My Three Lessons as a Psychiatrist in Romania

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PORTRAIT OF A PSYCHIATRIST

– Series Editor, H. Steven Moffic, MD

Psychiatry in Romania began, as in the rest of Europe and the world, as a humanitarian endeavor to offer care, refuge, and appropriate scientific attention to those whom society rejected or locked away because it failed to empathize with their suffering. While psychiatry should constantly evolve and be a step ahead of societal pressure, in Romania this process was considerably delayed.

I was only 10 years when Nicolae Ceaușescu met his demise during the bloody Romanian revolution in 1989, but I remember well the utter lack of hope that pervaded those last years of the Communist regime. I remember the literal darkness, the lack of food, of free speech-though also the wicked, clandestine sense of humor everyone seemed to develop.

Later, when I became a psychiatrist, I discovered that a whole generation had to accept fear and trauma in its day-to-day life, whether it was the general poverty, the imprisonment in one’s own country, the catastrophic natality policy (if you want to know what the consequences of anti-abortion and anti-contraception laws can be, study Communist Romania), or the constant surveillance by the political police. You never knew if your best friend, doctor, teacher, or coworker wasn’t informing the Securitate about your daily activities and ideas.

Picture a psychiatric institution in such a country: it isn’t hard to imagine the worst, and it was the reality. When it wasn’t a tool of political repression, psychiatry was utterly cut off from reality and the community. We had to wait for European observers, before the admission of Romania into the European Union in 2007, to become aware of the many institutions more akin to 16th-century insane asylums than to present-day hospitals, where patients spent decades imprisoned before dying of poor conditions of care.

A collectively traumatized community, which underwent rapid changes unimaginable only 30 years ago, has to grow and adapt to freedom or face extinction. The most frequent reaction to today’s challenges, however, seems to be flight rather than fight, as Romania has the world’s second highest emigration rate, surpassed only by that of war-ravaged Syria.

Although places like Poiana Mare asylum, which sparked international outrage in the early 2000s, no longer exist, Romanian psychiatry still suffers from being too detached from the community, too hospital-centered, and unavailable where it is most needed, in everyday dramatic life crises.

A collectively traumatized community, which underwent rapid changes unimaginable only 30 years ago, has to grow and adapt to freedom or face extinction. The most frequent reaction to today’s challenges, however, seems to be flight rather than fight, as Romania has the world’s second highest emigration rate, surpassed only by that of war-ravaged Syria.

When I chose psychiatry as my residency, my hopes, goals, and interests were very different than they are now, 13 years later. Back then, what fascinated me most was psychosis: hallucinations and delusions. I like to think that it wasn’t a morbid fascination, no more than any young doctor’s overly enthusiastic preoccupation with the object of his or her work and study. Let us call it “scientific curiosity.”

I spent many hours in libraries, my favorite by far being the French Institute in Bucharest. It occupied the attic of an old mansion and was naturally illuminated through a huge central skylight. I used to dive deep in the old masters’ works, like Clérambault, Minkowski, Kraepelin, Jaspers and, most of all, Henri Ey, a brilliant clinician and philosopher, unjustly ignored by the English-speaking medical community, who was perhaps the last of psychiatry’s great thinkers. In his monumental Traité des Hallucinations, I “saw the light” for the first time in my blind intellectual journey.

Psychosis is the Unintelligible, almost by definition. Not only is it difficult or impossible to understand on a basic, empathic human level, but it is the quintessential misunderstanding, the deconstruction of the mind and the meaning it produces. That is why it constitutes a source of fear and stigma, but also of fascination.

As for myself, I used to think that in psychosis resides, paradoxically, a key to understanding. Here we have a mysterious phenomenon, whose elucidation might reveal answers about ourselves and human nature in general and which, throughout history, humanity chose to repel, reject, or purposely ignore. I wanted to be part of the change.

As a resident, I spent hours talking with psychotic hospitalized patients. I thoroughly took notes, until the day one patient took the notebook from my hands and threw it away. Since then, I have taken only mental notes during interviews. I considered myself a phenomenologist, though a duplicitous one, because, in parallel, I was also fascinated by neurosciences and very much by psychopharmacology. Professor Stephen Stahl was my rock star.

But the first turning point of my training came very soon. At the beginning of my second year of residency, personal circumstances led me to become the sole caretaker of an elderly woman. Mrs C was 85 years old and had advanced vascular dementia. Her final years were a strange journey toward her origins. In her youth, she was the daughter of a rich family in Moldova, but after 1945 she had to flee from the newly Russian-occupied territories. At a certain point, she probably thought herself a child again, in her parents’ home, because she addressed me only in Russian, a language that I didn’t know; she seemed unable to understand Romanian anymore. I believe the technical term for this is anecphoria.

Mrs C stayed in bed and was completely dependent. In 2006, Romania had no public support system for such people and their families. I did everything myself, including washing, feeding, and giving her medication, every day of the next 4 years-my entire residency-until she died. We didn’t live under the same roof, so I visited her before and after my shifts at the hospital. Time suddenly contracted for me, and all my priorities changed. I no longer considered myself a doctor; I became another link on the caretaking chain, something between a family member and a nurse.

Before this happened, I had some prospects of a promising career. Several of my senior supervisors encouraged me, and I was very proud and ambitious. I became involved in research and started writing papers. I had a good start.

My years with Mrs C changed all that. I soon gave up my ambitions, not only because I didn’t have the time anymore, but also because they suddenly seemed meaningless. Witnessing up close, without the symbolic protection of my doctor’s lab coat, the unravelling of a human being, evaporated all my intellectual fascination. I was being taught a lesson, and I thoroughly absorbed it. I had my eyes opened to ubiquitous and absurd human suffering.

I gave up on phenomenology. It seemed obvious that this suffering, and not the phenomena, was all that mattered and should concentrate all our efforts. I felt as if I had been unaware through all the years of med school, and I was suddenly confronted by a very harsh truth.

I realize now that I was as arrogant as ever. I was under the impression that I had become wise. I still had everything to learn.

Near the end of my residency, I moved in with my then-future wife. Since a resident’s salary was very small, we leased an apartment in Rahova, one of the poorest and humblest neighborhoods of Bucharest. In centuries past, it was called Beggar’s Bridge for good reason. Humble it may have been, but it was full of life and, at least during summer’s dog days, nobody slept. Even today it is still a tough, patchy, and chaotic area, comprising Roma ghettos, blocks of Communist-era concrete buildings for the working class (we lived in one of those), two big and colorful, almost Asian-like markets, one of the city’s largest prisons, a huge drug problem, street parties whenever there is a wedding, a baptism, or even a funeral-and often for no reason at all.

When I didn’t have night shifts at the hospital, I worked nights from home as a translator of novels and medical literature. It paid the rent. I started a PhD in anthropology, which I subsequently abandoned for lack of time.

I was entranced by the life and people of the neighborhood. In my spare hours, I started writing stories about them; some even got published. I made friends with people with whom, in my prior life, I had nothing in common. Everything around me teemed with an exuberance akin to what we find in Latin-American, magical-realistic novels, but true and palpable. In this new light, my own personal difficulties seemed much less dramatic, less blown out of proportion.

I gave up on phenomenology. It seemed obvious that this suffering, and not the phenomena, was all that mattered and should concentrate all our efforts

I had found a new and inexhaustible lesson to learn. There was a lot of suffering here: the life of the Roma minority still is almost a case study of social inequality. But there was also happiness. I was discovering a new term in the mental health equation: human resilience.

Years have passed, and my life and career have taken many more turns and suffered many changes. Mrs C died; I spent some time working abroad (in France, since I was such a fan of French and German schools of psychiatry). I came back. I’m still learning. I’m the eternal student, and each new patient is a teacher for me. But what legitimates me as a psychiatrist are those three early lessons: the phenomenology, the suffering, the resilience. My descent from the library into the street, I no longer have the same fascination for delusional content; real life seems infinitely more complex and interesting to me. This continuing learning is what I love most about this job that borders somewhere between psychiatry, anthropology, and poetry. Whatever it is I have become, I am only afraid that I’m still not worthy of it, of this privilege. But I do my best to listen well.

The case discussed in this manuscript was a composite based on many actual patients encountered in clinical practice. -Ed

Dr Stroescu is a psychiatrist in Bucharest, Romania.