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« April 2014 »

Sometimes Silence Is Golden

I have occasionally had the honor of meeting some official or other - a legislator, captain of industry, or other person of influence - and have had to talk about what I do.   Many of us have. We are called upon to wax philosophic about the profession of psychiatry and comment on the human condition. And so I share with you my thoughts on this issue, knowing that mine is but one opinion in a field fraught with dissention. You remember the joke about talking to two psychiatrists and getting three opinions?

Basically, I treat people ravaged by illness and other disenfranchising conditions.   HIV, hepatitis, imprisonment, homelessness - all of these are outcomes of mental illness. Mental illnesses render the individuals who suffer from them vulnerable to behaviors that put them at risk for bad outcomes. You all understand that high risk behaviors, although many of us have had our momentary lapses of reason that led us to a momentary indiscretion, are problematic most of all for individuals who have impaired judgment. And mental illnesses can seriously impair the judgment of individuals who suffer from them.
Let's take a common mental illness for example - major depression. If one posits that major depression impairs an individual by reducing or eliminating the ability to register a pleasurable feeling or sensation, then one can conclude that major depression can impair judgment. The process is simple - since the individual can experience no pleasure from an experience, his or her conclusion after an experience is biased toward only the negative. Conclusions drive assumptions about how things are and will be, which drive further behaviors. Thus, major depression impairs judgment and can lead to high risk behavior. If you need more proof, there are many references linking major depression to injection drug use, unprotected sex, non-adherence to medical treatments, or other behaviors that lead to increased morbidity.
When I am asked what I think psychiatry is about, I commonly respond that psychiatrists are the doctors most trained to change attitudes and behaviors of patients.  Through our treatment of patients, both pharmacologic and psychotherapeutic, we strive to restore judgment, empower an internal locus of control, and explicitly aid individuals with mental illness to improve behavior and thus, outcome. It is in this that we excel. It is in this that our duty to the house of medicine lies.          
As such, we have a dizzying obligation. You see, we cannot afford to speculate or opine on matters lightly. We cannot speak, write, "tweet" or "blog" without caution. While we are not a religious order, we owe it to our profession to take the necessary care to comment only on matters that we have carefully researched and studied. We should not offer our opinions on individuals who have behaved badly without examining them - as we are often asked to do whenever some celebrity has misbehaved in public. We should refrain from pontificating about our beliefs as if they are facts, striving to study the available evidence for our positions on illnesses that fall under our area of expertise. And while we are not always the best examples of good behavior, we should be cognizant enough of our shortcomings to admit our choices and from where we believe our failings come. 

But most of all, I think our most pressing task is to focus on behavior - on doing what maintains function and leads an individual down a path of progress and improvement - as a key component of treatment of our patients. We all want people to feel better, but far better to strive for functional improvement even when sensation and emotion remain impaired. With demonstrable functional improvements as outcomes, we can integrate fully into the overall medical care of patients, and enhance our position in the house of medicine.


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