1 Boring Old Man

The Suicidal [or Homicidal] Patient: These patients are, indeed, the ones where we need to do things right. And the thing I saw over and over was that lethal patients frightened the resident and the interview turned into an is-he-going-to-do-it-? or a what-do-I-need-to-do-now-? agenda driven interview. People who become suicidal have plenty of things rattling around in their minds. In Man Against Himself, Karl Meninger said a suicidal person wants to kill [rage], wants to die [a communication], and wants to be dead [relief]. So they have lots of things they need to say and they don’t need some nervous interviewer who is focused on not making mistakes. They need someone who will deeply understand their suicidality from the inside. If you get there, you’ll know what to do. If you don’t, that tells you something too. There’s plenty of time at the end to deal with the agendas they obviously raise.

Crisis Intervention: This was the  outgrowth of World War II that inspired the Community Mental Health Movement – how to manage patients who are in crisis states filled with emotion and unable to think clearly or make rational decisions. All they can think of is feeling un-panic. It’s an essential skill with simple principles. Go to the library and look it up. Those dusty books from the fifties and sixties are full of wisdom. It’s a skill to never leave home without. It’s part of preventive psychiatry, because the goal is to head off the huge mistakes they make and bad patterns they learn acting in the crisis mode.

Identity: I’ve never been smarter or more competent than the day I finished my Internal Medicine Residency. I hadn’t been brought down to size by the whips and scorns of medical life, made my mistakes, been dwarfed by the afflictions that beset mankind. But my identity as a doctor was as solid as a rock. When I finished my psychiatry residency I felt anything but smart and competent. And that’s not vastly changed even now in retirement. I realized that I only feel like a psychiatrist when I’m being one. Otherwise, I’m just a guy with a bunch of diplomas and a ton of facts. And I noticed that was how my senior residents felt as they approached graduation – wary. I think it’s still true for them, even with their heads filled with neuroscience and evidence-based medicine, because you never know what’s going to walk in that door and our classification systems are hardly maps that lead straight to gold. I suggested that the residents start with a part time job doing something they already knew how to do – clinic, mental health center, etc. And let their practice grow slowly as they get in touch with how much they really had learned and how competent they really had become. We talk about how hard it is without biomarkers to guide our work. Internal markers are equally hard to find too, and hard to hold on to once located.