People want to do the same thing and experience different outcomes. Wouldn’t it be great if we could lose weight despite a diet of chocolate malts, beer-battered French fries, and triple-decker club sandwiches and an strict exercise regimen that only includes walks to and from the car? Or how about befriending jaw-droppingly beautiful men and women who sparkle with good humor and charm without ever leaving the house? Perhaps you can get that pay raise through the sheer power of wistfulness and hope, rather than suggesting to your boss, “I’d like a pay raise.”

Herein lies the difficulties of behavior change. (And, just to be clear, insight alone does not result in behavior change. Just because you recognize something needs to change doesn’t mean that something will change. Take the current war in Iraq, for example.)

Sometimes I’m surprised that people don’t storm out of the room in frustration. With my burgeoning skills, I advocate for functional change. With their well-practiced habits, people respond, “Yes, but….” It’s annoying to hear someone suggest that you try something different, whether that “something” is a thought or behavior. And even if something does change, progress can seem glacial—particularly to the patient, even if it is evident to everyone else.

Change can really suck. And when things aren’t going well already, the stress of change—or even just thinking about change—can result in people getting angry at the people who are helping them change. It’s grand.

What makes a “real” psychiatrist? I don’t know where I got the idea that “real” psychiatrists practice psychodynamic therapy (think psychoanalysis: free associations, dreams, “tell me about your mother”). I didn’t know any psychiatrists in my youth. The medical school I attended was not inundated with psychoanalysts, with or without tweed suits with the elbow pads, horn-rimmed glasses, and neatly-trimmed beards (though there were a few psychiatrists who routinely wore bow ties). I did not enter psychiatry because of the allure of psychoanalysis.

Therapy training seems to be polarized: there are the cognitive and behavioral people on one side and the psychoanalysts on the other. Most people gravitate towards one side or the other and, at best, limit commentary about the other camp to half smiles and monosyllabic utterances. (At worst, they verbosely disparage the asininity of the other side: It doesn’t work! It’s too simple! It’s too complex! It’s not helpful! Blah! Blah! Blah!)

I find myself leaning (significantly) towards the cognitive and behavioral side and yet, cognitive and behavioral interventions clearly aren’t the end all, be all or psychotherapy—if that was the case, then why do people still practice psychodynamic psychotherapy? (I recognize the fallacy in that argument; there are plenty of things we all do that don’t entirely make sense, yet we do them anyway—like knocking on wood. Or refusing to make any comments about the lack of consults/admissions/patients needing care for fear that if the words are spoken, the “spell” will break and patients will soon show up in droves.)

I’ve spoken with a few people who were fully trained in psychoanalysis and are now behaviorists (of varying degrees) and, when pressed, they will concede that they still peripherally use the ideas of transference and countertransference when interacting with patients. However, they also frame these ideas as “learning history”. For example, instead of (not this bluntly) “You are interacting with me as if I was your mother due to unconscious, intrapsychic processes”, it would be “You learned to interact with people of perceived authority this way because of your experiences with your mother”.

I rationalize that my brain just isn’t sophisticated enough to understand psychodynamics. The practicality of cognitive and behavioral therapies simply resonates with my personality and the way my brain processes information. (It’s also nice that the cognitive and behavioral interventions also have empirical data supporting their efficacy….)

And yet I struggle with the idea that I could be a skilled psychiatrist despite the fact that I do not embrace psychodynamic theory. (Maybe the answer does lie in McHugh’s Perspectives.) If When I end up in New York City (the bastion of psychoanalysis), I fear I might be ostracized for my cognitive and behavioral proclivities. Maybe the analysts will offer interpretations about my resistance to psychodynamics and help me overcome my defenses. Or not.

Brilliance is uncommon. What makes someone brilliant? I define brilliance as someone who can integrate varying and disparate ideas into a lucid discussion. Someone who not only knows a lot, but can make sense of the myriad of ideas. Someone who can easily grasp the different perspectives of the big picture and sort through the details without difficulty. Someone who is enthusiastic and passionate about thinking.

I am not brilliant.

Brilliant people, it seems, don’t sleep a lot. They also seem to have a lot of energy. (And, no, I will not digress into psychiatric diagnostic discussions here. That isn’t the point.) They also seem to have excellent memories; how else can they remember that Descartes said that, chaos theory suggests this, and anthropologists discovered this in some random cave? They have ravenous appetites—and not just for knowledge. (Think former President Clinton.)

I like listening to brilliant people—their brains seem to generate ideas the way weeds sprout throughout a garden.

Is there a way to become brilliant? Is brilliance learned? Or must we rely on our genes?

What is stopping me from writing on a daily basis? Long time readers know that for many years, I wrote every single day. In addition to the usual reasons I give for writing (helps me think better, allows me to exercise creativity, helps me reflect), I’d like to think that writing on a daily basis has helped me to become a better writer. This is debatable, of course. I can’t say that I’m particularly proud of anything I have written recently.

GruntDoc recently wrote

I and every other medical blogger don’t write about 99% of our interactions, and it’s because they’re either not noteworthy, or too noteworthy (not able to anonymize) or we just forget. Frankly, most of what we do isn’t that interesting, or notable, like our patients.

I agree. (I, however, think there are interesting and notable things about most things and people—sometimes these details just aren’t apparent at first blush.)

I’d like to write more about my observations; there are so many amazing, ugly, terrifying, stunning, beautiful, hilarious, ridiculous, amusing, humbling, disgusting, and entertaining events that we all witness everyday. However, just because I find two blackbirds fighting with each other on the sidewalk on a drizzling morning doesn’t mean that it’s worth writing about. Or maybe it is, and I’m selling the idea short.

I still believe in the power of the story. Although interesting conclusions can be drawn from data and other “objective”, measures, stories are ultimately the most effective method of engaging people and the imagination. The power of the story explains the success of Harry Potter and This American Life (this week’s episode, particularly Act Two, is excellent). Many of us organize our lives through narratives (e.g. “What I Did On My Summer Vacation” is usually more interesting than “The Itinerary of My Summer Vacation”).

I’ve had a hard time writing stories lately. I attribute it to my (potentially mistaken) idea that these stories aren’t worth writing about.

This too shall pass. Just not today.