Where Did the Listening Go?

I am an adult and child psychiatrist, psychoanalyst, trained in the 1980’s, pre-Prozac era, whose fundamental conviction about my role in helping patients is under attack.

This fundamental conviction is that mental health professionals make people curious about their own minds. Thinking about thinking is what psychiatrists contribute to society. As professionals, psychiatrists are skilled at approaching the complexity of human existence with a comprehensive framework to understand the human brain. In essence, my fundamental conviction about behavioral science is that psychiatrists are good at mining the mind. Psychotropic medications are part of this mining process, as is offering a place to sit and appreciate the various doors and tunnels which open when we give ourselves the space to contemplate our consciousness.

Psychiatrists have an important role in helping people find their way in the world. This role is developed by the psychiatrist becoming familiar with the many determinants of human behavior which include genetic, cultural and environmental factors. More specifically, understanding genetics helps one understand vulnerabilities. Understanding culture helps one understand the context in which symptoms develop. Understanding environmental issues such as trauma helps one understand how lives can be shattered and then rebuilt by unexpected and horrifying circumstances. It is only through a comprehensive approach that the complexities of the human experience can be appreciated and aided.

Listening is a complicated skill which takes a lifetime to hone. Psychiatrists who work on this skill offer their patients relief for various reasons. First, when a patient is heard then he/she can take themselves seriously and in so doing, can begin to value their own experience. Second, by modeling after the psychiatrist, the patient learns to listen to himself/herself and thereby enters on the first step towards introspection. Third, listening provides a basis for prescribing medication. When this listening has been done in a thoughtful and comprehensive way, then the doctor can give careful consideration to decide whether psychopharmacology is worth the trial and error process. Further, when the patient feels heard, then he/she is more likely to take the prescription seriously and give measured thought to whether the medication is helping or hindering his/her mental state. In follow-up, this thoughtful physician-patient dyad can struggle together to determine the risk/benefit ratio of medication management. Without the first step of active listening, then the follow-through becomes half-baked.

In addition to listening, psychiatric care involves encouraging introspection, identifying past troubles which have been confused with the present, hearing the mind-body connection and developing strategies to cope with life’s challenges. In order to utilize these skills, psychiatrists need to guard the space and privacy needed for patients to explore their minds. There is no justification for hurried evaluation and treatment. Psychiatry must return to the previous teachings of active listening and understanding. The pressure to work quickly is antithetical to the notion that we need time to think about the problem and then intervene accordingly.

One example of the need to return to the pre-Prozac notion of mental health care can be illustrated by looking at the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). ADHD is a disorder where the patient has difficulty developing a space between thought and action. Helping an ADHD patient understand his/her struggle to create this space between thought and action, along with prescribing stimulant medication, can help an individual have a more meaningful life. By helping someone expand this space between thought and action, a person has the opportunity to not repeat their past errors in judgment. This process of contemplation allows the individual to alter the course of his/her life and his/her children’s lives.

Despite these factors against the comprehensive approach to thinking about thinking, psychiatry can have a come-back.We can return to the value of deep understanding. We can return to the value of relationship building, otherwise known as a therapeutic alliance. 

The question arises that if we focus on how a psychiatrist is helpful outside of his/her ability to prescribe psychotropic medication, then we open up a discussion of what a psychiatrist can do and how they can be trained to do it. First, a psychiatrist is responsible to make a comprehensive assessment of why the patient is suffering. If it is determined that the patient is likely to respond positively to a therapeutic relationship then the psychiatrist must work on developing rapport with the patient. This rapport is based on the active process of establishing a relationship with mutual respect. Once this relationship is established then the psychiatrist uses his therapeutic skills to move the patient beyond his paralysis and into a place of movement and creativity. A psychiatrist learns these skills by exploring the many theories of human motivation. Psychoanalysis is one avenue of exploration which gives the psychiatrist a theoretical framework to understand how people behave for and against their own self-interest. Using these concepts allows a psychiatrist to challenge a patient’s defenses against moving forward and to help the patient see how they get in their own way. Friends, yoga and family members are not in a position to help a person explore the inner workings of his mind. In essence, psychiatry needs to appreciate the past teachings of listening and understanding along with our newer modalities of treatment which includes psychopharmacology. The psychiatrist is in a unique position to marry neuroscience with the humanities and thereby help patients in the deepest way possible.

For more thoughtful insights like this follow "The Musings of Dr. Vollmer" online.