The task facing anyone who wants to be a good psychiatrist is challenging. When a patient presents with an
episode of a disorder he/she presents with multiple behaviors, emotionally charged to varying degrees, embedded in a complex often changing social environment that involves distant, proximate, and immediate variables arrayed in often unclear relation to the immediate presentation. Usually the presentation is complex and multifactorial. This is not to deny that certain features such as a depressed mood, mania, or anxiety may possess their own neurochemistry.
How then is a psychiatrist to proceed in making an assessment with sufficient certainty that can reasonably lead to a treatment plan? As stated above, a person presents with a diagnosable episode as currently defined in the DSM-IV-TR. A psychiatrist must always be mindful that he/she is dealing with a person with a diagnosable episode not a diagnosable episode in a person. I start by getting the data. That sounds like such a simple concept; but, it is unbelievably complex as I will explain. The first set of data is the conscious set of data about the episode itself and reported history. These conscious, stored perceptions and history include material such as mood, interests, energy level, sleep issues, concentration, anxiety, marriages, divorces, children, prior treatment, physical illnesses, substance abuse, etc. I see these as having started in the more evolutionarily ancient unconscious as perceptions that have been perceived, integrated, stored, amplified and presented in the conscious. As such the presentation is limited but allows for novel and complex responses that rely on direct awareness. Consciousness also allows for complex integration of varied sensory inputs and then evaluation of that Gestalt. At this conscious level, the psychiatrist should be empathizing with the person in order to see and experience the world as they do. The second set of data is the result of unconscious processing. I need to digress for a moment to explain that I am not using the work "unconscious" as Freud did. He used it as a construct that housed primitive instincts and drives. I am using it as processing of perceptions outside of conscious awareness. This process has many characteristics including processing many perceptions/feelings/meanings/memories at the same time which is impossible in conscious processing which is restricted to a single issue or multiple issues processed seriatim. Unconscious processing also allows for multiple inferences from disparate data sets and assembling data from different data inputs. It can be adaptive in its responses as well as creative. It may or may not deliver to consciousness data for storage, perception, and manipulation. It can also screen out distracting conscious perceptions. So the unconscious is quite smart but not infallible.(Since the topic of its deception is complex and long I plan to write several future blogs detailing a variety of ways it can be misled).
The treatment plan emerges from a synthesis of the conscious and unconscious conclusions. On the conscious side are the standard and straightforward decisions regarding medications, side effect management, avoidance of stressors, instituting treatment or management of relations to others, social engineering, etc.. These are largely informed by the psychiatrist's education, training, and continuing education including evaluating practice experience candidly and ruthlessly no matter what the outcomes have been. I make a practice of always looking at the poorest outcomes first because you learn the most from them. The unconscious contribution to the treatment plan is best summarized by stating that the best psychiatrists have a very high level of pattern recognition. Some examples might include knowing what is wrong as soon as the person enters the waiting room for the first time due to the rapid recognition and integration of many subtle signals, a patient being early, a patient being late, a person with dice as key fob, use of a particular word in an unusual context, touching below the eye when talking, keen attention to metaphors, etc. These type of perceptions along with many modifying ones lead to multiple subtle judgments that modify what, when, and how decisions are made in treatment. In addition, I have always found it important to maintain a huge tolerance for ambiguity, nurture enormous plasticity in thinking which involves almost continuous building up and tearing down internal concepts and judgments. This implies always thinking, "Never say never." which means that revision of opinion is always possible. T.S.Elliot summed it up so beautifully, "We shall not cease from exploration, and at the end of all our exploring will be to arrive at where we started and to know the place for the first time."
As I was writing this I was reminded of G.B Shaw's comment that all professions are conspiracies against the laity. What he meant was that incentives are often at cross purposes and the professional will consider his own interest first. When a patient engages a psychiatrist they are paying for time and expertise and they are entitled to expect that the psychiatrist will act in their best interest. This includes not recommending more treatment than is truly needed even if this causes a financial disincentive for the psychiatrist. This also implies proportionality in dealing with their problem, maximizing efficiency and trying to make their decision making as rational as possible by pointing out the sources of their misjudgment. This must be said clearly without jargon or technical terms. Anything that can be said, can and should be said clearly.