Intuition and repoire

[chemist157]

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I'm curious about something... In your experience, do you find that some psychiatrists have an intuition about some or even most people that assists them in diagnosis and/or repoire (and hence therapy)? Do you feel like this makes them a better psychiatrist?

I'm talking about the almost ineffable quality of really understanding someone. Not on an intellectual level, not as an abstract, but almost a psychological empathy. And by that, I don't mean someone that has been depressed or abused relating to someone in a similar situation. I just mean...really feeling like you understand where someone is coming from and what they are going through (to the extent that is possible). Do you feel like this is possible or is it a delusion? Or conversely, do you feel this would cloud your judgement, to be so psychologically or emotionally involved/attached?

I suppose one could make the argument that any true empathy would be therapeutic, in some contexts. However, I mean it more in the epistemological sense. A true empathy.

 

[nitemagi]

Rapport, not repoire.

 

[Ibid]

I mean it more in the epistemological sense. A true empathy.

In an epistemological sense then both parties would need to have had the same or very similiar experience but I don't feel empathy alone requires that.

One way one can harness epistemological commonality is by using groups of people who have had the same experience and that happens all the time.

Do you perhaps mean real empathy as opposed to pretend empathy when you write true empathy?

 

[Atilla]

What is call intuition is more of a pattern recognition. I don't think psychiatrist or any specialist for that matter is born with the intuition. Its just a matter of practice for many hours/days/years. making mistakes, learning from them.

So if you are in psychiatry or thinking about it, don't be turned off if you feel you do not have the intuition or the temperament. It will come to you if you work your butt off for four years, have a good mentor etc.

Read "The talent code" if you are interested in learning more about what I saying.

 

[Bartelby]

I have tried to watch as many Psychiatrists in action as I can to learn about each individual's interaction style. Some are absolutely better than others in my mind. They make connections quicker, navigate easily through sensitive topics, and quickly seem to have the trust of the patient. Others seem more standoffish even if that is not their intent, or even appear disdainful of patients at times.

I think it comes down to several factors. Are you judging the individual? Do you genuinely care about the patient as a person? Are you patient enough to listen? Are you willing to be a 'lifelong learner,' always refining your style and continuing to grow? I think factors like these applied over time create the kind of Psychiatrist you are talking about, much more so than something like extroversion/introversion or some inborn ability to read people's emotions.

But that's just my guess as an observer.

 

[chemist157]

Rapport, not repoire.

Repoire. hahaha. damn wine.

 

[whopper]

do you find that some psychiatrists have an intuition about some or even most people that assists them in diagnosis and/or repoire (and hence therapy)? Do you feel like this makes them a better psychiatrist?

Yes, but you got to be careful with these things. The field is science, not Jedi mysticism. If taken too far, using intuition too much leads to several problems.

Per studies, there is no data suggesting that psychiatrists have certain abilities better than laymen such as being able to tell if someone is lying. Psychiatrists, in their ability to predict future violence, are hardly better than laymen unless they use specific psychometric testing, but few ever do.

Hunches, the hairs standing on the back of the neck, gutt feelings, these can be used, but I recommend doing so only appropriately. E.g. if I got a hunch a guy is malingering who is up for murder, it might lead me to do testing and see what the testing reveals. I'm not going to tell the judge he's malingering based on a hunch.

Another thing about intuition. If you think you are on to something, find out if that something is going on before concluding it is.

I'd also recommend against using judgmental conclusions against patients based on circumstantial evidence. I've seen several mental health therapists do that. E.g. a patient who complains several times that she's having problems keeping jobs. The frustrated psychiatrist fires back, "well maybe you're a terrible worker and that's why you keep getting fired!"

It could be a heck of a lot of things as to why she couldn't keep a job that have nothing to do with her ability as a worker. E.g. maybe she has PTSD, and things at the jobs are reminding her of past trauma and triggering acute anxiety. A doc responding in this manner could possibly make the situation far worse, and such as response suggests the doctor is acting out of his own needs (he doesn't like the patient, he's egocentric-always lived a privileged life and sees people in a lower SES as inferior.) Even if she was a poor worker, there's better diplomatic ways of bringing this topic up. Unfortunately I've seen several mental health professional do this, and on occasion even on the forum to other members.

"Why do you think you haven't been able to keep a steady job? I figure it's one to a combination of three things, things you can control, things you can't control and luck. Let's talk about this."

 

[dl2dp2]

Yes, but you got to be careful with these things. The field is science, not Jedi mysticism. If taken too far, using intuition too much leads to several problems.

Whopper is SO spot on and I cannot agree more with his post.

Along those lines and perhaps it somewhat reflects my own prejudice, I find that some of the old school/analytically trained psychiatrists are ESPECIALLY fallible in that they THINK they have a better grasp of the patient's problems than they do in reality, and their lack of knowledge in the evidence based literature can cloud clinical judgement.

I think the main "intuition" or the art of psychiatry today is at the SYSTEMS level, not at the psychological level. If you have a chronically mentally ill patient, and you can see 100 ways in which his life goes wrong and somehow still construct a watertight plan because you know the SYSTEM so damn well, then you are the star psychiatrist in my mind. Being able to relate/empathize at a personal level, while important in order to get the information out and building a therapeutic alliance, is in many ways the easier and secondary part. I've seen psychiatrists who are pretty BAD at it, but I haven't really seen anyone who really stood out as somehow better than anyone else, or a situation in which that supposed excellence in building rapport actually mattered.

 

[whopper]

I've seen many a mental health professional start making judgments on people without really knowing WTF is going on. Then when the person gets upset, the doctor pulls some type of invalidating bull$hit argument to the effect of "well this just goes to show you I'm right. Look at you, you're acting out. The simple fact that you're acting out just shows to me how right I am."

I used the same tactic above, quite inappropriately in college to convince a guy that he may have been gay. Everytime he denied being gay, I showed him a psychological text on defense mechanisms, and pointed out that he was in denial, and that the more he denied it, the more it just pointed to me being correct. Then finally, when he said, "okay I'm not goint to fight you on this" only then did I give him a response other than the above. Then I said things like "when you see a man's body are you turned on? Him: of course not! Me: well there you go again. You just had to react so brazenly. Again, does a man's body ever turn you on? Him: well, uh.......? Me: see? Was that so hard? Notice we're actually getting somewhere?

After a few hours of this, with the entire dorm floor laughing at the guy (in secret, some guys told me they had to run to their room so they could laugh to the point of crying), he was actually starting to think he was homosexual. It was evil, but I was in college, and I did it to defend a homosexual guy from this guy that was trying to gay bash him.

Like I said, studies show that psychiatrists really don't know more about some things, but out of narcissism, I believe several doctors believe they know more than they really know.

And the fact that people have to shelve out big bucks to some of these doctors, the degree, the license, etc, it all feeds into an idea that the psychiatrist really knows something when often they do not.

Doctor to patient: I've come to the conclusion that what is really going on is that you need my help because I'm highly educated. The fact that I'm a psychiatrist just shows to you that my expertise in the human mind is far more than yours. When I tell you something you disagree with, you must yield to what I say.

Some patients: Okay doctor (but thinking they doctor is not right but since he's got so many degrees, they don't know what to do, and will yield because they need someone's help.)

Doctor to patient that actually has education in the behavioral sciences: Doctor I didn't tell you that I have a degree in psychology and what you said is total bull. You really don't know me other than what I choose to say to you and you haven't yet done a look at me via collateral information. I can't believe I just paid you $100 for this bull$hit session where all you're doing is feeding into your own narcissim.

 

[Mattchiavelli]

There are some other fields that lay claim to intuition being a big part of their diagnostic work, neurology and EM are two that readily come to mind, but they bill it as "pattern recognition." I think all docs have to utilize empathy as a tool much like an actor or a traditional psychopath, it is what allows someone to have an emotional conversation with a wife about an end of life decision and then go on to the next patient on rounds. I think that takes intuition in the Jungian sense of pattern recognition and cognition at a level below conscious thought because if you had to think out "wife's face is scrunching up and she looks like she's going to cry. I should also look kind of sad. Her body posture is becoming more lax like she's being deflated. Initiate tissue sequence" you wouldn't be able to pull off the empathetic act.

and to what whopper is saying- I think any good doctor regardless of field always holds in the back of their mind that what they think is going on might not be going on and can have the humility to change course in light of new evidence. Bad doctors cling to their crappy suppositions like someone hugging a seizing porcupine... holding on is just increasing the damage

 

[kugel]

Intuition is less important than movies and novels and such would suggest. Experience does provide thousands of examples from which you can draw, but there's no shortcut to experience.

However, understanding the person in front of you IS terribly important. Even if you view yourself as a psychopharmacologist, making sure you understand what the patient is telling you and gaining his trust are vital to getting the patient to follow your treatment plan. If you don't sell the plan, he won't follow it, and then it can't possibly work. No matter what, you will never wish you understood the patient less.

So, what to do?
Try really hard to see the world through your patient's eyes. That doesn't mean you have to agree with his worldview, but you do need to understand it. You'd be amazed at how comforting it is for patients to hear, "Well, if that was happening to me, I think I'd be a lot more upset than you are. Tell me, how do you keep so calm?"

Whether your patient is experiencing abject terror due to paranoia, or righteous indignation that the police tackled him just for standing in the intersection praying, or the firm belief that he should be dead and intends to accomplish that - all of these are understandable if you can see life through his eyes. You are a very different person than him, so you may be sure you would never do what he did. But if you had his genetics and his experiences and his limitations and his strengths, you WOULD behave exactly as he did. Try, any way you can, to see things that way.

Ask lots of clarifying questions ("I'm not sure I understand. Can you explain more?"). When you feel you have a conclusion, ask ("Help me understand. Did you do this because you were anxious about that, or am I completely off base?") instead of announce ("You did this because you were anxious about that!") Until you've gotten agreement from the patient (or lots of experience with this patient) declarations about the patient's motivations are likely to be met with aversion or contempt. If you feel you have to make a declaration, do it tentatively ("Do you think it might be possible that some small part of the reason is _________?").

Once a patient is saying, "No doctor has ever understood me before," he will agree to almost anything you have to say. At the least, he'll be motivated to try to understand the situation through your eyes. And you can sometimes capitalize on that. When it looks like you are coming to an impasse, remind the patient of the understanding the two of you have reached so far. "I completely understand what you're saying and you already know that I care. But now I need you to see things from my perspective for just a minute. If I were to do what you're suggesting, I would lose all credibility and possibly my license, and then I'd never be allowed to help anyone again. I know you're going to hate this, but in this case I just have to follow standard practice. I hope you can understand that, even though you don't agree with the decision." It certainly doesn't always work, but sometimes it does.

I hope this rambling makes some sense.
I suspect my diatribe is suffering from an annoying excess of sobriety.

 

[DrGachet]

Reminds me of a certain authoritarian therapist on a multicultural channel, whose program I watched a few times. It makes me angry. It's naive and submissive callers/viewers combined with his reliance on validation (as opposed to falsification) that has made him into a guru.

Five minutes into one of the calls, talking with a supposed medical student, who's been going on and on about having low energy at times and lots of energy at other times and not sure if medical school is a good choice for him and thinking of calling it quits.

-I'm thinking you have manic-depressive illness. How is your sleep?

-Five hours a night, but sometimes....

-yeah, yeah, it's manic-depressive, you need to be on medication. Where do you live?

-New York

-Yes, I know a good doctor there, stay on the line, I'll have a talk with him and make sure he can see you asap. Don't worry, you'll be fine, I thought you had bipolar at first but now I know. But you gonna be fine.

 

[chemist157]

Thanks for the responses. This is a really interesting topic and I dig the different ways in which you can view it.

 

[whopper]

Reminds me of a certain authoritarian therapist

If you are referring to Dr. Laura, she's a quack. Her doctorate is not in the behavioral sciences. It's in physiology. So, since that's the case, why does Fox News put her on, announcing she's a "doctor" and asking for her advice on mental health issues? They should at least put a disclaimer.

I've had times where I intuited something about someone I evaluated that was out of the norm, but I'd like to think I didn't act on it unless the circumstances warranted.

E.g. I saw a guy on another doctor's unit who was on vacation. The guy was there for months being treated with antipsychotic treatment with hardly any benefits. I thought his symptoms weren't psychosis but seemed to be TBI based on disinhibition. I requested neuropsychological testing--> that pointed to him having specific problems that were likely from head trauma, and after I asked the social worker to call up several hospitals in the area, turned out he was admitted to hospitals for head trauma, not once but 3x, 2 of the cases were extremely severe.

I would've been way out of line to just say all of it was head trauma without doing the extra work.

 

[DrGachet]

If you are referring to Dr. Laura, she's a quack. Her doctorate is not in the behavioral sciences. It's in physiology. So, since that's the case, why does Fox News put her on, announcing she's a "doctor" and asking for her advice on mental health issues? They should at least put a disclaimer.

I've had times where I intuited something about someone I evaluated that was out of the norm, but I'd like to think I didn't act on it unless the circumstances warranted.

E.g. I saw a guy on another doctor's unit who was on vacation. The guy was there for months being treated with antipsychotic treatment with hardly any benefits. I thought his symptoms weren't psychosis but seemed to be TBI based on disinhibition. I requested neuropsychological testing--> that pointed to him having specific problems that were likely from head trauma, and after I asked the social worker to call up several hospitals in the area, turned out he was admitted to hospitals for head trauma, not once but 3x, 2 of the cases were extremely severe.

I would've been way out of line to just say all of it was head trauma without doing the extra work.

I was not referring to her though she certainly is a quack. But there are others, many of them. I think generally is important to have different theories about the possible disorder, make predictions in very operational terms, and don't go justifying to make it fit. Take every prediction that did not come true as the starting point for new theories, including the possibility that the original theory was dead wrong. Then make more predictions.

It's very difficult and it's too much work at times, and truth is so elusive, but I've found that in my personal life too, I have distorted my perception, my thinking process, and judgement just to avoid narcissistic injury, just to have a sense of certainty, and to have my views, most of which I was really emotionally invested in--and I did not know it, confirmed.

I think it takes a real commitment to finding the truth at any price, and upholding high personal standards. Of course we all make compromises but not losing sight of that ideal and not getting lost in business as usual, is key.

sorry, I got philosophical as usual.

 

[jiggabot]

Do you guys ever see good psychiatrists that are able to accurately understand the patient but are not popular with patients?

I have seen two types of psychiatrists, the logical ones (they secretly love psychoanalysis) and the emotional ones (they are great at giving support). I was wondering if logical ones don't fare as well (because patients are afraid of the confrontation) despite being able to fully grasp the problem.

 

[whopper]

But there are others, many of them.

Most of the people I've seen in the media as mental health figures practice inappropriately. Dr. Phil for example, Dr. Laura another. Dr. Drew is also inappropriate. He diagnoses people based on what little he gets from news reports.

Unfortunately had these people actually practiced within the guidelines, they likely wouldn't have gotten ratings. Another bad thing is that the media outlets that employ these people should've had higher standards, but no they don't (Yes you Fox News for Dr. Laura, CNN for Dr. Drew, and Oprah for Dr. Phil).

Do you guys ever see good psychiatrists that are able to accurately understand the patient but are not popular with patients?

IMHO a good psychiatrist is kinda like a personal trainer, a drill sergeant, a confidant, and detective all in one.

A good doctor doesn't give a patient what the patient wants, unless the patient has good insight. If a patient wants Xanax, a good doctor will ask why? Anxiety? If so treat it with long-term treatments that are not addictive. Addiction? Inform the patient that Xanax is potentially addictive and that it's not a good idea for long term treatment..

A doctor is not going to be popular when they tell patients the hard but true thing. E.g. "I can't give you Xanax because you seem to have a substance use problem with it."

I think it takes a real commitment to finding the truth at any price, and upholding high personal standard

Some cases are easier, some will demand a lot of time, especially if the patient is not being upfront with you. Unfortunately, several clinical settings will not afford you the time to investigate as much as you may like unless you do it on your own personal time and are willing to do it and not get paid. These are the more extreme cases, but they do happen.

I had a particular malingerer, where I had to read a book the mother wrote before I became fully convinced she was malingering to the degree where I decided toconfront the patient on it. The book was boring, not entertaining, but it detailed a long history of the patient since birth up until the patient's hospitalization. It took me about 20 hours to read it, and I got paid for none of it. The previous doctors that had this patient just kept her going with the same bull$hit diagnosis of schizophrenia for years, even though some of them didn't even believe she had it, but decided getting home before the rush hour was more important that putting in the time to figure the case out.

 

[DrGachet]

Gosh, 20 hours?! And not getting paid either?

I'm not a doctor but I have worked with a few psychiatrists and psychologists in different settings over the years, and reading your posts here I have to constantly remind myself that you actually work in a forensic setting. Why? Because you come across as a real caring and dedicated person. Not that I've never met a real kind and committed psychiatrist, but good doctors working in a hospital setting--who, by the way, are not dealing with psychopaths and murderers on a daily basis--can become numb to it all fairly quickly. It comes to a point that only the drill sergeant remains. Though it's fairly early in your career, I wonder if it takes real conscious effort to oppose the temptation of indifference and cynicism.

 

[whopper]

The person I mentioned was in the hospital for Aggravated Arson. In English, that means someone who committed arson knowing full well the buildling was full of people and they could've died.

She had factitious disorder and malingering. I never encountered a patient with both. She had factitious disorder since she was a small child, but after the event, she malingered because she knew she faced serious prison time.

On the order of every day, she made terroristic threats where if she didn't get what she wanted, she'd threaten suicide or something else that would hold up the unit.

The daily notes were to the effect of "patient again threatened suicide. Diagnosis: Schizophrenia."

I thought all of it was bull$hit. A terroristic threat is not psychosis unless you have reason to believe it was made as a result of psychosis. Her threats were done out of manipulation. What also rubbed me the wrong way were all the good clinicians on the treatment team who knew her didn't think she was mentally ill, and the first day I had her, she tried to convince me she had OCD, she couldn't tell me any symptoms of it, I told her I wasn't going to diagnose her with it, and then she started asking everyone in the hospital for the DSM diagnosis for OCD.

That's why I was actually read that darned book. She was ticking me off, and I was ticked off that over 5 psychiatrists kept up a bull$hit diagnosis. I felt someone had to fix this. The book was a vanity-publication. The mother wrote the book, no real publisher picked it up, so she had to publish it herself using one of those vanity press companies that promise "you'll be a published author!" I had reason to believe the mother, and the patient, were trying to make a career out of the alleged mental illness.

An M-FAST-suggested malingering. A SIRS suggested malingering. She had no signs of psychosis. I stopped all of her antipsychotic meds, and she remained free from psychosis. I told her that I did not believe she was psychotic or manic, and she eventually told me she made the whole thing up because she was scared of prison.

Thank you for your kudos, but IMHO I was just doing my job. I will say that I see plenty of doctors that just do what is convenient, and don't really push to treat a case to the degree where the case will move forward. In this particular case, like I said, some of the doctors actually believed she was malingering but were not willing to put in the time to investigate it.

One thing for me that allowed me to do this was the state job I have with forensic patients has a lot of free time. Many of my patients are stabilized and I cannot do anything further until a judge allows me. I write a letter to the judge and the judge will often not respond for months. In the meantime, I can sit and watch DVDs in my office, without avoiding my duties because the patient is doing as well as he/she can. I'm not slowing the patient's case, the judge is, and I can't overrule a judge.

I one time told a colleague of mine, "If I got the time to watch DVDs, and I don't let cases sit for months where the person is still sick, what the phuck are these other doctors doing?" (More the 50% of the doctors in this institution just sit on a patient for months, some only see their patient once a month if even that).

Doctors are in a situation where many of us can do what we want because if we do a bad job, many hospitals will take our crap because they can't easily replace us. IMHO a good doctor will do their job for real, not just do the convenient thing. I can afford to put in extra hours into a case in my forensic job because of the above.

 

[DrGachet]

Yeah, good question indeed, what are these other doctors doing with all this free time?! But to be fair, not every doctor would be willing to do this type of state job. For one thing, private practice and consulting is more profitable.

One thing is for sure, every case you have described has been quite complex. And specially when it comes to the legal matter of deciding whether to continue medicating a patient or send him to jail for many years because of crimes he had committed. It's a tough decision, and then to be able to stand behind the decision with all the necessary evidence...I can see how some doctor may want to go with path of least resistant, in this case, the schizophrenia diagnosis.

I'm actually curious, how long was the patient off the antipsychotics? When I used to do research on schizophrenia, I would see some people who were off meds for months and no psychotic episode.

 

[whopper]

She was off for about one year before the Court finally decided to release her from the hospital.

They actually didn't send her to prison. That's a long story. She plead guilty (which she should've done, she did it. We knew she did it). She had plenty of mental health issues, and the judge decided it would've been better to place her in a type of community setting where she was supervised, but not in prison. I think what got the judge to be so lenient was that the patient had successfully duped a bunch of doctors, but was willing to still plead guilty, she had MR, and although she as in her 20s, she had the stature and appearance of a little kid.

I wrote a few things about this case before though not in one complete thread. I mentioned in another thread once how she was going to commit suicide with laundry detergent, and she licked her lips, and put the detergent on on them, and then threatened suicide unless I gave in to her demands.

I double checked, called the IM doc and the detergent was non-toxic. I gave her a box of it and told her to knock herself out (not literally of course). Her face was blank. I think I shocked her because I was the only doctor she met that was going to stand toe-to-toe with her. The previous psychiatrists gave her everything she wanted other than letting her leave the hospital. E.g. ice cream, parties with her family in rooms in the hospital, internet usage, etc. I told the treatment team if other patients aren't allowed this, she wouldn't be either. This attitude of letting her get anything she wanted would stop while I was her doctor.

A few days later, she told me she had a severe pain in her right arm and demanded massage therapy. An hour later, (I let her mind get off the topic), I said "catch!" tossed a ball at her right arm and she caught it with no signs of pain. I told her she wouldn't get treatment for it.

After a few months of this, no meds, and me telling her it was my job to get her better, not give in to her demands, she told me all the symptoms she told me about were never true.

Off on a tangent, I did diagnose her with ADHD, and I do think she actually had that, but nothing else on an Axis I.

Anyways, I'm getting off on a tangent with the thread here too. Sorry about that.