We are a commune of inquiring, skeptical, politically centrist, capitalist, anglophile, traditionalist New England Yankee humans, humanoids, and animals with many interests beyond and above politics. Each of us has had a high-school education (or GED), but all had ADD so didn't pay attention very well, especially the dogs. Each one of us does "try my best to be just like I am," and none of us enjoys working for others, including for Maggie, from whom we receive neither a nickel nor a dime. Freedom from nags, cranks, government, do-gooders, control-freaks and idiots is all that we ask for.
(This series is a peek - a few samples - into what goes on in Third-year Psychiatry in Medical School. Very few of the students will select Psychiatry as a specialty, but all do clinical rotations through Surgery, Pediatrics, Internal Medicine, Psychiatry, OB-GYN, etc. - and further elective rotations in the 4th Year. I focused on Surgery and Orthopedic Surgery in my 4th Year. The Surgeons did their best to win me over, and almost did.)
In one of the teaching sessions, we watch a video of a half-hour intake interview of a patient in the Internal Medicine clinic, done by a third-year medical student. At the end of it, I ask "Let's list everything we now know, or might speculate about knowing, about this patient."
We go through the medical history, the patient's demeanor (what's their style? Dramatic? Passive? Grouchy? Warm? Arrogant? Sneaky? etc), physical appearance, dress, posture, eye-contact, tone of voice, nature of his interaction with the interviewer, apparent intelligence, knowledge about health issues, work history, family, special concerns, and so forth.
The students who have been science nurds and wizards are often astonished by how much information can be collected from a simple half-hour medical - non-psychiatric interview. I write it all down on the whiteboard, some as facts and some with a ?.
It usually fills the entire board, especially if I write large enough.
In Psychiatry, we have no high tech diagnostic tools - just our eyes and ears.
Moving to Psychiatry, let's assume that we are meeting with a patient in the Psychiatric consulting room - a new patient who does not require any sort of acute crisis intervention or triage. What do we want to know about this new patient right away, after they tell us why they are here?
First things first. We want to know about their general health. That is from their story, and via eyeball. (Over the years, I have diagnosed hypothyroidism, brain tumors, Lyme disease, MS, GI cancers, Parkinson's Disease, early Dementia, etc. in people who have come to me for Psychiatric help).
Then the obvious things. Their life story, their family history, their current life situation. We assume we are never getting the whole story, but we need a provisional frame for the picture. In the process of asking our questions and following up topics of interest, there are a number of other things we get from initial interviews, using our bag of tricks and our sensitive ears, which are solid data.
For some examples:
- We determine how self-observing they are, their capacity for "insight" - We determine their motivation to deal with their problem - We usually get a provisional DSM Axis 1 diagnosis - if they have one - We get an idea of what their coping devices are, and when and how they fail - We get a good idea of their IQ, their life skills, fund of knowledge, their adaptive success - what we call their "ego strengths" and level of functioning in important areas of life (eg relationships, work, avocations, etc) - We get a sense of how they relate to others (to us, being the case at hand), rapport, relatedness, and a sense of what their personality is like, their appropriateness, manners, boundaries, attentiveness, sense of humor, etc. etc. - We would like to be able to say something about the style of their thinking, and especially their patterns of defenses - We would like to know how they respond to our observations and comments (eg defensive? interested? insulted? embarassed?) - Try to assess their morality and impulse control, reliability, and any sociopathy or secondary gain, or manipulativeness (this can be difficult but, with experience, one can smell it)
(These are the sorts of observations that make some folks uncomfortable with shrinks in social settings. People are often not aware that when we shrinks are out of the office, we probably think about these things less than the average person. For us, it's work.)
The point is that the Psychiatric interview is just a variant of the medical interview, but one which usually takes more than a half hour. Sometimes, much more. With healthy patients with neurotic problems, sometimes it can take me 5 or 6 one-hour meetings just to come up with a provisional case formulation and treatment plan (if needed). With very ill patients, 3 minutes can be enough to make a triage plan (eg Agitated guy fighting with security guards and cops yelling that they are CIA trying to implant more transmitters in his brain. Easy. Get the guards to hold him down and give him IM Haldol and Ativan with a little Cogentin...and wait a while.)
What's our goal? Our goal is a thorough Psychiatric Diagnosis and a Case Formulation. In medical school, in Psychiatric Residency, and in an Analytic Institute you have to write these up as lengthy formal presentations, but at my stage you just kinda do it in your head and store it in your head, except in special circumstances.
As rank amateurs, medical students cannot be expected to do either of these in an expert way, but we require that they produce a couple of these on some of the patients they are following.
I like how you encourage the holistic view. Maybe that term sounds hackneyed, but there are so many in the medical profession who zero in on their specialty area and take nothing else into account.
I took Vaillant's course. Very good. His perspective is particularly helpful to people who come from high achieving but severely troubled families. He promotes hope, encourages constructive behavior and mature defenses as tools with which to build worthwhile lives despite tragedy and misfortune. A welcome break from victim psychology...
"He promotes hope, encourages constructive behavior and mature defenses as tools with which to build worthwhile lives despite tragedy and misfortune."
Are there psychiatrists who don't do this? I believe it is as natural for a psychiatrist to do these things as it is for them to breathe.
As for the victim psychology, there is no end to victims in the world of psychiatry. It is probably one of the hardest jobs for any psychiatrist to help a patient to understand that they are, indeed, victims. To deconstruct the fragile scaffolding and control a patient has used in order to function and reduce it to victimhood in order to rebuild a life is no small feat. I'm not talking about the perpetual victim: I am talking about true victims who have repressed much in order to make it until some random event causes the walls of their ego fold in on themselves and leaves them spinning out of control.
Many years ago while an undergrad I worked as a psychiatric aide for a year in a private psychiatric hospital. In writing notes on patients, staff psychiatrists directed us to write in three stages: 1) what did we observe, 2) what we concluded were the dynamics behind what we observed, and 3) what was our intervention. After working there I took a course in Abnormal Psychology, and found the extensive labeling useless. Had I taken the course before or during my work as a psychiatric aide, I doubt the course would have helped me any on the job- in any event much less than the simple three step instructions the staff psychiatrists gave us.
My cursory examination of the instructions for medical students are that they are in the spirit of the instructions the staff psychiatrists gave us, as opposed to simply labeling the patient. In both instances, the underlying question appears to be: what do you observe?