Rites of Passage: Initiation into the Culture of Psychiatry
Puneet Chawla Sahota, MD, PhD
"Over many generations, healers have learned from one another, passing
down wisdom gained in their lifetimes of clinical practice. Internship
was my chance to be part this legacy..."
I'm so happy to share this blog post by medical anthropologist and Penn psychiatry resident Puneet Chawla Sahota, MD, PhD.
Physician burnout is increasingly discussed in popular media, and of course, residency programs.
I am now over a year into my psychiatry residency, and have found perspectives from the field of anthropology most helpful in moments where I feel close to burnout.
Medical anthropology is a subfield of anthropology (broadly defined as the study of humankind). In medical anthropology, there is an emphasis on culture, that is, a community’s way of life. Healing systems are also viewed as having a culture of their own, and conversely, culture itself is an instrument of healing – for example, ceremonies and rituals have long been used by societies to help individuals heal from trauma.
Understanding psychiatry as a cultural healing system has helped me during my early years of residency. One tool of anthropology is participant-observation. In this research method, an anthropologist seeks an insider’s view of the culture through participating in community life while simultaneously maintaining distance as a scientific observer.
The intern year of residency is a rite of passage for all physicians. At moments in my internship, the learning curve felt unbearably steep. When close to exhaustion, I found that assuming the position of a participant-observer provided a much needed meta perspective, and helped me to cope.
I began to think of psychiatry as a culture into which I was being initiated. As a participant-observer, I tried to distance myself from the moment-to-moment difficulties of residency. I realized I was an initiate, still a novice, in this new cultural healing system. A steep learning curve was part of the process, and I needed to be patient with myself.
Rather than worry about how I was performing as an intern, in my best participant-observer moments, I would stop to curiously observe, without judgment, the clinical circumstances before me. I would ask, “What did I learn from that patient interaction? How does the feedback from my attending enrich the broader cultural schema I am building as a junior psychiatry resident entering the profession/community?”
Taking this participant-observer role also gave me an appreciation for all the gifts of internship. In cultural anthropology, mundane, daily experiences of community life are understood to be a rich source of data. As an anthropologist, then, I appreciate and seek meaning in everyday clinical experiences. In stepping back as a participant-observer in my residency, I realize that everyone I interact with is a teacher, a key informant in the culture I am studying. Every single patient care experience is an opportunity to grow as a clinician. Each time I reflectively observe myself as a new participant within the culture of psychiatry, I realize I am growing and changing. And it is the close mentoring I receive from senior residents and attendings that is responsible for my growth.
Many books have been written in anthropology about how healing systems are learned and taught in different cultures. A common thread is that of apprenticeship. Over many generations, healers have learned from one another, passing down wisdom gained in their lifetimes of clinical practice. Internship was my chance to be part this legacy, to be trained as an apprentice the way doctors have learned their trade for eons. I was an apprentice to many fellows, senior residents, and attendings. Understanding residency as apprenticeship, as a way to become acculturated and proficient in a healing system, gave me a deep sense of gratitude for my teachers. I felt like a small link in this vast chain of healers over time.
As an intern, I often stopped in the middle of a day thinking, “How lucky am I to be training as a healer?” I was grateful to receive the everyday gifts of knowledge from experienced doctors who took me under their wings.
Mentoring from senior physicians was what I treasured most about my internship. Although my internal medicine and neurology rotations also operated on an apprenticeship model, it was in my psychiatry months that I worked most closely with attendings, one on one, to learn their approach to caring for patients. It was during those rotations that I remembered why I had chosen to specialize in psychiatry.
Many aspects of residency are challenging for young physicians. Insights from anthropology about biomedicine as a cultural healing system, and residency as a time of acculturation, rite of passage, and apprenticeship, may help young physicians to keep a broader picture in mind and to appreciate the everyday experiences of clinical training. I remain grateful for both my anthropological and medical perspectives, and feel these two different ways of looking at the world have enriched my learning experience as a new psychiatrist.
Puneet Chawla Sahota is a medical anthropologist and psychiatry resident at the Hospital of the University of Pennsylvania.
We Don't Really Know How to Treat Depression and Alcoholism At the Same Time
Depression and Alcoholism can and should be treated at the same time: At
CCAF we partner with other programs within the Depatrment of Psychiatry
to treat patients and their families in a comprehensive and integrated
way. One of the programs we work closely with is The O'Brien Center for
Addiction; in this article, Dr. Charles O'Brien talks about his
research on the compelling need to treat alcoholism and depression at
the same time.
Click for article
Dr. Nancy Gambescia, sexologist, author, couples therapist and CCAF Training Faculty, discusses the topic of infidelity: How is it defined? What is the therapist to do with this complicated situation? And what about forgiveness? We are so fortunate to have Dr. Gambescia share her insight into this painful and complex issue.
When a partner consistently hides their thoughts, emotions, and behaviors from the other, a violation of the couple’s intimacy contract has taken place.
This is infidelity - the failure to abide by the couples’ contract about intimacy.
Couples’ agreements about intimacy may be negotiated and stated explicitly, or just implied. But when infidelity enters the relationship, a breach has occurred, whether emotional, physical, or both. Secrecy, lies, and other forms of dishonesty are harbingers of infidelity, even if no physical contact has occurred as in cyber-infidelity.
When infidelity occurs, intimacy is diverted away from the primary couple relationship and expressed through other outlets or relationships.
The Grey Area: Is it infidelity?
Typically, the point of departure from the couple’s agreement regarding intimacy becomes an area of intense conflict. Often the partners disagree about whether or not infidelity has occurred. One way of determining that a line has been crossed is to trace the onset of deceptive communication.
Deception hides the behaviors involved with maintaining the affair and is often both very confusing and frightening for the betrayed partner.
Discovery or disclosure of infidelity precipitates a crisis in the relationship. Common initial reactions include shock, anger, and denial. The partners struggle with grief, self-doubt, and pessimism. Previously held assumptions about loyalty, love, and the couple’s sense of “we-ness” are suddenly in question. Often, partners wonder if the relationship is irreparably damaged as it rapidly moves from a context of security to uncertainty.
The role of forgiveness
By the time the couple seeks treatment, varying degrees of dishonesty and discord are present. They come to therapy full of confusion, volatility, uncertainty, and pessimism. Each partner has extremely different reactions and it is challenging for either to understand how the other feels. Often, the betrayed partner is hurt and angry while the unfaithful partner is shameful, defensive, and sensitive to criticism.
Infidelity is a relationship issue
It is important to consider infidelity as a relationship issue, even if there is a clear offending partner. With infidelity, partners suffer together, and they must heal together to overcome considerable relational trauma and injury.
The process of rebuilding is typically fraught with emotional ups and downs. The couple can be helped to find reasons to stay together, develop the motivation to work on their relationship, and to forgive. This is accomplished by gradually recognizing the unifying factors that brought them together in the first place: empathy, hope, humility, and relational commitment. Commitment can be a struggle for a couple recovering from infidelity. Understandably, it is difficult for the partners to stay focused on healing in the presence of pain, misunderstanding, and pessimism. It is often easier to remain polarized through blaming and sustained anger.
Regardless of the circumstances surrounding infidelity, forgiveness is a central aspect of relationship healing. Considering the intense pain and confusion following the discovery of infidelity, partners, particularly the betrayed, may find the notion of forgiveness difficult to contemplate.
Four essential factors must be in place in order for forgiveness to occur: 1) a high degree of relational commitment, 2) genuine apologies and remorse from the unfaithful partner, 3) restitution for the emotional damage sustained, and 4) reassurance over time that the offending partner will not repeat the injuries.
The mutual desire to recover the relationship often provides the strongest motivation for engaging in the process of forgiveness.
Weeks, G., Gambescia, N., & Jennings, R. (2003). Treating infidelity: Therapeutic dilemmas and effective strategies. New York: W. W. Norton.
Stories as a Window Into Schizophrenia
A beautiful article on oral histories for those living with schizophrenia.
Click for article
Treating Bipolar Disorder: It Takes A Family
Dr. Hudak shares an article "It Takes a Family" about the necessity to involve family in the treatment of Bipolar Disorder.
Click for article
Bringing Family to the Table
Last week I had the opportunity to co-lead a family meeting with my colleague, Dr. Rob Garfield in the inpatient psychiatric unit here at Penn.
Dr. Garfield and I reviewed the patient, Anna’s history with a group of psychiatry residents and medical students. While the residents and students observed, we arranged a group of chairs in the front of the room to accommodate the family meeting.
Anna, an African American woman in her 60’s, was visited by two brothers and a sister. When the patient arrived in the meeting, although very upset, she recognized her family members and was quite emotional, eliciting stories from the past that clearly held deep meaning for them all.
Anna was too ill to remain in the meeting, but the family was eager to tell us about her and their family’s life. They spoke of the issues that triggered their sister’s initial break so many years go. With deep emotion and love, a brother spoke of the promise he made to his mother on her deathbed to always care for this sister.
Stories were shared about long held family secrets that, like pieces of a puzzle, added dimension and clarity to the struggles this patient has had. A narrative of devotion and care emerged, as one brother spoke about his need to assure his sister’s safety and take her to the hospital when needed.
After the interview was over, the family was invited to join those around the table who had been observing, and listen to what thoughts and reactions they had to the family meeting.
Residents and students shared with the family the commitment and love they observed. They spoke also of the courage of family members being able to discuss issues that were long silenced. “It was one of the most moving family interactions we have seen on the inpatient unit.”
The family joined in the conversation about what their experience has been like with a seriously mentally ill member, and around that table, talked about how their experience at Penn this was the first time that they had ever been consulted about their sister’s condition, or the burden of caregiving they experienced through the years.
Can there be any doubt that families deserve a seat at the table?
As psychiatry moves forward and espouses the need for integrative care, it is of utmost importance that families have a seat at the table, as a vital part of the collaborative care team.
Transcending Trauma: How the Study of Holocaust Survivor Families Sheds Light on the Challenges Faced by Today's American Military Families
The Center for Couples and Adult Families is co-sponsoring a talk with the University of Pennsylvania Jewish Studies Program on Monday, April 28, 2014. The talk will explore ways in which the study of Holocaust survivor families and their ability to rebuild after complete devastation sheds light on the challenges faced by today’s returning American war veterans.
What We Can Learn from Military and Veteran Families
Five questions with Evan Imber-Black
New Directions for the Center for Couples and Adult Families
The CCAF was featured in the February issue of the Department of Psychiatry newsletter, the Penn Psychiatry Perspective.
Click here for article
Love in the Time of Neuroscience
Interesting review of Sue Johnson's new book, "Love Sense."
Click here for article
When is it time to go to couple therapy?
I'm happy to feature the work of CCAF Clinical Faculty Member and couples' therapist, Dr. Steven Sayers. In this post, he writes about the often difficult decision to begin couples' therapy. In response to the question "How do you know it's time?", he has clear, concise suggestions that will resonate with any partnered pair.
Click here for article
The Stories That Bind Us
As a narrative therapist, I am acutely aware of the many ways in which family stories shape our lives: our identities, sense of history, and, perhaps most importantly, our sense of possibilities. I'm excited to share this research about the impact of family stories; it is intuitively what I have know from my many years of clinical work with families. Click here for NY Times article
Thinking About the Institution of Marriage
Dr. Hudak quoted by Dr. Alison Heru in Clinical Psychiatry News,"As family therapists, we are uniquely poised to transform the meanings attached to ‘marriage’ and ‘family,’ to focus on the quality of relationships rather than on the gender of a partner or the assumption of particular roles."
Click here for article
Family Therapy for the Holidays
Each year around this time, conversations with clients turn to the predictable stress of time with family over the holidays. Like ghosts in the night, old issues, long dormant, reappear at holiday time. How is it that an adult with partner and children can walk into their parents' home and instantly feel 10 years old again? The anticipation of a holiday encounter can lead any adult to feel slightly unhinged in a way that few other situations do.
Let's face it, no one can upset you like a family member.
Here are some ideas to try on this holiday season. They are born of basic tenets of family therapy theory and are utterly applicable to a variety of anticipated holiday situations:
1. Plan and be strategic.
It's always a good idea to warn someone that you are going to make a change before you actually do:
"I was thinking about the holiday, and this year I might do something a bit different."
You don't even have to be sure of what specific change you're going to make, the point is to warn others first. That way, you can attempt to avoid their shock and surprise when you decide not to follow the family script - you know, ‘the way it's always been and everyone (but you) wants to continue'.
This can be particularly useful when, for example, you have young children and want to begin to create your own traditions around the holidays. Perhaps you feel the stress of traveling with small children in an effort to please everyone, or because 'you've done it every year, and they're counting on you.' So let people know in advance and find allies to support your change.
Which brings me to the next point.
2. Expect a reaction.
It is true that relationships have much in common with physics: for every action there is a reaction. Families attempt to maintain a homeostasis - a state of balance, maintained by familiar patterns and expectations. Think of the tremendous impact it has upon relationships when a family member joins or leaves the system; these points of normative developmental crises, birth, adolescence, marriage, or death, each require a renegotiation of previous roles and rules in the family system. Holiday traditions are valued as markers of continuity, so changes, however minor, can feel disruptive and unsettling.
3. Focus on yourself.
You can change only your behavior, not the behavior of others.
Admittedly, this is a tough one. It's the balancing act between giving up the dream of what can be, and accepting what is. There is much integrity in changing one's own behaviors in a respectful and compassionate way, and it's sad to realize that, for now, others may just not be who you want them to be.
Developing a curiosity about yourself may help. This might be a good time to entertain the questions: Why does this person still hold so much power over me? Why do I still need my mother/father/sibling to compliment or recognize me? How is it that I have come to this place in my life carrying that old wound?
4. There's always next year.
Your opportunities to practice being different in your family are boundless. Try to think of this as one of many steps toward change. It will most likely take more than one conversation and there can be complicating factors: addiction, trauma, divorce, remarriage. Relationships take time, so keep in mind the long term; families are full of surprises and unpredictability as the family life cycle inevitably moves into the future.
When I hear a person in their 20's or 30's say "I'll never have a relationship with my brother, I respond, "Well, let's think about this for a moment. If you both live until you're 80, are you telling me nothing will happen over the next 50 years? Most likely, your parents will predecease you, and you and he will together become the oldest living generation in the family. You may each partner with someone, and perhaps become aunt and uncle to each other's children." There are endless circumstances that create opportunities for us to evolve in our family system.
5. Lastly, I try to remember at this time of giving thanks, that to even think about the quality of relationship is of itself both a blessing and a privilege.
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