Dave: Amy wrote about “dumbing down”, and appropriately implicated me. We had a conversation that started with the story of the child who was placed on Risperdol and how distressed Amy was by the outcome. I began complaining about widespread problems in medical care and in medical education. The problems may look like the result of ‘dumbing down’. But we also had Trump on our minds in this conversation. His manner of speaking certainly promotes “not knowing what you don’t want to know”. He is a disturbing model for over-simplified explanations and sneering at complexity or any level of sophistication or subtlety.
To be extremely simple, I think what looks like “dumbing down” is the application of business language to the management of all institutions in our culture. Good business men do not make good governors, nor do they make good physicians. Throughout the world of medical practice clinical decisions are heavily influenced by business language and the value system that language embodies. I call these trends the “Industrialization of Medicine”.
So here I am a child psychiatrist, a general psychiatrist, a family systems therapy psychiatrist. I am best known as a psychiatrist who works with families and who is a medication minimalist. I am all of these in a medical school department of psychiatry where I am a professor. Basically I teach by practicing and supervising. So why have I not corrected this errant system? It happens that there are many perspectives on how to practice Psychiatry. Unfortunately the clinical experience Amy described is very close to a standard of practice. Amy told me the story. I agreed it was disappointing, but far too common. I started thinking I might be part of the problem.
Then I told her about a case I supervised that took an odd twist. As I told her about it, I realized I was, in part, telling her about my failure as a teacher as a clinical role model. A couple of years ago I supervised an intake in our Child Psychiatry Clinic. The resident doctor receives a lot of information in advance from the parents and the school and reviews it with me. I have the resident doing the intake make certain the whole family comes for the intake. Most of my colleagues only expect one parent to come with the child who is a having trouble, a more conventional Child Psychiatry pattern. I coach them in how to pressure the parents to bring the whole family. But I am asking them to do something novel, out of their ordinary. In this case, mother and father and the 13-year-old girl came. There were two other siblings who didn’t attend, parents did not want to take them out of school. Like good business people, the residents tend to slide into thinking the customer is always right. They are hesitant to exert any authority.
The problem the 13-year-old girl was having was missing school, not doing well in school, changes in her behavior; she had been a good student. She was having frequent episodes of abdominal pain and trouble swallowing. Evaluation by her pediatrician and gastroenterologist were negative. No disorder found. A Child Psychiatry evaluation was recommended.
By the time the residents start doing Child Clinic Intakes they have had two years of intense clinical experience, working on the Psychiatry Inpatient service with very disturbed patients, doing consultation liaison work in the hospital, seeing psychiatric patients, adult and child, in the Emergency room, they work in the State Hopsital and in the University Hospital. They take call at night. They have had a lot of experience and worked with a variety of difficult clinical situations. But they do not know much about psychotherapy, nor have they had much experience with psychotherapy. I would add they do not know much about the symptoms of a healthy family.
On the morning of the intake, the resident did a good interview. The story: Five years ago the family had made a move to another state because of a promising career opportunity for the father. Things did not work out as they hoped. The company was sold to a larger conglomerate and father’s job was “down-sized” out of existence. After attempting to restart, they moved back to Syracuse. A dream died in that process. Father was unable to find another job for a long time after they returned. Mother resumed her career. Father described his experience of being depressed. His candor was unusual, he talked in a moving way about his experience of depression. The parents talked with concern about one of their other children who had become increasingly defiant. The daughter participated actively in the discussion, expressing her concerns about her parents’ distress.
This was a good interview with therapeutic elements. It is the kind of interview that makes a difference to children with symptoms. We discussed the interview, I congratulated him for his good work. I suggested they get the other siblings in, emphasizing the importance of the whole family, for the second interview. The whole family came, the resident reported it had gone well again. The family talked more about their experience. By the end of the interview everyone in the family, including father, was in tears. In my view this was evidence of an active therapeutic process, but in retrospect, I think the resident viewed the tears as a problem.
I recommended he should continue with the whole family and coached him on how to go about it. He arranged another appointment, but only the mother and daughter showed up. At that interview the resident reported that he started the girl on Prozac. He felt that it would help the girl. The mother was apprehensive, she didn’t particularly want her on a medication, but he assured and persuaded her.
I was disappointed, “Why did you feel the need to do that?” He said he wanted to be certain he covered all the bases. I think he found himself on unfamiliar ambiguous ground, and medicating the girl brought him back to a territory he better understood, where he felt more adequate. This young psychiatrist is a good and responsible resident, but the way I practice and teach took him into a territory off of his map. Thus, he has gone on treating the girl. The mother comes to the interviews with the girl. He never had the family back.
This is not exactly an example of “dumbing down”. The Family therapy way of thinking is an alternative view. The industrialized applied science of modern psychiatry is the dominant discourse—it fits the scientific way of thinking which offers legitimacy. I believe this resident, a decent and responsible man, certainly not dumb, had insufficient experience with psychotherapeutic practice. He didn’t know how to trust it. Partly it is a symptom of my insufficiency as a teacher. I didn’t teach him how to let things sit. That does not fit with Industrialized Psychiatry, Industrialized Medicine where the language of business and efficiency is blended with the language of science. And I guess I am only an impotent teacher, not a magician.
I have mentioned the following example in another essay. It hints at the subtlety of psychotherapeutic experience. I had seen a family for two difficult years following a very serious suicide attempt by their 16-year-old daughter. Therapy ended when she graduated from high school then left for college. When she came back after her first year in college the family wanted to come in for a ‘checkup’. At the end of the interview, the father, a very competent and successful business man said, “Dr. Keith, I really want to thank you for what you did to help my family and me. When I first met you I didn’t think much of the psychotherapy stuff. But it really made a difference, I know the way I think was changed by this experience.” He paused, then added, “But Dr. Keith, you never said anything.”
I was amused. The fact is I say a lot, but I say it in ways that seep into consciousness with little intellectual processing. That is the therapeutic process, much more like art than science. It is an art with which the resident had insufficient experience, and I think now, looking back, insufficient curiosity about it.