Recently I’ve given several “guest lectures” to college classes full of enthusiastic young people preparing to work in mental health and social services. I begin with three assertions:
- You all want to work with people that most people avoid. These might be children or adults, people with mental illnesses, drug addiction, trauma, homelessness, incarceration or immigration issues. Each of you is “abnormal in a certain special way” and so your heart goes out to people that ‘normal’ people might reject.
- You believe that the existing system is doing a bad job. Somehow, we’ve lost our way — become bureaucratized, started treating people like cases instead of with caring — and are just going through the motions.
- You believe you can do a better job than we have done and not fall into the same traps that we have.
The class laughs, but also nervously agrees.
As someone who has been pursuing that same dream reasonably successfully as a psychiatrist for 30 years, I should offer whatever knowledge and mentoring I can so you don’t burn out and fail to reach your dreams.
There are three levels of helping people:
- Intellectual/material/rational: making diagnoses, giving medications, case management, skills training, cognitive therapies, psychoeducation, etc. — requires expertise and collaboration.
- Emotional: compassion, empathy, believing in them, giving hope, caring, not judging, emotional healing, love, etc. — requires emotional connections, personal caring, and trusting each other.
- Spiritual: being “an angel,” God (or Christ) working through you, a “miracle” happened, “energetic healing,” praying for them, forgiveness, etc. — requires connection to selfless love and faith.
AA manages to combine all three levels in one program and environment, capable of moving ever deeper depending on people’s needs, hopes, and responses, but most other mental health and social service agencies operate predominantly on the rational level and in their best moments move to the emotional level.
In mental health, we have spent an inordinate amount of effort on the intellectual level, ranging from professional distance in our relationships, objective/observable syndromic diagnosis, behaviorally observable goals, overreliance on biological uses of medications, and measurable outcomes.
Nonetheless, since most people who come to us for help have deeper needs than that, primarily because of the pervasiveness of severe trauma, we’re going to fail most of them and be frustrated if we don’t instead operate predominantly at the emotional level and in our best moments move to the spiritual level. We need different strategies and skills to succeed on an emotional level than we use on an intellectual level (and different again on a spiritual level — but I’m focusing on the emotional level here since many people will respond to that level and you usually can’t skip over it anyway).
Here are my major recommendations for those emotional level strategies and skills:
1. Being able to connect emotionally to people who are normally rejected requires knowing why your heart got you into this work in the first place. Why are you “abnormal in a certain special way”? Keeping that flame of passion alive over the years is crucial to not burning out. I agree with Patch Adams that we burn out not by feeling too much, but by trying not to feel and distancing ourselves from our feelings until they’re forgotten, neglected, and deadened.
The program you’re working for must have a vision and a culture that aligns with your heart. It should feel like home, not like you’re the only one fighting for what’s right. Your coworkers are essential for your emotional nurturance and growth. They’re your “trench buddies.”
2. Compassion brings out our emotions and our desire to help. Compassion is very useful, driving us to a great deal of good. Unfortunately, it also can lead to compassion fatigue. Empathy is different than compassion. Empathy is a vicarious experience of the other person’s emotion, rather than a drawing out of our emotions. Empathy leads to connectedness, growth and even a shared stillness and fullness.
If we listen empathetically, we open a place in our heart for a person’s story to connect comfortably, knowing full well that it may change us, rather than listening with a focus on how we’re going to help them. When we succeed in connecting empathetically, they feel understood and cared about and trust us enough to quietly share even more. We also begin to realize that it’s not about us, it’s about them.
3. We need people to be emotionally motivated to pursue their own healing, growth and recovery rather than being dragged by us into doing what we think is good for them. Motivation is enhanced with:
- Hope: We need to help them see a possible better future one that they believe they can achieve and that has meaning for them.
- Client-driven approaches: People work harder on their own goals than on someone else’s goals.
- Shared decision making: Combining their expertise in themselves with our expertise in opportunities, skills, and resources to come to better decisions than either of us would have without each other.
- Motivational interviewing: Matching our support to the stage of change (precontemplation, contemplation, planning, action, sustaining) that they’re at.
4. Instead of running around frantically responding to crises, solving problems, and reducing suffering — all of which is wonderfully satisfying over the short run, but ultimately frustrating as the same crisis recur over and over again unless the pattern of suffering is addressed — we should focus on building protective factors (e.g. safe housing, money for necessities and emergencies, family connections, other supportive adults, positive roles and identity, and spiritual supports) so every problem doesn’t lead to a crisis. Once some practical and emotional security are established, we can focus together on learning new responses and building resilience. Almost everyone in the psychiatric hospital and jail and most homeless people have almost no protective factors.
5. Instead of focusing on what strengths we have available to use to help fix what’s wrong with them and protect them, we need to focus on what strengths they have within them (or even within their worlds) that they can discover, build upon, and ultimately be proud of. A successful recovery is not when they feel like we’ve been very helpful in fixing what’s wrong with them and taking care of them. It’s when they feel like they’ve found strengths within themselves, learned what’s really important in life, found gifts from their wounds and meaning and blessings from their suffering.
Trauma informed care is a powerful approach to reframing symptoms as coping responses, what’s wrong with them as what they‘ve gone through, and suffering as something to learn and grow from rather than to be ashamed of and removed — it is an approach that focuses on becoming survivors instead of victims.
6. Most situations can be helped with a combination of skills and supports. The more we focus on building their skills, the more they’ll be empowered, and the more their self-confidence, self-efficacy, self-reliance and independence will increase. The more we provide supports, the more dependent they’ll be on those supports and sometimes the more resentful they’ll become of the very supports they craved in the beginning.
A key component of recovery and community integration is self-responsibility. No one wants an irresponsible neighbor, or tenant, or employee, or father, or husband, or even primary care patient. To achieve meaningful roles in our society, we must achieve self-responsibility. Instead of blaming people for being lazy or “too ill,” we can help them build the foundations of self-responsibility including hope, empowerment, and especially skills.
7. Health and mental health are secured by a web of connection to our communities that reinforce positive identities, relationships and roles, not by a “safety net” that cares for people when they’ve fallen away from our community. We should be actively involved, not just in helping people be better able to belong in our communities, but also in helping our communities be a better place to belong in — more welcoming, inclusive, compassionate, and accepting.
We should actively practice community development — helping landlords, employers, families, doctors, schools, artists, etc. connect with people they’re likely to be frightened of or reject without support. We are part of our communities too.
Unless there are bridges back to community connection, we’ll forever feel burdened by caring for these people with ever-increasing caseloads stuck with us. If we work on islands on our own, eventually we’ll run out of both funds and compassion.
Taken together, I hope that these strategies provide enough of a vision to realistically believe in and enough of a guide to the skills you need to develop to make that vision a reality for you and the people you work with. Admittedly, it’s a vision on an entirely different level from the intellectual/rational one we usually teach you to focus on, but it’s likely the level you intended to focus on when you came to the field.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.