Dr. Grossi's Blog
A stark contrast was drawn in the office a few weeks ago by two patients seen back to back. The first had been diagnosed with secondary adrenal insufficiency and the second had been diagnosed with bipolar II disorder a week earlier. The first woman talked about the treatments she might receive and how her body would react and how her abilities might be affected. The second talked about how she would or should behave as a bipolar patient in response to events in her life. In short, her knowledge of her diagnosis might influence her to behave or feel in ways that would or should comport with the diagnosis of bipolar disorder. Indeed, she asked how she should lead her life as a bipolar person. This is a state of affairs in which knowledge of a classification or label may lead to actions reinforcing the diagnostic criteria for the disorder. Thus, a person could live out their lives in a DSM classification which is exactly what the bipolar patient alluded to above was worried about. Here we have one factor that differentiates medical illness from psychiatric illness.This effect of knowledge of one's classification influencing the criteria of the disorder was described by Ian Hacking in 1995.
It is true of attitudes toward a variety of life events as well. Take, for example, an individual diagnosed with bipolar disorder who fails in organic chemistry or calculus or achieves a poor score on the SATs. Such a person is apt to see such failures not as evidence of a lack of preparation, bad luck, or a problem in the individual circumstance but of stupidity or something to be expected of a bipolar person. Those events each confirm the person's negative view of themselves and the way they would likely approach other academic undertakings in the future. In other words, the response to failure is affected by beliefs about how a bipolar person would respond. On the other hand, calling a bipolar patient a scientific genius would likely affect their future capacity for scientific achievement. In this case, the person would likely experience the event positively but be skeptical of its permanence due to unstable self-identity and self-esteem. In short, the knowledge of the diagnosis can change the way an individual experiences himself/herself.
When discussing diagnosis and treatment in the office, I make every attempt to indicate to the person that they are an individual with an illness and not an illness in an individual, because I want the person to see themselves as individuals who have the ability to live individual lives coping with an illness which can be modified and which does not dictate a particular template or outcome for their lives provided fitting and appropriate treatment decisions are made and maintained over time.
I have never before written a film review; however, I recently experienced a film, The Tree of Life, by Terrence Malick that was so challengingly different from any other film I have seen and that exemplifies the unconscious processes that I wrote about in my prior blog (Some Thoughts on Being a Psychiatrist), I decided to tackle this difficult task. The film starts with a quote from the Book of Job: "Where were you when I laid the foundations of the Earth ...when the morning stars sang together and all the sons of God shouted for Joy!" This is accompanied by a filmy diffuse image and choral music, singing that evokes images of being in a holy place or church. The mother (Jessica Chastain) of the O'Brien family then softly talks about the way of nature which cares for itself, wants to please itself, and lord it over others and the way of grace which is loving, forgiving, accepting of injury and insult. All this is accompanied by soft muted music and said in barely audible dialog -- characteristics that extend throughout the movie. Then she receives a telegram announcing the death of their 19 year old son. With a broken heart she conforms to the way of grace.
Then suddenly we are presented with an array of cosmic images of stars, planets, nova, supernova and more accompanied by soft choral music and then images of stained glass arranged in a coil. Then images of bacteria, amoeba, jellyfish, trilobites, ancient creatures, dinosaurs, volcanic eruptions, smoke, waterfalls, sunrise -- the creation of the world, the dawn of the world. The mother walks in the forest and it becomes cathedral-like due to the soaring trees as well as the music and voice-overs which are whispers. This is almost not a film but more like a meditation.
The reader will notice that I have not presented a storyline as would be expected in a film review. The above is meant to reflect the film structure which is akin to a pointillistic painting. There is a linear story which is directly expressed but suggestion is still more prominent than direct expression. The O'Briens live in Waco, Texas in the 1950s and Jack, the oldest of the three boys, hates and wants to kill his tyrannical father (Brad Pitt). Mallick presents a church service in which the priest tells the congregation that they cannot expect God's protection. Jack's anger shows itself in his abusive treatment of his brother as well as his torturing of animals. Jack's erotic feelings for his mother are pictured as he watches her in her nightgown after he has spied on a neighbor and taken that neighbor's slip. Ultimately Jack says to his father "I'm more like you than her." He has identified with his father and the conflict is resolved in part. These sequences take place before the telegram announcing the death of the 19 year old brother. Jack as an adult (Sean Penn) is pictured as wandering about in a desert wilderness troubled and sad. The final scene is of a bridge from which swoops a single sea bird.
When people talk, they always talk about themselves, no matter what the case of the subject pronoun. We can't help it. This is then an autobiography of Terrence Mallick. He is a very private person. Some even call him a recluse and I haven't been able to find a picture of him. Mallick is the oldest of three brothers. His younger brother died as R.L. in the film by committing suicide. The other brother was involved in a car crash and was burned badly. In the film, one of Jack's friends has a burn of the left rear scalp which is shown repeatedly.
I fear that this attempt to encapsulate a cinematographic masterpiece which calls on the systhesis of many unconscious threads simply does not do it justice. For that, I apologize. I will undoubtedly look at this film again.
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 word "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 that 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 and 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," meaning that revision of opinion is always possible. T.S.Elliot summed it up so beautifully: "We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and 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.