Introduction to psychiatric skills Only people can change people: \200\230Alyosha \200\231 s arrival seemed to have a sobering ef- fect on him \200 as though something had awakened i n this prematurely aged man that had long been smothered in his soul \200 \200\234For you see, my dear boy, I feel that you are the only man in the world who has not condemned me \200\235. \200\231 Brothers Karamazof Dostoevsky; page 25 On starting psychiatry you may fe el unskilled. A medical problem will come as a relief \200\224you know what to do. Do not b e discouraged: you already have plenty of skills (which you will take for granted). The aim of this chapter is to build on these. No one can live in the world very long without obser ving or feeling mood swings, and without devising ways to minimize what is uncom- fortable, and maximize what is desirable. Anyone who has ever sat an impor- tant exam knows what anx iety is like, and anyone who has passed one knows how to master anxiety, at least to some e xtent. We have all survived periods of being \200\230down \200\231, and it is interesting to ask how we have done this. The \201 rst element is time. Simply waiting for time to go by is an important psychothera- peutic principle. (Voltaire teasingly remarked that the ro le of the doctor is to amuse the patient until nature eff ects a cure.) Of course, there ar e instances when waiting for time to go by leads to fatal consequences. But this does not p revent the principle from being useful. 318 y r t a h c y s P Another skill with which we are all more or less adept is listening. One of the central ten ets of psychiatry is that it helps our patients just to be listened to. Just as we all are helped by talking and sharing our problems, so this may in itself be of immense help to our patients, especially if they have been isolated, and feel alone \200\224which is a very co mmon experience. i Just as spontaneous regeneration and improvement are common occur- rences in psychiatry, so is relapse. Looking through the admissions register of any acute psychiatric ward is likel y to show that the same people keep on being re-admitted. In one sense this is a failure of the processes of psychiatry, but in another sense each (carefully planned) discharge is a success, and a complex infrastructure often exists for maintaining the patient in the commu - nity. These include group support meetings, group therapy sessions, and social trips out of the hospital. We all have skills in the simple aspects of daily living, and in re-teachi ng these skills to our patients we may enable them to take the \201 rst steps in rebuildi ng their lives after a serious mental illness. So time, listening, and the skills of daily living are our chief tools, and with these simp le devices much can be done to rebuild the bridges between the patient and his outside worl d. These skills are simple compared with the highly elaborate skills such as psychoa- nalys is and hypnosis for which psychiatry is famous. The point of bringing them to the fore is s o that the newcomer to psychiatry need not feel that there is a great weight of theoretical work to get through before he starts doing psychiatry. You can engage in the central proce ss of psychiatry from day 1. Use the knowledge and ex- perience gained as a foundation on w hich to build the constructs required for the more speci \201 c and eff ective forms of ps ychotherapy. Fig 1. Listening, not judging. So often when we listen the fact that we are also judging le aks out in an unconscious disapproving gaze \200\224 and our patient clams up. This mythica l ward round has adopted an extreme method to prevent this. Words waft up on thermals of ho t air, unimpeded by cold or quizzical or uncomprehending gazes. So don \200\231t let ward rounds descend into fact-based inquisitions. \201\201As one history-taker said, \200\234 They wanted facts. Facts! They demanded facts as if facts could explain anything! \200 \235 Joseph Conrad Lord Jim \201\201 Suspending judgment If we knew more about ourselves, we would understand more abo ut our fel- low patients, bearing in mind that \200\230all gods and devils that have ever existed are within us as possibilities, desires, as ways of escape \200\231. Herman Hesse 1 919.14 What we want our patients to achieve is insight. Our judging does not help this. Jud gment turns patients away from us. We cannot expect our patients to be honest with us if th ey know that we are judging them. \200 The good listener is not silent, but re \202 ecti ve \200\224a mirror not a message. Mirrors do not judge but they enable self-judgment. Unle ss some criminal act is underway, it really does not matter what we think about our pa- tie nts. What matters is how the patient thinks about him- or herself and his or her near-ones \200\224and how these thoughts can be transformed. \200 If we judge people they will not trust us. No trust \211\210 no healing. \200 If we judge, patients will leave us for oth ers perhaps less well quali \201 ed. \200 There is no evidence that judging improves out comes. Worse outcomes 319 . s i p m e K s a m o h T \200 t \201 o r p r u o o t s y a w l a s i y r t a i h c y s P r u o b a l are likely if the patient feels alienated. Patients know if we feel bad about them. They may internalize this, and assume that things will always be bad because they themselves are bad. Despite these bullets, there is a probl em that won \200\231t go away. If we \201 nd our- selves talking to perpetrators rather t han victims, we may not be wise to suspend judgment forever. If a crime is afoot putting ot hers at risk, you may need to break con \201 dentiality. Discuss this with a colleague. As k yourself whether Nazi and Rwandan doctors were too nonjudgmental with their fel- low pati ents. If \200\230tout comprendre c \200\231est tout pardonner \200\2311, then to pardon al l actions is to abdicate our moral selves. What is the consequence of this \200\224for us, and for our patients? Unless we exercise judgment, it might be thought, we may be condoning evil. \200\230For evil to \202 ourish in the world, all that is required is for the goo d to remain silent \200\231. If we remain silent long enough, then will our own moral sense sicken, and die? What human duties do doctors have which trump anything that goes on in th e consulting room? Whenever you think the time may have come to judge, check with yourself that it is not from outrage, or disgust, or through the exercise of pride, or from a positi on of power that you are judging \200\224but reluctantly, and from duty. The dreadful histo ry of some doctors in the twentieth century teaches that we must be human \201 rst, and p hysician-scientists second. Dr. Quarrell \200\231s letter \200\224 \200\234My dear Elvet \200 Phosphorescent patients I am growing suspicious about the extent to which I need yr p ermission to have feelings about my patients. Clinical detachment is a profoundly un- natur al state of mind and all sorts of evil can come of it \200 In Casualty amongst all that bat tered \202 esh \200 it was a survival tool. So it gets carried over into psychiatry. We o ff er our patients what appears to be human contact, human warmth \200\224and we give them a calculated simulacrum of human contact, with no \202 esh, no blood, no love, no desire \200 I do not know how to proceed \200 help \200 this [patient] is slightly phosphorescen t. \200\235AS Byatt 2003 p75 of A Whistling Woman r u o , s e v l e s r u o e g d u j e w f i t u b \200 e s o p r u p o n o t y g r e n e d n e p x e e w , s r e h t o g n i g d u j n I 1 Tout comprendre c \200\231est tout pardoner \200\224 \200\230To understand all is to forg ive all \200\231. I have found it necessary to inscribe this phrase around the bell of my s tethoscope. This bell then tolls in my mind \200\231s ear whenever my patient is making me angry or despairing \200\224in other words whenever I have not understood. \200\230Tout co m- prendre c \200\231est tout pardoner \200\231 is the most magnanimous phrase ever created , and was \201 rst promulgated by Madame Anne Louise Germaine de Sta l: \200\234tout co mprendre rend tr s indulgent \200\235 \200\224 \200\235To understand all is to become very lenient. \200\23515 The phrase was stolen by Tolstoy in the last chapter of Book 1 of War & Peace. Can we forgive this theft? Of course; not just because the theft gave anonymous im mortality to Madame de Sta l, but because Tolstoy probably needed to believe he had create d it to sustain him in the illusion of his own infallible magnanimity,16 without which his great literary enterprise would have been impossible.17 Vive nos illusions: Vive nos illusi ons magni \201 que! Listening (and swallowing) Some time ago, a child said \200\234To understand me you must s wallow a world \200\235.18 Taking this quest for truthfulness about the inner life further, one of our most rigorous therapists has said that he must perform \200\234the essential J onah act of allowing himself to be swallowed, remaining passive, accepting \200 \200\23519 The sign that we are listening properly, from within the whale, so to speak, is that we ar e immersed in our patient and that what we are hearing could, perhaps, change us. Patients intuitively understand and respond to this level of listen- ing. It takes great concentrati on. Doing something is always easier \200\224hence Anthony Storr \200\231s aphorism: Don \200\231t just do something \200\224Listen! 1 320 Once we had the good luck to work on a psychiatric ward with a would-be surgeon, who, befor e he accustomed himself to psychiatry, would pace rest- lessly up and down the ward after c lerking his patients, wondering when the main action would start, impatient to get his teet h into the business of curing people. What he was expecting was some sort of equivalent to an operating list, and not knowing where to \201 nd one he was at a loss, until it dawned that taking a history from a psychiatric patient is not a \200\230pre-op assessment \200 \231, but the start of the operation itself \200\224albeit a rather odd operation in which it is not the questions which are incisive but as often as not what happens in the silences . Even advanced textbooks of psychiatry appear to have missed this surgeon \200\231s insigh t, describing psychotherapy as something which should only happen after \200\230a full psy chiatric history \200\231.20 There is no such thing as a full psy- chiatric history. In des cribing the salient psychological events of a single day even the best authors (eg James Jo yce in Ulysses) need substantial volumes. This is why this chapter is starting so slowly: t o give time for these notions of listening to take root. So swallow hard. Calm your restles sness. Stop. Re \202 ect. y r t a h c y s P i Taking a history sounds like an active, inquisitorial process, with lists of questions, and the tone of our page on this process (p322 & mental state ex- amination, p324) seems to pe rpetuate this error. It isn \200\231t a question of taking anything. It \200\231s more abou t receiving the history, and allowing it to unfold. \200\207If you only ask questions, you will get only answers as replies. As the history unfolds, sit back and listen. This sounds easy, but during a busy or diffi c ult day you will \201 nd your mind wandering (or galloping away) \200\224 over the last p atient, the next patient, or some aspect of your own life. You may \201 nd yourself worry ing about having to \200\230section \200\231 this patient or see the relatives afterwards. By an act of Zen, banish extraneous thought, and con- centrate totally on the person in fr ont of you \200\224as if your life depended on it. Concentrate on the whole person \200\224 the language, the words, the nonverbal cues, and get drawn into their world. Initially don \200\231t even think of applying di- agnostic labels. Open your mind and let everything \202 ood in. Listening is hard. We wish we did it better. We all need to practice it more. Avoid interruptions and seeming to be too purposeful, at least for the \201 rst few minut es (or days). Expect periods of silence. If prompts are needed try \200\234and then how di d you feel? \200\235 or just \200\234and then \200 \200\235; or repeat the last words the patient spoke. Don \200\231t be anxious if the patient is not covering major areas in the history. Lead on to these later, as the interview unfolds. Early in your career you will ha ve to ask the relevant questions (p322) in a rather bald way (if the information is not upc oming during the initial unstructured minutes), but it is important to go through this stag e as a prelude to gaining information by less intrusive methods. Always keep in mind the ch ief aims of making a diag- nosis, de \201 ning problems, and establishing a therapeutic re lationship. 1 The converse of this aphorism is the Parris dictum: \200\234When people are anxious it i sn \200\231t clever to make a virtue of listening. Sometimes our patients simply need to be told. \200\235 Sometimes they need space for self- expression. Which approach is right \200\224when? We only know this by knowing our patients: this entails listen- ing, which is why, 9 times out of 10, Storr is right: but 9 out of 10 is not always. \201\201 What is the point of all this listening? Listening enables patients to start to t rust us. Depressed patients often be- lieve they will never get better. To believe that the y can get better, patients need to trust us, and this trust is often starts the therapeutic process. In general, the more we listen, the more we are trusted. Our patients \200\231 tr ust in us can be one of our chief motivations, at best inspiring us to pursue their bene \201 t with all vigor. A story bears this out. One day, in 334 BC, Alexander the Great fell ill with fever. He saw his doctor, who gave him a medicine. Later he received a letter say ing his doctor was poisoning him as part of a plot (it was an age of frequently fatal intri gues). Alexander went to his doctor and silently drank the medicine in front of him \200 \224then gave him the letter. His con \201 dence was rewarded by a speedy recovery. We thi nk it is unreasonable to expect quite this much trust from our patients, and one wonders wh at can have led Alexander to such undying trust in his doctor. We suspect that his doctor, above all else, must have been a good listener. Lifeworlds, and how to keep them intact Eve n if we all listen the same way, what we will hear will depend on our own expectations, anx ieties, and past experience. Take this dialog.22 321 1 2 . t s u r t f o n o i t a d n u o f e h t s i ) d r a w e r t o n ( y r t a i h c y s P e v o l t a h t t h g u a t ) r o t u t Doctor: Patient: Doctor: [impatiently] \200\234How long is that? \200\235 Patient: [giggli ng] \200\234How long have you been drinking that heavily? \200\235 \200\234Since I \200\231ve been married. \200\235 s \200\231 r e d n a x e l A ( \200\234For years \200\235. Perhaps the doctor hears \200\2304 years \200\231. e l t o t s i r A If, prosaically, all we want to know is how long her liver was exposed to alcohol, we need facts in linear historical time. But she chooses to answer in event-time, or personal time. This is Mishler \200\231s great distinction between the voice of medicine and the voice of the lifeworld.23 Sometimes we must set experiences not in linear time but in the order the y \201 rst become signi \201 cant to a lover or parent. Justine L Durrell 97 What would this patient have gone on to say if her doctor had swallowed her world? What did those gigg les signify? We will never know, but they might have explained her coming death. , C M G e h t o t y r a r t n o C Fig 1. Swallowing a world. Eliciting the history Introduce yourself; explain how long the interview may take. Describe its aim; emphasize that \200\234here is a safe place to talk \200\235. Find out how the p atient came to be referred, and what his expectations are. If the patient denies any proble ms or is reluctant to start talking, don \200\231t hurry. Try asking \200\234How are you? \200\235 or \200\234What has been happening to you? \200\235 or \200\234What are the most impor- tant things? \200\235 \200\234Does anyone else think there is a problem? \200\235 \200\234Who does it eff ect most? \200\235 These are beautiful questions because they impo se no categories, and seeing what categories your patients imposes, unprompted, will often tell you rich things. Listen, without interrupting, noting exact phrases. By inhabiting and using the categories your patient gives, you may enter his world. 2 min- utes may be neede d for this phase \200\224or 2 years \200\224depending on how unspeak- able and distressing his or her thoughts are. Events surrounding war, torture, rape, and family dislocations may take years before they can be told. Presenting symptoms Agree a problem list with the pati ent early on, and be sure it is comprehensive, eg by asking \200\234If we were able to dea l with all these, would things then be all right? \200\235 or \200\234If I were able to he lp you, how would things be diff erent? \200\235. Then take each problem in turn and \201 nd out about on- set, duration, eff ects on life and family; events coinciding with onset; solutions tried; reasons why they failed. The next step is to enquire about mood and belie fs during the last weeks (this is diff erent from the mental state exami- nation, p324, whi ch refers to the mental state at the time of interview). Spe- ci \201 cally check for suic idal thoughts, plans, or actions \200\224the more speci \201 c these are, the greater the danger. Discussing suicide does not increase the danger. Questions to consider: \200\234Ha ve you ever felt so low that you have considered harming yourself? \200\235 \200\234Have y ou ever actually harmed yourself? \200\235 \200\234What stopped you harming yourself any m ore than this? \200\235 \200\234Have you made any detailed sui- cide plans? \200\235 \200 \234Have you bought tablets for that purpose? \200\235 Depression \200\224ie low mood, anhe donia (unable to feel pleasure), self-denigration ( \200\234I am worthless \200\235; \200 \234Oh that I had not been born! \200\235), guilt ( \200\234It \200\231s all my fault \200 \235), lack of interest in hobbies and friends plus biological markers of depression (early morning wak- ing, \200\201appetite, \200\201sexual activity, \200\201weight); mania (p3 54); symptoms of psychosis (persecutory beliefs, delusions, hallucinations, p316); drug and alcohol use; ob- sessions; anxiety; eating disorders (eg in young women; often not volunte ered, and important). Note compulsive behavior, eg excessive hand-washing. The present Hous ing, \201 nance, work, friends, spouse/partners (negotiated or non-negotiated non-monogam y?).24 Physical and mental health, job, and per- sonality of family. Who is closest to whom ? Any stillbirths, abortions? Birth, growth, and development How has he spent his life? Ask about school, play (alone? with friends?) hobbies, further education, religion, job, sex, marriage. Has he always been shy and lonely, or does he make friends eas- ily? Has he been in trouble with the law? What stress has he had and how has he coped with it? NB: noting ea rly neurotic traits \200\224nail-biting, thumb-sucking, food fads, stammering (not really a neurotic feature) \200\224rarely helps. Premorbid personality Before all this happened, ho w were you? Happy- go-lucky \200\211driven, gentle \200\211sadistic,1 tense \200\211laid-ba ck, happy \200\211depressed, social \200\211antisocial? Impulsive, sel \201 sh, fussy, irr itable, rigid, insecure/schizotyp- al,2 shy, hostile, competitive? \200\207 Talk to whoeve r accompanies him, to illumine premorbid personality and current problems. But don \200\231 t let her speak for the patient (at least make sure the patient has the \201 rst and last word). Relevant medical history eg on retroviral drugs, or frequent asthma attacks. Next, examine the mental state (p324 & p353). You may now make a diagnosis, or decide that labeli ng is unwise. Ensure the areas above are covered in the light of any diagnosis so that the questions \200\234Why did he get ill in this way at this time? \200\235 and \200\234What are the consequences of the illness? \200\235 are answered. 322 \200 y r t a h c y s P i 323 \200\235 ! d e s u b a s a w I Discussing childhood sexual abuse (CSA) with an adult who is currently experiencing psychol ogical diffi culties A frequent question to arise is \200\230how far does past CSA account for current problems, and how much should this issue be explored now? \200\231 Each person is diff erent: try to learn to use whatever your patient gives you, for their bene \201 t . See p328 for how to talk about sexual issues. Sometimes it is possible to be optimistic, despite the fact that many patients and professionals believe that CSA causes intense, perv asive harm in the general population, regardless of gender. This issue has been examined in careful meta-analyzes looking at 59 studies based on college data. These show that student s with CSA were, on average, only slightly less well adjusted than controls. But this poore r adjustment cannot be attributed to CSA: family environment is consistently confounded wit h CSA and explains much more adjustment-variance than CSA. Self-reported reactions to and e ff ects from CSA indicate that negative eff ects are neither pervasive nor often intense. A lso, men react much less negatively than women. Even though this college study is consisten t with data from national samples, this optimistic meta-analysis should not blind you to th e possibility that the patient sitting in front of you might be very damaged by CSA \200 \224but do not assume that CSA is the underlying reason for everything.25 \200\207When in doubt, get further help. Using whatever your patient gives you to make subjective but highl y accurate, even valid maps of patients \200\231 worlds. Doctor: \200\234When you are like this, what \200\231s most diffi cult? \200\235 Dawn: \200\234Looking after the children \200\224and going out to work \200\235. Doctor: \200\234Which is harder? \200\235 Dawn: \200\234Well, going out to work; sometimes the children help. Jo and Nick. \200\235 Doctor: \200\234Anyone else? \200\235 Dawn: \200\234Well \200\224my husband? Fat chance, even wh en he \200\231s sober. \200\235 Doctor: \200\234So the children don \200\231t take after h im, then? \200\235 Dawn: \200\234Lord no! Not yet, anyway \200\224but all the blokes in hi s family drink like \201 sh, e s u a c e b t s u j e f i l y m l l a m i t c i y r t a i h c y s P v a e b o t g n i o g t o n m \200\231 I \200\234 so I \200\231m worried for Nick when he gets that bit older. \200\235 Doctor: \200\234You worry more about him than Jo? \200\235 Dawn: \200\234Yes \200\224even though Jo cannot read yet, which is a worry. But she \200\231s got a way of looking after us somehow. She \200\231ll be all right \200\224she \200\231s like her gran. \200\235 Doctor: \200\234She still looks after you all sometimes? \200\235 Dawn: \200\234Well, she did, but she died last year, and then I went back on drugs. \200\235 All families evolve t heir own ways of communicating, and much goes on under the surface. In this dialog, Dawn in stigates a dozen categories or concepts. In an unconscious tour d \200\231horizon, she draw s a map for us, and as we impose none of our own suggestions, we can be fairly sure they re present some of the chief landmarks in her world. Don \200\231t place people and events on other people \200\231s maps: let them populate their own. Don \200\231t superimpose the qua si-objective platitudes and longitudes of time and place. It is better to let the map grow organically. You yourself are on the map, partly revealing and partly hiding the other elem ents. Move around a bit, and by a process of psychological par- allax3 you can estimate how far your patient is from the center of her life. \201\201 1 Narcissism + paranoia \211\210 \200\234authoritarian \200\235. When paranoid, antisocial, narcissistic, schizoid, and schizotypal elements conjoin with sadism we have a perfect storm (Hitler, Stalin, Saddam Hu ssein, Kim Jong-il etc are such examples). As ever, if you identify this combination, get s enior help (from the Royal Navy? or the Pope? or John Lennon?). 2 Schizotypal \211\210 the socially anxious, friendless loner with magical thinking, odd fantasies clairvoyance. 3 Parallax=apparent angular displacement of a celestial body due to a change in the position of the observer. With a baseline of known length between 2 observations, the distance to t he object becomes known. The mental state examination (MSE) This assesses state of mind at the time of interview. Ta ke notes under the following headings. \200 Appearance and behavior: Eg signs of self-ne- 324 \200 Direct questions to try \200 Any odd thoughts? \200 Might your thoughts be being interf ered with? \200 Do you feel anyone is glect; slowness, anxiety, or suspiciousness. Mode of speech: Speech rate, eg gabbling (pres- sure of speech), or slow/retarded. Note con tent. \200 Mood: Note thoughts about harming self or oth- ers. Gauge your own response to the patient. The laughter and grand ideas of manic patients are contagious, as to a lesser extent is the expression of thoughts from a depressed person. controlling you? \200 Is anyone putting thoughts into your head? \200 Do other people access or hear your thoughts? \200 Is any one harming you? \200 Any plots against you? \200 Do you hear voices when there \200 \231s no one nearby? What do they say? Echo- ing you? Telling you off ? \200 Do you see t hings that Beliefs: Eg about himself, his own body, about other people and the future. Note abnormal b e- liefs (delusions) eg that thoughts are overheard, and ideas (eg persecutory, grandiose). See p316. \200 Unusual experiences or hallucinations: \200\234Some- times when people a re low they have unusual experiences; have you heard anything unusual re- cently? \200\235 Note modality, eg visual. others cannot see? Are you low/depressed? \200 Is life worth living? \200 Can anything give you y r t a h c y s P Orientation: In time, place, and person. What year? What season? What month/day of week? Is it morning or afternoon? What is your name? pleasure? i Sleep and appetite ok? \200 Energy levels \200\200 or \200\201? \200 Can you concentr ate ok? \200 Are you feeling guilty? \200 Is your con \201 dence low? \200 Are you w anting to harm anyone? Yourself? \200 Any worries/anxieties? Short-term memory: Recall a name & address 5min after learning it. Ensure he really has lea rned it before waiting for the 5min to elapse. Concentration: Months of the year backwards. \200 Patient \200\231s insight and degree of your rapport. \200 Long-term memory: Current aff airs recall. Who is the monarch/head of state? This tests other functions, not just memory. Non-verbal behav ior Why are we annoyed when we blush, yet love it when our friends do so? Part of the answe r to this question is that non-verbal communication is less well controlled than verbal beh avior. This is why its study can yield valuable insights into our patients \200\231 minds, particularly when analysis of their spoken words has been unrevealing. For example, if a pa tient who consistently denies being depressed sits hugging himself in an attitude of self-p ity, remaining in a glum silence for long periods of the interview, and when he does speak, using a monotonous slow whisper unadorned even by a \202 icker of a gesticulation or eye contact \200\224we are likely to believe what we see and not what our patient would seem t o be telling us. Items of non-verbal behavior: \200 Gaze and mutual gaze \200 Facial ex pression \200 Smiling, blushing \200 Body attitude (eg \200\230defensive \200\231). Si gns of auditory hallucinations: \200 Inexplicable laughter \200 Silent and distracted w hile listening to \200\230voices \200\231 (but could be an \200\230absence \200\231 seizu re, p206) Dress: ( \200\230The apparel oft proclaims the man \200\231)26 \200 Hairstyle \200 Make -up \200 Ornament (ear-rings, tattoos, piercings). Anxious behavior: \200 Fidgeting, tr embling \200 Nail-biting \200 Shuffl ing feet \200 Squirming in the chair \200 Sits on edge of chair. Random, meaningless gestures. Signs of a depressed mood: \200 Hunched, self-hugging postu re \200 Little eye contact Downcast eyes; tears \200 Slow thought, speech, and movement. 325 What is a mental state? A true description of mental states entails valid knowledge about c urrent emotions plus their reactions to those emotions. These reactions are them- selves em otional (eg being relieved that one \200\231s sense of remorse over X feels authentic), as well as being the bedrock out of which beliefs and attitudes are formed. These interactions make a picture to an observer which is com- plex, paradoxical, subjective, error-prone, co ntradictory \200\224and fascinating. t h g N h t f l e w T \200\235 . o o t i s r e h t o r b e h t Describing and communicating mental states is the central puzzle that confronts not just ps ychiatrists and our patients, but also artists. Poets and songwriters summon up diverse men tal states (herein lies their genius) but none can control them or their in \201 nite prog eny (what happens next). This is the province of psychiatry. If we could control mental sta tes at will at least half our job would be done (no doubt there would be unfortunate side e f- fects). Drugs, psychotherapy, and behavioral methods are the tools availa- ble for this task, and they all, crucially, impinge on mental state. You cannot tell if these methods ar e helping if you cannot access your patient \200\231s mental state, which is why the page o pposite is so important. If you think you can access mental states just by applying the for mulaic regimen opposite, you will often fail, as any trip into the mind of another is not j ust a voyage with- out maps, it is ultimately a creative and metaphysical enterprise. l l a d n a , e s u o h s \200\231 r e h t a f y m y r t a i h c y s P f o s r e t h g u a d e h t On this view, knowledge of mental states is doubtful, but often this is not so, eg a baby b eing put to the breast after separation from her mother, or an audience giving a standing o vation, or screaming fans waving at an idol, and we know without doubt that these mental st ates comprise unalloyed satisfaction, pleasure, and adulation. So often it \200\231s non-ve rbal behavior that allows valid judgment about mental states: don \200\231t rely on words a lone \200\224 those capricious (but indispensable) tokens of disguise and deception. How ma ny diff erent selves are rolled up into your patient? \201\201 Here is an example: a perso n who happens to be black, who happens to be Muslim, who happens to be male, who happens to be questioning his sexual orientation while trying to be a good son and a good brother. He is trying on new identities and new relationships with Allah. How do these identities invo lving race, culture, religion, gender, and sexuality feed into his mental state now?27 In t he mental state examination, give space to \201 nd out about these roles, to get a feelin g for which causes most turmoil, ambivalence, and introspection, the 3 \200\230vital signs \200\231 of psychic life \200\224TAI.1 Aim to understand how good the patient is at articu lating these roles. Try to understand from which platform the patient feels most comfortabl e in tackling his problems \200\224and pay respect to each role separately, in order to gai n trust.28 Try to \201 nd out how plastic or rigid each identity is \200\224the more plas tic, the easier it is for the ego to function harmoniously (ie \200\230good identity integ ration \200\231).29 Lear: \200\234Who is it that can tell me who I am? \200\235 Fool: \200\234Lear \200\231s shadow \200\235. Just as Shakespeare creates metaphysical places, su ch as Lear \200\231s30 and Viola \200\231s Illyria, where answers to questions of identity can take shape, so psychia- trists create spaces in the silences of mental state examinatio ns where our multiple personas can visit each other. Our masks shift and a few rays illu- m ine our \200\230shadow selves \200\231, as we come to know the diff erence between who we are and who we think we are. Acknowledging that we have a shadow is hard, but vital.31 Ment al state examinations start this process leading to questions such as \200\234Who knows mo st about who you are? Who else? How do their views diff er? What truths about you do they a cknowledge or hide? \200\235 l l a m a I \200\234 : a l o i V . h t a e d o g e = n o i t a r g e t n i y t i t n e d i t c e f r e P . s e v l e s y h t w o n k \200 f l e s y h t w o n K 1 Tai Chi in Confucian philosophy is the mother of yin and yang, the Supreme Ultimate Fist which trans- cends and harmonizes those \200\230internal necessities in our our being \200 \231 which forever drive us on. Herman Melville Moby Dick Ch 36 How to avoid doctor-dependency A patient may become over-dependent on his or her doctor in many spheres of medicine. This is a particular danger in psychiatry because of the intimate and intense rather one-sided or asymmetrical relationship which may be built up between th e patient and psychiatrist \200\224who will often know more about a patient \200\231s hopes and fears than any close friend. This encourages the patient to transfer to the therapist thoughts and attitudes that are often directed to parent- \201 gures. This process (known as transference) powerfully stimulates doctor-dependency, sometimes with serious consequenc es. Other risk fac- tors for doctor-dependency: Chronic illness/prescribing; inability to a chieve the sick role \200\224eg if you have chronic back pain, your suff ering is hidden fr om others (no scars, no bleeding, etc), and you may feel delegitimized in your sick role be cause you cannot be diagnosed or helped. But equally, because of this, you hold power over your doctor. It is diffi cult for her to challenge your ideas without damaging the therapeu tic relationship. So the doctor is forced to col- lude with your de \201 nition of ill-hea lth. This may harm you and society.32 Signs of non-therapeutic dependency Repeated phoning for advice, inabil- ity to initiate any plan without help from a therapist, and disallowing of your attempts to terminate treatment (eg by threatening relapse). Assessing whether dep endency is a problem Clearly, in the examples above, the patient \200\231s dependency on hi s doctor is non-therapeutic. At other times, for example, early in treatment, doctor-depend ency may help. In these circumstances the danger is that the doctor will be \202 attered by his patient \200\231s dependency on him. Most therapists either want to be loved by thei r patients or want to dominate them (or both), and it is important to know, in each session with each patient, just where you lie within the space marked out by these axes. Ask yours elf: \200\234Why do I look forward to seeing this patient? \200\235 \200\234Why do I drea d seeing Mr X? \200\235 \200\234Why do I mind if this patient likes me? \200\235 \200\207 When you feel good after seeing a patient always ask yourself why (it is so often because h e is becoming dependent on you). Avoiding dependency Planning and agreeing speci \201 c, l imited goals with pa- tients is one way of limiting dependency. If the patient agrees from the outset that it is not your job to provide him with a new job, wife, or family, he is mo re likely to have realistic expectations about therapy. 326 y r t a h c y s P i Planning discharge from the start of therapy helps limit doctor-dependency. Discharge is ea sy from the outpatient departments, but for the GP the concept of discharge is diluted by t he fact of his contractual obligations. The patient is quite within his rights to turn up t he day after being \200\230discharged \200\231 and de- mand that therapy be started all ov er again. The GP must have more subtle methods at his disposal to encourage the patient to discharge himself. For ex- ample, he can learn to appear completely ineff ective, so that t he dependency cycle (patient presents problem \200\203doctor presents solution \200\203pati ent sabotages solution \200\203doctor presents new solution) is never started. Another meth od is to bore your patient by endlessly going over the same ground, so that the pa- tient s eizes control and walks out as if to say \200\234I \200\231ve had enough of this! \200\235 . The foregoing makes patients out to be perpetual seekers after succor and emotional support \200\224and so they may be. But a great mystery of clinical medi- cine is that, spontaneou sly and miraculously, many apparently irremediably dependent patients can change, and start leading mature and independent lives. So don \200\231t be downcast when you are looking af ter such people: there is much to be said for simply off ering a sympathetic ear, staying w ith your pa- tient through thick and thin, and waiting for time to go by and for the wind t o change. Of course, the wind may change back again, but, if it does, you will not be back at square one, for you will be able to inject the proceedings with the most powerful psycho therapeutic agent of all, namely hope. 327