In Praise of Psychiatric Nursing, or I guess there are Some Positives to having a Job.

Traveling for a year and a half, as Angel and I recently were, there were bits and pieces of home that we missed, some more consciously than others. We were sad to be away from friends and family in a very open, conscious way. We clearly missed Seattle as a city. And we undeniably pined for Northwest coffee and beer. But I missed work for reasons I couldn't easily put my finger on. I couldn't figure out why I was sad to not spend 30 - 40 hours of my week on a psychiatric unit, but there was a niggling sense in the back of my mind that I lost something important when I left Children's to travel.

Being back on the unit these last few days, it struck me that a big part of what I lost traveling (and what I've gained being back) is, simply, empathy.

Backing up a bit, psychiatry, I've come to be aware, is likely the most stigmatized field of medicine. Without speaking to the stigma that surrounds psychiatric patients and psychiatric diagnosis (not because it isn't important - just because it isn't my topic at the moment), the actual provision of psychiatric care seems frequently to be seen as a questionable endeavor at best.

Part of the stigma can be chalked up to fear of the unknown. Psychiatry, for reasons both legitimate and unjustifiable, has historically been practiced primarily behind closed doors out of public view: in unmarked clinics, or locked units in hospitals, or old-school asylums in the country with names like Shady Acres. The average person, I'd guess, doesn't know what professional mental health treatment looks like in practice. And, I'd guess, hopes that they never have to learn, having watched One Flew Over the Cuckoo's Nest and Girl, Interrupted

But part of the stigma is grounded in some justifiable outrage about real-live inhumane practices carried out in the name of psychiatric care. Nurse Ratched type ish (remembering, of course, that she's not real): careless manipulation of some of society's most vulnerable members. Experimental medication and forced sterilization and lobotomies and Nazi eugenics. Nowadays, it's overmedication, the psych unit as a prison for weirdos that society doesn't want to deal with, and the attempted legitimization of sexual conversion therapy using psychiatric categories.

Also, L. Ron Hubbard and Tom Cruise and John Travolta.

(I'm a little concerned that this next paragraph will contribute to social stigma against psychiatric patients, so let me just preface by saying that mental 'illnesses' are at the end of a spectrum that we all live on at some level, and I genuinely believe that everyone is at risk of developing something diagnosable under the right set of stressors. And let me also preface by saying that there is a big difference between being diagnosable with a mental illness and being a bad, or immoral, or dangerous, or unhappy, or (mos def) uninteresting person.)

But it is true, especially in more severe cases, that part of the defense of psychiatry is that messiness is, indeed, the nature of the psychiatric beast. To mix my metaphors, psychiatric care is work in the trenches, frequently with people with issues that most would rather not confront, or would rather pretend don't exist. It is work with people who's brains don't work correctly, people who don't feel that their lives are worth living, who don't have their act together, who have emotional swings of epic proportions, who can't control their behavior, or have thought processes that are completely incomprehensible even to themselves. It is sometimes work with people who are volatile and dangerous - occasionally to others, but most often to themselves - and it is at times work with people who have already done terrible things. (Again, sometimes to others, but most often to themselves.)

And, if one views mental health through a medical lens, where the goal is a 'cure', psychiatric care is very frequently a losing battle. Mental health issues (especially in adults) tend to be chronic: more aspects of an individual's personality that they have to deal with rather than a passing infection - either because of physiological makeup, a degenerative condition, the way that their personality was formed through traumatic life experiences, or physical damage to the brain, which doesn't heal itself as effectively as other organs.

With all of that in mind, you wouldn't be faulted to question why anyone would actually 'do' psychiatric care, and how it could possibly be viewed as meaningful.

For me, the key has been to recognize that psychiatric care - although it involves medication and other interventions focused on physical and structural issues in the nervous system - doesn't fit that neatly into a medical model, because it frequently isn't (just) aimed at finding a 'cure' for some physical abnormality or disease (though ojala que si!). The concept of a 'mental illness' has its functions to the extent that many issues are related to physiological problems, but it is also misleading to the extent that it implies that treatment only involves medications or other physiological interventions. In its best form, and in every context that I've seen it practiced, psychiatric treatment is actually a holistic field, because it involves medical interventions like medication and surgery at times, but it also includes social, spiritual, educational and physical therapies.

And that holistic approach points towards what I think of as a helpful (albeit very broad) definition of psychiatric care - the attempt to help psychically suffering people live the best, most fulfilling lives that they can using whatever available tools work for them. That sounds under-grad idealistic, and not that different from how many religious leaders or philosophers or self-help authors would describe their work, but I really do think that the best practitioners in psychiatry tend to be motivated by that sort of mission.

What that means in the trenches is that psychiatric care is (at least in part) a troubleshooting mission focused on alleviating suffering: it is an attempt to figure out what issues are disrupting an individual patient's life, and what can be done to address them. I'll be the first to say that some healthcare systems and providers are really terrible at this, and that psychiatric care has in many cases caused more suffering than it alleviated. But regardless, that's the goal. And with that goal in mind, in order to be a good psychiatric practitioner, along with having a good scientific understanding of how the brain works, one has to be a good empath: that is, you have to be able to understand another person's lived experience, to be able to understand what another person is thinking and feeling, why they are thinking and feeling it, and what actions can be taken so that they will be able to decrease the amount of distress they experience as a result.

All of this is to say that I've realized that leaving psychiatric work at Children's meant leaving what amounts to regular empathy training in an extremely challenging environment.

In order to get admitted to an inpatient unit like ours, things have to be going really badly: patients have been so behaviorally out of control that their parents can't manage them safely, or they have attempted suicide, or they have assaulted family members, or are having first manic or psychotic breaks, or are severely autistic and aggressive or locked in a pattern of self-harm, or a host of other issues that make it impossible to manage safely outside of a locked unit with constant supervision. Bearing in mind that the goal of psychiatric care is to treat the issues that are causing these levels of distress, and leading to destructive behaviors, the people who work on our unit spend their days trying to understand the situations of some of the most distressed patients in the state, and trying to figure out interventions that will help - when in most cases everything obvious has already been tried at home. Add in the fact that we work in a pediatric hospital, and that kids as a rule think and feel differently from adults, and what this adds up to is a huge challenge for the would-be empath.

In a huge spectrum of patient's, we deal with a full range of human suffering, and consequently a full range of 'things that help'. Patients who respond well to medication are on one end of the spectrum, and at times our goal is basically just to keep them safe until meds kick in. Patients whose issues are more related to trauma or socialization than physiological issues, or who respond not at all, minimally or negatively to medication are at the other, and for them we work our asses off.

Being in that environment on a daily basis, charged with the responsibility to understand and help, shapes you. It can be emotionally exhausting work, and breaks like the one we just took are really valuable and maybe necessary at times. But because Children's is an incredibly supportive place, staffed by brilliant people and extremely well resourced, the level of challenge involved generally creates a growth environment - a place to practice empathy for patients who I sometimes completely don't understand and process with peers and mentors what exactly might be going on in those minds and hearts. The value for daily life is huge, and when I was gone, I missed it. I didn't realize it until I went back to the unit last week, but I missed it.


callista said…
I'm so glad you're there doing what you do, Tim. They're lucky to have you.
Julia said…
So well written. It gave me some insight into my own sense of missing the unit. I'm so lucky to have worked there.
Unknown said…
Well written. Can't wait to meet you.
Unknown said…
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Unknown said…
I literally just thought to myself "I need some words of wisdom written by a fellow psych nurse". Thought I would check your blog and found this great post. Thanks for the perspective.