Some Thoughts on My Psychiatry Practice

The meta lesson I learned by squinting at things and holding them at arms distance was this: don't be middle class. Live like a grad student and then retire having never acclimated to consumptive patterns that seem to be more about auditioning to be upper class than about enjoyment of the life material prosperity can provide.

It was interesting to re-read this article 2 years later.  It reminds me that I am generally working with a unique subset of the population, which is not fully representative of human psychology.  That being said, I believe this article is misleading in important ways, which should be clarified.  The article focused too much on class, and it is hard to see it as anything but classist. While I wrote an addendum at the end, this really should have been incorporated into the entire article and not tacked on, as the conclusions one would reach without it are quite different. I believe I didn’t incorporate it largely because I am not a strong writer and didn’t know how to do this in an elegant way without losing my other points. 

This article needed some discussion of internal vs external locus of control. My current clients have a strong sense that they have control over their lives.  This leads to attempting more actions to change their situations but also internalizing their failures.  The population at the Medicaid clinic feel that they and in fact do have less control over their lives.  This is an important thing to point out.  I had one older minority client who basically described a lifetime of being buffeted about by various government policy changes and oppressive interference in her life for the last several decades.  She suffered many tragedies that were not within her control.

I believe I also over-simplified the psychology of both my current and former patients for clarity. The majority of clients who come to me do want medication.  I do see people struggling with past traumas and current situations which are out of their control.  I definitely saw people at the Medicaid clinic suffering from identity crises.  Money was not absent from the concerns of people on government assistance.  I still think the spirit of my comparisons is accurate, but the oversimplifications are dangerous, and I’m not certain that the greater point was worth the confusion. 

I still believe the conclusion that struggling to hold onto identity leads to great human suffering. It is not a simple problem to solve, nor necessarily one that should be fully solved.  I will leave that to others to debate.  I do spend a lot of time working with people on examining their expectations of themselves, where they come from, and whether holding themselves to these standards leads to anything positive in anyone’s life. 

This is pretty much what The Last Psychiatrist is about. Nearly all his late blogging is a combination of:
(1) Poor people are assigned disability status and drugged to stop them from rioting because their lives are shitty and society doesn't want to (or perhaps can't) spend the resources necessary to fix the problem.
(2) The rest of us have been raised to be narcissists in a way that would have been genuinely exceptional a couple of generations ago, and are desperate to have our narratives affirmed by someone else with the right to pass judgment.

This post steps into a larger picture than what I see as normal rationality style optimization of life. I think on the margin people do far too little of this sort of dive into their motivations.

I felt so hilariously called out by this post I actually bothered to make an account after years of lurking. I fit that patient description quite well, or did anyway. This is one aspect of why I always went for CBT and never even considered psychoanalasys.

I'd be highly interested in further thoughts on the matter. In case you care for a patient reflection (I'm no psychologist): I think the social connection between identity (for example job) and social relations can be close. I chose to hold onto my identity because I thought all my relationships would crumble if I gave it up, even after the identity was no longer serving my experience. This is also not entirely unreasonable - many relationships do rely on collective identity, for better or worse. It is about preserving the one life that was aquired through the means of this identity, the job etc., and not building a new life with a new identity. This might be why patients rather stay in a job that makes them want to kill themselfs and don't see a way out - they might try to save the life connected to this identity by all means.

Thanks for writing your thoughts out loud. Curious to follow your progress.

If someone will stay in a relationship or job that drives them to the verge of suicide for "identity" reasons, it means that the person/institution providing someone's identity has almost unlimited power over them.

I'm thinking of something like academia, which is used to dealing with people for whom their identity as an "academic" is the most precious thing in the lives. It's not just internal "culty" things like academics having their own friend groups, markers, and even language. It's also how external society sees them, like academics having special social status and even different names ("My name isn't No, it's Doctor No!") that reinforce "academic" as a precious identity. As a result, academia can impose arbitrary rules on its members, overwork and underpay them, and cause them to be depressed and anxious at 6 times the rate of the general public.

Perhaps the antidote to this is to build up an identity that is self-conferred, rather than being dependent on the approval of other people. You can call yourself a "rationalist truth seeker" for example even if the rightful Caliph thinks you're a moron, so that's an identity that doesn't open you to exploitation.

Your patients seem to have a problem deeper than depression. They seem to be spending their lives doing things that they hate. Taking a pill to hate it less is probably a sub-optimal solution.

Thanks for the portraits; I appreciate getting to read it. I'm curious what would happen if you got one of them to read "The Elephant in the Brain". (No idea if it'd be good or bad. Just seems like it might have some chance at causing something different.)

This post is an observation about a difference between the patients in the doctor's prior practice dealing with poor Medicaid patients, and her current practice dealing with richer patients. The former were concerned with their relationships, the latter with their accomplishments. And the former wanted pills, the later often refused pills. And for these richer patients, refusing pills is a matter of identity - they want to be the type of people who can muddle through and don't need pills. They continue at jobs they hate, because they want to be the type of person who has that job. These richer patients are obviously more similar to LW readers.

In one sense this idea that people make decisions that cause suffering because of their attachment to identities, this has been observed for mellenia, most famously in Buddhism. This post simply makes the observation from a more scientific standpoint, from inside our community and epistemology. That is a contribution.

The author acknowledges that she isn't sure what the point of these observations is, and I wish she had written a follow up post on that. For me, I have certainly felt resistance to the idea of even talking to a mental health professional because of this same type of identity, not wanting to be the kind of person who needs that. Perhaps the point is that members of our community should be more open to the help of mental health professionals. Perhaps the point is that in a community where we pride ourselves on keeping our identities as small as possible, we ought not to identify as people who don't need professional mental health care in general or pills in particular.

Tell me more about how I can use self-referential sarcasm to free myself of the identity trap. I definitely see myself as the type of person who's good at that,,,

I've been meaning to think more about ego and identity. I also sense that a lot of people have problems where they don't feel accomplished enough, and where they compare themselves with other people. I know that I have those sorts of problems.

On the one hand, it seems silly to compare yourself to other people like that. Especially when it is taken to such an extreme. But on the other hand, it seems like something that is deeply ingrained in us, and that is very hard to avoid. In reality, that sort of thinking is probably establishing a false dichotomy. Clearly there are some people who are more invested in how accomplished they are than others.

The question that I'm interested in is how to change your mindset, such that you retain your ambition, but aren't caught up in it, if that makes sense. Where you pursue improvement and accomplishment either because you are intrinsically motivated to do so, or because you want to do good for the world, but not because you want social status points. And where you see the accomplishment as a "nice to have", rather than an "I'm happy if I get it, and sad if I don't". And especially not where you see it as a "I feel normal if I get it, and depressed if I don't". I find for myself, and sense that the same is true for many others, that a "logical" understanding often isn't enough, that your brain still may act as if it's a necessity rather than a nice to have, even though you logically understand that this mindset is silly. I suppose that this is a much more general problem, and a very important one.

I wanted to respond because your description of the reasons people give for not wanting to take medicine is related to the reasons I would rather not take it, but doesn't include some steps in the decision making process that led me to avoid the medicines. I see the world like this: Suffering increases the chances you will have experiences that are negative and uncomfortable which leads you to be more prone to do things that others don't like. Responding to this reality, psychological theorists have categorized people's responses to suffering so as to separate the acceptable from the unacceptable or the healthy from the pathological. Psychological terminology designates people who exhibit certain characteristic as unacceptable.

I wish that we'd develop a response to suffering which acknowledges that we all suffer and that we all have different responses to suffering and also encourages us to support each as we deal with the pain of being human. People's actions stem from their experiences and once we see the world through this lens we can attempt to understand people in the context of their life stories. If this were the standard approach to dealing with suffering, and if there were a specific and clear result that was expected from taking a medication, then I'd be all for it.

As an example of a what I mean by establishing a direct connection between a medicine's impact and expected mechanism for improving life, I offer this: Setting aside the potential for addiction, if a person was told that they should take a small dose of an anti-anxiety medicine just as they were to starting to panic, that the calming effect of the medicine would be part of a kind of self-study program where you are examining your reactions and by doing so becoming better able to intervene during the earlier stages of a conditioned response that becomes harder to stop the further along it goes, then it would make sense to take the medicine.

My suffering been a barrier between me and the life experiences I believe are important like having a job where intellectual curiosity is an integral part of what I do, which in turn would allow me to interact with others who value using their intellectual curiosity. I have had a persistent sense of my own powerlessness and inability to shape my own life. If I were to turn to psychology, I would feel even more powerless because in order to be helped, I need to be designated unacceptable. I already feel separated from the life experiences that I want to have and so don't want to reinforce the distance between me and those experiences which I believe are worth pursuing. From past experience I know that the medicines available aren't given as part of a process of increasing self-knowledge.

Although the chronically unemployed may not express a desire for more money in their lives, I think that we should keep in mind that they don't represent all those who are poor in our country or in our world. We should also consider the fact that the life experiences of the medicaid patients are surely responsible for their lowered expectations. How can we not want to contribute to a world in which everyone has the opportunity to use their minds and explore their potential, even this world takes several generations to bring into being? Rather than identity, maybe the answer is to value and pursue meaning, the search for what matters, putting effort into ensuring that worldwide everyone's basic needs are met and then into supporting each other as we all explore our unique gifts.

I was so amazed to see that the author responded to some other comments. I am not sure if I will be so lucky because my comment is so long and it is pretty personal.

Very interesting. May I ask whether by "psychoanalysis" you mean that as referring to the school of thought founded by Freud, or just as a general description referring to a get-to-know-yourself process?

A spelling note: It's Goodhart's law. A question: do you come across patients with DID, not "just" C-PTSD?

The observations here are things I want a lot of my friends to know about and attend to, with an exclamation mark following Romeo's comments and Laura's:

Identity seems to be everything. Experience is there to tell you if you’re on the right way to assuming the proper identity. If you go through the motions properly you can look the part.

They will often be dismissive of its effects on them, noting that they clearly got over it in order to get where they are now. Which is, you know, in my office.

This is trenchant.

There's something that I've always been curious about but never had the chance to ask: as a psychiatrist and psychologist, to what extent has your training helped you avoid or solve your own mental health problems? How helpful has it been?

My guess is that it is only somewhat helpful. Many doctors smoke and eat unhealthy foods even though they've spent years studying just how harmful that stuff is. It seems to me that this is an area where "incremental improvements in rationality don't always lead to incremental improvements in winning" is true.

Great article Lara. I think that a form of 'Ego death' is indeed the answer, and I've decided to start a blog to ponder this very subject. I think you've touched upon the fact that for the suffering of most of your patients is rooted in unhealthy identities or self-images, rather than in poor life circumstances. For if people who are well-off and live satisfying lives 'on paper' can't find happiness, that would seem to say more about their lived experiences rather than in their external life situations. Focusing on their resistance to medication is in some ways missing the point; the issue is not so much that they refuse to take medication, but that their identities are so fragile to begin with that they can't even entertain the benefit of trying medication. In the end then, I would argue that overcoming resistance to medication is less important than fixing - or rather discarding - one's entire self image.

My full response can be found here:

http://www.depersonalization-and-enlightenment.com/2019/01/24/mental-illness-and-ego-identity/

How is this not a problem that's solved by pointing it out? "Trying the pill doesn't cause you to be the kind of person who should take pills. It tells you whether you are one."

There is a wonderful scene in the new Pixar film Soul where they show a "lost soul" who turns out to be a hedge fund trader who just keeps saying, "gotta make the trade". Your description of your high income clients reminded me of that. 

I kinda feel them... its always about just hearing the right positive things you wanna hear... to give a momentary burst of happiness... one bad moment and it all shatters.. have been there... its a constant struggle to cope with reality and is really hard to calm your nerves down and think of optimum solutions and move ahead... you're haunted by one awkward moment or one misstep for days... its misery... and society has collectively failed to embrace the fact that this is normal and is becoming the norm.