Sunday, May 25, 2014

You Change Someone's Mind By Listening To Them

I was skipping around on the internet this evening reading blogs, which is something I do sometimes at night when my husband and daughter have gone to sleep but I'm not tired yet and I don't have to get up early for work the next day. I start at a blog I like and then just follow links around, skimming through articles as they catch my interest. Most of what I read tonight was by Christian authors and, unfortunately, involved a lot of theological name calling by people who were distressed by the opinions of other people. It's quite frustrating and I'm sure that any non-Christians stumbling across the arguments were either confused, put-off, or both. Why can't people come together or at least speak respectfully to one another? Why do people get so stuck on certain issues?

It got me thinking about an article I read recently from The New Yorker ( written by Maria Konnikova. Her article examined the fears that people have about vaccines and why people's minds are so hard to change. To sum up the research she quoted in her article, people don't change their minds easily when the belief in question is central to their identity, but they are more likely to change if you affirm them or get them to affirm themselves (by writing an essay about something they have done well) before exposing them to new information. I found it quite ironic that in the comments section there is an angry tirade about the dangers of vaccines from a mother who chose not to vaccinate her children, which all in all demonstrated the author's point quite tidily. I have found this general idea to be quite true in my own work. When people are affirmed then they are more able to assimilate potentially identity altering information. You might say it's a key tenet of psychotherapy.

It also feels similar to one of Steven Covey's principles in "The Seven Habits of Highly Effective People." (And yes, I really liked that book. I read it for work because I do administrative and management tasks and didn't expect to enjoy it but it was quite thought provoking. I'm sure I'll have more to say about it again.) His fifth principle is "seek first to understand, then to be understood." He unpacks this phrase to mean that when you are trying to work out any kind of difference with someone you should listen to them with the intention to understand them fully. Before you even try to formulate a reply you should listen so carefully that you can and do explain their position with its motivations and logic even better than they can. He makes the observation that people become much less defensive when they feel fully understood. He terms the process giving someone "psychological air" analogous to placing an oxygen mask on the face of someone gasping for air. It's life-giving. Once they can breathe, psychologically speaking, they stop struggling. I can tell you from experience that being listened to and understood in this way is deeply affirming and opens people up in amazing ways.

I don't know how well this kind of understanding and affirmation could occur over the internet. I suspect that part of what comes across as life-giving is genuine interest; the obvious effort of one person listening to and learning from another. I think quite a bit of communicating genuine interest is non-verbal; the pitch and cadence of voice, the tilt of the head, the set of the shoulders, the little angles around the mouth and eyes that make the difference between sarcasm, polite condescension, pro-forma recitations of formulas, and genuine caring and communication. Perhaps we could all try a little harder, though, to deeply listen to and affirm each other before presenting our own views. Perhaps we could devote words and space to listing the other's accomplishments, or good deeds, or views we do agree with, before criticizing a point they have made. Perhaps we could summarize the arguments of others in clear, fair and respectful ways, asking for correction for any misunderstandings on our part. It would be more work, certainly. But perhaps it would be more Christ-like?

Friday, May 23, 2014


Medical culture doesn't value rest. I've often heard other doctors speaking at length about their long hours and their many patient encounters. There is a physician I work with who routinely stays past 9pm caring for patients. His comments are greeted with half admiring, half commiserating responses from everyone else. We tell him he's working too hard but no one criticizes him or pressures him to change. We tacitly agree that this is appropriate behavior for a medical provider.

I've never heard a doctor say "Well, I sign out every day at 5pm no matter what in order to take care of myself and spend time with my family."  I'm not sure how such a comment would be greeted. Probably with quiet and then an awkward change of subject. Certainly with some internal jealousy on the part of the listeners, along with unverbalized scorn. Medical culture values hard work. The rule is that the harder you work, the more diagnostic puzzles you solve, the more patients you see, the better physician you are. It's as if everyone is competing for a "best doctor" medal that is never handed out. No wonder so many doctors are burned out.

I've often mourned my own needs for rest and sleep. Sometimes when talking to friends I'll say "I wish I could get by on 5 or 6 hours of sleep per night. I could get so much more done!" I always have a list of projects to be done, books to be read, lectures to be written that occupies the back of my mind. I consume more caffeine than is good for me so that I can manage on 7-8 hours and suffer the headaches and irritability that comes from sleep deprivation so I can get that little bit more taken care of. But I'm coming to realize that this is crazy.

I've been reading "The Seven Habits of Highly Effective People" by Steven Covey. One of the themes in the book is balancing between production and production capacity. Rest is part of the investment you make in production capacity, something you do in order to preserve your ability to keep on working. This is a concept I see people paying lip service to, but most people don't live it out. A friend recently posted a quote from the Dalai Lama that said, in essence, that he is surprised by human beings, because we sacrifice our health in order to make money and then spend money in order to restore health. That one hit home with me, because I definitely do this. And when you put it that way, you realize that it's pretty pointless.

Last weekend I attended a women's gathering at the church I am attending. The theme of the gathering was rest, and the central message was that G-D wants us to rest in him. He created us and adores us, not for what we do but for who we are. We don't need to check everything off on our to do list to be loved by G-D. That it is not only okay but is actually commanded that we stop, that we rest, that we spend time on a regular basis in quiet restoration. That rest isn't for when everything is done but that it is something that needs to be done no matter how many or how urgent our projects.

Honestly, I'm terrible at this. I will hear a message like this and start trying to rest more and then I crumple under the pressure of life. It takes discipline to rest; it takes saying no to certain things and it takes accepting my own limitations. It is painful to recognize that my personal to do list will never be completely checked off, that there are interests I won't be able to pursue. It's difficult to disappoint others by saying no to them. It's easier (although not wiser or healthier) to just go with the flow of saying yes and skimping on rest. However, I am coming to realize that it's not sustainable over a long period of time, and that saying a measured, reasonable "no" now will strengthen my ability to say "yes" far into the future. I'm not sure how to live this out. I don't know what that life of regular rest would look like. But I'm beginning to recognize that I might want that life, and that it is up to me to make the choices that would get me there.

Wednesday, May 14, 2014

Psychiatrists Doing Psychotherapy: added value? or waste of resources?

I always come away from my annual professional meetings (American Academy of Psychoanalysis and Dynamic Psychiatry and American Psychiatric Association) with new information and ideas. This year I've heard about and thought about collaborations with primary care, the connection between inflammation and depression, and detailed exercise prescriptions as a treatment for depression. However, the big thing I'm taking away from this year's meetings is a question that has been floating around both meetings in various sessions I've attended. What do I, as a psychiatrist who provides psychotherapy, bring to the table that is unique and valuable?

Many psychiatrists don't provide psychotherapy anymore; they prescribe medication and monitor side effects and leave the psychotherapy to counsellors, psychologists and social workers. It's more economical that way. A psychiatrist can see a patient for medication management in about fifteen minutes, which means that psychiatrist can bill for four patients an hour. When you have loans to pay off and bills to pay, or an office manager and a nurse to pay, that is a pretty big difference in income. It also means you are helping four patients an hour instead of one, which given the scarcity of mental health resources is not a negligible factor.

When I was interviewing for jobs a few years ago most of the groups I spoke to weren't interested in my psychotherapy skills. I would explain that I have a special interest and extra training in psychotherapy and ask if I could continue to offer it to patients. The reactions to that question ranged from "No, we wouldn't want you to do that." to "That's strange, but you can have a few psychotherapy patients if you want. But not more than one or two and you won't make as much money." It was discouraging, to say the least, and it was a big factor in my choosing my current job which offers me the freedom to continue to practice psychotherapy.

My impression after talking to my colleagues is that they have had similar experiences, although often without finding a congenial job opportunity. Among those who do continue to practice psychotherapy there is a sense of defensiveness and anxiety to their practice. There is a sense of something being lost or taken away and a determination to hang on to it. I resonate with this. I value my psychotherapy work. It interests me and challenges me in a way that medication prescriptions just don't. I worry that at some point someone will tell me that my work isn't economically valuable or viable and pressure me to stop.

The value of psychotherapy as a treatment is, I believe, indisputable. I can locate dozens if not hundreds of studies that demonstrate both efficacy and cost-effectiveness of psychotherapy as a treatment for mental illness. The question I am asking is what is the added value of me, as a psychiatrist, providing psychotherapy? When it means that I see fewer patients for my organization, making my care per patient more expensive and causing me to be available to fewer people, what is the value that I am adding?

It's not a comfortable question to ask. My hope (or perhaps my bias) is that I do add value. I believe that by understanding health in a deep as well as a broad way that I can give more to patients. I can recognize signs of medical illnesses that require evaluation and care and I know how to get patients access to those treatments, and I can do this better for patients I know well. I can discuss health management and maintenance in detail as part of behavioral psychotherapy. I understand the medical system and the impacts of chronic and severe illnesses on a person's body and on their life. I can move fluidly between medications for illness and psychotherapy for illness, allowing me to prescribe medication in a way that is right for each patient. My goal is to prescribe the right medications in the right doses at the right times for the right duration for the right patient so that my patients experience the most benefit for the least side effect and cost burden. Conducting psychotherapy concurrently helps me do that because I know my patients well. I believe that the healing relationship created by psychotherapy helps my patients accept, tolerate and benefit from medication. I am able to talk about what daily medication means to my patients and why they might hate taking it. I am able to work collaboratively because my patients trust that they can speak the truth to me. I also believe that the extensive and demanding training I have completed gives me a higher level of expertise that benefits the patients I see. I believe my patients are more likely to get better and stay better because I am offering more comprehensive care.

Those are just my beliefs, though. I can't prove them, and I obviously have some motivations for them. I don't know if anyone has looked at these questions in order to generate objective evidence about this question; I'm doing a search of the medical literature to find out. So far I haven't found much except opinion, but I'll keep looking. In the meantime, I wonder what other people think? People who don't have the same biases I have?

Friday, May 9, 2014

Books, Disappointing and Not

Recently I picked up a book series that I remembered fondly from my early days as a science fiction and fantasy fan. I remember a friend in 7th grade lending me this series book by book as she finished it and I devoured them, reading on the bus and during lunch and after my homework was done. I hadn't seen them in years, so I was excited to find them available on kindle format and purchased the entire series at once.

The reason I'm not naming book or author names is that I was sadly disappointed. Rereading the first book now, as an adult, the material is poorly written. Most of the characters are flat; they don't come together as full people and they make stupid choices just to make life easier on the main character, who doesn't have to work very hard for a happy ending. To put it bluntly, the book was very dull. I kept reading, hoping that I would get through the dull parts to the good parts I vaguely remembered, but the story didn't improve. I won't be reading the 2nd or 3rd books and will probably return them. Which, by the way, you can do with Kindle purchases within seven days of purchase, in case you didn't know.

I recognize that in many ways the difference in the reading experience is a difference in me. I am, thankfully, a more sophisticated and complex thinker than I was in seventh grade. I know more about people and about life and I'm also much more aware of how much I don't know. I'm more tolerant of paradox, of ideas held in tension, of complicated and contingent answers. I think these changes in myself are for the better, since they've made me kinder, more compassionate and more flexible. It is sad, though, to have an old fond memory replaced by this new contempt.

It makes me appreciate the books that endure all the more. For example, I've recently picked up the Galactic Milieu series by Julian May (9 books in all, spanning three separate sub-series) once again. This series is something I've read many times over the years, starting in college, each time enjoying it more as I picked up on more details and reflected further on what the author is saying about people and about life. The writer weaves together religion, space travel, aliens, psychic powers, and time travel with an astute but compassionate view of people. This series, at least, I suspect I'll continue to enjoy for a long time.

Tuesday, May 6, 2014

I Love NYC

My family and I have been spending the week in New York City so that I can attend the annual meetings for two of my professional associations, the American Psychiatric Association and the American Academy of Psychoanalysis and Dynamic Psychiatry. I haven't been here in a while and I'm really enjoying being in the city. We're staying in an awesome Vacation Rental By Owner apartment across the Hudson River in West New York, NJ and commuting into Manhattan each morning to spend the day. The apartment's living room window features a view of the midtown skyline.

 I find Manhattan really easy to navigate. It is one of the few places on this earth where I don't get lost, because it is on a very sensible system of numbered avenues running north and south and streets running east and west. Since I have a genetic predisposition to be lost and get turned around on the streets around my house on a regular basis this is really saying something. It also has excellent public transit and so far this week I have taken buses, ferries, and subways as well as used my own two feet to get around. I liked the ferry best, which picks up immediately behind the convention center. The streets appear to be chaotic for cars but as a pedestrian I find that the city flows very smoothly. It's busy but it's organized. If someone is going slowly it's easy to step around them and speed up, although mostly people do walk very quickly here, which I like. I generally don't like crowds but New York City crowds move fast and make sense to me and walking down the street is like a dance. 

It's fun to feel the energy of the city as you walk down the streets. You can see hundreds of different stores and restaurants and entertainment venues with flashing signs and ironic names. The Actor's Studio is next to an old church converted to a theater which is just a few blocks from the barn for horse drawn carriages. Walking down the street you see different clothes and different ethnicities and hear different languages. You overhear scraps of conversations about people's lives and experiences. 

There is endless opportunity to see, explore and learn. On Sunday I took a day off from meetings and we decided to go to the Metropolitan Museum of Art ( Serendipitously we walked into Sunday Studio, a weekly program that lets museum goers make art. We spent a happy hour as a family sketching statues, designing fabric prints and then draping the fabrics in an effort to copy the statues we saw. On Saturday evening we met some friends at the American Natural History Museum ( and saw the pterosaur exhibit. I now know how to pronounce "Quetzelcoatal" (ket-zel-kwat-al) which tickles me. My husband and daughter have had even more fun going to various museums, parks and playgrounds while I have been at my conferences.

I know it's not the reputation of the city, but the truth is people are actually really nice here. We're not efficient or quick, moving around the city with a small child in tow. But we've received smiles, hellos, advice, directions and help when needed and a general warm welcome. Our daughter has made friends with kids on the playground and has even gotten a few hugs. One evening walking I saw a young girl, about ten years old, trip and fall on her scooter as she rolled down the sidewalk. Three people (I was one) stopped to help her up and make sure she was ok. People here are in a hurry, but they come across as engaged and friendly. I can't wait to come back.
Variations: Manhattan Skyline from West New York