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.

How To Be Happy

I think one of our primary goals on this earth is to be happy.

Call me selfish if you will, but almost all of our actions are motivated, either directly or indirectly, by a desire for happiness.

Sometimes it’s for short-term happiness, such as buying yourself ice cream just because. Other times it’s long term, such as forking out thousands and thousands of dollars for higher education.

Either way, we want to be happy, either now or later. Or both, preferably.

But the question that stumps so many of us is: how?

We’re not always clear-headed about what it is that will make us happy, especially since it’s so ambiguous. Is happiness pleasure? Contentment? Satisfaction? Is it a chemical, or is it the knowledge that things are the way you want them to be? Is it meant to be pursued here and now, even if it comes at the price of long-term happiness, or the other way around? Or maybe are we supposed to take the average of the two?

It can be confusing business. And maybe there’s not one right answer for everybody. But I do believe there are some tips that can aid everyone in their search.

Buddhism talks a lot about happiness by looking at the nature of suffering. One of the Four Noble Truths is that suffering is inevitable. It’s just going to happen. In other words, our lives aren’t always going to go the way we want them to, due to circumstances outside our control.

So here’s the first thing I glean from this basic truth: happiness is transient. When it comes to us, we should recognize that it can leave just as easily. And we should be grateful for it when it happens.

But here’s the second thing: suffering is transient, too. It will happen, but as they say, this too shall pass. What it takes to weather the storm is patience, and recognition that, in the grand scheme, a little bit of suffering really isn’t that big a deal.

I like the photo of the Buddha statue in the snow as a metaphor. He sits, constant and eternal, as the weather changes and flows around him. Sometimes it’s sunny and warm; other times he becomes buried in snow. But no matter the circumstances, he sits with a little smile on his face. He’s seen it all, and he knows that just as snow is part of the earth’s natural cycle, so too is sun. And he just has to wait for it.

I’m sure you’ve known someone like this: they always have a smile on their face, always have a positive outlook to offer. They are a rock, steady and stable, grounded in reality, not moved by the rise and fall of outside circumstances. I certainly know a handful of these people, and I asked a few of them what they think is the trick. Here are the two main things they talked about.


PERSPECTIVE

It’s so easy to get caught up in the pitfalls of our day-to-day life. Here’s an idea: write down all of the things that make you unhappy through the course of your day. Every single thing. At the end of the day, look at your list and think about how ridiculous it is. You missed the bus, so you were late for work or school. Sucky, sure. But life goes on. Tomorrow, you won’t even remember it. Besides which, please consider how lucky you are to have a job, or to be enrolled in school. Consider the luxury of cheap public transportation. Life is pretty awesome; why are we getting hung up on the tiny little things that aren’t perfect?

Perspective also means where you focus your attention. Will you pay more attention to what goes wrong or what goes as planned? I'll tell you right now that pessimism is more common than optimism, and I think that's because it's easier. We have to go out of the way to notice when things DON'T go wrong, because it's less obvious than when everything blows up in our face. But if we can practice gratitude for life's little gifts and blessings, it can make a big difference in the way we perceive the world.


CHOICE

Think of it as a matter of dignity: the trivial things that happen to you every day DON’T HAVE THE RIGHT to make you unhappy. You deserve better. They can only make you unhappy IF YOU LET THEM. And it’s not always easy, but it just takes practice. Honest. When it comes to the self-discipline it takes to make this happen, I’m a firm believer in the difference between thoughts and emotions. Emotions are triggered by events: when the crate of eggs drops and they break all over the floor, our first emotional impulse will probably be anger or frustration. But it’s what comes NEXT that is crucial: how we will choose to perceive it.

Here’s the process:
1. Anger—arrrgh!! (This will happen, and it's natural. But the key is step 2...)
2. Deliberate thought—okay, I don’t need to let this ruin my day. In the grand scheme of things, this is so not a big deal.

By exercising our discipline by going through this kind of routine every day, we can literally train our minds to be able to skip that first negative emotion and go straight to the deliberate, disciplined thought.

Optimism can be learned. It’s a skill, and as such, some people are born with a knack for it, and the rest of us just have to work harder.

And that’s really the crux of the whole issue: If you’re not happy, you can work to become happy. There are plenty of things that have been demonstrated to help:

-TAKE ON a new perspective.

-PURSUE goals that you care about.

-ENGAGE in every area of your life; make it count.

-FOCUS on the good, rather than the bad.

-EXPRESS gratitude.

Notice that these are all action words. Nowhere is there anything about BEING a happier person, or BEING more optimistic. They’re not character traits that you either have or you don’t. Happiness is, as they say, the journey, and a journey is made up of each step you TAKE.

Here's one last thing I want to mention, and it may be more important than anything else: this is all meant to apply to our lives in times of uncontrollable misfortune. However, sometimes there are terrible things about our life we CAN control. If the answer to the question "Is there anything you can do about it?" is yes, then the next question is: "Why aren't you doing it?" I'm a believer in self-efficacy, as I have discussed in earlier blog posts. Sometimes it comes in the form of us choosing to be happy; sometimes it means we take our lives in hand and make the changes we need to make in order to BE happy. All we have to figure out is where we fall on that spectrum, and then do something about it.


These are just my half-baked thoughts on the subject. What I'm interested in, really, is hearing from miserable people. I want to know why these things might not work. Let's have a conversation about it.
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Here's some handy links if you're interested in Positive Psychology, which greatly inspired my thoughts in this post.

Authentic Happiness: The Official Website of Martin Seligman, the psychologist at the forefront of the Positive Psychology movement. This great website describes his theory, has helpful questionnaires and gives great tips for what it takes to be happy.

TED Talks: Martin Seligman on Positive Psychology: Hear it in his own words.

The Happiness Project: An extensive blog hosted by Psychology Today with a plethora of interesting ideas and theories regarding how to be happy.



Photo used with permission. Source: http://www.flickr.com/photos/21556557@N06/2284840450/