Long Walk Out of the Woods: A Physician’s Story of Addiction, Depression, Hope, and Recovery
It wasn’t work with addiction, depression, or hope that led to a Long Walk Out of the Woods: A Physician’s Story of Addiction, Depression, Hope, and Recovery. It was the fact that Adam Hill discussed his suicide attempts – and that his history is from Indiana and Indianapolis. A colleague recommended the book, and despite my relative resistance to reading stories, I decided it was worth an investment.
Cultural Indoctrination
Context is important. If you’ve not been a physician, it can be hard to understand the culture of medicine and its training process today. The training process is bipolar, that on one hand tells us that they’re “baby doctors” and leads them to expect greatness from themselves and their peers, while on the other hand simultaneously asks how they could have made such a stupid mistake.
It starts with the competition to get into medical school. Hill recounts his struggle as a waiter while he awaited news that he’d be accepted to school – and the internal struggle with inferiority. Once there, top spots are coveted, because they mean that there are more options. However, the winnowing process has elevated the competition so that students who were used to being at the top of their class find themselves struggling to get by. Everyone is clear that the curve has changed.
The final, unspoken, piece is the recognition that peoples’ lives are literally in your hands. Few professions routinely make life-or-death decisions, and that can weigh on physicians. It’s one of the reasons why people can be ostracized. Their peers wonder if they have “what it takes” to be a doctor.
It’s in the context of this culture that doctors are discouraged from admitting their weaknesses and seeking help – particularly if the struggle is a mental one. It’s okay to get tutoring on anatomy, but it’s not okay to say that you’re struggling to cut into a cadaver. This destructive system pushes many to the brink and beyond. Luckily, Hill came back.
Hiding in Plain Sight
Sometimes, the seeds of destruction were with us and visible all along – if anyone were able to put the clues together. Hill shares his social anxiety and his strive for perfection. It’s a recipe for concern. He had learned to hide his imperfections. Life Under Pressure explains what a culture like that does to create the conditions for a suicide cluster. Perfectionism explains the dangers of perfectionism itself – in the failure to accept that anything less than perfect is good enough. In The Paradox of Choice, Barry Swartz explains how satisficers learn to accept what’s good enough while maximizers must have the absolute best – and how the psychological consequences aren’t good. Maximizers is another way of saying perfectionist.
The problem with hiding imperfections is captured in the saying, “You’re only a sick as your secrets.” It’s such a prevalent topic that it’s come up in numerous book reviews, including Opening Up, The New Peoplemaking, The End of Hope, Safe People, and more.
Visible Scars
Hill recounts a fractured tibia requiring crutches, and how this was an outer sign of injury. For this, others questioned and commented – to the point his sister made him a t-shirt with the answers. However, while the outer injury was visible and the topic of conversation, his internal brokenness was unspoken – by either him or by others. The visible was easy. The hidden and the mental were culturally inappropriate to discuss.
Hill suggests what a shirt might look like with the inner struggle: “Yes, I am broken. It happened during medical school. It really hurts. I do not feel like a good person.” While I struggle to disagree with how someone feels, I do believe that the roots of the problems were present before medical school, like the tiniest of fractures that is barely able to be detected being aggravated by continued stress (abuse). Athletes – particularly child athletes today – encounter these microfractures and must take time for them to heal. However, that’s not a luxury we’ve ever afforded to those who are struggling with their own worth as a human outside of what they can do or who they will become.
The Stigma
Stigma is simply different than “normal.” It’s different than the socially prescribed path that you’re supposed to walk – and it matters. (See Stigma for more on the concept of stigma.) It’s important to understand that stigma is resolved by normalization. The more that we normalize a behavior, the less power stigma holds. Thoughts of suicide at some point in their lives are present in more than 1/3rd of the population – and it appears to be growing. The belief that suicidal thoughts are rare is a myth. (See https://SuicideMyths.org.)
When I grew up in the 1980s into the 1990s, gays were to be feared. I don’t know why, but the social message was clear. (True to my nature, I really didn’t care.) Books like After the Ball, which advocated techniques for normalizing alternate sexuality, were scooped up by zealots and largely destroyed. I still think After the Ball is a great guidebook for how to make things more normal – thereby evaporating the stigma.
One of the barriers to anyone speaking out about their struggles is the fear of repercussions; one part of that is the reality, and the other is the fear. In Dreamland, Sam Quinones shares about the terror tactics used by the Mexican cartels to ensure that people would remain afraid. The incidence rate was low, but the message was clear.
We face these twin barriers in stigma within the medical community. There are some real problems with the ways that licensure boards ask questions that violate ADA standards. These must be fixed, and it’s one of the missions of the Dr. Lorna Breen Heroes Foundation. Beyond the literal requirements of the ADA, they’re pushing for licensure and credentialing standards that don’t penalize people for seeking appropriate help.
The other barrier is the stories that we hear of people who were penalized or condemned for their stories – and fear that if we share our weaknesses it could be us develops. That’s where finding approaches that maximize protecting the public (what licensing boards are for) and provider dignity are needed.
Numbing
There are echoes of workaholism throughout the medical industry, whether it’s coming back to work early after surgery, those insane number of hours in residency, or the tendency to slip back into work when things were getting harder to deal with. But, across the planet, the big tool for numbing is alcohol.
While we find books like The Globalization of Addiction and Chasing the Scream that are focused on narcotics, the number one tool for numbing is alcohol. Alcohol is not, however, inherently bad. Neither is numbing. Numbing is used for procedures to make the process easier. We encourage it for short-term use – it’s the long-term use that creates a problem.
It’s a hard line. How much numbing is too much? How much numbing do you need to be able to process the day-to-day trauma of life?
Numbing as the only strategy doesn’t work, because it becomes less effective over time. That’s the trap of numbing and how it leads to suicide. Numbing is used without healing. Short-term numbing is fine – but only when used in a pathway towards healing.
Suicide
Hill recounts the fellow medical student who died by suicide and how their death was never spoken of in a public forum. He shares that even in the first few years of his career, he lost five people to suicide. Between his words you can hear echoes of confusion: on the one hand, some of these people seemed outwardly fine – on the other, he recognizes that he appeared okay on the outside as well.
Suicide happens when the numbing is no longer effective enough. The pain gets to be too much. (See Suicide as Psychache.)
The title of the book comes from the pivotal moment for Hill when his wife called him at just the right time to interrupt his suicide attempt. The literal is a part of his figurative Long Walk Out of the Woods.