I’m not really sure where to start in this series (which I shall henceforth arbitrarily label The Workbook).

Let’s start with a definition: The practice of psychiatry involves the diagnosis and treatment of behavioral, cognitive, and emotional problems. (Hm—my definition doesn’t stray too far from the definition offered in Merriam-Webster… and the American Psychiatric Association website is not loading for me right now. I will refrain from making any comments about that. (Full disclosure: I am not a member of the American Psychiatric Association. Nor am I a member of the American Medical Association. Neither of these are oversights.)

Already, my mind leaps to problems with that definition, but I don’t want to get sidetracked this early on in this task.

What are some examples of “behavioral” problems? Let’s begin with “obvious” problems, like

• jumping off of bridges with intentions to die (suicide is a complex one—I would be wise to leave this one for later)
• standing in the middle of highway/freeway/parkway traffic and (unsuccessfully) directing cars due to (untrue) beliefs that a celebrity has specifically provided instructions to do so
• not eating or drinking due to concerns that the physical opening of the mouth will permit ghosts to enter the body and inhabit it forever

What are obvious “cognitive” problems?

• the inability to remember anything, new or old
• the inability to manipulate information in a “rational” fashion (e.g. “I don’t want to undergo that surgery for my infection because I am certain that my saliva has healing powers—I just need to spit into it”)

And obvious “emotional” problems?

Well, that’s actually a tough one to answer. Behaviors and thoughts are easier to observe than emotions. Furthermore, behaviors are usually what elicit clinical attention. Crying is ostensibly a manifestation of sadness; people get referred for psychiatric care because they are “crying all the time”, not necessarily because they are “sad all the time”. (There are plenty of people walking around who are “sad all the time” and no one else knows.)

The above examples make it clear that behaviors, thoughts, and emotions are intimately related to each other. (People bicker about this a lot, though; some experts believe that thoughts always precede behaviors; others think that people “emit” behaviors all the time without thoughts triggering them. And some people learn to avoid experiencing emotions for various reasons, so they essentially experience thoughts and engage in behaviors without “feeling” anything. None of this parenthetical stuff is necessarily pathological; it’s just complicated and we don’t data one way or the other.)

Anyway.

So, some people experience severe behavioral, cognitive, and emotional problems. Psychiatrists diagnose (put a label on? accurately describe? get the gist of?) and treat (cure? minimize the symptoms? help people cope with?) the condition.

(I ask myself a lot of questions about diagnosis and treatment—particularly the former, since diagnosis is what guides treatment—but I’ll get into all of that later. But, briefly, psychiatric nosology is hazy. If I give a diagnosis of schizophrenia, does that person really have a diagnosis of schizophrenia? Or does he actually have another condition that no one has yet elucidated? Better yet, what if he “meets criteria” for schizophrenia? Does that still absolutely mean that he actually has the condition known as schizophrenia? What utility is there in assigning a diagnosis if we do not yet have effective treatment? What does “effective” mean? Who decides what “effective” means?)

(This is why I’m putting this off until later.)

In thinking about The Workbook, I had some preliminary thoughts about the function of psychiatry (notwithstanding all the confusion above). Psychiatrists should:

Rule out all potential medical causes and contributors to the behavioral, cognitive, and emotional problems. Psychiatrists should be the biggest skeptics that someone has a “primary” mental condition. Most people in the world do not have severe mental conditions. (I know there are statistics out there stating that nearly a quarter of the US population “suffers from a diagnosable mental disorder in a given year” and that antidepressants, the most commonly prescribed medication in the US, are now used twice as much in treatment as they were over ten years ago (now 10% of the population)… and all of this goes back to my above questions about diagnosis and treatment.) People can develop behavioral, cognitive, and emotional problems due to primary medical conditions. Think strokes, toxicity from medications (or other substances, like alcohol and/or drugs), low blood sugar, low oxygen levels in the blood, systemic infections, organ failure (kidney problems, heart problems, etc.), and on and on. Available psychiatric treatments won’t work if the diagnosis is incorrect.

Be mindful of the context. While working in a consult-liaison position last year, I primarily saw patients in the hospital. The vast majority of the referrals came from the physicians and family members, not the patients themselves. Hospitals, as entities, can actually have very low tolerance for what they interpret as “abnormal” behavior. Some behaviors that occurred in the hospital (that triggered a psychiatric consult) would probably not get any attention outside of the hospital. This includes things like

• crying
• not taking medications regularly
• “having an attitude”

People pay a lot of attention to patients in the hospital. And hospitals, in general, don’t like to deal with people who are ignoring the rules of The Hospital Game. Combine these two together and you generate psychiatric consults.

All of this is to say that context matters. People don’t live in vacuums. Behaviors, thoughts, and emotions that are acceptable in one setting—say, at your local dive bar—may not be acceptable in another setting—say, at your parents’ house.

(Admittedly, for more severe conditions, context may matter less, because the same behaviors, thoughts, and emotions appear regardless of the context.)

This also (partially) explains why a lot of people in jails and prisons receive (sedating) psychiatric medications.

I’m not phrasing this one as eloquently as I’d like, but something like Help people reach their goals through the least “invasive” means possible. The vast majority of people have (reasonable, effective) goals. Psychiatrists have training in tactics and strategies to help people reach these goals. Thus, people are experts about themselves (sometimes they just need some nudging to realize that they are experts about themselves) and psychiatrists are experts in these tactics/strategies. The goals of the psychiatrist should not supercede the goals of the person.

Most people do not have the goal of taking psychiatric medication. Psychotropic medications are not benign substances and they should be administered with care and, in my opinion, after less “invasive” means (psychotherapy, other less clinical interventions, etc.) have been explicitly and jointly tried.

Not to get too shrinky about it, but in prescribing medications to people, psychiatrists can send the message, “There’s nothing you can do to help yourself. Here. Take this pill instead.” Medications can leech any self-determination and mastery a person has. Believing one is ineffective has never helped someone reach goals. This isn’t to say that medications have no role in psychiatric care, but, when appropriate, sometimes—often—the way that psychiatrists can be of the most help is to help people help themselves. (Again, this can be much easier said than done, particularly for those individuals with severe conditions… but, even then, sometimes none of us give them enough benefit of the doubt. “Psychotic” does not mean “stupid”.)

Okay. That’s enough for one day. I think the next task—which is actually really challenging—is to delve more into psychiatric diagnosis. I don’t even know how coherent I will be in trying to explain that one to myself.

(Part of The Workbook Series.)