The problem with medicine is not just thatweare distracted by our technologies, but that medicine has too much authority to interpret the meaning of our bodies. Until very recently, medicine was only one among many interpreters of the body. Over the last two centuries, the authority of medicine to interpret the bod has steadily increased. It is now hard to imagine how regular events of human existence like birth, puberty, sex, sadness, menopause, aging, and death can be understood as anything other than medical incidents. Whether we examine patients directly or not,we physicians can renew medicine only if we allow the body to be interpreted as something more than a pathology text.
We looked for answers in the medical literature.We will apply them to your situation, but none of those answers perfectly fits your situation, so we will sit with you. Not as interpreters who will take responsibility for your troubles, but as teachers, as physicians who are more aware of the limits of our discipline, and more willing to help you return to the communities outside of medicine that support your well-being.
Dr. Nussbaum completed his undergraduate degree at Swarthmore College, where he studied religion and English literature. He completed medical school and psychiatry training at the University of North Carolina, along with a master’s of theological studies at Duke Divinity School. His research interests include the history of psychiatry, medical professionalism, psychiatric diagnosis, and the treatment of people with schizophrenia. He is currently co-organizing a conference on the care of persons with mental illness by Christian communities.
A lot of psychatrists and other mental health types feel really defensive in the face of the criticism that we don’t know enough. I don’t feel that. I guess I worked my way through that as an Internist. I don’t know enough then either. I had been taught that the most important task was knowing-when-you-don’t-know and hitting the books, looking for help, or knowing that no-one knows and doing my best with the not-yet-known. Psychiatry was no different. We know a lot, but the field of the unknown just happens to be really as big as being human. That’s just the way it is, speaking of humility. A lot of my personal complaints about psychiatry today are the lack of appropriate humility, and the seeming abandonment of the attitudes expressed here by Dr. Nussbaum.
What I needed as a patient was to find a place outside my life and a mind outside my mind to help me figure out the things that plagued me that I couldn’t see myself. They were too automatic or too embedded in conflict to yield to personal reflection. When my helpers slipped up and told me how to live, I reminded them that that’s not what I came for. I have slipped up in that way more times than I’d like to admit myself, and received those same reminders. So the kind of advice I’m talking about is something different. It’s in the form, "I notice you’re doing this particular thing over and over and it’s getting you in trouble over and over. Let’s take a look and see why." Seeing how people trip themselves up is actually the easiest part. The much harder part is everything else. With so many people criticizing that approach, how can I justify my criticism of the DSM and the over-medication of patients?
It’s easy. First, I only saw patients who came looking for a me. I only saw patients I thought had a chance of using that approach to their advantage. And finally, I made it clear it was a we proposition, that I was no fixer and there were no guarantees. I take and took the same approach prescribing medications. I don’t do it unless I think it might help, and I’m obnoxious about discussing the down-side. This blog has helped me a lot with that. I’ve learned more than I could’ve imagined about the down-side. It’s just another part of being an adviser, or a teacher. It was a rewarding career and I’m glad I found it. And like Dr. Nussbaum, I lament the past – the days of thorough physical exams, long histories, humility, therapeutic alliances, and most of all, honesty. Growing up, I swore I wouldn’t be an old man that talked about the good old days. Well, so much for childhood resolutions.
I’m encouraged by seeing more articles such as this, like the one recently by the Critical Psychiatry Network [see a long and lonely wait… ]. When psychiatry changed so dramatically in 1980, I expected a more reasonable balance after a time. But it has been a third of a century and I’m still waiting for that pendulum to budge some. Maybe it is finally happening…
Anyone else hearing Handel’s hallelujah chorus, right now?
The first time I stayed in a mental ward I went to the flight deck at a V.A. Hospital. I had hoped to get through my life without ever having had the experience— it was my worst fear— but it was kinda nice in there, in February of 2003 when out there the war drums were beating madly and I had just made the mistake of watching The Sum of All Fears. I thought that there was just one nuclear bomb so it wouldn’t trigger me ((har) the Bush Administration had been triggering me for two years so it was a last straw)). I was also exhausted, fragile, and burned out from four years of being an in-home caregiver without a full day off and was feeling some grief.
The V.A. staff didn’t push. One of the psychiatrists— I think he was an intern— was a wonderful listener. He and I met for the last time the day before I went home to re-cap. I talked about how it was harder for me not to watch the news than it was to watch it, I needed to find a middle-ground. I listed stressful things in my life that I planned to take care of so I could give myself a break. And then said, “Oh, yeah. And I watched The Sum of All Fears” (for the third or forth time in a week, I said that). I kept forgetting about the Biggest Trigger.
Then I expressed that I’ve been trying for to find a way to deal with my trauma and terror of total global annihilation and human extinction for 23 years.
He said— very solemnly and kindly— “We can’t help you.” ( with that specific issue). I adore him for that. He was absolutely right and I knew that, but for him — a psychiatrist— to give me the gift of saying so was wonderful. It cheered me up immensely and I felt like it had been given back to me to judge for myself, completely. It was liberating.
Of course, during my involuntary stay at a local hospital, I was just “bipolar” and talking about the contents of my psychotic episode (that was all about my trauma) was “lacking insight.” It was irrelevant. They had me all figured out, knew what my problem was, and knew what I should do about it. Fortunately, I know how to reflect, to do real art therapy, to reevaluate my life experiences in a new light, to question myself, to look at the landscape. I spent hours everyday I was locked up there giving my experience the respect it was due. I’ve always been all about the landscape.
Plus, as a woman, being fed everyday and not having to do house work was like a vacation and I met some interesting people. The smug psychiatrist is nothing to me but the “it” of psychiatry. He didn’t help me. He didn’t hurt me. He ought to read your post and buy Interpreters or Teachers? It would make him a better human being.
So, recap: I don’t know and don’t conflate the landscape with the map—- these are religious feelings in my book.
Your post, Mickey, and the first page of Dr. Dr. Nussbaum article is a bright light in the dark night of psychiatry’s soul. More psychiatrists like you could do more things for people with a blog than a lot of visits do. I’d pay for I could afford for this.
It’s very peculiar how humility, the cornerstone of our field, seems so out of fashion these days. From the APA presidency on down, we’re told we have no reason to be defensive: Psychiatry is a neuroscience, dammit, so stop being a luddite scientologist mysterian party-pooper. How odd that it has come to this.
The truth is that whenever a medical cause of mental illness becomes known, the condition leaves psychiatry. General paresis (syphilis) went to internal medicine, myxedema to endocrinology, Huntingtons and Alzheimers diseases to neurology, brain tumors to surgeons, etc. We’re always left with what isn’t well understood. Schizophrenia and bipolar disorder will be “of unknown etiology” until they’re not, at which point they’ll leave psychiatry and be treated by geneticists or virologists or whatever.
Things are obviously no more certain on the non-medical side. We arrive at understandings by co-constructing them with our patients. I like to say that in psychotherapy, the patient is driving the car. I’m in the passenger seat, pointing out curious parts of the passing landscape, and neither of us knows where we’ll end up.
You wrote: “A lot of my personal complaints about psychiatry today are the lack of appropriate humility.” I completely agree. It’s almost comic, if it weren’t tragic, to hear such hubris. But as psychiatrists ourselves, we should neither laugh nor cry. We are trained to have compassion and empathy for those who deny reality to maintain their equilibrium. The inherent uncertainty of our field must be shameful or diminishing for many of our colleagues. I wish them a speedy recovery — before more patients are harmed, and before our profession loses what respect it has left.
You wrote about the change in medicine, I see the change in those outside communities. A friend and I walked almost every morning for tens years. We openly spoke about how men no longer had the time and luxury of spending time with men.
I could write a book about the feminization of society, starting with the religious communities. Conflict is no longer allowed, and anyone protesting and not following the party line is considered to be unenlightened. Feminization is very different that what should have been an influx of women and their strengths.
Back to my point, over those ten years we walked through injuries, the death of a parent, and more recently my friend went from one day everything being fine to the next day his wife having cancer.
In today’s world there is a pill for every person and every person needs a pill. We are not suppose to be happy and productive unless we are sleep deprived and chasing some new gadget.
Doctors have all the answers and all the answers come in five minute blocks where the patient is interrupted seconds after starting their story.
Maybe we need the corner bar, the little 25 cent beer, and a chance to unload to a group of people who understand and will not repeat what is said. For my friend and I what is said on the pavement, stays on the pavement.
There are advantages to not knowing, but giving someone a safe place to vent, and then helping them work through a problem. Pronouncements and pills may make the doctor feel good, but often does nothing for the patient.
Steve Lucas
Here’s the thoughts of an emergency room doctor that mirrors your article. Seems it took her 10 years to unlearn medical school bravado.
http://www.huffingtonpost.com/leana-wen-md/medical-tests_b_3735156.html?view=print&comm_ref=false