The Pain of Empathy: Coping with Mental Illness as a Clinician

During my time at Willowbrook Residential Center, I had the unique experience of coming face-to-face with people suffering from severe mental disorders. It was a surreal experience, to be sure, as I tried to reconcile living with mental illness as a more or less permanent part of one’s identity. I attended my placement, all the while feeling distinctly disconnected from the clients I was supposedly there to assist.

The most difficult issue to face in this field is, in my opinion, working with those clients who may never get better. There is definite stress and sadness associated with working with those for whom their mental illness is, quite simply, a way of life, and will be until they die. How do you cope with such a bleak prognosis—both as a client and as a clinician? I am left wondering if this was the source of that disconnect—was I afraid of the disappointment, of the futility of trying to aid in a hopeless cause? It felt like befriending someone who you know has terminal cancer. How do you get around the undeniable fact that they will never get better?

This is a question I grappled with during my time at Willowbrook, particularly in the times I was called to work with a particular patient, who we will here refer to as Steven. Steven has severe symptoms of obsessive-compulsive disorder, as well as schizophrenia, to the point where he uncontrollably collects trash and junk in his room, and is virtually incapable of parting with it without strict guidance. When I first became acquainted with Steven’s case, I was told much about how intelligent he was. How he, despite his illness, frequently went to community college classes and thrived there as an engaged and enthusiastic student. I was encouraged, believing that he would have a lot of insight into his disorder, and that it would be easy to communicate with him.

However, when I finally met Steven, I was met with the reality of the situation: that he was barely communicative, not at all aware of the facts of his illness, and it seemed impossible to get anything through to him. Steven’s coordinator informed me that he had been working with Steven for a long time, and had tried everything he could think of. He also confided that, though I had been brought into the case as a sort of last-ditch effort to prevent Steven from being evicted from Willowbrook due to his unsanitary habits, he (the coordinator) didn’t really believe there was any hope that there would be any actual improvement.

This was a bit of a harsh reality check—why was I even there, then? What was I hoping to accomplish with a client who had cycled around in the mental health system for literally as long as I’ve been alive? It felt like such a futile effort, and I began to wonder whether anything we were doing here—indeed, in the mental health system at all—was worth all the time and money that’s being poured into it, if there are so many clients, like Steven, who never experience relief from their illness?

I spoke to my supervisor, bringing to her some of these concerns. I was confident that, given her years in the field and close contact with the clients, she would have some insight. I was correct; not only had she grappled with the same sorts of questions, but she also had some interesting light to shed on the situation, and by the end of our conversation, I had come to some conclusions.

The cold hard truth is that some clients never do get better. This is a very basic fact that clinicians must learn to accept. While some more fortunate clients can be counseled through rough patches in their illness and eventually rejoin the community, for other clients, all we can do is maintain them at baseline. We—and they—must learn to accept the illness, much as a cancer patient must accept the cancer. We can try treating it, sure, but at a certain point it becomes unavoidable to realize that it may be futile.

It requires a certain amount of realism to accept that some people may be in this position for the rest of their lives. In discussing this with my supervisor, I found myself reflecting that I am much more of an idealist—I like to believe that, eventually, everyone gets better, if they put in the required effort. Hearing her say that one must be realistic rather than idealistic, therefore, made me a little nervous. Does becoming a so-called realist mean I have to become jaded?

But my supervisor had something to say to this too. Being a realist is not to say we are giving up on our clients; on the contrary, they require even more commitment—more effort and time—than their more fortunate peers, because the goal for them is to develop an environment that as closely approximates a happy, healthy home as possible. Willowbrook—and places like it—create a stable community, a more compassionate and therapeutic version of the real world, so that these people can live as close to a normal life as possible while still being cared for and treated for their illness.

As for becoming jaded, I learned something that was encouraging. Of course it’s true that, in my own experience with clinicians, I have seen plenty of those who seem to not care at all, who don’t connect with their clients as people, but only take notes and spout out textbook phrases and coping skills. These people have truly frightened me, and I find myself wondering if this is my future. Am I doomed to become a cold, impassive therapist, building a wall around myself to avoid the heartache of failed interventions? My supervisor doesn’t think so.

I’m learning that the most important thing is to avoid burnout at all costs. It is so easy to slip into complacency where you find yourself just going through the motions, not actually invested in their welfare or their future, just doing your job to get through the day. But it is possible to avoid this future, with constant effort and reflection on why you got involved in the field. It is so crucial to never let human beings become merely names and diagnoses. They are more than their symptoms, more than their illness. There is a reason we no longer refer to them as “schizophrenics”; they are people—real human beings—with a mental illness. To cease to see them as human beings means to not care whether they get better or not. And if you don’t care about your efforts actually being successful, why are you in this job to begin with?

The point is that we must do everything we can do ensure we are getting the best possible treatment for people. Always question yourself, always confer with others—get a reality check so you don’t become isolated in your own limited worldview, with a perspective of apathy and disengagement. Be making every attempt to help them get better, but at the same time find a way to accept that they may not be able to get better. Therefore, in addition to providing them the best care we can, we must also give them a healthy community, with healthy connections, because only with those things can people truly thrive.

To Be Yourself Or Not To Be Yourself

Don't Talk to Strangers.
Eat Your Fruits and Veggies.
Stop, Drop, and Roll.
Look Both Ways Before Crossing the Street.
If You Can't Say Something Nice, Don't Say Anything At All.
Remember the Boy Who Cried Wolf.
Treat Others as You Would Want to be Treated.

As children we are taught many things above and beyond addition and subtraction. There are certain lessons we were all instilled with, until they become part of our very worldview and means of approaching our lives.

One of the primary examples is very simple: Be Yourself.

We were inundated with the sense that we should not conform for the sake of winning others' approval. We should not be afraid of what others think. We should never try to change ourselves for someone else. So basically, we don't need to adhere to social norms if we believe they're wrong. Right?

There's just one problem I have with this easy, feelgood moral. There is a word for people who don't adhere to social norms: they are called psychopaths.

The technical term for this is Antisocial Personality Disorder: these are people who frequently infringe on the rights of others in very real ways. They are your classic serial killers or CEOs who rob their company of millions of dollars-- they are cruel and vicious and feel no remorse. Social norms mean little to them.

There are some theories as to how this may come about. In normative development (i.e. the way it's supposed to go), we experiment and test the boundaries of behavior. When we act badly, we are punished, either directly, by a parent or teacher, or indirectly, by being alienated from social groups. We develop a sense of what is "normal" in society, and through this, we are accepted by our peers. Individuals with Antisocial Personality Disorder may be less able to undergo this type of conditioning: something about their biochemistry is prohibiting them from anticipating the consequences of their behavior, or of seeing the effect their actions may be having on others. As a result of this, they never develop a sense of what is right or wrong in their environment: they never develop a conscience. In actuality, these people are only interested in being themselves, and have no sense that there might be something very misguided about that.

Where I'm going with all this is that people need to conform, to some extent. There are many reasons why, among them being that conformity promotes friendship, and the acceptance of our peers is important for our mental health. We need social bonds in order to develop well emotionally and to have good self esteem. But mostly-- and here's my primary thesis-- people need to act a certain way so society can run. It is one of the most basic tenets of a working civilization: that the individuals therein follow an implicit social contract of how to behave and interact with one another. When individuals have no regard for others' thoughts and opinions, in less severe cases, we get those people who have no courtesy, tact, or sense of social grace. They are obnoxious and sometimes offensive, but it doesn't usually go beyond that. It is in the more extreme cases that we get liars, cheaters, abusers, and psychopaths: those people who undermine the fabric of society.

While I certainly don't condone mindless, sheeplike behavior, and I will always argue that people should think for themselves above all else, I believe that conformity gets a pretty bad rap. We need to care what others think of us, so that we can remain decent human beings. A wise friend of mine once told me that "The human mind, when left to its own devices, is a dangerous thing". So true. We need others to keep us in line, as our system of checks and balances.

Our brain lies to us, frequently. Our emotions mislead us. Our gut reactions make us do terrible things, to ourselves and others. When people tell you to "Be Yourself", they forget to mention that the "self" is not one constant, unchanging thing. It is very much the product of our upbringing, and our environment, and our personality continues to change into old age. Moreover, we are different people depending on what context we're in, or who we're interacting with, or what we think is expected of us. They never tell you which "self" to be. They can't, because the "self" is as transient as sand, and if we rely too heavily on it, we will be carried away on its unstable flow.

I understand that these ideas may seem evil and tyrannical in this capitalist society, where we hold the Individual as the highest standard of good. But I think it is crucial to highlight the need for balance and moderation: being true to ourselves, and only ourselves, to the exclusion of what society wants from us can easily lead down a more insidious path than we may have been led to believe as children.

It's Your Funeral

Imagine…

You are dead. Your life is over, there is no more work to be done, and now everything about you is past-tense. There is nothing left to the concept of “You” but what exists in others’ memories. If you have ever left a negative impression on someone, you have no chance to redeem yourself. You have hit “send” on the manuscript of your life, and it has been submitted to the editor for critique.

How would you like to be described at your funeral?

Some funerals have pastors officiating, where they read off a one-size-fits-all description of a generic decent person’s life. Some are sparsely attended, and people struggle for profound things to say about a person who really wasn’t all that profound.

Others (these are the really memorable, awe-inspiring ones) have people crowded, standing-room only in the back, waiting in a line to get up and say what a truly amazing person this was. Stories and tears flow freely as loved ones paint a picture of an individual who will live forever as a saint or a hero.

There are those people who live their whole lives to serve others, and the ones who knew them best will swear up and down that there wasn’t a selfish bone in their body. There are those who touch many, many lives, inspiring them to be the best they can be, demonstrating a life’s full potential. There are those who are the matriarchs or patriarchs of ginormous families, helping bind them together in strength and love, leaving an ongoing legacy that will never die.

It’s a question I’m asking myself these days: how do I want to be remembered?

Remember that memories erode, and eventually all that will be left of you is an abridged version, with just the most important/memorable stuff. So it’s something to ponder as the days flow past us, unceasingly… what are we doing with our time here? What will our Greatest Hits CD sound like? Any given morning you wake up, you could start composing a new song for it. You could do something huge and amazing, or start down some new path that will change things forever. All that it takes is a decision to make it happen.

I think that many (most?) of us tend to live without real purpose or direction, making decisions that are arbitrary or short-sighted. To live deliberately means to live with a big-picture sort of mindset, acting based on long-term reasoning, keeping always in mind what sort of life we want to live.

It’s so easy to just exist. It’s another thing entirely to live a life you’ll want to be remembered by.