Wednesday, August 08, 2012

Does it Help to be an Optimist in Psychiatry?


I am basically an optimist (I think).  I feel hopeful about most things, and I have this funny faith that people are basically good.  When people come to see me and they are severely depressed, I think they are going to get better.  Mostly, they are kind enough to humor me and they do get better.  The statistics seem to suggest that SSRI's work 40% of the time, and while that does seem to be true for the first go-around, I've found that if I fiddle with the medicines, augment, switch, augment, tweak, that many more than 40% of people get better.  If someone is doing well, and suddenly feels down, I encourage them to return soon, talk about it a bit, and don't rush to changing the medicines at the first sign of "the meds aren't working and I'm a little down."  Often (but not always), people get better without increasing or changing medications.  Clearly, though, my practice is not the stuff of double-blind-placebo controlled studies.  I tell people they will get better, I look for the good in them, and I encourage people to look for their strengths and try to get the good parts of who they are to work for them.  

Some people would say this is wrong: I shouldn't tell people they are going to get better.  How could I know that (? experience), and I may be offering false hope.  I may be.  And I've had at least one patient tell me that I try to normalize problematic behaviors.  Most patients, however, seem to feel encouraged by my optimism, and boosted by the good things I see in them.  Ah, remember my post from long ago: What I Like About You.

Another psychiatrist I know says he thinks you have to be an optimist in order to be a good psychiatrist.  Really?  I don't know about that.  I'm kind of optimistic that pessimists can also be good psychiatrists.  What do you think?

Ah, comment moderation is on for the time being because some of our commenters have been shaking my generally positive faith in humanity and I find myself feeling a bit pessimistic about blogging.  As always, it's not the message, it's the delivery.     

Please do listen to Podcast 68!

20 comments:

Anonymous said...

I went to therapy for the first time a year ago for major depression. On some level I knew it'd get better - odds are it will - but it was taking a very long time and the wait was getting unbearable. I think gentle reassurances from time to time from my therapist helped a lot. Her "it gets better" and "it just takes time" always helped. And she didn't say it all the time, just when I asked or just when the going was the toughest. It didn't feel rehearsed, nor did it feel hopeful for hopeful sake (even if it was). It felt real. I believed her. It helped, a lot.

Jane said...

I think it's good you're an optimist because I could see being a pessimist creating problems. From my patient POV, I think any kind of treatment is much harder to accept when you feel the doc has no faith. I actually feel like docs are pushing their problems onto me when they are too pessimistic. I actually dumped a doc once partly for this reason. I feel sort of like the doc needs to be able to believe in me in order for me to believe in the doc.

Anonymous said...

There's nothing wrong with optimism so long as it also comes with a little bit of realism.

Medications aren't miracles, they don't always fix everything and, especially with the mind, things never quite return to how they were once before because the memory of that event is going to stick with you and affect the choices you make and sometimes bring up emotions you might not want to feel.

I think there's a happy medium in there, where one shows optimism for the future but also acknowledges that things won't be exactly the same as they were before.

Of course, when I'm depressed I don't want to hear any of it and I'm going to think you're daft, but I'll start to believe you when it actually happens ;)

WQ said...

I think instilling hope in patients (and families and caregivers where applicable) is an important part of the work of a psychiatrist.

I don't think it's false hope either - I remember being taught that antidepressants could take up to a month to have any effect on mood, so some allowance for time is required. Although, I believe newer literature suggests that there should be something noticed within the first week if there's going to be any benefit at all.

Also important to routinely reassure patients that if a medication of one class doesn't appear to work, it doesn't mean others will necessarily also be ineffective. I think that just knowing that there's a wide choice of options out there can also be of therapeutic significance.

Sideways Shrink said...

I underwent a lot of psychoanalysis/shrinkotherapy while in school and training. Until that point I was a fairly acerbic person, well, angry person. The longer I do psychotherapy the more optimistic and (something no one talked about in my hidebound training) more spiritual I become. Given the general cultural stigma attached to psychiatric treatment and mental illness, growing optimism and spirituality in a previously "non-spiritual" person would seem to be paradoxical. Fortunately, just because something is widely believed does mean it is true.
Being able to witness people feel symptom relief, gain insight into themselves, decide for themselves what they want to change in their lives, attempt change, see what happens, and so on is a wonderful and sometimes maddening process. I feel it is an honor to be trusted by a fellow human in this way.

Sideways Shrink said...

I underwent a lot of psychoanalysis/shrinkotherapy while in school and training. Until that point I was a fairly acerbic person, well, angry person. The longer I do psychotherapy the more optimistic and (something no one talked about in my hidebound training) more spiritual I become. Given the general cultural stigma attached to psychiatric treatment and mental illness, growing optimism and spirituality in a previously "non-spiritual" person would seem to be paradoxical. Fortunately, just because something is widely believed does mean it is true.
Being able to witness people feel symptom relief, gain insight into themselves, decide for themselves what they want to change in their lives, attempt change, see what happens, and so on is a wonderful and sometimes maddening process. I feel it is an honor to be trusted by a fellow human in this way.

Lynn said...

I truly appreciate my doctor's optimism in me. It is helpful to be reminded of my strengths and to practice positive behaviors. It's all good but sometimes it has the opposite effect for me. It actually makes me want to do something negative to prove that "my deal" is still with me and always will be. It's almost as if I'm not believable to him. It can be frustrating, annoying and tempting. Still, I'm thankful he is persistently optimistic

Anonymous said...

A psychiatrist myself, I think that I am somewhat pessimistic by temperament, but I go out of my way to project (realistic) optimism in clinical work. There is after all the evidence that "normal" people have a certain degree of irrational optimism, whereas the (mildly) depressed may have a more coldly realistic self-appraisal. Yet there is also evidence that pessimism can be helpful in certain situations.

Based on many years of seeing patients, though, I am a bit surprised by your reported success rate. Maybe we treat different populations, but I find that a significant fraction of people do not in fact get lastingly better, even if they do take a certain comfort in the treatment. I think that a neglected area of the field is the art of caring for the refractory mentally ill.

Sunny CA said...

I agree with your philosophy of using optimism in your clinical practice. If you are an optimistic person, it would be pretty hard to be pessimistic, anyway.

My psychiatrist is upbeat and good-humored in sessions. Since his policy is to not give a diagnosis to patients, then there also isn't an accompanying prognosis. In general he was reassuring, and repeatedly told me I am "normal" (which I guess is a diagnosis) and have coped remarkably well considering my upbringing. He was a lot more positive than the 10-minute-a-session psychiatrist who was only concerned with pigeon-holing me into a diagnosis.

Imagine if a very depressed patient saw a psychiatrist who told him there was a 40% chance of improvement. That might be depressing enough odds to give up. I think in the mental health profession, even more than in physical medicine, I think and optimistic attitude is appropriate.

@Sectioned_ said...

I'd describe myself as an optimistic realist. I don't know about my psychiatrist.

Whenever I say to him, "I want to work in partnership towards a cure", his facial expression doesn't change, he pauses, then carries on as if I haven't said those words. He's told me that my diagnosis is lifelong; there is no cure. For him, there is no hope. I don't believe him.

He once told me, when I described some difficulties I was experiencing in functioning in daily life, "You're unique". Even though he said it with a tinkling laugh, I found troubling. He seemed to be dismissing the idea of being able to help me.

I think, in summary, that I'm pessimistic that my psychiatrist can help me.

A said...

It depends. False optimism or relentless, canned, cheer is not helpful to anyone. If you are working with moderately perceptive people they will absolutely pick up on it.

Pessimism does not necessarily mean you'll be a bad shrink, but it will probably lessen your effectiveness. Again, your even moderately perceptive patients will absolutely pick up on it. If your shrink is pessimistic about your future, well, why the heck shouldn't you be?

My shrink is very hopeful about my future. Occasionally I push her on it and ask why, or if she just thinks that about all her patients. She comes back with clear reasons why she thinks that yes, I will feel better/increase functionality/depression will remit/etc etc etc, and that based on her experience, those factors are why she feels helpful. That is reassuring and helpful to me - it is concrete, evidence-based, if you will. Not a general, generic, well, everyone will feel better b ecause I am a happy, feel-good sort of person. That would not be helpful because it is not realistic. That would also lead me to greatly doubt a shrink's ability to be effective - if her perception is that skewed!

It is not all that different from a teacher. You are hopeful you will make a difference, you believe your students will learn and grow each according to his/her ability, but you do not - if you are a good teacher - naively and idealistically optimistically and categorically assume all your students will become geniuses, certainly not as a function of your intervention in their lives.

(And let's not begin to get into SSRIS and placebo effects.....)

Suji said...

I'm not really certain if being optimistic is 100% effective in psychiatry. But I strongly believe that we should always be optimistic in life. Positive thinking creates positive results.

Anonymous said...

I would agree with that. Both my psychotherapist and psychiatrist are generally optimistic. They are both incredibly level-headed and weigh the pros and cons of every situation.

I feel like they both must really work on keeping themselves mentally health, with all of the stuff they hear and deal with day in and day out. It could really bog you down.

There is no way I could keep that optimism day in and day out... with a mood disorder. ;)

Anonymous said...

What an important and interesting blog post. Hope is vital to recovery so having the skills to promote hope and optimism should I believe be central to psychiatric training and development. There are tools and techniques to apply like employing strengths based practices to temper the focus on deficits that will inevitably arise when services are rationed on greatest need and the people using them financially rewarded for severity of illness/disablement. It can though be very hard to retain hope and optimism when working with people for whom hope is hard one and despair more the norm so we need to cherish and support our mental health professionals and help them to be as open as possible about their own feelings and emotions. Finally being optimistic does not preclude being realistic. For any psychiatrists who find it hard to be optimistic I do hope they can at least avoid making the following statements:
- You’ll be on medication for the rest of your life
- Think of yourself as a diabetic
- Probably best you don’t work again

jesse said...

I'm actually quite like Dinah in regard to her attitudes and expectations, but in this instance I don't think "optimist" is the operative word. Psychiatry is a profession that sees most patients improve in certain ways, and those ways can be life-changing. I never think in terms of "getting well," however. That term is for other specialties. I feel confident that most of the time I can find a way to be helpful, and that is very important. I like people and don't give up on them.

But an optimist? It depends: Peace and democracy in the near east? Global warming? Eventual calamity? The second coming?

As Hamlet said, "the readiness is all."

Liz said...

wonderful post...thank you

http://pocketshrink.blogspot.com

Dinah said...

Jesse-- You don't think in terms of "getting well" ?
Huh? Maybe you've got a guest post in you about this?
I think in terms of people getting well. It's sort of like "normal" -- "well" is a spectrum thing, not an absolute. But I do think of people as getting well, at least to the extent that any of us are truly "well"-- the human condition, with or without psychiatric disorder, contains suffering, angst, self-doubt, unmet striving...so even those who are "well" are not consistently so.

It seems to me that many people walk in the door quite distressed and having trouble functioning, and then go on to feel fine and be very productive. Isn't that well?

jesse said...

Yes, Dinah, it can be thought of that way. But many times patients change in ways they did not even imagine. Their conception of "well" embodies elements that were entwined with their problems. For certain types of problems - an acute depression following the death of a loved one, for instance - a person may regain his former functioning, but he will not be the same.

The way you just described it above is indeed how I see it. I think I am just using different language.

Dinah said...

Jesse, Okay, different language, I buy that. I think of "well" as being "well" from psychiatric illness, and people get well. They may need medicines to stay that way, or ongoing therapy, and at some point they may have a recurrence and not be well (or get hit by a bus or diagnosed with terminal cancer), but I do think in terms of being acutely ill and getting well.
If we suffer, experience anguish, are changed by the events or relationships in our lives, well certainly those are topics that people process in psychotherapy, but those are issues that come with being human, which in the very best of circumstances includes angst & disappointment.

jesse said...

I completely agree with what you said.