The Patients Taught Me

Posted Dec 15, 2022

The Patients Taught Me

Paul Zung & Kate Brouwer

CMDA Canada’s Dental Ministries Manager, Dr. Kate Brouwer, sat down with Dr. Paul Zung to interview him about his diverse career in dentistry and mental health.

This article originally appeared in the December 2022 issue of FOCUS Magazine.

Thanks so much, Paul, for taking the time to chat with me. Please tell me how you became interested in helping patients with substance addiction or mental illness.

There was this one psychiatric patient that I met during my hospital residency in Chicago the year after I graduated. He had delusions that fascinated me. I got to thinking about whether there was a pattern to his beliefs and I think I’ve been interested in psychiatric patients ever since. This hospital residency allowed me to see a lot of chronic disease by day and a lot of acute trauma overnight. During the day we had specialists from three universities come in to teach us and work with us on clinical cases. The patients there were poor, but a sliding fee scale allowed us to do much as we could for them– including the types of complex work that specialists favour. We were encouraged to do a lot of daring stuff with the luxury of somebody holding a safety net beneath us.

When I got back to Toronto, a friend suggested that I join him at Queen Street Mental Health Centre, a big psychiatric hospital downtown. I was still interested in working with psychiatric patients, so I took him up on his offer and have since spent my entire career there. In retrospect, the sliding scale and the willingness to learn how advanced dental care can be applied to my patients in Chicago left an imprint on me; this became the set of conditions that made it possible to address the needs of psych patients throughout my career. 

Did you feel called to this type of work? 

In a way. I always had an interest in the inner workings of the mind. Though I liked the hands-on, I thought dentistry was a bit too technical for me. I like work that causes me to think about what other people are experiencing. So, I was drawn to psych patients as these people really needed dental help at the same time. I thought, “Here’s my chance – I can do something daring for patients who would otherwise lose most of their teeth, with little financial burden on them. And the hospital was paying me the same wage to do hygiene instruction as they were to perform advanced procedures. I find that the psych hospital is a good fit for me in terms of many of the things that I wanted to try.

Eventually, the patients taught me. They taught me what they most valued, what bothered them, and what they’re usually looking for in full-mouth rehabilitation. In the early years, I was doing a couple of dentures every week and a lot of extractions, cleanings and fillings. And then a merger happened. Queen Street Mental Health Centre had 500 inpatients and 3000 outpatients but overnight we went to 24,000 potential patients, many of them from the Addiction Research Foundation (ARF). My initial fascination with psych patients grew to include the dynamics of motivation I saw in my addictions patients. 

These patients tended to be younger, and they were watching shows like Total Makeover – they wanted the big smile and they wanted it restored with fixed restorations. So very quickly, I had to learn how to do crowns and bridges more efficiently and to make better judgment calls about who would be likely to perform the oral self-care needed to maintain that. More recently, the demand for extensive implant-supported restorations ramped up dramatically and I decided to retool. In the last five years, I needed to look after family members so I cut time at the hospital. Even so, I took a year-long fellowship in tissue grafting and implantology and devoted my clinical work to that. So, my calling was more of a journey that was led by the changing needs of the hospital’s patients.

Do you feel that being a Christian has impacted your work?

It probably has. But I can’t separate its effect on my work from its impact on my life, in the way that I can’t possibly separate the impact of the many wonderful mentors I’ve had on both my life and my work. Raised in a nominally Christian home, I became a tentative atheist in my adolescence before experiencing how God could supply the faith that I could not muster on my own. I think I always had an interest in God, but also in how our minds and emotions work, and how that affects the way we relate to Him. I got married and started having children without really knowing what to do as a husband or father. And by this time, I was also thinking, “I’m going to spend the better part of my career with psychiatric patients. Hadn’t I better learn more about what makes people tick?” So that’s when I decided I’d go to seminary and sign up for the six core counselling courses. But after that, spiritual direction and theology both captured and held my interest. While my kids were growing up and studying, I too was studying and growing up. 

I hope that what attention it took away from the family in terms of time got paid back in terms of a more discerning relationship with my wife and kids. Perhaps I was a better husband and better father. I acquired counselling skills and learned how to listen to patients. A dentist doing extensive treatment usually has more extended time one-to-one with a patient than most healthcare professionals. My hospital, the Centre for Addiction and Mental Health provided training as well, and I joined the psychiatric residents for their psychotherapy seminars at the hospital. I really found that this was an environment where I could develop my interests in counselling and dentistry. I wouldn’t have gone into seminary if I weren’t a Christian. Having gone to seminary, I had a chance to explore many foundational philosophical and spiritual questions – questions I’ve been asking for decades. I gained an awareness of what I think most people really need, and the spiritual importance of empathetic love and nurture.

Whether a person is a Christian or an atheist or a Muslim, I have confidence in how each seeks fulfillment – the basic structure of the needs that are shared by all of us: how we cope with disappointment and pain, what makes us feel loved, what makes work gratifying. I think seminary helped me to think deeply about that. I think my own Christian walk is connected to conversations with others who have provided testing grounds for these ideas. When I listen to clients or talk to patients, I’m delighted when they express, “Wow, I feel you really understand me; you really care.” A few have called me up years after they’ve left the hospital and looked for me, not just to talk about their dental needs, but to talk about their personal needs. But the same attention to listening has made me aware of how often I get it wrong – how easily I may enter cycles of misinterpretation with another person. I need to be regularly told of my blind spots so that I can ask forgiveness and rebuild an empathetic connection. So, I really felt in many ways, between the church, family, and going to seminary, I learned how to love with greater compassion.

That is a beautiful and compelling answer to that question. I had an idea of how you would answer that question in my head, and your journey with that was so much more. Can you tell me a little about your observations on people’s addictions?

I realized we’re all deeply affected by what we find rewarding. Because motivation fuels every effort we make we need to be responsive to the prospect of finding pleasure. To be a motivated human being is to be susceptible to the reward system being hijacked. The addictions specialists would probably find my use of the word too broad because they deal with life-crippling addictions whereas I’m referring to something more subtle, so I will call it dependency.

I have talked to students about disciplining our emotions. Some people struggle with alcohol. Some people become dependent on cocaine. For others, it’s being needed. Some people are driven compulsively through a medical career, unable to stop as long as it provides ever-increasing status and influence. How do we know how strong is the grip of our dependency until we try to quit?  When I suddenly stopped my dental career to take a three month parental leave to look after my daughter, I got cabin fever. I felt I wasn’t accomplishing anything. To give me that feeling of accomplishment, I started taking apart perfectly functional computers and fixing things that weren’t broken, then was unable to put them back together. Luckily she was a very quiet baby and just sat in her room smiling at the walls. Even so, I realized this wasn’t normal. It was because I was so used to working and producing something that brought immediate satisfaction, that I didn’t know what to do with myself when I had to care for a baby that didn’t need fixing. And I’m wondering if it’s the same dynamic that keeps many healthcare providers driven.

I thought about dependency on vacations or cars or maybe there’s more than a little bit of craving for always being needed to help other people. I realized how important spiritual formation is in grounding a motivation that can’t be bought by external rewards. In the desert, it was crucial that Jesus affirmed that his own devotion was not for sale. It’s all-important that we also are rooted and grounded in a love that renews itself by basking in the presence of God and in knowing that he makes it possible for us to imitate him. And lest we forget what that feels like, we must break from our work regularly – which is painful, and then we can take up our work again, knowing that at any time, if we for any reason couldn’t work anymore or we stopped producing, we would still be loved. We could still feel deeply connected inside. 

The idea is that our identity comes from being a child of God as opposed to being a successful dentist, for instance. You have said that teeth are an archaeological record of what the patient has been through. You see patients who maybe have struggled their whole life with a variety of issues, but then other patients who through addiction to prescription pain medications, whose life has taken a real downward turn. They maybe had great access to dental care for several years. And then because of, let’s say a motor vehicle injury and a painkiller addiction, now they’re struggling, maybe they’re homeless and have very different dental needs.

Yes, that fits the pattern. I think of the man who never partied or drank or did any recreational drugs, but he got hooked on narcotics after trying to lift an air conditioner all by himself and straining his back. Another person was fine until she had TMJ problems, and she was prescribed narcotics for dental reasons. So there are all kinds of entry ways into addictions that could happen to anybody. More vulnerable though, are people who have emotional pain, which is relieved by the narcotic that masks the back pain, but still cry out after the back pain is gone. 

So, this could happen to anyone. Do you feel that the average person is judgmental sometimes of those who find themselves disadvantaged? Do we tend to assume they made bad choicesor that they were weak? That sort of “judgy” attitude. Instead of thinking, “this could happen to me, this could happen to my kid, this could happen to my best friend” attitude.

Yes, there certainly is that. But I’ve listened to so many stories that I’ve absorbed into my thinking the realization of how similar another person is to me. We work up the street from Strachan House, an initiative that sought to house people who could not get free of their addictions. Usually, you have to be clear of your addictions before someone would provide you with a place to stay. But clearly, a lot of people were just going to freeze if they did that. There I met someone who felt compassion for a resident. She visited her friend regularly trying to support her to help her get free of her addiction. Yet the helper ended up becoming addicted herself, losing everything, including a lot of her teeth. I ended up treating them both. There’s another woman who never wanted to get into drugs. But the boyfriend wanted to. And he said, well, this is part of my life, I want you to be with me, try this. And then she got hooked. That’s all too common. 

Just think how we feel when we lose the use of our cellphones for three days. You reach for it and it’s not there. Aside from the inconvenience, don’t we miss the perks of the periodic notifications that remind us that we’re needed and affirmed? That neurological reward runs down the same pleasure pathways as the cocaine fix, only cocaine is so much stronger. But who isn’t attached to something? We see something, we try it, and if we like it, then our minds get conscripted into supplying reasons why we have to have it. 

As with mental illness, I can say what I see in addictions is the whole spectrum that stretches between health and illness – mild dependency to a crippling addiction. I have been through times when I didn’t want to get up in the morning, feeling overwhelmed by life’s challenges. I know that’s sort of a small taste of what some of my patients go through. I also think that when we allow ourselves, we can really identify with the experience of getting pulled deeper and deeper into a web of disturbing feelings and crazy thoughts. 

If we’re not always guarding our minds against the awareness of depressing or anxious thoughts – not in denial of our own troubled ruminations, or distancing ourselves from those who are, then I think it’s plain that mental health is a continuum. This is the fabric from which our worlds of thought are woven. You put enough stress on anybody and they will develop what we would call symptoms. And just to recognize a lot of that vulnerability embedded in our humanness is a good thing. 

Do you sometimes get discouraged? Do you sometimes take on the weight of people’s struggles and personal tragedies and bring them home with you? I work mostly with your typical middle-class family that’s taking their kids to their basketball game and going home to check on homework and make nice lunches. They’re upset they need a crown for a heavily restored molar. You must feel the weight sometimes of people’s personal stories that are so tragic, so heavy. Is that something you’ve had to learn to manage, or do you compartmentalize it?

What I’m now saying is descriptive, not prescriptive. I’m not sure that I’m very good at being aware of getting overly involved with people I’m trying to help, but the people around me are. My kids will say, “You’re always talking about this at home. Aren’t you beginning to invest too much attention and emotion into this?” But generally, I’m comfortable with what attention and emotion I invest. In fact, I feel people often need more than what I can provide. 

Your clinic has the dental chair oriented so the patient faces out, towards the exit, opposite to most clinics, with the patient’s back to the exit.

The hospital thinks it’s a good idea that no one can sneak up behind a staff, but the better reason is that patients can see what’s coming. When they can see the exit, they don’t feel trapped. A lot of my energy is focused on reducing fear for the patient. I’m the scary guy in the room, right? In their minds, they’re the helpless victims, mustering all the courage they can to open their mouths. For me, total love does cast out all fear, just as total fear casts out all love. When we realize how much courage and trust patients display by being there, we lose our own fear. 

Do you use sedation for anxious patients or is that complex within this group of patients?

We’re trained in it, but there’s a practical reason we don’t use it. Years ago, they told us there’s no nitrous in the psychiatric hospital because if you mix nitrous with a major tranquillizer, which so many people were on, then be prepared to support their breathing – it may stop entirely. Well, we aren’t prepared to do that. We don’t give them anything. We find that if we give them a compassionate and boring session – we just bore the fear out of them. “Nothing’s going to happen except what we say is going to happen. You can stop us anytime by raising your hand”. Usually, people who stick with us long enough will habituate and learn to relax. That’s also kind of what we do in counselling when people are dealing with anger or fear of a job interview or something like that. Learn to tolerate the uncomfortable situation long enough, and the body and the mind will calm down.

Paul concluded with this prayer, for which I am so grateful.

Lord, I pray for Kate and the work that You’ve called her to do, and may she find blessing upon blessing because there are many practitioners who do feel they’re on their own, and they’re just glad when somebody comes knocking and offers a chance to talk about their work and the meaning of their years and service to you. She stitches together that quilt of dentists who are serving you and serving their patients, please strengthen their fellowship and their trust in you. Bless her work. In Jesus’ name, amen.