The Responsibility of Freedom

In my current position, I see a very wide array of patient presentations and ages. They also come from very different backgrounds socioeconomically, ethnically, and culturally. But, they also present with various psychological traits. Some of my favorite patients to work with are those who have a keen sense of awareness, potential for reflection, and ability to cultivate insight. In psychiatry, insight refers to one’s understanding of one’s own self, afflictions, patterns of behavior, motivations, so on and so forth.

One of the things I love most about psychiatry is that interactions with my patients consistently teach me more about myself. The engagement with other human beings act as a mirror for myself in some ways. In psychiatric lingo, we may call this countertransference, or the types of emotions, behaviors, and thoughts that patients elicit from their doctor. Over the years, I’ve had a number of moving encounters with patients. Just recently, however, I had a patient who stirred up in me great emotions (and perhaps anxiety) about the unfolding of our lives.

My patient grew up in a large family as one of the youngest siblings. Due to cultural pressures and immigration across continents, their life was uprooted not only in physicality but in connection with their older siblings. Between the age gaps and different schooling, there was already a deep disconnect that evolved into deep-seated issues of identity and belonging. For much of their upbringing, my patient obeyed the obligations thrust upon them from both their cultural heritage as well as their family. That is, all control was surrendered to external forces.

It wasn’t until adulthood that my patient started advocating for their own needs, desires, and wants. To struggle against the monolith that forms the foundation of one’s identity can be so difficult. Through this struggle, however, they clawed back a semblance of control and with it, a heightened sense of agency in their life. They were finally able to pursue avenues and experiences more aligned with their values. As they embarked on this journey, however, they were met with more anxiety than they’ve previously faced.

The concept of responsibility is a theme central to many of patients’ struggles. With the aforementioned scenario, the regained control meant that they were now solely responsible for the outcomes of their own lives: that they could no longer externalize their shortcomings on circumstance or others around them. Surely, this is a daunting realization that in this life, we design not only our happiness, but also our own suffering. In other words, because we are the authors of our own lives, we have a choice in the ways that we suffer. I once heard that the word “responsibility” is derived from two separate words: response and ability, otherwise understood as the ability to respond. It has changed my understanding of responsibility itself, and how a lack of such creates for learned helplessness.

I’ve long struggled with analysis paralysis. Peter says I’m in my own head too much. I’m constantly overthinking and analyzing situations which have contributed to feelings of stuckness. As Peter and I traverse various experiences together as a couple, we find that I am more often restrained by my own hesitancies. These hesitancies are almost always derived from “what if,” perceptions entirely fabricated within my own fantasies. Heavier than that, however, is the fear of having to live with any subpar consequence as a direct result of my decisions. Could I accept that I was the sole arbiter of my own suffering?

For most of my adult life, I felt as though I relinquished control in so many ways. Throughout medical school and residency, there is seemingly little power as a trainee. It is easy to perpetually feel at the mercy of others—the admissions committee, your attendings, and especially the yearly dreaded “Match.” Though that experience (or belief moreso) of having minimal control produced its own anxieties, there’s a comfort to be found in having an externalized locus of control.

We cognitively tell ourselves that “it’s out of our control”—an appeal to the fragility of our egos. Perhaps it is a way in which we guard our egos from the humiliation of poor choices. Should I have doubled down on my studies instead of that 20th League of Legends game that week? Maybe I should have read up on pertinent clinical cases prior to 6:00 AM rounds fully knowing that my attending loved bedside teaching. These small but daily decisions culminate in life-altering results. I cannot blame anybody else for not getting into the medical school or residency I desired. I also cannot blame anyone else for my poor grades. Though obvious now, I find it so important that Peter and I both stay intentional in the way we navigate through life.

This sense of agency or control is a double edged sword. On the one hand, it alleviates so much control of the unknown. But on the other, it confronts us with the burden of responsibility: that we are the masters of our own lives. Certainly, we do not live in vacuums, and there are elements that may be entirely out of our control. When we understand that events do not just happen to or at us, we are empowered with the ability to respond. To live our lives means that we are an active participant within the environment around us. Even for minutia, we try to adopt this mindset simply by re-organizing the thoughts. “I dropped my wallet” accepts responsibility and allows for more actionable change compared to “the wallet fell out of my hands.”

So many of my patients encounter the thought of “I can’t” when, by all physical and cognitive measures, there are no such limitations. To surrender one’s power is to abandon any hope for meaningful change. The great irony here is that motivation for change, or at least the insight that one is able to change, is a powerful predictor of clinical improvement. Yet equally powerful is the belief that we are own agents of change—that change is molded from within. I’ve often found that inertia in treatment is often associated with an undercurrent of self-helplessness.

Peter and I are coming upon some of the biggest questions in our relationship, territory in which neither of us have much experience. Needless to say, I’m still learning to address the cognitive distortions that arise along with the emotional duress that accompanies them. If there is one thing I’ve learned from this reflection, it is that the weight of responsibility is more easily managed than the anxiety that comes with helplessness.

In usual fashion, however, Peter bulldozes through all the presenting problems, paying no heed to cumbersome emotions of anxiety or trepidation. Contrary to how it may seem, I don’t think he is entirely emotionless; rather, I think he’s just comfortable with managing responsibility. And with his skill and leadership, we hope to accomplish some wonderful things in the coming months.