My Elephant

July 27, 2009
Jeffrey T. Junig, MD, PhD

One nice thing about a 'psychodynamic blog' is that it can be about anything, since any issue involving humans will have a psychodynamic aspect. But when looking for a story about psychodynamics it is hard to find more content than a story about a drug addict.

Most physicians have heard the reference to ‘the elephant in the living room’. The phrase refers to an alcoholic in a family ruled by collective denial. References to ‘pink elephants in the living room’ are mixed metaphors; drunks classically ‘see pink elephants’, whereas the unseen living room elephant is just a garden-variety pachyderm. This latter point is only a pet peeve of mine, and has nothing to do with the rest of the story… so I’ll move on.

One nice thing about a ‘psychodynamic blog’ is that it can be about anything, since any issue involving humans will have a psychodynamic aspect. But when looking for a story about psychodynamics it is hard to find more content than a story about a drug addict. An impaired physician will be an even richer source of content. We might find, for example, a perfectionist who tried to temper his personal insecurities through academic accomplishment. When ‘tolerance’ took away pride in his accomplishments so even straight As felt inadequate, he faced the unconscious choice to either acknowledge his insecurities and become a ‘whole person’ made up of assets and liabilities, or to repress the uncomfortable feelings and develop a split to his personality where his perfect, outer, public side appears cocky and happy, and his inner, ashamed, insecure persona lives in hidden pain. A person in this condition is ripe for developing an addiction, as addiction makes such a split even more complete. The addict fancies himself as doing pretty darn well… except for that ugly, addicted part that is repressed and split off from his self-image. This repression is what we refer to as denial.

When I look back on my own life I see that schoolwork always came easy to me, but I was socially inept and insecure. I ignored my loneliness and found solace in my accomplishments, but the positive feelings from my successes didn’t erase my core insecurities. If I set my mind to it I could learn almost anything, yet I felt naive and incompetent. I completed MD and PhD degrees in just six years of very hard work, but always felt like I wasn’t working hard enough. At 18 I travelled to Mexico to help build a church and at 19 I risked my life to save a drowning woman, yet I always felt guilty for sins I couldn’t remember committing. I found ways to validate myself, but at some point they all wore off—they ‘weren’t enough.’ And fittingly, I eventually become an addict.

I’m explaining this because I don’t want to leave an elephant in my blog’s living room. As part of my recovery I constantly try to avoid the splitting of my personality—something that is a natural force for any addict with a public presence or image. It is tempting to hide my background and become only the perfect doctor with the record of accomplishment. Maintaining that persona is impossible, of course, in an era of search engines, but the danger of becoming that ‘perfect’ person is more acute for someone with my disease history. Addiction is a disease that limits insight, and the more I pretend that my illness doesn’t exist, the less insight I have to find my way back to the whole, imperfect person that I really am—and the person I must be in order to stay sober. I can’t be dismissive of my history even after 8 years of recovery. There is NO doubt in my mind that my addiction is a permanent condition; a potentially fatal disease for which, at this point, there is no cure.

The hard part for me is deciding in each situation the point where I disclose my history. If I point it out too soon, some people will envision elephant dung in my living room, consider me a fool, and never pay a visit. But if I point it out too late, some people will be angry that they didn’t hear about the elephant dung until after they stepped in it. For those who find metaphors challenging, by ‘elephant dung’ I’m referring to the consequences of my addiction for myself and others. For myself this includes the physical evidence of my addiction—old Board orders and National Practitioner Data Bank information—but also the personality characteristics that are common to those with addictions, and which (chick or egg) either came from or contributed to my addiction history. For example, I can be quick-tempered at times—is that premorbid impulsivity, or is it a consequence of the self-centered grandiosity engendered by addiction? For others the ‘dung’ includes their conscious and unconscious attitudes toward addicts and addiction. When I mention my history to others I get a clue toward the amount of elephant dung they are carrying, which is largely a function of their past experiences with addiction. Their reactions vary—surprise, contempt, sympathy, patronization, or in rare cases a hug, the secret handshake of recovery—but there are always reactions. These are the elephant reminders that I most dislike, as I have little choice but to accept them.

At any rate, this is the disclosure of my elephant. If anyone is interested in more of the story, you will find it here and there on the Web; I tell my own version on one of my own Web pages (there is a link from Suboxforum.com, a forum I run for information about opiate dependence), and Men’s Health told a more graphic version a few years ago (Google ‘junig’ and ‘mens health’ and you will find that one). The Men’s Health write-up introduced a conflict in that I wanted to tell my parents that their ‘son the doctor’ had been discussed in a national, popular magazine… but something about the title made me hesitate. The article was entitled ‘The junkie in the O.R.,’ and featured a picture of a guy in scrubs injecting something into his ankle. The person in the photo wasn’t me, by the way—they apparently have junkie models, and didn’t need me. Who’d have thought?

Most recovery stories have a hidden blessing, and I should share mine. Finding a ‘blessing’ from anything that lands one in the National Practitioner Data Bank is probably a transparent attempt to make sour lemons into overly sweetened lemonade, but I will let you be the judge of whether I am fooling myself or not. I loved anesthesiology, or at least I thought I loved it—periods of boredom interspersed with rare episodes of terror suited me fine, although in retrospect I probably had a couple bushels of repressed fear in my unconscious, and maybe a few acres of resentments growing toward those 3:00AM bowel obstructions. But being an anesthesiologist was quite lucrative and was rewarding in many other ways as well. I still vividly remember some of the more dramatic ‘saves’—the ruptured uterus in the OB unit that both mother and baby survived, the heroic intubations in the ER… there are no comparable experiences in psychiatry. But eventually the thrills were ‘not enough’ (do you detect a pattern?), and I became unhappy. I remember telling my partners that only a fool would ever leave such a job voluntarily. I am now more careful for what I wish for! If I had to name one thing that pushed my life off track, I would describe how at some point money became a way of keeping score for how was doing in life, and a source of security to the point where I almost considered money a source of immortality. I now understand the seductiveness and the fallacy of those thoughts.

To explain the positives I have to provide just a small amount of background: my life came undone when I turned 40, and I entered treatment the following year, in 2001. Three and a half months later I completed the residential stage of treatment and found myself unemployed with what seemed like an impossible period of monitoring and aftercare stretching years into the future. But one day followed another, and I followed the good advice I received from other recovering people. ‘Just keep doing the next right thing.’ ‘Take it one day at a time.’ And in my opinion the best advice: ‘Be grateful.’ I eventually started doing things that I never would have done had my life stayed on track. I acted in several shows by our local Community Theater, after years of sitting in the audience and wishing that I could do that. Singing to the orphans as Mr. Bumble in Oliver as my son played the Artful Dodge rivaled any of my OR experiences, and gave me a sense of fulfillment that I had never had before. I replaced every beige wall in our home with a color (after consulting, of course, a book about colors and temperament). I began to write, and eventually established a regular column in Psychiatric Times and placed occasional articles in other publications. I spent more time with my children, and did my best to repair the damage I caused in our relationships. I appeared on TV in a story about addiction (a nicer presentation than my Men’s Health story!). And I eventually struggled to learn humility as a new resident, this time in psychiatry. Residency was more enjoyable without the fear of learning IVs!

I discovered that I love to teach, and I now teach at a nearby medical school and also in the residency program where I learned to be a psychiatrist. I have a radio show that I use to teach my local community about psychiatry and addiction. None of these jobs, by the way, pay a dime—yet they each make me feel like a million bucks. I am grateful for those who were willing to see me as more than ‘a junkie in the OR’, and grateful for second chances.

To end on a psychodynamic note, being a psychiatrist has taught me that we ALL have our outer projections of who we want to be, and we ALL have our shameful secrets. We are, of course, neither of those things, but rather we are all of them and more. I see too many people engaged in a battle that cannot be won, trying to be only one part of who they are. I also realize that people who seek happiness the most never seem to find it—those with addictions being at the top of that group.

I hope you all, the readers, will accept me elephant dung and all. I want to thank the folks at HCPLive for not dumping my blog after a background check. The new physician rating systems out there are relatively merciless for doctors like me, but that’s a story for another post. Until then… please do your best to keep your shoes clean.