On The Ethics of Mental Health Clinicians With Their Own Diagnoses - OC87 Recovery Diaries

On The Ethics of Mental Health Clinicians With Their Own Diagnoses

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Listen to Executive Director Gabriel Nathan read this post aloud:

It’s 3 am. I’m crying on the stained rug of our dining room. It feels like the only place that makes sense to sit. A couch or chair would reflect a sophistication that I don’t feel. I don’t want to coax myself back to sleep because next thing I know, the alarm will go off and it will be time to do it all over again. I’m wailing. Half of me desperately wants Adam (my husband) to wake up and hear me and half of me doesn’t because then I may end up telling him that earlier this week I held a knife to my wrist just to see how it would feel. I already know he will be loving and comforting but I’ll never be able to rid myself of the thought that he’s burdened by my illness. I continue to debate if I should go get him but it’s a null point because Adam shows up and sits next to me. I exhale and tell him everything. We agree I’m going to make an appointment with a psychiatrist. Maybe my meds are off. We also agree I’m going to call out of work the next day. I need a mental health day. I feel guilty about this, but I remind myself I can’t be the clinician I know I am if I don’t tend to myself the way I want my patients to do so for themselves.

I’m working with teenagers at an adolescent intensive outpatient program (IOP). This is for teenagers who have just been discharged from a psychiatric hospital or who need more than weekly therapy. I do hours of group, individual, and family therapy a day. I am completely dedicated to and in love with my patients. And I am completely miserable. I don’t know if this is because my heart breaks for these kids, or because my boss is too burnt out to care, or because I have been these kids before and sometimes I still feel like I’m one of them. The truth is this is the first time I have had an urge to cut since I first abstained 10 years ago. If you had asked me in the interim why I cut, I probably couldn’t have told you. But when I hear these teenagers talk about it as the only way they can get relief, I remember why I started in the first place. I too wanted relief.

I see my misery as irrelevant. I’ve always seen this work as a calling and not a job. I have this image of myself as a person who feels a lot of pain without a lot of good reason. I’m able to point to this job as the reason for my suffering, but secretly I worry that even without the job, the suffering would stay. When I’m with these kids I am brought outside of my own internal monologue. I am fully with them. This gives both them and me the gift of my presence. My own internal angst suddenly feels trivial and insignificant. While this sentiment often leads to self-invalidation, I usually welcome it. I’d rather spend my energy worrying about other people’s big problems than my seemingly little ones. I figure if I’m going to suffer I may as well do it in a way that’s not so self-involved.

My desperation on this dining room floor feels familiar.

I’m brought back to my childhood apartment in San Francisco. I’m 15 or 16. I love this apartment. But today everything feels wrong. Lying on this worn, denim couch suddenly feels terrifying instead of comforting and familiar. Whether it’s the boy who just rejected me or the anatomy of this particular day, who knows. I look at the window and feel tempted. I don’t want to die. But at this moment, being in my own skin feels utterly intolerable. My psychiatrist prescribed me a medication I can take on days like today. I do. But the twenty-minute kick-in time feels like an eternity, so I sneak into my parents’ liquor cabinet and take a shot of their very upscale scotch. This makes everything worse. I tell my dad. I don’t usually tell my dad these things but I’m beyond pride at this moment. He wants to know what’s wrong. I find the question invalidating. I feel like it should be obvious. Asking is the right thing to do, but I still feel like if he has to ask he’ll never know. Everything is wrong. The fact that it’s sunny outside when I feel dark inside is wrong. The way the air feels sharp instead of soft is wrong. The fact that I can’t get comfortable on my favorite couch is wrong. People talk about rose-colored glasses. These moments feel like gray-colored glasses. Nothing is wrong and yet everything is wrong.

My dad calls my therapist and comes to sit on the couch. I ask him what she told him to do. He tells me that he’s going to sit down and talk to me. I tell him I don’t like this option. Well, I probably scream it. He says the next option is to go to the emergency room. I tell him this feels much more appropriate. We live two blocks from the emergency room. He asks if we can walk. At first, I say yes. Then this doesn’t sit right. Walking feels like an absurd activity for this moment. He drives me. We get to the emergency room. Some bald guy is asking me questions. I remember him as a police officer but I don’t really know who he was. I’m gripping handfuls of my hair. He asks me what’s wrong. I get angry. Isn’t it obvious? He tells me to calm down. I get more angry. Public service announcement: never tell a person who is having a panic attack to calm down.

They put me in a room and a psychiatrist comes. My mom meets us there. They do what I now know to be a suicide risk assessment. I tell them that the truth is I’m not going to kill myself. I don’t have a plan, I don’t have intent. I just can’t stand feeling this way. They say that I could go to a 72-hour teenage observation unit. This sounds like a relief to me but no one seems to think I need this and I don’t want to be dramatic so I agree to go home.

Knowing all I know now, I would have made a different decision. I would have advocated for the part of me that demanded to come to this emergency room in the first place, that knows coming off as dramatic is not the worst thing. It wouldn’t have solved everything. But maybe I would have met other teenagers who also found being a teenager unmanageable.

One of the most miraculous things I have witnessed as a clinician is the way teenagers can connect with each other when given an environment that fosters it. I have seen adolescents from vastly different families, cultures, socioeconomic statuses, who may never have crossed paths in the non-clinical world help each other feel less alone. I was riddled with this feeling that something was deeply wrong with me. I now have the knowledge and insight to recognize and reflect on elements of my own ecosystem that were damaging and contributed to my despair. But at that time, I just felt desperate and doubled down by telling myself I didn’t have a right to feel this way. Maybe if I had gone to that observation unit I would have felt less alone. Maybe I never would have developed the cutting issue that followed.

But I do. I don’t understand my psychological pain. This scares me. I don’t know where it started, so I don’t know where it will end. The physical pain makes more sense to me. It’s tangible. I can see where a cut starts and where it stops. One day my mom catches me. This is too much for her to bear. I feel guilty, so I stop. It is one thing to do this to myself but it doesn’t seem fair to do it to her. I tell myself that, once again, I was just being dramatic.

Growing up, my mom always told me that she didn’t know what I would spend my life doing, but she knew it would be something in a helping profession. I was the kid in elementary school whose parents were constantly being told by other kid’s parents that I was kind when no one else was. They were so proud of this. And so was I. But I found the implication that my kindness made it my duty to spend the rest of my life caretaking to be a burden.

Over time, as I had more good days and less bad days, I decided that maybe my mom was right. Maybe it is my calling and my duty to help others the way I was helped. I am acutely aware of the privileges that I hold as a white woman from an upper-class family. I know that my treatment was expensive. That the resources I had access to are not readily available to all. On the one hand, I feel ashamed and embarrassed for struggling so much in my outwardly cushy life. On the other, I judge stable people as boring and detached. I decide if giving back is not my duty, it is, at the very least, the only way I know how to make sense of all the pain in the world and all the pain inside me.

 

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So I become a licensed clinical social worker. Working with teenagers feels like coming full circle. I am good at it. I know this for sure. I am genuine and this is felt. I’m empathetic while being able to hold boundaries that teens may not like but help them feel safe. I meet them where they’re at and can stay present with them in their pain. I help them advocate for them when they feel mistreated by the adults in their lives, without villainizing others. I make it known that what they think and feel matters, even when they mess up. I am consistent and they trust me. I’m praised by other staff for what a talented clinician I am, what a “natural” I am. But they don’t know the cost. My patients sense that I understand them. And I do, not only intellectually, but experientially.

It’s hard for me to take ownership of my own challenges because I find myself wondering if I’ve earned my suffering. As a result, I can’t figure out where my duty starts and where it ends. How to do enough when nothing feels like enough.

These are the thoughts that swirl in my head like a tornado with exponential growth. They bring me to think about cutting again for the first time in over a decade. The only thing that shuts them up is weed. Everyday, I count how many hours are left until I can get on my couch and get high. I smoke a lot of weed. A part of me knows this isn’t healthy. Another part of me feels it’s ridiculous to expect me to do this job and this life without escaping every night.

I decide I can’t do this anymore. Maybe if there were institutional support, I could. But there isn’t. I decide to look for work in the medical social work field. I get a new job quickly. I feel immediate relief. Then Adam reminds me a new job means a potential drug test. The relief leaves as quickly as it came. I decide to stop smoking immediately. I worry about how hard this is going to be. It’s twice as hard as I fear.

My first sober day in a while, I’m standing in our kitchen trying to make tacos and my head will not stop spinning about everything and nothing. I have another flashback. This time I’m in fourth grade. I’m standing in my pink room next to my twin bed. I’m wearing a brown v-neck shirt and an undershirt because I have huge boobs for a fourth grader but am scared I’ll be made fun of if I wear a bra. I have a sense that not everyone else’s brain is like my brain. I’m scared of my own mind. I remember thinking “I hope my brain isn’t like this when I’m 40.”

My brain is still like this. I’m not 40, but I’m closer to 40 than I am to fourth grade. I describe this feeling as there “being hamsters in my head.” My brain just will not “shut the fuck up.” I can get no relief. I decide I need to stop lying to my psychiatrist about the weed I’d been smoking. I come clean. She adds a medication to my regime. One that helps with both substance cravings and anxiety. One night, Adam and I are playing our favorite board game. I realize I am doing only one thing, playing a board game. Not playing a game while beating myself up for all the decisions I made today and worrying about all the decisions I will make tomorrow. I can’t remember the last time I just played a game.

I start my new job. I’m better. I don’t love it, but I like it. It doesn’t fire me up in the same way which is a good thing and a bad thing. My nervous system is much calmer; however, I find myself feeling a bit bored and even missing clinical work. I hadn’t realized something could give you so much while taking so much at the same time.

This is more of a job than a calling. But now there is room for other things in my life. I enjoy my evenings and weekends with Adam and my friends instead of spending every moment I’m at work wanting to get home and every moment at home worrying that the moments until work are ticking away so fast I can’t even enjoy them.

Several months after I start my new job, I meet up with a former co-worker. The lone soldier who has managed to stick it out way longer than the rest of us could. She updates me on life in the intensive outpatient world and I find myself getting a tinge of envy. She even has tan, glowing, and refreshed-looking skin that accompanies her positive outlook. She is the one who has found a way to make this job work for her. The exception that I thought I would be. It’s enticing to tell myself that it’s easier for her because she’s not as good at it as I was. But I know this isn’t true. She’s excellent. She’s able to care deeply and then go out to dinner with friends and not wonder if she deserves to be going out to dinner when some people can’t even put food on their tables. She doesn’t view herself as a bottomless well of unrelenting duty.

When I was in graduate school, it seemed to me that there was a disproportionate amount of my peers in therapy themselves, compared to the general population. Are we all secretly trying to help ourselves through helping others? If so, how ethical is this? Do we want to make sure that we understand what it is like to be a patient in therapy? Does everyone have the same sense of duty that I have due to their own experiences?

I have heard contradicting narratives about this trend. Some say, you shouldn’t be a therapist if you haven’t experienced mental health challenges and been through treatment yourself as it is a prerequisite to truly understanding your patients. Others say that those who have their own mental health challenges aren’t stable enough to help others heal their own wounds. I don’t prescribe to either of these narratives. One probably wouldn’t say that a cardiologist can’t practice unless they themselves have experienced a heart attack. One also wouldn’t dismiss their cardiologist if they themselves have cardiac issues.

Another narrative is that it is okay for a clinician to have had mental health challenges as long as they have been treated and are now in recovery. While I see this perspective as closer to the truth, it’s flawed as well, as treatment and recovery are not linear processes. You don’t want your clinician in crisis, the same way you don’t want to be in the doctor’s office or on the surgical table with a cardiologist who is actively having a heart attack.

While this narrative is the closest to the truth I have found, there is still a dialectic here. While I never acted on my urges to cut or ended up in the emergency room, the end of my time working in IOP was the closest I’ve come to crisis since the day I demanded to be taken to the emergency room a decade ago and its aftermath. And yet, even during that time that makes me shiver every time I think about it, I know I was able to help others the way I couldn’t help myself. I know it from the parents who told me our family session was the most productive hour they’ve ever spent with a professional, to the teenagers who told me my facilitation was the only reason they were willing to stick with group therapy, to the stellar performance review I received right before I left.

I don’t know what would have happened if I stayed. And I’m glad I didn’t because I’m trying to learn not to be a martyr. But once again, the truest truth is always more complicated.

​EXECUTIVE DIRECTOR: Gabriel Nathan | EDITOR: Evan Bowen-Gaddy | DESIGN: Leah Alexandra Goldstein | SITE ORIGINATOR: Bud Clayman

 

 

Naomi Hanna Kunstler Twickler (She/Hers) is a licensed clinical social worker in Connecticut. She has spent her early career in a variety of hospital settings providing both case management and clinical interventions. Naomi is currently working as a therapist in a college health center providing services to students while also building her private practice. Naomi is a leader for the organization Mom’s Demand Action for Gun Sense in America. She spends her free time acting in local theatre, skiing, hiking, and camping with her husband and their beloved dog, Macklyn, watching football, reading, taking baths, and napping. She is currently accepting new clients in Connecticut and can be found at NHKTherapy.com.