unfortunately, psychiatric nomenclature deflects the crucial links between psychological pain, brain function, and lived experience.
For me, his assessment was more a bureaucratic obligation to fulfill his commitment to the hospital and the insurance company that was paying for his services, than it was to help me. The words he used to describe me were all pejorative. He made no mention of any characteristics that he respected. He lacked any understanding that my experience of suffering was unique to me and that I might resent his feeble effort to fit me into his favored diagnostic categories. Dr. W.’s delusion of understanding, his felt knowingness, was an obstacle that blocked him from understanding me with any reasonable degree of compassion.
Nine years later, I am still amazed that Dr. W. could so easily suppress any compassionate feelings toward me. The truth is he never said anything to me, or wrote anything in my medical chart, that might vaguely be seen as respectful, kind and caring. He made no effort to manage or monitor his negative countertransference, which might have allowed him to consider the iatrogenic effects of his words upon me.
I write not to establish my “innocence” but to understand the confluence of life-threatening circumstances that once held me captive. The relationship I had with Dr. W. is a cautionary tale; a reminder of the importance of all physicians abiding by the Hippocratic Oath — primum non nocere — above all else, do no harm.
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