Sunday, March 10, 2013

If Not, Why Not?

If Not, Why Not?
How Psychiatrists and Patients Talk to Each Other 
Mike Barnes

I started seeing my current psychiatrist, Dr. Lindsey George[1], eight years ago.  We meet once every three or four weeks—not as often as I would like, but we live in different cities and have conflicting schedules.  Still, Lindsey has done me a world of good, and—as she would prefer me to put it—helped me to learn how to do myself a world of good.
            For some time I’ve wanted to write about just what it is that has made this experience of psychiatry so different from my previous ones.  After all, it’s been forty years since I sat in my first office and received my first prescription.  Long stretches of those decades—which included multiple hospitalizations and five years on total disability—were spent running away from psychiatric treatment.  Away from any treatment.  As bad as things got, I didn’t see how they could be helped by telling my story—or not my story, my symptoms—to another clinician who didn’t listen well, who quickly reached a definitive diagnosis, and who offered no strategies beyond drugs that sometimes helped a little but always came with nasty side effects that negated their modest benefits.
            But that is the bad psychiatric experience—which is worth describing, but not what I want to describe here.  What makes good psychiatry different?
            Beyond some indispensable fundamentals, positive doctor-patient relations are hard to define exactly.  Like the best soups, they need a little magic that goes beyond the recipe:  a base of personal warmth and trust and mutual respect, certainly; but also dashes of timely intuition, the spice of sudden breakthroughs and discoveries; and the patience for long simmerings to consolidate gains and prepare for the next step.
            At their core, however, is a special kind of good communication that both comforts and challenges.  It is a way of talking that assures patients they are in expert hands, while helping them to see that they themselves are the most reliable and experienced experts when it comes to their own conditions.  It is a way of speaking and listening by which a physician refers the patient constantly to another specialist in the room:  the healer within the patient.
            Three exchanges I’ve had with Lindsey—and keep having, in various forms, because I forget their lessons and need to be reminded of them—will illustrate, I hope, what I mean by this kind of communication that enables two people to become partners in mental wellness.[2]

Will you still treat me if I don’t take the drugs you prescribe?
            Of course.  I’m  here to advise.  The decisions are up to you.
            The first speaker here was me.  Hesitantly, with a churning stomach.  Everything was at stake.  It was our second session, and although the first had gone well, I was prepared to walk away if I got the wrong answer to the question I’d brought.  Pushed by concerned loved ones, I’d come to Lindsey (or Dr. George, as I called her then) from another psychiatrist I’d been seeing for nine years but with whom I didn’t talk, in a therapeutic sense, at all—just a few minutes of chat while he made his coffee and wrote out the prescription for the escalating doses of clonazepam I was getting by on.  I needed more than a new scrip-writer.  I needed to talk.  To try, if I could, to make sense of my long tangled history of living with bipolar disorder—beginning with my initial misdiagnosis of schizophrenia and eighteen-month hospitalization, with its endless electroshocks and drug trials (including a near-fatal overdose), out of which I’d spilled onto the streets and away from professional treatment.  I needed to sort some of this mess out.  And some of the non-mess:  things I’d found that worked, that helped.  I wasn’t closed to the idea of trying another drug.  But I was closed to the idea of someone making that a condition of talking with me.    
            Of course.  Before these two words, the reader has to insert Lindsey’s look of surprise at the question.  And then my own surprise, amounting almost to shock, at words that came as a revelation:  I’m here to advise.  The decisions are up to you.  Had I heard her right?  I had an expert I could call on, but I would remain in charge of my own treatment?  And was she saying, also, that she assumed at the outset I had the wisdom to make my own best choices, and that the onus was on me to do so?  Yes, she was.  I felt the disorientation of having landed in a place I’d never been before.  Possibilities as well as challenges I’d never guessed glimmered in the distance. 
            For the moment, all I could do was nod gratefully and a little numbly.  Too stunned, at first, to begin the dialogue she’d invited.

I don’t know.  What do you think?
            Lindsey is frank about when she’s reached the limits of her knowledge, when a question stretches beyond her experience and intuition.  It doesn’t happen often, because she’s smart and resourceful and has a wealth of medical and life experience to draw on.  But when she’s honestly puzzled by something, she readily admits it.  Her humility and honesty help me to trust her:  if she has no trouble admitting she doesn’t know, then I can be sure her definite declarations come from genuine certainty, not from the need to appear infallible. 
            And so she asks:  What do you think?  She does me the honour of acknowledging that I may know things she doesn’t—and she does so simply and naturally, without condescension, just as I imagine her turning to another colleague about a point that baffles.  And it makes therapeutic sense, too, to turn many questions back on their asker:  after all, what better place to look for answers to questions than in the lived life that produced those questions?  What richer store of knowledge, both general and fine-grained, could there be than the mind of the person living that life?  As Lindsey said to me early on—another casual, gobsmacking moment—You’re the expert.  Who else, after all, could be?
            For all my long experience as a writer, it still amazes me how much power is encoded in the ways we speak about each other and ourselves.  These new ways of talking with a psychiatrist keep surprising me with their capacity to help me regain a sense of control over my own life.  The control is not built on “You can do it!” bromides, which however well meant often sound false and condescending, but on a deepening reconnection with an original and effectual self that was submerged by mental illness and its treatments.  The right kind of talk can be a skylight through which new views pierce the ceiling of low expectations put in place by self-stigma[3].  For it was certainly such a low self-ceiling, even more than the serious disruptions of mental illness, that caused me to settle for a series of low-wage menial jobs in the ten-year gap between my third and fourth years at university, and then, just three years after graduating with an A+ average, to settle for five years of unemployed seclusion, eked out by disability cheques, shunning treatment of any kind.  Worn out and discouraged, I’d come to believe subsistence was all I could attain and, perhaps, all I deserved.  You’re the expert—like The decisions are up to you and What do you think?—were the ice picks that began to break up this frozen sea.  Slowly, tentatively, I dared to ask for more and to believe I could get it.

Sounds like we have a plan.
              What I’ve said so far may give the false impression that after thirty-plus years of floundering with bipolar disorder, through bad treatments and no treatment, I finally lucked out in finding a good doctor and the rest was smooth sailing.  If only!  Of course, it’s not like that—and can’t be.  I struggle, slip back, recover, find—on my own, and with her help—another trick to add to my tool kit of personal medicine.[4]  It goes on.  Not mere endurance, but not cure either; rather, better and better management.  The ghosts of failure and the expectation of failure still ambush me regularly.  And that is why the special communication between doctor and patient needs the comfort of a sympathetic heart as well as the challenge of a shrewd mind.  And must be why Lindsey chooses to close so many of our sessions with the same six words:  Sounds like we have a plan.
            Look at—listen to—the words.  Sounds like—if I’m hearing you correctly (which I may not be).  We—we’re in this together; I’m not going anywhere.  Have a plan—not the answer, maybe not even an answer, but steps to follow which may help, a hopeful procedure to try. 
Humility, compassion, mutual respect and responsibility.  These are the core qualities that inform the communication I’ve found with Lindsey, the communication we’ve developed together over the past eight years.  Beyond medical acumen and clinical experience, they are at the center of what makes her a good doctor, and at the center of the long and gradual process by which I am becoming a better doctor to myself.
            There is widening recognition these days of the need for “contact-based education,” that is, education about mental illness through people who are successfully managing such an illness.  Yet, as Drs. Arboleda-Flórez and Stuart point out in a recent article, “Despite being one of the most promising practices, contact-based education has not been used widely in the training of health professionals.”[5]  As a first step in changing that, we need more of the sort of linguistic feedback through which mental health care providers learn about the very real effects their language has on the patients they meet.
            How might that feedback begin?  Like most things in life, it begins in a room, and with the words spoken or not spoken in that room.  In the room where mental illness is being addressed, the question might be asked:  Are we speaking here, care provider and consumer, as collaborators on a project—collaborators with different spheres of expertise, and different means and ways of articulating that expertise—but collaborators nonetheless, colleagues and stakeholders in the same enterprise? 
If not, why not?  And what might be changed, how might we speak, to make it more nearly so? 

[1] I identify her here with her permission.  It is also at her invitation that I address her by her first name, though it was years before I accepted that invitation.  The formal hierarchy signified by Dr. had a tenacious grip on me, for reasons that would probably take another essay to explore.
[2] Although the remarks that follow originate in sessions with a psychiatrist, they apply as well to other kinds of health care providers and helping professionals and, ultimately, to anyone wishing to ground human interactions in supportive mutuality.
[3] In their work on stigma and mental illness, Corrigan and Rao define self-stigma as the internalization of “negative attitudes held by members of the public” about mental illness; they discuss the stages by which self-stigma leads to “low self-esteem and poor self-efficacy” and the “why try” effect, which taken together correspond to what I am calling a low self-ceiling.  Corrigan PW, Rao D. On the self-stigma of mental illness: stages, disclosure, and strategies for change. The Canadian Journal of Psychiatry. 2012; 57(8): 464-469.
[4] I first heard of Pat Deegan’s term “personal medicine” from Lindsey and then from Deegan herself in a presentation.  I use it to refer to the entire repertoire of ways and means an individual develops and employs to enhance well-being.  Thus, whether it is a subtle shift in attitude or an obvious change in diet, personal medicine is always practical, a self-directed step toward increased wellness.    
[5] Arboleda-Flórez J, Stuart H. From sin to science: fighting the stigmatization of mental illnesses.The Canadian Journal of Psychiatry. 2012; 57(8): 457-463.


  1. Hi Mike,
    My name is Dan Murphy and I am the President of the Union of Psychiatric Nurses of British Columbia. I am also a Psychiatric Nurse. Your article really spoke to me about your philosophy of grounding human interactions in supportive mutuality. Though we are taught as psychiatric nurses to listen and respect the lived experience of those we work with and support them in finding what course of action/treatment they believe is in their best interest all to often the systems we work within does not afford us the time to follow this way of caring. It is wrong and as I sat and read your articles I found myself reflecting on the continuous stream of stories from psychiatric nurses that tell of their situations where they are forced to work in nurse to patient ratios that leave them with little time to build this mutual respect without feeling like another patient is being left behind or neglected. Beyond my union frustrations I just want to say you are so right and I respect that when you found the one person who empowered you to learn and teach to best ellevate yourself to the most healthy and productive you can be at any given moment you were willing share and teach others about what works. I agree 100%. Cheers Mike.

    1. hi dan. thanks for writing (and reading!), and for your encouraging comments. you're right, of course, that in an underfunded system with inadequate staff to patient ratios, the chances for the full range of supportive kinds of communication i discuss are diminished, to say the least. on the other hand, even small adjustments can make large differences. i remember a patient who was always asking staff, "What do I do? What am I supposed to do NOW?" most times, the staff just told her. but one day this one very forthright nurse said, "You seem like a capable person. I'm sure you can work it out." the patient's mouth literally dropped open in shock, but after some dithering and grumbling, she did in fact hit on a course of action. even if it hadn't gone that way, that day, she received a vote of confidence in her own abilities. all these years later, i still remember it. still, it's hard to bring those kinds of fine discriminations (right time? right person? right approach?) to bear when you're just rushing from task to demanding task. i don't know what the answer is, but i know that large-scale change will only come when mental health care is considered on an equal footing with all other kinds of health care by both the health care system and the public--as it most certainly isn't now. in the meantime, though, i think all of us can try to modify our language use and make a difference in our own circles. every day i catch myself making missteps that unwittingly perpetuate powerlessness and negativity, then correct them (maybe with the same person, maybe another) in a more positive direction. a work-in-progress, these continual veerings off track and course corrections. an art and a science...and i applaud anyone's who's trying to practice it mindfully, as you obviously are. kudos to you! i'm sure your efforts are making a huge difference. all best, mike.


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