Jessi Gold's Search for Humanity in Medicine
Interview by Audrey Clare Farley
Jessi Gold, MD, MS, is a psychiatrist and the Chief Wellness Officer of the University of Tennessee System and an associate professor in the Department of Psychiatry at the University of Tennessee Health Science Center. She is a highly sought-after expert in the media on everything from burnout to celebrity self-disclosure. Her book, How Do You Feel? One Doctor's Search for Humanity in Medicine, was released today from Simon Element. Here, she discusses that book with Audrey Clare Farley, PhD.
Farley holds a PhD in English literature and is the author, most recently, of the award-winning Girls and Their Monsters: The Genain Quadruplets and the Making of Madness in America, about the four women behind NIMH’s famous case study of schizophrenia.
The interview was conducted over Zoom, then edited for clarity and length.
Farley: You went to medical school certain that you’d never become a psychiatrist like your father. And yet, here you are. What happened?
Gold: I’m sure Freud would have an answer to that! In all seriousness, I was always fascinated by the brain. I tried to focus on neurology, joining interest groups and seeking mentors with that specialty. But I kept finding myself happiest when I could talk with patients and hear their stories. Even when I was supposed to focus on a procedure or make a difficult diagnosis, I just wanted to pull up a chair and talk to people about their lives.
Farley: But you quickly found that disciplinary conventions circumscribe the conversations you’re allowed to have.
Gold: Yes, in psychiatry, you’re not supposed to be the patient’s friend. You’re supposed to be a blank slate, upon which patients can project their stories. You can’t self-disclose. You shouldn’t display pictures of your family, nothing like that.
And that philosophy explains a lot of the resistance to my work, which focuses on the emotional burdens of healthcare, but specifically psychiatry. Many psychiatrists think I’m narcissistic in sharing my own story or wanting to put it out there. They’ll say, “It’s all about Jessi.” They suggest that I’m not good at my job because I talk too much about my own mental health struggles online or in lectures. I’ve never loved that, but I’ve tried to carve a path for myself in the field despite that.
Farley: What are the emotional burdens of working in psychiatry, and what can be done about them?
Gold: Like other clinicians, psychiatrists have burnout, especially systems burnout. We have to chart a certain way, we have to deal with insurance companies who dictate when a patient should be discharged, what we can and cannot prescribe. We have lawmakers telling us what to do. Insofar as we are constrained by these forces, we suffer from “moral injury.” Knowing something is the right medication but not being able to prescribe it—that goes against our moral convictions.
In psychiatry, we also encounter a lot of trauma, especially raw and unprocessed trauma. And then there is the unappreciated burden of patients dying, especially by their own hands. In training, we’re told this will happen. But when it happens, it’s devastating. There is shame and guilt but no space or time to grieve. I think we need to talk about these things. We need to heal the healers. That is why I wrote this book.
Farley: How did the book come about? I imagine many psychiatrists, perhaps not your critics, wonder about writing a trade book.
Gold: I became more and more convinced that the topic of clinicians’ wellness was important and that I had a unique perspective to tell it… Still, I had to learn how to write in a way that foregrounded human stories.
Gold: Even though I’d written a lot about psychiatry and wellness for outlets like Slate and the New York Times, no literary agent or editor ever approached me to ask, “Hey Jessi, do you want to write a book?” The idea came from talking to friends. I became more and more convinced that the topic of clinicians’ wellness was important and that I had a unique perspective to tell it. Wellness is a topic where psychiatrists have the responsibility to enter the conversation—to combat misinformation, to ground it in science. Still, I had to learn how to write in a way that foregrounded human stories. Initially, my book proposal focused on the research. The feedback was overwhelmingly, “Can you tell stories?” It was basically “narrative or bust.” And so I had to spend a lot of time learning to develop characters and storylines, including my own.
Farley: I want to circle back to the metaphorical nature of the patient/psychiatrist relationship. It interests me how variously you describe that relationship in the book. In one case, the parties are like a child and parent; in another, two lovers. What is it about the psychiatric setting that makes it so easy for patients to transfer and psychiatrists to counter-transfer?
Gold: There is an unequal balance of conversation. One person talks more, the other listens. The talker doesn’t know much about the listener, which is why it’s not a friendship. The listener cares about the talker and asks questions. If you’ve never had anyone pay attention to you this way, it can feel like a loving relationship. It can feel like the psychiatrist is a parent, a schoolteacher, or even a romantic partner. This is true for the psychiatrist, too. We imagine ourselves fulfilling a certain role in the patient’s life.
Farley: It seems to me that there is another, less acknowledged relationship, that of a person and her priest. I suppose it could be any religious figure, but I grew up Catholic with the sacrament of confession. Whether psychiatry admits it or not, it seems patients often bring moral, not just clinical, concerns into the room. Where does the clinical end and the moral begin? What do you do when you encounter a patient whose psychological troubles suggest moral problems, such as hate?
Farley: Where does the clinical end and the moral begin?
Gold: We’re taught therapeutic neutrality. We’re told we should be able to see the person who sexually assaulted someone and the person who was assaulted. We’re told that the patient’s feelings are always valid—and this is true.
As psychiatry has evolved, some have put up boundaries. So, for instance, if I don’t think I can neutrally treat someone, I can say, “I’m not the right fit for you.” But I am wary of doing that. There aren’t enough psychiatrists; further limiting access is inappropriate. And gently getting people to understand their role in their behavior is one of the arts of what we do. I would never say, “You’re hateful.” Instead, I would ask, “What brought you to those beliefs? Do they impact you? Have you ever thought of how those beliefs affect other people?” Our job is not to change people’s beliefs; it is to help them see that they have them.
Farley: I want to press you on this idea that patients’ feelings are always valid. You write, “If someone feels hurt, they are hurt." In the realm of your book, this makes sense. Your patients are so earnest and sympathetic! But I can’t help but think of how many Americans today are animated by fears of racial and sexual “others.” Perhaps some of them experience their terror on a physiological level, but their fears are not supported by external reality. Does psychiatry empower you to challenge such people? And if not, is this another moral injury? That you must sit and listen to their bigotry?
Gold: I can always point out this or that, and see how a patient takes it. But I never do that until they’re ready. This is why psychiatry is not like confession. It’s not like the person admits to a moral failing, then I offer a penance or whatever happens—I don’t know, I’m Jewish! It’s not like I write a script for their racism, and then we’re done. It’s a process. It unfolds slowly.
Farley: Do psychiatrists even engage as much as you do? My impression is that many do a med check and leave the talking to therapists.
Gold: I was trained in psychotherapy in residency. Some programs are more strictly clinical. It won’t surprise anyone that I’m partial to keeping talk therapy in psychiatry, especially when patients struggle to access care and so many of their issues aren’t fixed by medication alone. And, shouldn’t be.
Farley: You write about the importance of trauma-informed care. I have to confess that I have such conflicted feelings about the ascent of trauma as a framework for understanding the way certain experiences “get under the skin.” I grew up in a high-control religious community. On the one hand, the language of trauma has helped me to understand how my body is haunted by the past. On the other, it enables me to cling to that past, be dishonest with myself about the power I now wield, and leave no room for my wrongdoers to reform. As someone whose care is trauma-informed, how do you help patients to acknowledge the past without foreclosing a future? How do you help them to mutually attend to what is and what is possible?
Gold: I would say that diagnosis in general—not just trauma—can sometimes become a crutch, even though that’s not how we intend for it to be used. Some people identify with the label, and that’s it. They don’t do the “work” that is required to heal. This could be avoidance. If you have trauma rooted in your body, it’s not going to feel good to confront it. I get it!
Gold: Diagnosis in general—not just trauma—can sometimes become a crutch, even though that’s not how we intend for it to be used.
The over-desire to affiliate with a label may also stem from the authority people perceive the label to confer and from social media’s influence. I recently formed a Wellness Council on campus. More than half the student applicants cited only their diagnoses as credentials. It wasn’t, “After I was diagnosed with X, I learned about this topic or went on to do this work.” It was purely the diagnosis. Lived experience is important, but it doesn’t substitute for other expertise (or talking about your diagnosis with an expert!).
Farley: Both in your book and your practice, you draw widely upon literature and music. You quote the likes of Shel Silverstein, Charlotte Bronte, Victor Frankel, and Taylor Swift. Beyond specific truisms, what do the arts bring to psychiatry?
Gold: The arts provide other ways to tell stories, other ways to emote. In my own life, they are a place to turn when I don’t have words and someone else does. Or when I feel lost by how big my feelings are. I often encourage my patients, when they’re struggling to communicate, to bring in memes, song lyrics, or poems. Together, we will process them. In psychiatry, and really medicine in general, we don’t do enough with the arts. It’s seen as fluffy. I regret that.
Farley: That is interesting because the “psy” professions undergird literary studies. We are encouraged to understand reading in terms of the therapeutic setting. We’re told that Freud’s “hermeneutics of suspicion” made us paranoid readers, but we can learn other modes. We can be playful like D. W. Winnicott, or we can read for “repair” a la Melanie Klein. We definitely study your literature.
Gold: (Laughs) We don’t return that gesture, but we should.
Farley: If you had to boil the book down to one of its sentences, what would it be?
Gold: A quote from the poet and author David Jones: “It is both a blessing and a curse to feel everything so very deeply.” It sums up so much of what I believe and what I do. Feeling deeply makes me who I am, but it also burns me out. That’s the message of the book.
You can order a signed copy of “How Do You Feel?” here.
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