Lately, there have been a couple of movies that remind me of what it’s like to be a Psychiatrist, even though they ostensibly have nothing to do with Psychiatry at all.  I wrote about Inception a little while ago, and how the premise of the movie has analogies to the practice of Psychodynamic Psychotherapy.   This time, I’ll talk about Up In The Air.

In Up In The Air, George Clooney plays a man (who I’ll just call George from now on, because I can’t remember the character’s actual name) who flies around the country to fire people whose bosses are too scared to fire their employees themselves.  He works for a mercenary employee terminating company.  Pretty terrible, right?  When I tell you that his job really reminded me from time to time, of the practice of Psychiatry, you’ll probably gasp in horror.  Why would anyone choose such a profession?!  Go with me a little on this one, it might be hard to relate to at first.

I’m not sure what other people saw when they watched his character.  Maybe you saw a callous man, who doesn’t care about people at all (and in fact gives inspirational talks about how to sever all personal connections to other people,) and just does his job to earn money without remorse.  That’s not what I saw.

In one particular scene, George is showing a new intern (in his own company) how the job is done.  She has just told a man that he has lost his job.  The man becomes distraught and expresses fears about how he will pay for his daughter’s asthma medication.  The intern, who has been trying to grasp onto any silver lining she can find, is overwhelmed by the horror of this situation and can no longer think of anything to say.  George steps in and references something he had read in the man’s file about how he had considered going to culinary school at one point. He goes on to encourage him to use this terrible experience as an opportunity to pursue a long lost dream, and set an example for his kids about following their dreams (which could easily have gone poorly, but he is an artist, and this conversation goes very well.)   To that character, it seemed to be just enough hope to make the immediate events tolerable.

George, in this case, is so much more than just a messenger. He is a bridge, or a guide, to help these employees navigate one of the toughest times in their lives.  He swoops into their lives at a pivotal moment to rescue them from utter despair and hopelessness, and help them walk out of the office with a little bit of dignity. It is something his character takes very seriously.  When his own company was considering using the internet (with a program similar to skype) to fire people remotely, he balked.  He knew that there was a personal human connection that he could offer, one that has great value to them.

Very often, especially when Psychiatrists consult in the hospital for other services, we are called in to help give bad news.  Maybe someone is dying.  Maybe the doctors think a patient is faking their symptoms and don’t know how to tell them without starting a fight.  Maybe someone isn’t allowed to leave the hospital. Maybe someone has to leave the hospital against their will.  Maybe the primary doctor and patient just can’t stand each other any longer. Maybe someone is about to find out that they’re insane.  Frankly, Psychiatrists deliver a lot of bad news.  Sometimes things are going so wrong, that the primary doctor just can’t find the words to say (which is pretty bad, because all doctors are pretty practiced with tough conversations.)  I guess one of the things we specialize in is having conversations that others can’t.  That’s why Psychiatry consult services are often called Consult and Liason. Helping one of those conversations go as well as it can, even though it still might be very painful, is extremely personally rewarding.  Sometimes, you feel like you just rescued someone from a cliff.  And sometimes it even goes pretty well.  There’s a lot of pride that comes from being able to walk into some of the darkest moments in life and make that moment a little better.

However, it is also dishearteningly thankless.  Maybe you even get yelled at (which can sometimes be a victory in and of itself.)  Nobody is going to call up George and say, “thanks for firing me with such grace, it really made the transition in to unemployment much more tolerable!”  He’ll just be remembered as “the guy who fired me... jerk.”

People just remember the bad news. The person who delivered the news is remembered along with the entire situation.  During these situations, people are very rarely aware enough to catch the nuance that the situation went any better than it could have gone.

But you know, that’s the way it should be.  If someone is going to find hope and resilience in a time of suffering, it is much more rewarding for them if they feel that they found it all on their own.  If they think  “Well, the only reason I was able to get through this was because George delivered the news instead of my own boss,” that isn’t as helpful to them.  The story of their firing is really a story about their life, not about George.  And the story of someone suffering in the hospital is their story, not a story of a Psychiatrist.

You might compare what we do to doing a spin job.  When you’re referring to the news media, it’s generally considered a bad thing. But in life, frankly, where would we be without it?  There are many sides to every situation, and people need to be able to see the more hopeful aspects if they’re going to make it through.  If someone ever gives you the worst news of your life, wouldn’t you want someone help you find a glimmer of hope, no matter how small?  I’m not going to give any examples of what this might be, because it’ll just sound trite (the same way my example above about the guy who wanted to go to culinary school probably sounded trite in writing.)  To do this well, there is no one-size-fits-all speech. You need to jump down into the trenches with someone, splash around a bit, find out what’s important to them, and then talk to them where they are.

But all of this has consequences.  As rewarding as Psychiatry may be, witnessing the pain of others, struggling with it along with them, and maybe not being appreciated, can be very disheartening.  In fact, Psychiatrists have one of the highest rates of depression and suicide of among medical specialties. (I’m not suicidal though.  Just in case you were worried.) This might be for several reasons, but I think this is certainly a contributor.

I think the pain of his job explains why this character, George, doesn’t have any personal connections.  When you see the pain of others, you naturally want to protect yourself from it.  George sees that what gives people pain when they are fired is the fact that they will let a loved one down.  He figures that if he doesn’t have any loved ones, he’ll never feel that pain.   All physicians can be guilty of similar behaviors from time to time.  We all see suffering (physical, mental) all the time.  It’s tough to think that it could all happen to you.  So, we grasp onto reasons why the ailments of our patients won’t ever happen to us.  (usually subconsciously) That won’t happen to me because I don’t smoke. phew.  That won’t happen to me because I’m not african american... because I use birth control... because I eat fish... because I’m married... because I don’t have kids... because I’m vegetarian... it can get pretty ridiculous.  And in the end, we all have to admit that we’re just as vulnerable to physical and mental suffering as the next person.

So, I don’t see George as a callous character. I see him as someone who is striving to be the person he needs to be for the sake of his “subjects” (for lack of a better term) without losing himself in the process.

Thankfully, unlike George, Psychiatrists spend a lot of their training learning how not to take the struggles of their patients home with them.  So, we don’t all have to sever human connections to stay sane.

And when I think about the patients who did take the time to thank me for being there with them in the trenches, it is so incredibly marvelously rewarding, it pretty much makes up for all the ones who stayed quiet.