In our preclinical psychiatry courses, we learn about the ideas of transference and countertransference, which is when patients project their own thoughts and feelings onto their therapists and vice versa, respectively. We’re told that patients who had close relationships with their parents start to develop similar relationships with their psychiatrists. Additionally, we are informed that sometimes the psychoanalysts who harbor feelings of hostility and resentment toward their spouses will start to hold those sentiments for their patients.
What we don’t learn about, and for which I was most unprepared, is what happens when we see our reflection in the people that we help to take care of on a daily basis. We can intellectually comprehend defense mechanisms, the DSM-5 criteria for major depressive disorder or the pharmacology of psychotropics; however, we’re never taught about what to do when, sitting across from patients, we end up sitting across from ourselves.
I completed my six-week psychiatry clerkship at an inpatient facility in Greater Boston; I helped to care for adults, pediatrics and the elderly. I gained substantially from my experience, learned tremendously from my patients, preceptors and even discovered quite a bit about myself.
I’ve always been an anxious person; I can’t remember a time in my life when I didn’t over-analyze or worry about something inconsequential. As a kid, I burst into tears at the thought of having to make a phone call, and as an adult, my heart beats out of my chest when spending time with people who I don’t know very well. I have always been slow feel comfortable around new acquaintances and have made only a few close friends in my twenty-five years. Other than my parents, my support system has proven at best tenuous among my peers.
This past summer, my long-term girlfriend and I went our separate ways, which deepened my anxiety and allowed depression to seep in as third year began. I felt my isolation intensify as my classmates and I scattered across New England, leaving me to face my loneliness and all that came with it alone.
It seems appropriate that at this unique time in my life, I started my psychiatry clerkship. I began to understand the emotions I was experiencing through the lenses of the patients I met and interviewed; it was both enlightening and deeply uncomfortable. Months later and I am still grappling with what I felt.
One day on the adult inpatient psychiatric service, I was asked to speak with a man in his mid-thirties who was admitted the previous weekend for symptoms of major depressive disorder including suicidal ideation. My attending stated that he would be good for me to talk to and get to know.
Many of the details of his life were foreign to me: trauma, substance abuse and bouncing between jobs without a sense of direction. I listened to him discuss his struggles, offered advice and counsel where I could and thanked him for being willing to discuss his life with me. In a Boston accent that Matt Damon and Ben Affleck could be proud of, he always reassured me that I was welcome to talk with him anytime.
I hoped to at least lend a listening ear to this patient. I wasn’t expecting to see bits and pieces of myself and my life in him and to have his story so deeply resonate with me.
This patient struggled deeply; not with self-confidence, not with a lack of belief in his own talents and abilities, but with a firmly held belief that he had nothing to contribute. He stated that he felt like he was worthless. His anxieties seemed to eat at him as he told my attending and me how depressed he felt about his life. He told us about toxic relationships, about how the smallest bit of criticism sent him spiraling and how so often, he felt like a burden.
Through tears, he stated that he always let people take advantage of him. He felt as though people always wanted something from him, that he allowed it and didn’t know how to stop it from happening. Never before had I seen myself in another person like I did that day. I thought of my own struggles and feeling like my world was collapsing around me. My mind turned to my own feelings of worthlessness such as having nothing to offer anyone, the intense, all-consuming fear that no would ever need me and that no one would ever love me. Right in front of my eyes were memories of days when I felt so horribly about myself that I would spend hours wandering around with nowhere to go or to be and hiding my tears behind sunglasses. I thought of my own relationships including ones in which I felt both taken advantage of and also that I was burdening the other person all while feeling as though, somehow, I deserved it.
My patient stated that he became depressed about everything and questioned whether or not he would recover. It frightened me to hear those words. I felt as if my patient’s mental state was my own writ large. I was worried that I could very well end up in the same situation and feeling as if life was no longer worth living to the point of being confined to a locked unit for my own safety. I felt the same feelings that my patient was feeling; I no longer enjoyed what I previously had, no longer looked forward to anything and no longer felt that things would turn around despite my desperate efforts to convince myself otherwise.
In many of our talks, my patient would fall quiet for seconds or minutes at a time letting silence fill the room, and our thoughts would permeate the space between us. In these moments, I was most at a loss for words; I wanted to say something comforting or reassuring, but I knew that I wouldn’t believe those words myself. I faced an impasse on how I should respond. I questioned whether I should perform my role as a student doctor and offer what I believed to be false hope or if I should speak as a friend and inform him that I had though those same thoughts, had those same feelings and knew intimately how he felt. Frankly, neither felt very appropriate.
Thankfully, my attending stepped in during our conversations. She told our patient that he was a good person and reminded him that she saw him as a kind, sensitive person incapable of hurting anyone.
He stated that he didn’t know, and he didn’t want to hurt anyone.
Neither do I, I thought. So why do I always feel like I am?
My attending continued by saying that the keys were to build up mental armor and find ways to not let little things bother him.
Never truer words spoken, I thought. Why can’t I do that?
She told him that we build up the armor so that we can keep living. If we don’t have the armor, we would never live. Every negative thing that anyone ever said about us would destroy us. We build up the armor to only let the things that matter affect us.
Our patient seemed to understand this. Seemingly defeated, he stated that he didn’t know how to do this and that he just let it all get to him and then he felt awful again.
I let the words sink in for myself. I let every negative thought or feeling weigh on me and lay me low. Neither I nor my patient seemed to have the armor that my attending spoke of, nor did either of us seem to know how to build it up to its original height. I didn’t know how to stop it all from flooding my brain or how to stop from feeling as though I was merely a hindrance to others. Like my patient, who often felt like he offered only that which could be extricated from him, I felt I could offer nothing but medical advice that felt increasingly meaningless and unfulfilling. Like my patient, I felt that there was no way out and no way to cope with how bad things had gotten.
My attending concluded that our goal was to help our patient get better, as we wrapped up our interview. She told him that we would talk more tomorrow.
As we got ready to leave and continue our day, I again offered thanks to my patient for being willing to talk to me even when he didn’t have to do this.
One final time, he reassured me that it was no problem.
I rotated off the unit not long after this patient was discharged; I crossed paths with him one final time as he was headed to an outpatient appointment at our hospital. He seemed brighter and more relaxed; maybe I was only seeing what I wanted to see. In the months since my psychiatry rotation ended, I’ve had the proverbial good days and bad days. In general, I say that things have gotten better, but like when I saw my patient for the final time, I wonder if I’m only seeing what I want to see.
I carried with me from psychiatry a far greater experience and understanding than I ever anticipated. I learned what it truly means when we say that we are not alone. Through my patient’s same wants and needs, I saw my own thoughts, feelings, hopes, dreams, fears and my own desire to be liked, to be wanted, to be needed. I felt, for the first time in a very long time, a genuine human connection. I learned not transference or countertransference but, rather, empathy.