The Doctors' Tic



In the beginning, when I was starting out with one on one therapy sessions in a polyclinical setting, I lived in abject fear of being put on the spot for some clever feedback. I felt the patient was waiting for a one-liner that would summarize all of their problems and provide the solutions to them in one big swoop. Just like in the movies. I felt pressure to provide something that would give immediate relief, something the patients could hold in their hand on their way out. Then I would be able to check it off my list, like the neurotic overachievers we doctors all are. I would sort of rush through the patient history questionnaires apologetically (in psychiatry it does go on rather). It felt wrong to ask so many questions; as if I hadn't payed proper attention to begin with. I sat tensely at the edge of my seat, ready to swerve any expectation I couldn't meet, and often went into long tirades of psychoeducation to prove myself. I would be only too happy to prescribe antidepressant medication, and if not effective, another type, another class and maybe also a sleeping aid to match. I wish that these were just the machinations of a rookie resident, but my actions were always closely supervised.

Only in my second year of the psychotherapy degree did something happen that really changed this way of working. A lecturer told us, that as doctors we have an innate problem. Our first impulse is automatically to "treat, prescribe, act!" We had to practice leaning back and getting a full picture. Here, the psychologists had an advantage over us, he said, they are very good at this. A thorough anamnesis, a patient history often hides the answer. I went back to to my therapy room, all motivation, I was going to lean back, come what may. I asked probing and intrusive questions, but told myself that this was not a social call. And what resulted was a really good conversation. In addition, it turns out that patients are rather relived, not just by being asked a lot of questions, but by being asked the awkward ones; it's information they would never reveal unprovoked. For example, in casual conversation one would never ask someone how their libido is, as this would cause severe situational discomfort. But if someone is depressed and struggling with their sexual life, this is an important diagnostic indicator, and asking about it creates an almost palpable sense of relief - finally they are able to talk about something troubling them. After all, if the talking is supposed to be the medicine - isn't it meant to feel a little unpleasant? 

Furthermore, many physicians tools are counterproductive to the psychotherapeutic goals. 
For example, a person suffering from anxieties should be encouraged to face their fears with you in order to become braver, not be given tranquilizing medication. In the same vein, a depressed, isolated patient should be given structure, regular exercise and frequent consultations, not merely sick-leave and a random one-size-fits-all antidepressant. Learning to view these tools as such, helped me discern when to don the "therapist hat" instead of the "doctor hat".
  
I learned this the hard way, because in Switzerland, all the psychologist and resident doctors have to go together to an external supervisor (a Guru if you will) and present cases or patients they're struggling with. This was terrifying and awful, and incredibly helpful in the end. It took me a full year of these weekly torture sessions before any realizations set it.  And I was amazed to see, that it was sort of the same message I'd received from the "leaning back"- lecturer. I would present the case, list the medical interventions I'd tried, and the clever methods I had learned from books, but say the therapy wouldn't progress no matter what I did. Every time I finished, the Guru would ask me a simple question about the patients relationship to a family member, or dig into an incident in the patients life that I had judged insignificant at the time and not investigated further. Ever time I hung my head, and had to - tomato-faced -  tell him I didn't know this piece of information. After a second of judging silence, he would tell me to go back and do the anamnesis again and come next time. And that would without fail get me unstuck. I think what I learned through these experiences, is that people come to us, not because of some debunked neurotransmitter unbalance that responds to medication, but because life is hard and awful things happen to them.  

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