I Won’t Analyze You.

“Oh, you’re a psychiatrist? I hope you won’t analyze me!”

I never know what people actually mean when they say that upon learning that I work as a psychiatrist.

I think they’re[1. I can’t remember an instance when a woman said to me, “Oh, you’re a psychiatrist? I hope you don’t analyze me!” The men who offer that response are almost always trying to make someone laugh—me, them, the people who are observing the conversation.] saying, “I hope you’re not going to spend our time together trying to discern my flaws.” Nobody wants people to seek out, highlight, and exploit their vulnerabilities and faults, so I can understand that. Of course, that’s not what psychiatrists do.[2. Unfortunately, there are psychiatrists who focus on discerning and amplifying individual vulnerabilities. This is abuse of power and is not limited to psychiatrists.]

Anyway, let’s just take the statement at face value—that people hope that I won’t “analyze” them—regardless of what the underlying concern may be. Let’s also assume that when laypeople say “analyze”, they mean “do the things you do when you’re working as a psychiatrist”.

I cannot speak on behalf of all psychiatrists, but let me assure you: If you and I meet in a non-clinical context, I won’t “analyze” you. These are the reasons why:

1. It takes a lot of energy to “analyze” someone (a.k.a., “do the things psychiatrists do when they’re working”). When I’m working, these are the things I’m attending to:

  • What is the person saying? What words does he choose to express himself?
  • How is the person saying what she want to communicate? What is the tone of her voice? What nonverbal signals are present?
  • Is what this person is saying congruent with what this person is doing? What about his facial expressions and other physical movements?
  • What are the underlying or recurrent themes behind what this person is saying and doing?
  • What are the underlying assumptions the person has about himself? How are these underlying assumptions manifesting in what he says or does?
  • Is this person avoiding certain ideas or perspectives? If so, what are some possible reasons?
  • How did these ideas and behaviors come to be? Were they helpful or lifesaving in the past, but are now causing problems for the person? How do these thoughts and behaviors help this person now?
  • Is there something else going on that might explain this person’s thoughts and behaviors? Maybe this isn’t psychological; this might be a medical problem or related to substances (prescribed or not).

While attending to those tasks, I’m also:

  • Doing all the nonverbal stuff—often with intention—to let the person know that I’m listening
  • Saying things and doing nonverbal stuff to help the person feel both physically and psychologically safe in disclosing information to me. If I don’t receive accurate data from someone, I cannot help them as much as I possibly could.
  • Tracking the conversation and putting mental bookmarks in places to either revisit later during this dialogue or in the future (is this the right time to ask that question? how about now? should I phrase it differently now?)
  • Making mental notes of the important details I need to put in my note later
  • Gently (or more assertively, as the case may be sometimes) steering the conversation with questions and comments to make sure I get as much relevant information as possible, given the current circumstances (amount of time, condition of the individual, setting that we’re in)

All of these actions—not always visible, but definitely happening—require active listening, which means I shouldn’t space out.[3. When I’m working, I shouldn’t space out, but I have. The goal is zero instances of spacing out. Still working on it.] I need to be present and focused. We all know when someone isn’t paying attention to us.

When I do speak, I try to ensure that every sentence serves a purpose.[4. When I’m feeling more ambitious, I try to ensure that every word I say serves a purpose. Sometimes that makes me sound pedantic or brisk, which often makes people feel uncomfortable. I learned early on that most people feel more comfortable with a psychiatrist who is a human being, not a psychiatrist who could be a robot.] Sometimes I ask questions when I want to make a statement; sometimes I say nothing, even though the individual may want me to fill the space with something (reassurance? confirmation of inaccurate ideas? answers that no one has?). I’m frequently generating hypotheses and testing them (is this person experiencing paranoia, or would he say more to another colleague? if this person intoxicated, or is there a medical issue present? does she actually want to die, or is she feeling powerless in the face of adversity?), while trying to show empathy and kindness.[5. Kindness is often associated with warmth. However, people can demonstrate extraordinary kindness without warmth. Consider people who put themselves in danger to protect others. Warmth is often absent there, but kindness overflows.] I don’t want to come across as an automated flow chart.

All of that—and more!—is happening when I’m doing clinical work. That takes a lot of energy. If I don’t have to use that energy, I won’t.

2. I don’t know how to “analyze” people. Upon hearing the word “psychiatry”, some people conjure up images of New Yorker cartoons with couches and stodgy psychiatrists sitting behind them. Psychiatrists and other mental health professionals usually go through extra training to learn psychoanalysis. The tradition of “analysis” goes back to Freud and, well, I’m not a fan.

Now, to be clear, there are some ideas that stem from psychoanalysis that I think have some value (for example, Malan’s text on psychodynamics offers interesting and, at times, useful perspectives on symptoms and behaviors). However, I don’t think everything boils down to love and work. Or sex and violence. I don’t think women are envious of men because men have penises. I think we all probably have an “unconscious” or “subconscious”, but I can’t prove it. I also don’t think the unconscious/subconscious is simply an arena where good and evil, depravity and virtue, and other polarities are constantly duking it out.

My disdain of psychoanalysis stems, in part, from cultural reasons. Freud and his buddies came from Western Europe (particularly Austria and Switzerland). America is a product of Western European ideas, and while I was born and raised in the US, I was raised by people who were not. I was inculcated with Confucian, Buddhist, and Taoist ideas. The psychologies of these traditions don’t refer to constructs like ids, egos, and superegos. They instead focus on filial piety, the importance of community over the individual, harmony as a paramount virtue, and the reality of suffering. These manifest more between, rather than within, individuals.

3. I’m not my job. Yes, I have been fortunate enough to go through medical and psychiatric training and do the work that I do, but that’s just one aspect of who I am. In my youth, psychiatry was not a part of my identity. If I am lucky enough to live long enough to retire, psychiatry will be something of my past. This is just a long phase of my life.

So, rest assured, I won’t analyze you. If I ask you questions, maybe I just want to get to know you.

Lessons Medicine Nonfiction Reflection

On Gratitude.

Expressers significantly underestimated how surprised recipients would be about why expressers were grateful, overestimated how awkward recipients would feel, and underestimated how positive recipients would feel.” – Undervaluing Gratitude: Expressers Misunderstand the Consequences of Showing Appreciation

The past 30 days have been unusual because of the number of professional gestures of gratitude I’ve received:

  • I received a clinical faculty award from psychiatry residents for my teaching efforts.
  • An hospital administrator contacted me in my professional capacity; she later revealed that she was a former patient of mine and thanked me for our time together.
  • A former patient contacted me to let me know that she is about to start law school, something she did not think she could ever do. She attributed her change in perspective to our time together.

These gestures are deeply meaningful to me. At a time when arguments, conflict, and discord seem to dominate our collective consciousness, how refreshing it feels to receive thanks!

As I do not work in an academic medical center, I never expected to receive a teaching award. While I do some teaching for the residency, I have limited exposure to the trainees. That the residents even thought of my name for the ballot is meaningful. In my professional role, I have the privilege of teaching topics related to psychiatry to a variety of audiences—community members, attorneys, judges, case managers, nurses, social workers. Praise from students, though, is of greater value to me than praise from judges and others who have similar social status. As one of my more precocious medical students once commented, “I should know what a good teacher is, since I’m a medical student and many people teach me….” It makes me grateful for the teachers[1. I believe that literally everyone you encounter in life is a teacher. Sometimes you don’t want to learn what they have to teach you, but that doesn’t dilute the value of the lesson. And sometimes the best teachers in our lives aren’t identified as “teachers”.] in my life who have helped me develop my teaching skills.

Similarly, it is always a delight to receive thank you notes from past patients. Even though I often cannot remember the names of people who were under my care in the past, I recall how many of them taught me how to improve my skills in listening, using plain language, and applying interventions—medications or otherwise—to improve their health. I also recall the shame, fear, and suffering that they shared with me… and how, sometimes, I screwed up and gave them reasons to distrust me in the future. Sometimes I did better. Sometimes I think I did better when, in fact, I did not.

My boss (who is not a physician) recently gave me some feedback: “Maria, you’re hard to read. I usually can’t tell how you’re reacting to something.”

I laughed. “You’re not the first person to tell me that,” I said before continuing, “Like, when I was a fellow in New York, I had supervision with an attending (a physician) and, for whatever reason, I burst into tears because I was upset. To his credit, he didn’t freak out. He, a native New Yorker, sat with me and commented in that direct way that New Yorkers are known to do, ‘I had no idea you were so upset. You should know that you don’t show any signs that you’re upset.'”

After my mom died, I have put more effort in expressing my emotions. (To be fair, though, most of the expressing happens in words, not in my face.) Most of these expressions are of affection and gratitude. It sounds dramatic, though it is true: We never know when people will leave our lives, whether from death or other reasons. As noted in the opening citation, we might not think that what we say has much impact on others. However, expressions of affection and gratitude, at least, cause no harm and, at best, are emotional gifts that strengthen social bonds and foster harmony.

There is value in expressing displeasure, too. Sometimes people need to know that we’re upset, that we feel distress with current circumstances. Though it might make us uncomfortable, expressions of displeasure can ultimately strengthen social bonds and foster harmony. Sometimes we must travel the difficult path, even if it means that we will travel alone for a bit.

I am not old, but I am also not young. I am grateful to have the opportunity to work as a psychiatrist and to teach others the little that I do know. I am grateful that you, dear reader, have made it to the end of this post. Thank you.