Jack Pula, MD

Since Freud, the fields of psychiatry, psychology, and psychoanalysis have grappled with trauma and its role in psychopathology. In modern times, these fields remain uncertain about the relative influence that biology, character, and environment play in disordering the lives of traumatized patients. Modern theories try to make sense of early attachment and its impact on development and resiliency. Most bluntly put, why do some soldiers go to war and return seemingly well adapted, while others can not reenter civilian life because the psychic scars are too constricting?

In the psychiatric emergency room, psychiatrists quickly take in multiple, complex facets of a patient’s life in an attempt to assess and judge the patient’s ability to withstand their predicament in the community. Our raw purpose is to assess safety and decide whether the patient needs be committed to a psychiatric inpatient facility. In that assessment, the doctor quickly tries to take in the history, biology, character, and the social milieu of the patient, and judge the degree of risk that patients pose to themselves, their families, and their communities.

The task of the psychiatrist in this job is immense. It is profoundly complicated. It is rich and riddled with considerations. It is not seen so by many in our field, and not by our patients. To patients and the public, we are at worst jailers. To our field, we are at worst crude physicians in a souped-up triage unit.

But think about what we really do. We are surveyors and judges of trauma and character.

Freud knew that sexual abuse and death on the battlefield occurred in his time. He was profoundly struck by both. He created theories to explain these dark experiences. Freud also knew that our deep human psyches contain capacities beyond immediate experience and that one could project and layer fantasy into lived experience. He grappled with the role that fantasy plays in our interpretations of experience. He angered feminists and others because his theoretical changes undermined the role of real trauma and highlighted the role the individual mind plays in repeating trauma.

In the psychiatric ER, we witness the real traumas that weave through patient lives. We often experience these traumas, even to the extent of avoiding certain patients whose realities strike too close to home. This is especially potent for psychiatrists with young children working with patients whose stories and affects stir our worst fears for our own children and families.

We also deal with patients and personalities who seem to seek repeated suffering in the form of both micro- and macrotrauma. We sympathize with the involuntary, victim-bound suffering, and we cringe at and speculate about the conscious and unconscious degrees of self-sabotage on display.

There are several forms of social, political, and historical trauma that are close to home for me and my contemporary American peers that repeatedly come up in patient narratives in the emergency room: racism, sexism, homophobia, and transphobia. In my 41 years of life, I have encountered or experienced all of these forms of oppression, trauma, and microaggressions. I know that they are "real." Many psychiatric ER psychiatrists know that they are real. But in the psych ER, where profound decisions weigh on individual assessment, what is real and what that means becomes relative.

It may be obvious upon arrival that a patient has just suffered a serious physical injury, sexual assault, or severe and obvious abandonment by a loved one. But when patients report histories of such events and a seeming pattern of repeated abuse, we naturally wonder about their perception and their own role in creating self-destructive experiences. Because we have experience and understanding of the human compulsion to repeat even painful life experiences, we are cautiously skeptical when a narrative is full of catastrophe, especially when presented as accidental or without agency.

For instance, even though we know about the depth of racism in our history and its profoundly traumatogenic potential (though this gets little or no attention in formal training!), we must be curious about the meaning an individual attaches to it, and how that meaning may serve or defeat his or her psychological existence and progression across life development.

The same goes for women, gay people, and transgender people who are so exposed and vulnerable to real and perceived physical and emotional trauma and aggression on a daily basis.

How does a person suffer in the moment after an infliction of trauma or aggression? How does a person encode that experience in her character, early in life and later in life? How does it color her experience and interactions? In the comprehensive psychiatric emergency program (CPEP), we must try to answer all these complex questions in what seems like a blink of the eye!

We only see a slice of a person’s life. We focus on the patient’s "history of present illness," the narrative history told in that moment, and the mental status exam. We rely heavily on collateral information to corroborate as much as possible. We use this to measure accuracy and distortion, always holding a skeptical lens against our patient!

While we want to believe our patients and take their histories at face value, we can’t fully do so because we know, instinctively or through training, that fantasy permeates the human mind and transforms meaning. Yet, at the same time, we assess that very idiosyncratic meaning for what it is, because that meaning stays with patients as they move from our ER to the street or the unit. And it is that meaning, embedded in an individual’s coping strategies and character that partly predicts what and how the person will do. It is an inherent consideration of risk and resilience, and we instinctively factor that into our decision making. This is the art of psychiatry at its best.

The CPEP is the frontline of psychiatry. Some residents dislike it because it vibrates with anxiety and responsibility. It is a place in which clinicians tend to come unglued behind the scenes, joking as if at a party, talking loudly and blurting out inane and obscene lines from TV shows and real life. In the back room, the burdened frontline psychiatrists and staff attempt to regain control and wrestle back their own meaning in life, in the face of withstanding traumas, distortions, and psychosis – the delinking of meaning – while rendering verdicts of risk and resilience based in rapid assessments of social, cultural, characterological, and biological factors that make up patient lives.

We swiftly analyze our patients and decide their immediate fate – street, home, unit, extended observation, needles, blood, medications, even visitors and babysitters. We hold them, or we jail them, depending on your view. But we do it with benign and perhaps grandiose intentions to protect, comfort, and quickly "know" them in order to progress them to the next most right place. And we do this almost without knowing that and how we are navigating a delicate and profoundly intricate path of evaluation and decision-making that is uniquely human in its intellectual and emotional nuance.

It is a job full of sharp edges and soft curves, a job that makes a bouncer an analyst and an analyst a bouncer. It is a job never to be reduced to algorithm or computation.

Dr. Pula is a psychiatrist at New York–Presbyterian/Columbia University Medical Center. He also is in private practice and is a psychoanalytic candidate at Columbia.

Since Freud, the fields of psychiatry, psychology, and psychoanalysis have grappled with trauma and its role in psychopathology. In modern times, these fields remain uncertain about the relative influence that biology, character, and environment play in disordering the lives of traumatized patients. Modern theories try to make sense of early attachment and its impact on development and resiliency. Most bluntly put, why do some soldiers go to war and return seemingly well adapted, while others can not reenter civilian life because the psychic scars are too constricting?

In the psychiatric emergency room, psychiatrists quickly take in multiple, complex facets of a patient’s life in an attempt to assess and judge the patient’s ability to withstand their predicament in the community. Our raw purpose is to assess safety and decide whether the patient needs be committed to a psychiatric inpatient facility. In that assessment, the doctor quickly tries to take in the history, biology, character, and the social milieu of the patient, and judge the degree of risk that patients pose to themselves, their families, and their communities.

The task of the psychiatrist in this job is immense. It is profoundly complicated. It is rich and riddled with considerations. It is not seen so by many in our field, and not by our patients. To patients and the public, we are at worst jailers. To our field, we are at worst crude physicians in a souped-up triage unit.

But think about what we really do. We are surveyors and judges of trauma and character.

Freud knew that sexual abuse and death on the battlefield occurred in his time. He was profoundly struck by both. He created theories to explain these dark experiences. Freud also knew that our deep human psyches contain capacities beyond immediate experience and that one could project and layer fantasy into lived experience. He grappled with the role that fantasy plays in our interpretations of experience. He angered feminists and others because his theoretical changes undermined the role of real trauma and highlighted the role the individual mind plays in repeating trauma.

In the psychiatric ER, we witness the real traumas that weave through patient lives. We often experience these traumas, even to the extent of avoiding certain patients whose realities strike too close to home. This is especially potent for psychiatrists with young children working with patients whose stories and affects stir our worst fears for our own children and families.

We also deal with patients and personalities who seem to seek repeated suffering in the form of both micro- and macrotrauma. We sympathize with the involuntary, victim-bound suffering, and we cringe at and speculate about the conscious and unconscious degrees of self-sabotage on display.

There are several forms of social, political, and historical trauma that are close to home for me and my contemporary American peers that repeatedly come up in patient narratives in the emergency room: racism, sexism, homophobia, and transphobia. In my 41 years of life, I have encountered or experienced all of these forms of oppression, trauma, and microaggressions. I know that they are "real." Many psychiatric ER psychiatrists know that they are real. But in the psych ER, where profound decisions weigh on individual assessment, what is real and what that means becomes relative.

It may be obvious upon arrival that a patient has just suffered a serious physical injury, sexual assault, or severe and obvious abandonment by a loved one. But when patients report histories of such events and a seeming pattern of repeated abuse, we naturally wonder about their perception and their own role in creating self-destructive experiences. Because we have experience and understanding of the human compulsion to repeat even painful life experiences, we are cautiously skeptical when a narrative is full of catastrophe, especially when presented as accidental or without agency.

For instance, even though we know about the depth of racism in our history and its profoundly traumatogenic potential (though this gets little or no attention in formal training!), we must be curious about the meaning an individual attaches to it, and how that meaning may serve or defeat his or her psychological existence and progression across life development.

The same goes for women, gay people, and transgender people who are so exposed and vulnerable to real and perceived physical and emotional trauma and aggression on a daily basis.

How does a person suffer in the moment after an infliction of trauma or aggression? How does a person encode that experience in her character, early in life and later in life? How does it color her experience and interactions? In the comprehensive psychiatric emergency program (CPEP), we must try to answer all these complex questions in what seems like a blink of the eye!

We only see a slice of a person’s life. We focus on the patient’s "history of present illness," the narrative history told in that moment, and the mental status exam. We rely heavily on collateral information to corroborate as much as possible. We use this to measure accuracy and distortion, always holding a skeptical lens against our patient!

While we want to believe our patients and take their histories at face value, we can’t fully do so because we know, instinctively or through training, that fantasy permeates the human mind and transforms meaning. Yet, at the same time, we assess that very idiosyncratic meaning for what it is, because that meaning stays with patients as they move from our ER to the street or the unit. And it is that meaning, embedded in an individual’s coping strategies and character that partly predicts what and how the person will do. It is an inherent consideration of risk and resilience, and we instinctively factor that into our decision making. This is the art of psychiatry at its best.

The CPEP is the frontline of psychiatry. Some residents dislike it because it vibrates with anxiety and responsibility. It is a place in which clinicians tend to come unglued behind the scenes, joking as if at a party, talking loudly and blurting out inane and obscene lines from TV shows and real life. In the back room, the burdened frontline psychiatrists and staff attempt to regain control and wrestle back their own meaning in life, in the face of withstanding traumas, distortions, and psychosis – the delinking of meaning – while rendering verdicts of risk and resilience based in rapid assessments of social, cultural, characterological, and biological factors that make up patient lives.

We swiftly analyze our patients and decide their immediate fate – street, home, unit, extended observation, needles, blood, medications, even visitors and babysitters. We hold them, or we jail them, depending on your view. But we do it with benign and perhaps grandiose intentions to protect, comfort, and quickly "know" them in order to progress them to the next most right place. And we do this almost without knowing that and how we are navigating a delicate and profoundly intricate path of evaluation and decision-making that is uniquely human in its intellectual and emotional nuance.

It is a job full of sharp edges and soft curves, a job that makes a bouncer an analyst and an analyst a bouncer. It is a job never to be reduced to algorithm or computation.

Dr. Pula is a psychiatrist at New York–Presbyterian/Columbia University Medical Center. He also is in private practice and is a psychoanalytic candidate at Columbia.

Since Freud, the fields of psychiatry, psychology, and psychoanalysis have grappled with trauma and its role in psychopathology. In modern times, these fields remain uncertain about the relative influence that biology, character, and environment play in disordering the lives of traumatized patients. Modern theories try to make sense of early attachment and its impact on development and resiliency. Most bluntly put, why do some soldiers go to war and return seemingly well adapted, while others can not reenter civilian life because the psychic scars are too constricting?

In the psychiatric emergency room, psychiatrists quickly take in multiple, complex facets of a patient’s life in an attempt to assess and judge the patient’s ability to withstand their predicament in the community. Our raw purpose is to assess safety and decide whether the patient needs be committed to a psychiatric inpatient facility. In that assessment, the doctor quickly tries to take in the history, biology, character, and the social milieu of the patient, and judge the degree of risk that patients pose to themselves, their families, and their communities.

The task of the psychiatrist in this job is immense. It is profoundly complicated. It is rich and riddled with considerations. It is not seen so by many in our field, and not by our patients. To patients and the public, we are at worst jailers. To our field, we are at worst crude physicians in a souped-up triage unit.

But think about what we really do. We are surveyors and judges of trauma and character.

Freud knew that sexual abuse and death on the battlefield occurred in his time. He was profoundly struck by both. He created theories to explain these dark experiences. Freud also knew that our deep human psyches contain capacities beyond immediate experience and that one could project and layer fantasy into lived experience. He grappled with the role that fantasy plays in our interpretations of experience. He angered feminists and others because his theoretical changes undermined the role of real trauma and highlighted the role the individual mind plays in repeating trauma.

In the psychiatric ER, we witness the real traumas that weave through patient lives. We often experience these traumas, even to the extent of avoiding certain patients whose realities strike too close to home. This is especially potent for psychiatrists with young children working with patients whose stories and affects stir our worst fears for our own children and families.

We also deal with patients and personalities who seem to seek repeated suffering in the form of both micro- and macrotrauma. We sympathize with the involuntary, victim-bound suffering, and we cringe at and speculate about the conscious and unconscious degrees of self-sabotage on display.

There are several forms of social, political, and historical trauma that are close to home for me and my contemporary American peers that repeatedly come up in patient narratives in the emergency room: racism, sexism, homophobia, and transphobia. In my 41 years of life, I have encountered or experienced all of these forms of oppression, trauma, and microaggressions. I know that they are "real." Many psychiatric ER psychiatrists know that they are real. But in the psych ER, where profound decisions weigh on individual assessment, what is real and what that means becomes relative.

It may be obvious upon arrival that a patient has just suffered a serious physical injury, sexual assault, or severe and obvious abandonment by a loved one. But when patients report histories of such events and a seeming pattern of repeated abuse, we naturally wonder about their perception and their own role in creating self-destructive experiences. Because we have experience and understanding of the human compulsion to repeat even painful life experiences, we are cautiously skeptical when a narrative is full of catastrophe, especially when presented as accidental or without agency.

For instance, even though we know about the depth of racism in our history and its profoundly traumatogenic potential (though this gets little or no attention in formal training!), we must be curious about the meaning an individual attaches to it, and how that meaning may serve or defeat his or her psychological existence and progression across life development.

The same goes for women, gay people, and transgender people who are so exposed and vulnerable to real and perceived physical and emotional trauma and aggression on a daily basis.

How does a person suffer in the moment after an infliction of trauma or aggression? How does a person encode that experience in her character, early in life and later in life? How does it color her experience and interactions? In the comprehensive psychiatric emergency program (CPEP), we must try to answer all these complex questions in what seems like a blink of the eye!

We only see a slice of a person’s life. We focus on the patient’s "history of present illness," the narrative history told in that moment, and the mental status exam. We rely heavily on collateral information to corroborate as much as possible. We use this to measure accuracy and distortion, always holding a skeptical lens against our patient!

While we want to believe our patients and take their histories at face value, we can’t fully do so because we know, instinctively or through training, that fantasy permeates the human mind and transforms meaning. Yet, at the same time, we assess that very idiosyncratic meaning for what it is, because that meaning stays with patients as they move from our ER to the street or the unit. And it is that meaning, embedded in an individual’s coping strategies and character that partly predicts what and how the person will do. It is an inherent consideration of risk and resilience, and we instinctively factor that into our decision making. This is the art of psychiatry at its best.

The CPEP is the frontline of psychiatry. Some residents dislike it because it vibrates with anxiety and responsibility. It is a place in which clinicians tend to come unglued behind the scenes, joking as if at a party, talking loudly and blurting out inane and obscene lines from TV shows and real life. In the back room, the burdened frontline psychiatrists and staff attempt to regain control and wrestle back their own meaning in life, in the face of withstanding traumas, distortions, and psychosis – the delinking of meaning – while rendering verdicts of risk and resilience based in rapid assessments of social, cultural, characterological, and biological factors that make up patient lives.

We swiftly analyze our patients and decide their immediate fate – street, home, unit, extended observation, needles, blood, medications, even visitors and babysitters. We hold them, or we jail them, depending on your view. But we do it with benign and perhaps grandiose intentions to protect, comfort, and quickly "know" them in order to progress them to the next most right place. And we do this almost without knowing that and how we are navigating a delicate and profoundly intricate path of evaluation and decision-making that is uniquely human in its intellectual and emotional nuance.

It is a job full of sharp edges and soft curves, a job that makes a bouncer an analyst and an analyst a bouncer. It is a job never to be reduced to algorithm or computation.

Dr. Pula is a psychiatrist at New York–Presbyterian/Columbia University Medical Center. He also is in private practice and is a psychoanalytic candidate at Columbia.