The Point, If There Is One.

Carroll’s 22nd Law of Psychiatry: If you can’t talk about psychiatry, you’re boring.

I’m blogging.

This is not a thing I expected to write. Ever, really.

Which then leads to the eternal, dangerous, and often useless question of why am I doing this?

By way of introduction, about the title: Carroll’s Laws of Psychiatry are a set of rules of thumb I started writing down lo these many years ago. I can’t remember when, exactly; but it was long, long before I had any right to think I should be writing anything about psychiatry, or anything else, and calling it a “Law.” I was like that, back then.

I’m better now, but I still have a high estimation of my own abilities and a propensity to self-reliance. That would be the polite way to phrase it, others might throw about words like “stubborn, ” “oppositional,” “perfectionistic,” and “pedantic.” (The latter I have to thank a dear nurse for.) I attribute that to the fact that I can be stubborn, oppositional, perfectionistic, and pedantic. I have, happily, had a heavy dose of humility and gratitude beaten into me over the years, mainly by my patients and my wife; these being the people who have far and away taught me the most in my adult life.

So these things are not laws. What they are, first and most importantly, are jokes. That’s one part of the why. I like cracking wise about this stuff.

What we do in psychiatry, and all the related caring professions, is hard work. We often are grappling with some of the nastiest diseases and most pernicious problems available to human beings. We have to do this while laboring under a lack of evidence, or even conceptual clarity, that a lot of medical fields have put behind them (though fewer than you might think). Psychiatry’s portrayal in common culture is… unflattering. The two movie psychiatrist types are the guy in the white coat who comes in to inject your brain with green glowing fluid; or the idiot who diagnoses the hero as delusional when he’s really been right all along, you fools! Soylent Green is people!

OK, there was no psychiatrist in Soylent Green. I think you get the point.

Our patients – with whom we share the most soul-baring sorts of conversations and care about immensely – are blamed or ostracized or both. Sometimes, they want to do stuff that’s bad for them and we have to put ourselves in conflict with them for their own good, which is a hard spot to be in.

In with all that, we have to grapple with level of self-examination that most people don’t have to employ. The best of us are asking a whole slew of questions constantly: “How is what I’m thinking affecting whether I’m doing the right thing for this patient?” “What’s his responsibility and what’s mine?” “Do I have some kind of bias that’s shifting how I deal with this patient?” It’s tricky to keep this from degenerating into self doubt.

There are a lot of moving parts to this.

It is also tremendous amounts of fun. Partly because it is, and partly because it has to be.

It is because the s–t that we see and hear and say is really, really hilarious. Case in point: The homeless guy griping to me about how hard his hospital bed is. Of course, the fight wasn’t about a hospital bed. The fight is never about what the fight is about. That’s another post.

I have said things like “Please put down the feces” with a straight face. I have seen the face of someone who was about to inflict grievous bodily harm on another person he though stole from him, only to realize he had spent the money and didn’t remember a blessed thing from the last week. I have walked into hospital rooms and been challenged to a dance-off. That last one would have you changing your underwear if you knew me better.

So we see some really funny stuff.

It also has to be funny, because if we weren’t laughing we’d be in rough shape. The guy griping about the bed was craving heroin and finding some excuse to sign himself out of the hospital. The guy who didn’t remember spending his check did so in an alcoholic blackout.

If we took this stuff as seriously as it is all the time we would be no use to anyone. Which by the way also means just because I’m joking about it, doesn’t mean I’m not taking it seriously. It just means I’m not being serious about it. It’s the kind of balancing act we do all the time.

That gets to the other part of the why. I see very little of what it is like to do psychiatry out there. There are authoritative outlets for psychiatric knowledge. That’s not the same thing as what it’s like to be in a room with somebody who is deliberately picking a fight with you over a mattress when he was sleeping in an abandoned house 24 hours ago. Then realizing that he’s relapsing to a condition that may put him in a box by midnight. Then realizing that the conversation you are about to have could be all that is between him and that box. Then realizing that the odds are against you, and you very well may have to move on to the next one and hope you see this guy above ground again one day to give it another shot. Then finding a way to laugh about it so you can go on to the next one.

So it’s funny, and it’s fun, and it’s difficult, and it’s as serious as life and death; occasionally more so. I don’t see anybody conveying all that. I don’t think I can either, really. But it’s what interests me.

I’m not doing this as any kind of authority. I do have some hard earned expertise, but I am not going to be referencing my every word and providing reasoned arguments for my opinion here.

I’m not doing this as the voice of any institution. I’ve been associated with some good ones, but anything I write here is entirely my own. If I reference any of those who went before me, it’s my interpretation and not their thoughts I’m talking about. You want to know what they think, ask ’em.

Feel free to assume any patient references I make are heavily altered, composites, and/or remote in time. This is one time when assumptions will be rewarded.

I curse. A lot. I will make efforts to censor myself using the universal symbolic code for unprofessional language (#%^@#), but stuff could come out.

Back to the reasons: I just feel like it. One of my English teachers once told me that “writing clarifies thinking.” I like clarifying my thinking (rf that perfectionistic, pedantic thing). And walking down the halls of a psychiatric unit mumbling to yourself looks bad on a psychiatrist.

So here, dear reader, if you exist, are my hall mumblings. Feel free to listen, the people in the walls are.

(Yeah, that was a joke.)


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