The Harm in Listening Conditionally: Importance of Treatment with Compassion
I work at an inner-city psychiatric hospital as a counselor, the only freestanding psychiatric hospital in DC. I call myself a counselor because that’s my title, but a more realistic assessment of my position is that I’m a behavioral technician. The hospital administration brings us on as counselors so that we can do groups, but there’s no serious qualification involved. For this reason, most of my coworkers at the hospital refer to themselves solely as PCs — abbreviated from psychiatric counselors — and will give you a strange look when you refer to the job as “counseling.” I tell my patients I’m a counselor because I try to be one, but it’s a position which does not award me much prestige.
Empathy is a two-way street
I go back every week because being faced with disorders of consciousness and severe emotional distress not only offers a look into the black box that is a well-integrated neural machine, it also gives me the tools to examine myself and my behavior as a neuroscientist when I encounter such people. With any interaction, an automatic cognitive coupling process is set into motion that allows us to understand each other’s mental state. Neurons firing in one person’s head have their neural counterparts in the other person’s light up in synchronicity by the simple virtue of observing behavior. Physical cues and demeanor transfer massive amounts of unconscious data which is processed and filtered to the part of you responsible for thinking and feeling and results in snap judgments.
When we drop an emotional observation token into the plinko board that is our brains, cascades of activity across our cortex determine which emotional response slot the piece will land in. How the piece bounces is dependent on an individual’s neural architecture, one reinforced through feedback from decisions. A lot of the time, the paths an observation token will make are well defined. If you input distress, most people respond with kindness. Happiness invites approach and anger elicits avoidance.
It means when you encounter someone who’s emotional state triggers a heuristical process within you, be it they are jarringly offensive, reek of bad intentions, or perhaps remind you of yourself a little too closely — it is immediately fed into the weights and measures which decide your next interaction. This live connection also means if that process makes you recoil, non-verbally or otherwise, the other person you’re interacting with will feel it too. It’s a miracle with all our basic human needs and social standards and powerful internal selves that we manage to interact competently at all. I certainly don’t most of the time.
How we choose to treat others is not always a conscious choice, but the ramifications are real. Dealing with these automatic reactions is part of being human, but getting good at it is a lifelong process. I’ve found through the intensive crash course that is my hospital it is a skill which develops with time and purpose. When I started working I had no training or experience. I didn’t have a college degree and I got the job through connections I had developed through epidemiology research that I was conducting with an associated medical provider. However, I found out very quickly that background doesn’t really matter where I was about to matriculate.
The only psychiatric hospital in D.C.
Nothing can prepare someone for work in an environment where we’ll occasionally get patients who have killed people. Where some patients will have voices in their head telling them to harm others. Where one of the kindest people I know has nasty scars from a patient who, for no discernible reason and entirely unprovoked, took it upon themselves to claw at their face from behind. We effectively don’t reject patients and there is no security at our hospital. Instead, the counselors are given basic Aikido training during orientation branded as the Handle with Care program. Aikido, for those unfamiliar, is more art than a martial art. This is the environment I work in.
People react very differently to these emotional pressures and those who have worked there longer tend to become jaded. Many of them act like they’re responsible for looking after regular people who happen to have a killer attitude, rather than literal mental cases in need of treatment and compassion. These burnt out staff members will also call in psychiatric emergencies on the unit more frequently, referred to as codes. When codes are called, all able-bodied persons in the hospital swarm the unit to assist, and a cocktail of antipsychotic and sedative medications is prepared to order. The nurses call it “the shot” which I think is rather ominous. I prefer the nomenclature from the patients on the kids floor who affectionately refer to the injection as “booty juice” based on a common route of administration for uncooperative subjects. I’m happy to say in the year I’ve worked at my hospital, I’ve never needed to call a code on my unit. It may be because I only work around two or three shifts a week, or because I primarily work on the substance use disorder floor rather than the intensive care unit, but I like to think it’s because something I’m doing is driving positive outcomes.
Burnout is the enemy of listening
Those who start at the hospital become increasingly unsympathetic over time. They’re told by the veteran staff to be careful as the patients can be manipulative, will lie to you, and are dangerous if you make them angry. We’re made to understand that the patients largely come from the street and operate based on implied respect. This is, given our patient population, true in a very general sense. Coming in with this understanding, even with the best of intentions, makes it very difficult to listen openly to patients because what they say a lot of the time is white-hot displaced aggression, insulting, or occasionally delusional nonsense. A patient’s anger at the hospital over their treatment or lack of access to amenities when spat in your face feels like they’re holding you personally accountable.
Feeling attacked when this happens is an automatic response and an easy conclusion to draw. It makes separating emotional response from emotional observation challenging to say the least. It compounds when you decide not to listen based on that conclusion and the patient realizes you’re not feeling them and results in you becoming part of the problem in their mind. When I shut patients out and redirected them, I got threats on my life or nasty comments on my race given I’m white in a predominantly black psychiatric hospital. All the times I was called a white dog playing tricks or more commonly a descendant of slave owners (perhaps ironically given my immigrant family wasn’t even in the United States until recently) their biting assumptions about who I was as a person and my intentions with my behavior cut deep. For most complaints I couldn’t deal with immediately, I would fall back on a predetermined response in my head to end the conversation as quickly as possible without addressing the patient personally. Maybe coupled with a few surface-level affirmations of their emotions. It makes me nauseous just thinking about it.
While I was acting by example and certainly within the realm of my job description, I still walked away feeling like I had compromised myself somehow. It took hundreds of displays of passion and reflecting on my patient interactions that I realized what made me feel the most whole is when I didn’t take the energy directed at me as personal attacks. It’s trauma from assaults or violence. Uncontrollable emotion from maladaptive neural circuits. It’s pent up anger from a person who’s had their freedoms taken away and confined in a bland building surrounded by rude and many times unsanitary patients who could decompensate on a moment’s notice. It comes from people who may have checked themselves into the hospital but require someone else to check them out. The key was listening to what they were trying to say, not what they were saying. Checking your ego at the door means repressing your reflexive emotional response to despicable personal attacks. It takes a ton of energy to maintain this unconditional positive regard especially with all of the volatility of our hospital in particular. Understandably, this isn’t the go-to for most of the counselors working there, despite their job title. To work at this hospital for as long as some of the PCs have is a marathon, not a race, and running a unit five days a week sometimes 16-hours in a day requires taking the path of least resistance.
Listening without putting up barriers requires appreciating the motivation more than the tangible things people say. Not taking it personally means I don’t have personality conflicts anymore. Like magic, the blatant and chronic animosity towards me from the patients has become acute in all but a few specific cases and has been replaced by much preferred open communication and apologies for their behavior after the fact. Even with our depressingly common cases of extreme schizophrenia, listening openly to the senseless semantics and simply identifying the emotions in play means when I end the conversation, I get a smile from someone who may not have been speaking coherently, but nevertheless feels listened to.
The idea of not only unconditionally regarding a person’s treatment potential as positive, but also their validity as a speaker is a skill which is applicable for all voices in all settings. I discovered this first when communicating with other staff. The big personalities required to be on the unit day in, day out means those who should be acting like dipoles on a magnet are instead confined together on a psych ward. I remember distinctly when in a hilariously terrifying reversal of roles, a code had to be called for a nurse and a PC settling their differences with closed fists and the patients having to intervene. I’m not the type to have these sorts of conflicts for the most part, but I’ve noticed when they do come up their severity is vastly improved when I suppress the urge to rally behind on what I know is correct and just listen. It stops being about winning or coming out on top — which are really just higher-level functions of the basic preservation instinct I feel with some of the patients’ verbal assaults — and instead opens you back up to that unfiltered unconscious feedback. And conversely, the other person doesn’t sense me tensing up in apprehension which makes them less likely to feel as if the situation has escalated. For cases where neither person wants to be angry, expressing an air of calm is much more likely to influence someone.
All communication is equally valid
One of my guilty pleasures is reading charged posts on social media regarding race and identity for an angry little kick of dopamine. I’ll do a panic scroll through Twitter or Reddit in between classwork and get my weekly serving of exasperation at a post saying that every person in [insert political demographic of the month] is an evil lizard person and deserves to be eaten by the poor. I think a lot of people do this with their politics of choice, which is certainly a terrible mental diet but like delicious carbs is an addicting one. As we interact online with the absence of physical feedback, the only information we have about a person is what they say in a literal sense. It’s simplistic, but simple is like candy for the reward pathways in our brains looking to find structure from all of our messy biological inputs. What we lose in this process of snap deterministic response is the human passions behind those statements.
Shouting to be heard has become a touchstone in how we communicate. Browsing online can sometimes feel like my psych unit and every day I go home it feels like I’m taking more and more overtime hours. Complete with codes being called. I understand what it’s like to have people levy daily unreasonable and sometimes nonsensical attacks on your person. I also understand why it’s important not to be dismissive of those statements outright even if they are undeniably absurd and perhaps hypocritical. Casting that emotional token arbitrarily into your personal neurological pliko board results in the deeper motivations of that anger to be lost. It’s a trap people fall into when we close ourselves off to the passions and energy of a group of people because many supporters inelegantly voice their complaints. And an indication we’ve become conditioned so generally that we’re comfortable dismissing whole groups of people as invalid. We cannot allow ourselves to be limited or even cause harm by deciding habitually the people we permit for our consideration. Intentionally fighting this urge allows you to moderate your own internal heuristics and avoid being a captive audience to the construction of your own neural circuitry. It is a life skill taken from a very extreme circumstance, but the skill is transferable and the effects are real.
Does this make pervasive and radical statements like those mentioned above acceptable? No, of course not. No more than the racial and threatening remarks I’ll still get occasionally from my patients. But to take it personally is to welcome the status quo. And where I work, the status quo is not acceptable.