As part of a transplant workup, each potential candidate goes through a series of grueling tests, including meeting with a psychiatrist on the team. I wish that one particular psychiatrist were capable of being even mildly sensitive about cultural, gender, and trauma issues. As in, having even a modicum of familiarity with basic psychology and sociology, which should be part of any mental health professional’s development. I was truly dismayed and disturbed in what vicarious trauma experts have now dubbed “moral distress”. Moral distress is the stress that “occurs when one knows the right thing to do, but institutional or other constraints make it difficult [read impossible] to pursue the desired course of action.” That definition hits interpreters very hard, as the limits of what we can do are so incredibly narrow. Yet we are literally first-hand witnesses to every possible manifestation of healthcare, and observe with our hands tied.
This psychiatrist did not give the patient any context for her to understand his role and what was expected of her. He failed to inform the patient that she was not actually under any obligation to answer all his questions or give details that bring up severe trauma as part of the evaluation. He failed to protect her. I believe he had no clue that she would feel absolute compulsion to answer every question he put, even when he delved into what seemed a selfish indulgence of his prurient personal curiosity rather than any part of a transplant workup. I believe he is completely clueless about her culture, her respect for authority figures and men, and how obligated and helpless she would naturally feel under his rapid-fire interrogation. And she had zero context for what he was asking and why.
I would love to have patients receive something like this as an opening: Welcome to my office! Allow me to give you background on why the transplant team has each patient meet with me, a psychiatrist. Studies have shown that something as intense as a transplant can bring up all kinds of feelings besides joy and relief. People who have had depression or anxiety may get those feelings again. People who have had trauma, whether from abuse, growing up in a war zone, car accident, or whatever, which is pretty much all of us, so don’t feel alone, can have our post-traumatic stress come up. That’s okay, as long as we have supports and coping skills in place to help with these things. It’s all a part of normal life. Some people deal with these feelings by self-medicating with drugs or alcohol, but as you can imagine, with a brand new organ, and all the prescribed medications, that would be the worst thing we could do! Luckily, there are so many other ways to deal with sadness, worry, bad memories, and other human feelings.
I am here to help the team, and to help you. For the team, I am evaluating what kind of skills you already have in place to deal with the difficulties you will be facing. I will report on your strengths, your support system, any counseling or meditation, exercise or whatever you already have in place, so the team knows you would be a good caretaker of a donated organ. I may make suggestions as well. I am also here to offer you support and resources. I have lists of support organizations both before and after transplant in your area, and a list of resources for counseling and support in your language. Let me start by asking you some questions. And please understand, although I may ask about specific traumatic events, it is not my job to investigate your past. My focus is on your coping skills. You can always let me know if you would rather not delve into something, as we will not have time to really do healing therapy in this short hour! And I wish to apologize ahead of time, as these sessions can be uncomfortable. I will try to be sensitive. Any questions before we start?
That is what I wish would have happened. Here is what did:
I am a psychiatrist and I need to write a report as part of the transplant workup. Let’s get started. What is your full name? What is your date of birth? Are you married or single? How many children do you have? How old are they? Do they live with you? Do you think they would take care of you? Do they work? How could they take care of you if they work? Can they get time off? Have they asked their bosses? You think so, but can you find out for sure? When can you find out for sure? Who lives with you? Is it really just a roommate, or something more? Do you work? When did you last work? Why did you quit working? But you weren’t on dialysis then, so why did you quit then? Why couldn’t you work then? What did you do? Housecleaning? How long? How many years? How much schooling do you have? Can you read and write? Why did you quit school so young? What did you do then? Was there violence in your home? Did you ever see your Dad hit your Mom? Did he hit you, too? How many siblings did you have? Where do they live? Are you in touch with them? Are you close? Did they quit school, too?
This goes on for half an hour. The patient is clearly distraught, but there is no recognition of that. No acknowledgement. No breather. No time. The psychiatrist is taking calls, texting messages to colleagues about in-patients on his computer screen, between writing into her open chart, and clearly thinking of other things. Time is money. I am sure he considers himself great at multi-tasking, a picture of professional efficiency. The interruptions hardly slow him down. He doesn’t seem to feel it disrespectful, but simply his right. He is important! He is a valuable professional! He has so much to do! So let’s push ahead with this interview so he can wind up his report to the team, which he is typing as we speak. He keeps firing off his questions, rat-a-tat-tat:
So your Mom left your Dad. How old were you? Where did you live? Why did you live with your Grandma? Why didn’t you live with one of your parents? Oh, your mother lived there, too! Okay. Have you ever been sexually abused? By whom? Your stepfather? How old were you? How long did it go on? Pregnant? I am sorry! Did your mother find out? What did she do? She made you marry your stepfather, but stayed with him herself! I am sorry! Oh, I must answer this page, sorry. Where were we? Oh! Your mother made you marry your stepfather and then you had his baby. Is that your older child then? Does she know her father was your stepfather? How is that for you? Do you think about it a lot? When’s the last time you thought about it? That long ago? What brings it up? How do you deal with it? Are you in touch with your stepfather, your husband, or I guess your ex? Oh, he’s dead? What about your other child, was that the same father? A second marriage? What does he know? Oh, the second husband is dead, too? Oh! I see from your chart you used to drink a lot. Why is that? Because your second husband got killed? How old were you then? Did you really only started drinking then, and not before? How did he get killed? I am sorry. How long did you drink? How many years? Did you ever black out? How many drinks could you drink? Did you ever miss work? Did it affect your children? Do you drink now? How did you stop? Did you go to treatment? How long? Why did you quit after two months? It was all men? You mean AA? I see. Okay, well, I think I have enough now.
The patient has been trembling for over half an hour. I am the one who offers her to kleenex because the psychiatrist doesn’t think of it, although she is using her coat sleeves to wipe her face. I place my hand on her arm in support as she stutters out the words of her shameful (to her) life story and the horrible things she had to survive, and faces the excruciating pain of this clinical retelling to an unknown and frankly distracted, possibly dissociating male authority figure. A doctor. A rich man. A white man. A citizen of the country where she lives underground. The kind of person whose house she cleans, when she is well enough. A gatekeeper who potentially will stand between her and the life-saving transplant, if she cannot show that she can deal with her trauma and pain well enough to pass muster. And she cannot, at this moment, after this interview. She gets up still in tears, still trembling, to politely thank him for his time and his business card. He nods with a grimace and dismisses her as he stands up to mark that she is excused and may leave now. I may leave with her.
Well, thanks for coming in. I will send my report to the transplant team., and they will let you know. Here’s my card. You can call me if you need me. Goodbye.
I personally find this as unconscionable as doing surgery on a patient and failing to sew them up properly. A properly trained psychiatrist should surely know something about the psychology of trauma. Can he really not see, does he really not care, that by opening wounds that he cannot close, he is leaving these already very ill, very vulnerable patients to heal themselves as best they can? The gratuitous, completely unnecessary human suffering! It astounds and distresses me to no end. And across these power boundaries, encounters such as this one are carried on in hundreds, thousands, millions of settings, in hospitals, tribunals, war zones, workplaces and in the often dangerous privacy of our family homes. We are created equal, that I do believe, but we are certainly not all in a position to be treated equally. And it is just so damn unfair.