REFLECT

Model stories written by young professionals/students.

Rational Detachment

A student gains a new perspective on the benefits and challenges of providing care that is both professional and personal.

There was a thump and a yell and Sarah* was up in a second, three Mental Health Aides (MHA) following behind her, to see what the problem was.  The unit in Long Point Psychiatric Hospital had otherwise been quiet, composed mostly of elderly patients, many of whom were suffering from dementia as well as other mental illnesses such as bipolar disorder or schizophrenia. The MHAs fanned out down the hall, popping their heads in every room, looking for the source of the noise.  I followed Sarah, the psychiatric nurse I was shadowing, down to the last room on the right.  She immediately noticed Mr. Jerry sitting on the floor in the middle of the room, looking confused.  Mr. Andrew sat in the bed and did not say much as Sarah rushed to help Mr. Jerry up.  With severe dementia, Mr. Jerry mostly wandered the halls and got into trouble by going through other people’s belongings, as was the case in this instance when he had wandered into Mr. Andrew’s room.  As an MHA led Mr. Jerry out of the room, Sarah asked Mr. Andrew what happened.  He became agitated, yelling that Mr. Jerry had been trying to steal his socks and he was “taking matters into his own hands”.  Despite the fact that he was yelling at her, Sarah remained calm but firm, reminding Mr. Andrew that he had to call a nurse if someone was bothering him.  Mr. Andrew continued to yell and Sarah continued to instruct him on how to properly address an issue.  Finally, he calmed down and Sarah smiled at him, asked if he needed anything, and then made her way back to the Nurse’s Station. 

Back at the Nurse’s Station, Sarah sat down and tried to give me some background on Mr. Andrew, who I had not seen out on the unit because he preferred to stay in his room.  Mr. Andrew was diagnosed with schizophrenia that seemed to not improve with medication.  His family, unable to care for him, had gotten a court order that meant he would be living in the psychiatric hospital for the rest of his life.  Sarah obviously felt sad for Mr. Andrew as she told me this, saying that the hospital was not somewhere people were supposed to live indefinitely.  However, she quickly moved on, choosing to see the bright side of the situation: Mr. Andrew was “living a nice life in his head”, brought on by the delusions of his illness.  “Sometimes,” Sarah explained, in an effort to bridge the gap between her sadness surrounding the severity of Mr. Andrew’s illness and the silver lining she found in it, “it is necessary to practice rational detachment.”

This idea of “rational detachment” stayed with me after I left the hospital.  It seemed at odds with my preconceived ideas about what quality medical care looked like.  Weren’t healthcare providers supposed to cultivate personal, caring relationships with their patients in order to give more individualized, compassionate care?  Rational detachment did not sound in line with that idea.  But how were providers supposed to provide personal care when they were working with 25-30 individuals struggling with severe mental illness and who could, at times, be angry, violent, or verbally abusive?  In my time shadowing at the psychiatric hospital, I had seen MHAs hit by patients, nurses yelled at by patients, and patients in tears, begging for something to ease the pain and anxiety they were feeling.  Despite this, none of the nurses seemed to be upset or surprised by these behaviors, even in those extreme situations.  I realized this was what Sarah meant by rational detachment – she knew information about her patients, she cared about how they were doing and if they were getting better but she had also drawn a line where her feelings about their situations had to be limited in order for her to continue providing them the quality care she was trained to deliver.  If she let every hurtful comment, raised voice, or swung fist become personal, her job would be significantly more challenging and her personal feelings would cloud her medical decision-making.  It was seeing this juxtaposition between how she interacted with patients and how she internalized those interactions that showed me that rational detachment was not a bad thing.  In fact, it just may be something to strive for in order to become a compassionate and competent healthcare provider.  Rational detachment, in other words, is not a code for a lack of humanistic care, but rather a way to ensure that providers can practice humanistic care without being overwhelmed by the pain and stress their patients often feel, compromising their ability to provide objective, professional care. 

Sarah showed me that medical care is not a black and white profession.  The supposedly clear-cut relationship between patients and providers is not as defined as it seems.  Each provider has to decide for themselves how to connect with their patients on a human level as well as on a medical level and set those boundaries between what they can feel with their patients and what they have to let go of in order to continue providing quality care.  Rational detachment is a skill that one can only learn from experience and is a necessary skill for every healthcare professional to have in order to face the hardships that come with providing the best medical care possible to people who are often struggling with some of the most challenging aspects of life. 

- Marlaina Parker