Wisdom and it's role in Psychiatry

[thelastpsych]

So, I've been reading about the science of positive psychology and it's perspective on the development of wisdom, considered to be one of the many Positive Psychological Traits (PPTs).
Although a multifaceted and difficult concept to pin down, it is usually regarded as the ability to make good decisions in a practical manner, usually with a pro-social and empathetic tone, acquired with life experiences and insight. It is, however, not synonymus with aging, and geriatric patients can have poor coping and PPTs as well - a certain element of conscious observation and insight are definately necessary.

Having said that, and recognizing that it is more of a psychological construct, still, I think there may be some opportunities for us psychiatrists to use these tools in our practices. I'll start with a few open ended questions:

- Do you feel that Psychiatry has made you 'wiser' in your life? And has that made you better in counseling patients?
- Do you think cases in terms of PPTs such as wisdom? Do you try to develop it in your patients?
- Do you think there are important limitations in constructs such as PPTs/Wisdom? And in the Positive Psych movement as a whole? (I've read somewhere that more psychodinamically minded clinicians can be weary of this line of practice).

One of the most obvious obstacles I think we are faced is limited time-constraints, and sometimes we are relegated to mere 'med checkers'. Still, even in brief evaluations, I think we have the opportunity to foster these characteristics in our patients, even if in a more restricted manner than someone conducting psychotherapy.

I'd say that practicing psychiatry has helped me tremendously in developing better coping mechanisms and getting insight from 'second-hand' life experiences from patients. It's hard to tell if these traits have made me a better, more empathetic listener and clinician, but I can certainly say that it made me less prone to get involved in patients pains and problems, although with the side effect of making me too technical in some situations.

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[FlowRate]

I had a patient who was on the more "supportive" end of a psychodynamic treatment for a while in residency. I saw a good chunk of our work being essentially the development of "wisdom" for him--some combination of building better mentalization capacity, understanding others better, making "wiser" choices, etc. I would not be surprised to hear if there was a more precisely targeted therapeutic framework for doing that. It seemed to work over time, to at least some degree, though.

I think there are some psychiatrists--many of the ones that come to mind are current or former CL docs--who sort-of always have their "psychiatrist" hat on in a way that can be channeled as moving through life with a lot of "wisdom."

 

[R. Matey]

IIRC, an important component of the development of wisdom is self-reflective practice. So one way a psychiatrist can develop wisdom is to reflect on on what they are doing well vs. what they may need to improve upon.

 

[mistafab]

- Do you feel that Psychiatry has made you 'wiser' in your life? And has that made you better in counseling patients?
Yes, absolutely. Psychiatry has helped me to think. I worked hard to develop the evidence-based practice and scientific thinking, which took an enormous amount of time. Additionally, it built wisdom to consider and understand where its limits are, and figure out how to talk about those limits with patients in a way that was empowering rather than disempowering. The knowledge itself produced no wisdom, it was supervision, reflection, and practice that brought that wisdom to me. All my therapy training, and specifically dynamic thinking, supervision, and reading, is where a large amount of my current wisdom growth continues to come from. Every time I've gotten wiser, my patients seem to do better, and it makes treatment and practice more rewarding.

- Do you think cases in terms of PPTs such as wisdom? Do you try to develop it in your patients?
I do not think in PPT terms when formulating cases. I think wisdom is subjective, and my objective in a therapeutic relationship is always to promote an environment that helps the patient become more of themselves. I tend to have parallel formulations of EBM vs psychodynamic formulation, they inform and assist each other in caring for the patient. I work with the patient to develop agency, choice, and eventually 'wisdom' in a sense that dynamic work is always people oriented, and focuses on deepening understanding of ourselves.

- Do you think there are important limitations in constructs such as PPTs/Wisdom? And in the Positive Psych movement as a whole? (I've read somewhere that more psychodinamically minded clinicians can be weary of this line of practice).
I think it can be tempting to put generic, 'therapized' language into the patient's head. PPT can be included, but is not unique in this way. I think if we jump to labeling things prior to understanding the patient as they are, it runs the risk of shutting off their brain in curiosity about themselves, which unfortunately, is the opposite of what I'm doing to build true wisdom. I need them to explore themselves, and not turn their brain off, so they can grow in ways that reduce their suffering.

Great topic

 

[Merovinge]

- Do you feel that Psychiatry has made you 'wiser' in your life? And has that made you better in counseling patients?
Yes, absolutely. Psychiatry has helped me to think. I worked hard to develop the evidence-based practice and scientific thinking, which took an enormous amount of time. Additionally, it built wisdom to consider and understand where its limits are, and figure out how to talk about those limits with patients in a way that was empowering rather than disempowering. The knowledge itself produced no wisdom, it was supervision, reflection, and practice that brought that wisdom to me. All my therapy training, and specifically dynamic thinking, supervision, and reading, is where a large amount of my current wisdom growth continues to come from. Every time I've gotten wiser, my patients seem to do better, and it makes treatment and practice more rewarding.

- Do you think cases in terms of PPTs such as wisdom? Do you try to develop it in your patients?
I do not think in PPT terms when formulating cases. I think wisdom is subjective, and my objective in a therapeutic relationship is always to promote an environment that helps the patient become more of themselves. I tend to have parallel formulations of EBM vs psychodynamic formulation, they inform and assist each other in caring for the patient. I work with the patient to develop agency, choice, and eventually 'wisdom' in a sense that dynamic work is always people oriented, and focuses on deepening understanding of ourselves.

- Do you think there are important limitations in constructs such as PPTs/Wisdom? And in the Positive Psych movement as a whole? (I've read somewhere that more psychodinamically minded clinicians can be weary of this line of practice).
I think it can be tempting to put generic, 'therapized' language into the patient's head. PPT can be included, but is not unique in this way. I think if we jump to labeling things prior to understanding the patient as they are, it runs the risk of shutting off their brain in curiosity about themselves, which unfortunately, is the opposite of what I'm doing to build true wisdom. I need them to explore themselves, and not turn their brain off, so they can grow in ways that reduce their suffering.

Great topic

This is the mother of all good problems to have in the world. When you learn more and become wiser, you directly help others. While this is true for a lot of jobs, it is true in such a concrete way in psychiatry.

It is also inversely true for many corporate jobs in the world. As the Zuck becomes better at growing shareholder value, he will continue to increase the amount of direct harm he causes others. Imagine what the top 1% of whole life insurance salesperson is doing out there...

 

[Stagg737]

- Do you feel that Psychiatry has made you 'wiser' in your life? And has that made you better in counseling patients?

To the first part, not really. My dad was a psychologist and I was always the guy that friends would come to discuss problems when I was younger. A lot of aspects of therapy have just seemed like common sense to me (which it has shocked me how much of this is not common sense to most people). Unfortunately, I also feel like psychiatry has made me a lot more jaded in that I was somewhat oblivious to just how many of people's problems are truly self-inflicted as well as the level of resistance people have to basic interventions and self-sabotage (even if much is unintentional). It's a big part of why treating anxiety and working with these patients continues to be more and more of a chore to me, and I do recognize that I'm unfortunately a more impatient person in my personal life than I used to be.

What psychiatry has helped me do is put names and learn the language to express a lot of these concepts and ideas more effectively. Being able to discuss the actual basis of some of these core problems has been helpful with simplifying things for patients, which I do think has been very beneficial for them in general.

- Do you think cases in terms of PPTs such as wisdom? Do you try to develop it in your patients?

Not really, but this likely comes from how I view and define wisdom. Unfortunately, I don't think all patients are capable of developing what I would consider wisdom, so I don't really think of cases in this way. However, I do think that insight (which is one component of wisdom), at least at a basic level, is something that almost all patients can develop and improve in some capacity and is absolutely part of how I formulate cases. I do try and work to develop greater insight in most of my outpatients and I think it's a core part of being a psychiatrist. I would go so far as to say that outpatient psychiatrists who aren't doing this at all are failing at their responsibilities to their patients.

One of the most obvious obstacles I think we are faced is limited time-constraints, and sometimes we are relegated to mere 'med checkers'. Still, even in brief evaluations, I think we have the opportunity to foster these characteristics in our patients, even if in a more restricted manner than someone conducting psychotherapy.

Time is a huge barrier, and a big part of why I dislike outpatient. I prefer to be able to spend as much time as I see fit with patients, which is hard to spend more time with someone with those time constraints. For inpatient/consults the timing is far more flexible and I think amenable to good therapeutic progress than shorter outpatient appointments. Obviously this isn't the case for those doing 60 minute appointments or specifically doing psychotherapy, but most people doing 30 minute or less med management it's a different story.

 

[Sushirolls]

[insert long jaded rant here]

 

[clausewitz2]

Time is a huge barrier, and a big part of why I dislike outpatient. I prefer to be able to spend as much time as I see fit with patients, which is hard to spend more time with someone with those time constraints. For inpatient/consults the timing is far more flexible and I think amenable to good therapeutic progress than shorter outpatient appointments. Obviously this isn't the case for those doing 60 minute appointments or specifically doing psychotherapy, but most people doing 30 minute or less med management it's a different story.

You're missing the part where those 30 minute appointments happen frequently over time. I am sure spending a couple hours with someone once in their life produces more change talk at the time but nothing beats longitudinal work for actually producing change.

If you're talking about seeing someone only 3-4 times a year for 30 minutes, sure, I agree you're not getting a tremendous amount done.

 

[thelastpsych]

IIRC, an important component of the development of wisdom is self-reflective practice. So one way a psychiatrist can develop wisdom is to reflect on on what they are doing well vs. what they may need to improve upon.

I think there are two components to this:
1) The ability to have more intuitive formulation and management of patients. I would guess this is a more technical insight, similar to an internist who can organize all the various informations in his mind and 'kinda know' that a patient needs additional diagnostic investigation or a more agressive antibiotic treatment.

2) The ability to self-reflect on your practice and develop some personal traits such as compassion, wisdom, insight, etc, AND be able to reflect that back on patients. I think most other jobs don't have that much chance to develop it, and as someone else said, some jobs are antagonistic to the idea of wisdom (retail insurance salesperson come to mind).

The counterargument to that is that you can develop wisdom living everyday situations in your life, wich is how most people that develop it do, and some mental health professionals are EXTREMELY unwise in their personal lifes. I was in a line the other day, kinda stressed out about the waiting and some older guy said something along the lines of 'it's not worth sweating over these small things'. Usually, I would shrug it off, but now that my mind is focused on this concept, I was able to comprehend that this was a small - but interesting - example of practical wisdom in everyday life.

 

[smalltownpsych]

The counterargument to that is that you can develop wisdom living everyday situations in your life, wich is how most people that develop it do, and some mental health professionals are EXTREMELY unwise in their personal lifes. I was in a line the other day, kinda stressed out about the waiting and some older guy said something along the lines of 'it's not worth sweating over these small things'. Usually, I would shrug it off, but now that my mind is focused on this concept, I was able to comprehend that this was a small - but interesting - example of practical wisdom in everyday life.

The least wise mental health professionals are those that begin to believe that they have more wisdom than others. Having a beginners mindset in life is wisdom. Being able to maintain an attitude of openness despite having much knowledge and experience is part of our challenge. As an experienced clinician myself who is providing clinical supervision for several new folk, I am confronted with that dialectic everyday and the more I embrace it and remain open to learning the healthier I am and the more I can foster growth in others while providing access to the experience and knowledge that I have attained.

 

[Stagg737]

You're missing the part where those 30 minute appointments happen frequently over time. I am sure spending a couple hours with someone once in their life produces more change talk at the time but nothing beats longitudinal work for actually producing change.

If you're talking about seeing someone only 3-4 times a year for 30 minutes, sure, I agree you're not getting a tremendous amount done.

Sure, longitudinal outpatient care should be more impactful in the long run than an inpatient stay or therapy from the C/L service. And if you're seeing patients regularly (every 2-6 weeks) and focusing on therapy, then I certainly agree with you.

Most OP psychiatrists I know don't focus heavily on therapy though and are mostly doing med management seeing patients every 2-3 months. Even if you are seeing patients for 30 minutes every 4-6 weeks, what happens when there is a major life event or exacerbation that needs to be processed more in depth than can be done in one appointment? If you don't have the freedom to increase frequency to weekly/bi-weekly or extend the appointment past 30 minutes, it's a huge missed opportunity and something I don't have to worry about as an inpatient/CL doc.

 

[thelastpsych]

Sure, longitudinal outpatient care should be more impactful in the long run than an inpatient stay or therapy from the C/L service. And if you're seeing patients regularly (every 2-6 weeks) and focusing on therapy, then I certainly agree with you.

Most OP psychiatrists I know don't focus heavily on therapy though and are mostly doing med management seeing patients every 2-3 months. Even if you are seeing patients for 30 minutes every 4-6 weeks, what happens when there is a major life event or exacerbation that needs to be processed more in depth than can be done in one appointment? If you don't have the freedom to increase frequency to weekly/bi-weekly or extend the appointment past 30 minutes, it's a huge missed opportunity and something I don't have to worry about as an inpatient/CL doc.

There is something about CL that really is powerful for these interventions. I think that patients are usually freightened by their health conditions, and thus much more susceptible to interventions. I vividly remember a couple of patients that were really impacted by my interactions with them, even though I don't even think I said anything really that profound as a resident.

Regarding outpatient, I'd say that you develop a powerful connection after years of followup, and that can certainly change how these patients view their life. Not the norm by any stretch of the imagination, as most patients probably will follow you up for some months. Still, even on brief outpatient follow-ups, I've seen patients be impacted by punctual actions, even though I didn't have the flexibility to intensify the follow-up.