You are dust: Ash Wednesday on a psychiatric ward

The Ash Wednesday service in the state psychiatric hospital where I work was hardly an elegant affair. The sterile, brightly lit multipurpose room, with its white plaster walls and tile floor smelling faintly of cleaning solution, hardly qualified as sacred space. An end table covered with a faded purple cloth held a scuffed-up wooden cross and two small containers of ashes; an overhead projector stand served as a lectern. As I came in and sat down, an older hospital employee was playing gospel hymns on a keyboard that had been unpacked for the occasion.

The sign advertising the service had drawn me in: “Ash Wednesday Service, 2-3 p.m., patients and staff welcome,” but now I felt uneasy. Other than a few therapists and nurses who were there to keep an eye on the patients, I was the only staff member present. I watched as 40 or so patients, some of whom I knew well, shuffled into the room and sat around me. They were a diverse group—old and young, male and female, white and black and Latino, some in street clothes and some in hospital pajamas, some well groomed and others haggard, unkempt and malodorous. Their only bond was that at some point each of them had needed inpatient psychiatric hospitalization, and for whatever reason—no insurance, a history of violence, criminal charges or illness too chronic and severe for other hospitals to handle—they had been sent to this state hospital.

As a doctor I work long hours with these patients every day. I often congratulate myself on my tenacity, for after all I am using my medical expertise to help not just the mentally ill but the indigent mentally ill, “the least of these” in my region of North Carolina. But now they stood around me singing the words of our first hymn, “For thee, my God, the living God, my thirsty soul doth pine,” and I realized that my day-to-day relationships with my patients were more limited then I’d realized. Within the walls of the hospital, my physical proximity to my patients is heavily qualified by a vast power differential. I wear the white coat and tie, they wear hospital scrubs or pajamas. I have keys, they have none. I go home at night, they do not. I have book knowledge about psychiatric illness, they often do not. I address them as “Mr.” or “Ms.” but they call me “Dr. Kinghorn.” Furthermore, since I’m aware that many of my patients have been badly harmed in violations of relationship boundaries, I guard my boundaries with diligence and care.

But now I was singing the powerful words of this hymn next to my patients and they next to me. As the music stopped and I sat down, the boundaries seemed to be fading away, and again I was uneasy. Was I really singing with my patients, listening to scripture with them, praying beside them?

The celebrant, a gentle-faced, irenic woman who serves as a chaplain in the hospital, read two scripture verses, delivered a short and rather forgettable homily, then invited the congregation to pray—first with her, she said, and then aloud. Oh no, I thought. Did she really mean “aloud”? I was stunned by the result. Prayers echoed throughout the room. “Lord, be with me and give me strength as I leave the hospital and go out into the real world.” “Lord, please help us to be what you created us to be.” “Lord, forgive me for abusing my child.” “Lord, thank you for getting us up at five a.m. and bringing us here today.” “Lord help me, Lord help me.”

The priest blessed the ashes and invited us to come forward. As the staff member played more gospel hymns, our ragtag crew stood and formed two lines. As we moved forward I heard the words of imposition, “Remember you are dust, and to dust you shall return . . . Remember you are dust, and to dust you shall return . . . Remember . . .”

Fifteen minutes later I had washed the ashes from my face and was in the inpatient ward conducting business as usual. The boundaries had snapped back into place. But I was not the same. Or perhaps the point is that I am the same—that is, made of the same essential stuff as my patients. We are all dust. We are all given breath only by the grace of God. We are all subject to God’s judgment and in need of God’s mercy.

This realization was not welcome news to me. I’ve chosen to spend my career caring for people with mental illness, but I do not want to be like my patients. I want no part of their hell, and I work to keep my life as distant from theirs as possible. The more distance I can maintain, the easier it is for me to walk and work among them. How easily my attitude then becomes: God, I thank you that I am not like these people—alcoholics, schizophrenics, borderlines!

Yet God rebukes me with the incarnation, with the One who entered earthly hell in order to redeem both “them” and “me.”

The ashes remind me of this; they are imprinted on my forehead whenever I face a new patient. I still believe, of course, in appropriately defined boundaries between doctor and patient. As a physician I must do everything possible to guard against exploitation of my patient and must take care that the patient is the focus of the clinical encounter. This is especially true when I am forced to curb the autonomy of my patients temporarily (e.g., by involuntary commitment to a psychiatric unit) in order to save life and preserve freedom in the long run. Pastoral relationships, medical or otherwise, are inherently uneven and therefore vulnerable to exploitation.

But it is critical that I not misinterpret the necessary role distinction defined by my professional boundaries as an ontological distinction between my patients and me. The ashes on my forehead remind me that there is, ultimately, no such distinction.