The Couch Reversed

After a long absence I am back.  I have a few thoughts about what made it possible for me to come back today.  Last few months have been a whirlwind for me to concentrate on this blog and muse much.  I don't think there are enough hours in the day to contain what goes in my life on any given day.  I am nearing the end of my 3rd year and it is only 3 months away.  Hard to believe I started here midway through second year.  I have bad days and I have good days.

I worry about my impending cord severing in 17 months to be on my own and it scares me to think I will be on my own.  One would think moonlighting is a good practice to run solo but I still have options to consult, mainly because I am probably quite lucky to have that option.  I am losing one of the best times of my life at the end of these 17 months and I feel like I want to grieve at times.  I am sure, I am starting to.

One of the best things I have done for myself over the last 2 months is exactly what the title of this post says.

Have you figured it out yet?

And if you thought of therapy; you are the winner.  You are pretty awesome at this guessing game.  

So after 8 months of monkeying around this idea of getting in therapy for myself, I finally gave in.  The proverbial couch is literally reversed.  It is quite a transformation and one that I never knew would make me think so much.  

For many psychiatry residents, esp. if they are like me and see or want to see a lot more therapy patients, it is something that just has to be done.  I hope all programs provide supervisors for therapy cases, as they should but I also hope that many psychiatry residents do not end up ignoring the need for their own work to be done.  If you have a supervisor that is open to working simultaneously with you and on you, that is great.  My supervisor on other hand never had a choice and mainly because of me.  I am used to taking charge and in my mind, I had this one hr a week for case consultation, so I would walk in and use every minute of that hour for my patients.  He got to get glimpses in my personality but by the time I brought up the question of my own work with him, I already had a mindset that this is an hour paid by my program and I shouldn't use it for myself.  Not to mention I had 8 cases for therapy and at times 10-15, so I needed this hour more than ever.  

I started noticing my anxiety as a therapist get louder, the more intense therapy with my patients got.  The emotions and reactions in me were what forced me to be very honest with myself about what did I want myself to be able to do when I take on people for therapy.  

I started reading more this year.  Yalom, Bowlby, Beck, Wachtel, Gabbard, Robert Karen and numerous articles here and there.  None of these people that I admire so much and learn so much from, got so good at what they do without having their own work done.  

I want to be half as good as any of them.  That is what I want.  So I can't ignore the need to be the patient in order to be an effective therapist.  

I finally gave in and asked my supervisor to be my therapist.  That in itself was an intense experience from having to process my need to have the safe path to therapy with a known person than to open to a totally new therapist, finding a new supervisor and then realizing I lost my supervisor relationship with my now therapist.  It was something that came so unexpected yet proved to be a great stepping stone into the new relationship.  

Now 5 weeks into it, I have started to understand why my patients, who come sit across from me in my office; keep coming every week.  I understand that they are the ones doing the work and when they ask me questions about what to do, they are not meaning to put me on spot, neither are they looking for a magic formula; but rather exactly the opposite.  They already know what they are asking me, I just help crack the code.  Sitting across from my therapist when I share things that make me question my own abilities, limitations and that frustration that I feel with myself many times; I hear myself say things I only think about but am too scared to admit to myself.  It's like I believe, as if I am superhuman or should be superhuman.  I have started to understand my worries and anxieties in ways I probably already knew.  It is so odd how actually saying them out loud is akin to giving life to something many of us like to keep buried.  Reversing the role makes me see how without this step, I was never going to be able to fully understand the person who sits across from me every week without doubting the process every step of the way; because I never had the experience from the other side.  

Dealing with my own life and facing my own limitations, I have to do it; to do what I want to do.  The proof is in this post.  Took me 2 months from my pledge to write here to actually write this.  The only thing that has changed is that now once a week I get to be the patient.  I get to be able to let it go and face myself without reservations.  Something so hard to do but has a profoundly liberating effect.  Most probably one of the reasons I am back here writing again.  

So if you are a therapist, psychiatry residents or aspiring to be either one of those, keep your work on yourself in your mind; not as an option but as a necessity.  Not because it is cliche; but because it is anything but.  

As Irvin Yalom says, 

"Self exploration should continue throughout life, including entering therapy at various stages of life."

    

Let It Go!!

Is Elsa singing about empowerment, liberation and accepting yourself or is this one of the all times, most reproduced, re-sung, reposted expression of the anger we as human beings carry around all the time?  Anger, rage, fury, incensed, irate, pissed off, livid, there are over 75 synonyms out there for this very basic yet one of the most consuming human emotions.

Anger like sadness is not socially appealing, accepted or appreciated.  We don't like to deal with sadness and we don't like to face anger, be it personal or not.  At one point or another all of us have come across these emotions beyond what is normal and necessary for daily ho hum of the life, yet for the most part I personally am responsible for not handling it right when it happens to me.    

Why am I talking about this today?

Our process group had to deal with this question yesterday.  

"How do you deal with people who are angry or make you angry?"  We couldn't answer this.  Not one of us offered to confront the anger nor we suggested setting boundaries to protect ourselves from the rage others would displace onto us.  That in itself said a lot about us as a group.  Why is it so vital to address this and yet we don't or we can't?  

First off as a group of residents who have various roles in the span of our residencies ranging from over time to day to day role transformations like brand new intern to different roles from one rotation to another and more frequent role changes of on call doctor after hours to the resident on unit or clinic during the day, we are required to switch hats frequently.  

In the bigger picture of training this is completely normal and actually required for us as residents to be able to switch between decision makers on call to an active learner in normal duty hours, so we can eventually be able to work independently.  But the fluidity and flexibility also leads to confusion among ancillary staff leading to conflict and many times residents are front and center of attention in such conflicts.  The concept of physician autonomy is at times hard to apply to residents because they are still under training and therefore are easier to be put in the middle of such situations.  At the same time being residents we also feel obligated to make everyone happy and play nice mostly to get over with the day, call, rotation and residency in general.  

We all beat around the bush yesterday, some of us tried to see the other side and tried calming the negative feelings we were having and so on.  We were unable to allow ourselves to be angry and were uncomfortable with expressing that anger even in the safe and contained setting of our group.  Not because we can't get angry but because we worry about the natural consequences of expression.  But it doesn't help the fact that the longer you don't deal with your feelings the worst it gets.  Again so easy to tell your patients yet so hard to apply to self.  

We will deal with angry bosses, angry administrative staff, abusive supervisors and loud and obnoxious staff who will talk over us and yell at us because for the most part such people do get away with their behavior because we fail to protect ourselves from their rage.  People who express anger in socially and at times blatantly disrespectful way are at ease with it because most people want to get over with it and go back to business but it doesn't address the issue nor does it avoid a repeat.  A simple "you are yelling and I am sorry I cannot talk with you like this." was so hard to produce yesterday from all of us that I was taken aback by how we would allow this to happen to ourselves.  I realized yesterday why we were lucky to have the group leader we have because he pointed out the basic flaw in our approach.  We are two extremes of responders, too angry to engage and too avoidant to disengage from our therapist role for the aggressor even when we are the victim.   

Anger doesn't dissolve when it is pushed back and denied it's existence.  It is consuming and drains us of energy while we try to tell ourselves it doesn't bother us that much.  It piles up with each occurrence and makes us anxious because of how uncomfortable we are with the conflict.  Avoidance of setting boundaries doesn't resolve conflict but actually gives way to passive aggressive even more toxic conflicts.  

I hope yesterday's process taught us that it is okay to protect ourselves from abrasiveness and set limits.  We have to let go off the anger in ourselves to continue to maintain fluidity our roles as residents and for us to be able to say "I do not appreciate your tone." without being afraid of it's impact and be able to disengage ourselves.    

The only way to "Let It Go." is to actually stop and deal with it because your anger is almost always a sign that you have been quiet for too long and besides Elsa didn't save Arendale by running away from it.