goertz psychiatry

Suggestions On How To Treat Psychiatric Patients

The following is based on my own personal experience and my own style of interacting with patients. Others may find thatsome of what I suggest may not suit them or may require modification in order to fit their style of interacting withpatients. However in my opinion the general principles of what follows are applicable to anyone who treats psychiatricpatients.

LOVING INTENTION: This underlies any positive interaction. Loving intention is necessary for all other suggestions whichfollow. If your intention is not genuinely for the benefit of the patient, none of the following suggestions areapplicable.

COURTESY: This is a basic tenet for any positive relationship between human beings, which includes the staff-patientrelationship. Patient or staff we are all human beings, we all have our problems and no-one is better than the nextperson. Specifically, no matter how deteriorated a patient may appear, no-one is better than the patient. It isappropriate to verbally communicate this to patients. When I have done so, some patients have thanked me. On suchoccasions I have felt somewhat sad, realizing that the patients feel inferior and that staff often does not address thisissue.

  • Shake hands when meeting the patient, shake hands when saying goodbye if you are not scheduled to see the patient againe.g. when the patient is being discharged from the hospital[exceptions: e.g. obvious dirt, feces eon the patient’s hand;you feel the patient is on the verge of assaultiveness; the patient is paranoid and does not want to shake your hand].This should apply to all staff[if a patient is in a hospital], not only M.D.’s.
  • Knock before entering a hospitalized patient’s room.
  • When you want to speak with a patient in the hospital, ask the patient if it is O.K. with them to talk now.
  • When you speak with a patient keep your hands out of your pocket, do not chew gum.
  • Use the words “patient”[not “client”] and “doctor, social worker, nurse etc.”[not “health care provider”]. The terms inbrackets allude to money rather than only illness or treatment.
  • Ask how the patient would like to be addressed. If the patient would like to be addressed by their first name, offer thepatient the option of addressing you by your first name.
  • When speaking with a patient sit in the same quality of chair as the patient. It is not respectful toward the patient ifthe doctor sits in a morecomfortable chair.
  • In a group setting e.g. a community meeting, where multiple patients and multiple staff-members are in attendance, staffand patients should beintermingled i.e. there should not be a group of patients and a separate group of staff-members. Rather individualstaff-members should sit between patients.
  • In an outpatient setting begin and if possible end sessions punctually. This provides structure for the patient. It alsoshows your reliability. Endingsessions punctually if possible shows your ability to set limits with the patient.
  • If a patient is barefoot have socks/shoes provided to the patient. If a patient complains of a physical problem examinethe patient[if you are a doctor]. If the patient would like a cup of water provide it to the patient.
  • Clothing provided to patients on a hospital ward should be of the same quality as that of staff members. Staff memberson a psychiatric ward should not wear white coats. Food provided to patients should be of the same quality as thatprovided to staff.
  • All rooms including bathrooms and seclusion rooms should have windows. It should be possible to open windows for freshair in a secure fashionwithout risk of patients jumping out of the window.
  • All patients should have the option of daily time[this should include the option of exercise] spent in fresh air andnature, even it is only grass and a few trees.
  • Do not interrupt outpatient sessions for telephone calls unless absolutely necessary.

HUMOR: This can instantly change a patient’s perspective. It requires sensitivity, proper timing and good judgement andunder such circumstances rarely if ever backfires. Using humor shows the patient that you are human, that you recognizethat the patient is human and that you respect the patient. Humor makes work more enjoyable for you and your co-workers.The patients pick up on whether or not you enjoy your work. The principles of the use of humor in the staff-patientrelationship also apply to interactions between staff members.

  • One form of humor is exemplified by a paradoxical appearing approach. Examples include saying things such as:”the nurseis trying to poison you”[the nurse is standing in front of the patient trying to get the patient to accept themedication], “don’t take your medications, use alcohol and drugs and don’t go to your appointments”[the patient is aboutto be discharged from the hospital], “the nurse told me you are refusing to be discharged”[the patient is scheduled fordischarge that day and is very happy to be leaving the hospital], “I’ll tell the nurses to stop putting medication intoyour food”[a paranoid patient does not want to eat the food for fear that the nurses are putting medication into thefood], “the medication destroys all of your organs”[a patient had expressed concern about organ damage due tomedication]. Such “paradoxical” statements surprise the patient who generally
Other examples of use of humor include:
  • If a patient calls you by the wrong name or pronounces your name incorrectly you reciprocate by calling Ms. Smith “Ms.Jones”.
  • A patient requests that their nursing report be read to them. You ask the reader to “leave out the four letter words”describing the patient’s condition and behavior.
  • A patient of yours whom you have spoken to many times on the ward calls out to you while you are passing by or closingthe door to the ward. Your initial response is:”do I know you Ma’am?”
  • A patient walks toward you on the ward wanting to speak with you. You pretend to run away when you see the patientapproaching you.

HEALTHY ASPECTS OF PATIENTS: Encourage patients to cultivate healthy aspects of themselves. Encourage them to immersethemselves in activities which they are interested in and passionate about. When patients are doing so their signs andsymptoms can vanish for that period of time. A patient on a 1:1 suicide watch hearing the voice of the devil telling himto kill himself played guitar on the ward. While he was playing the auditory hallucinationsdisappeared.

  • If a patient plays a musical instrument encourage this on the hospital ward and in the community.
  • If a patient draws, paints or writes encourage this.
  • Encourage the patient to work, whether she/he is being paid for the work or not.

PSYCHOLOGICAL BACKGROUND OF THE PATIENT: There are always psychological issues worth addressing, if the patient iswilling to do so, even if thepatient’s psychiatric illness is felt to be caused entirely by physical issues e.g. stroke. The question of when toaddress which psychological issues is one of clinical judgement. Sexual, physical and emotional abuse are very common inthe life histories including childhood of psychiatric patients. Psychiatricillness may in fact be the long term result of such abuse. Generally an initial psychiatric interview should addressthis issue. Patients, especially chronic patients, may become invested in or attached to their psychiatric illness. Thismay manifest in an unwillingness[conscious or unconscious] to improve their psychological state. Instead they cling to avictim-mentality.

In psychotherapy the following are general principles and successive stages:
  • The patient becomes consciously aware of adverse experiences in the past.
  • The patient emotionally embraces this awareness.
  • The patient emotionally digests and processes this awareness.
  • The patient releases the painful emotional awareness of adverse experiences in the past.
  • The patient forgives persons associated with these adverse experiences, e.g. parents.

Signs and symptoms of psychiatric illnesses frequently have meaning in the context of the patient’s life i.e. they arenot random. A patient who had been abused as a child by his father experienced auditory hallucinations of his father’svoice verbally abusing him. Sexual feelings of patients should beacknowledged and often can be openly talked about. Sexual activity between patients on a psychiatric hospital-ward is tobe prevented. Patients suffering from psychiatric illnesses are frequently sexually vulnerable to exploitation by othersespecially when the patients are in severe emotional turmoil, which is frequently the case in hospitalized psychiatricpatients. Psychological factors frequently contribute to patients’ abuse of substances, however once a patient isabusing substances the substance abuse generally needs to be addressed with resulting abstinence before successfulpsychotherapy can occur.

In addition to the multiple, significant and often overwhelming psychological difficulties patients enter the hospitalwith the patients during their hospital stay are frequently exposed to multiple potentially traumatic issues. Patientsare assaulted and at times significantly injured by other patients, patients witness such assaults and subsequentphysical restraint of a patient, patients witness other patients receiving injections of psychiatric medication againsttheir will, patients witness sexual activity between patients, patients hear screaming and verbal abuse by otherpatients, patients are exposed tounpredictable, grossly disorganized and bizarre behavior of other patients, patients are exposed to a gross lack ofhygiene in other patients, patients are exposed to suicide attempts and completed suicide in other patients. Patientshave been raped in psychiatric hospitals by staff-members and by otherpsychiatric patients. Patients have become pregnant in psychiatric hospitals. Patients are exposed to medical illnessesof other patients. A young manengaged in anal sexual intercourse with another man, who was HIV-positive. Of course many patients do not feel safe onpsychiatric wards and wantnothing more than to be discharged. These events which occur in the hospital can have far-reaching consequences.

PSYCHOLOGICAL ISSUES AND EMOTIONS OF STAFF-MEMBERS: It is important for staff members to apply the above mentionedgeneral principles andsuccessive stages to their own psychological issues and emotions including their emotions toward patients. If this isnot done the emotions can express themselves in actions which adversely affect patients[this falls under the termcountertransference]. For example if a staff-member is struck by a patient this incident should be discussed amongststaff members, possibly in a group setting. Subsequently each staff-member can process their emotionsindividually. Working on locked inpatient psychiatric wards brings with it a constant sense of danger for staff-members,a staff-member can be assaulted by a patient at any time. If a staff-member has an instinctual urge to removeherself/himself from a given situation they should do so as quickly aspossible, rather than have a situation escalate and e.g. be cornered by a patient. It is never advisable to try to be”macho”. In psychiatry we treat manypatients who are capable of inducing strong negative emotions in staff-members, unless the staff-members are alert tothis danger and adjustquickly[thereby preventing what is called projective identification]. While moonlighting one Christmas in thepsychiatric emergency room a doctor noticed that money was missing from her purse. An intravenous drug abusingHIV-positive prostitute, who was a frequent patient in the psychiatric emergency room, was subsequently found to haveinserted the money into her vagina. Upon learning this the doctor confronted the patient exclaiming:”you f…ing b..ch”.An intern in the pediatric emergency room in the middle of the night tried multiple times unsuccessfully to get theattention of a nurse. Very tired and wanting to get some sleep he finally gave up and went to bed. As a consequence ofthe lack of communication between the intern and the nurse a young girl received an inappropriately high dose ofmedication. The intern’s feelings of frustration resulted in his going to bed which led to the young girl’s receiving aninappropriately high dose of medication, i.e. the intern’s inadequately acknowledged and processed emotion expresseditself in action which adversely affected the patient. Senior staff-members e.g. supervising psychiatrists experienceemotions just like anybody else. If you are asked by a superior to do something major which you know is not acceptable,stand your ground. It is better to lose your job than to relinquish your personal integrity.

It is essential for medical students in their psychiatric clerkship to process their emotions related to theirexperiences in the clerkship, where they are exposed to intense human suffering with all of it’s ramifications e.g.suicidal ideation, violence, abuse, social isolation, bizarre behavior etc. It is necessary for you as a psychiatrist tospeak to the medical students about their emotions. A medical student had just begun her clerkship on a lockedpsychiatric ward of a public hospital. One of her patients, a heroin abuser, was transferred to the medical servicebecause of hemoptysis. The next morning he was found dead with a needle in his arm. Another of her patients assaulted apsychiatrist on the ward. A group of medical students in their clerkship on a locked psychiatric ward of a publichospital experienced the nearly fatal attempted suicide by hanging of a patient who died a week later and the cardiacarrest related to a seizure of a patient who died a week later.

A patient who was resting in bed on a ward was urinated on by another patient; when the patient arose from bed heslipped in the urine and fell onto the floor. When a medical student in his clerkship related these events to thepsychiatrist, the student could not keep himself from laughing. Laughing in such instances appears to represent oneentirely appropriate way of processing one’s emotions. A middle aged man had been admitted after being found floating onan iceberg in a river of a large city. Staff-members could not hold laughter back as they mentioned these circumstancesof the patient’s admission. In front of patients it is preferable for staff-members not to laugh about such issues.However at times one can be blindsided and it can be difficult not to laugh. A medical student was performing an initialinterview on a middle aged chronically delusional man with the psychiatrist present. The student asked how the patienthad come to be hospitalized. Deadpan and with no connection to the question, the patient began speaking about havingundergone”orchiectomy”[which was delusional]. Just as deadpan, the medical student proceded with the interview without missing abeat. At this point it was difficult for the psychiatrist to conceal his laughter from the patient.

NON-MATERIAL ASPECTS: It is essential to be aware that non-material processes and things exert influence on materialprocesses and things and vice versa. This is clearly illustrated in simple examples. If you walk down a dark alley andsomebody jumps in front of you your heart races; the person in front of you however has not physically touched you; itis non-material thought or emotion that caused your heart to race, as it can for example in dreams. The non-materialthought or emotion causes release of epinephrine[material] into the bloodstream which leads to your heart racing.Conversely ingestion of a material substance e.g. an antipsychotic medication can influence thoughts or emotions[whichare non-material]. Of course thoughts and emotions have material correlates e.g. neurochemical processes, however thethoughts and emotions themselves are non-material. In research involving neurochemical processes, the mechanisms whichcorrelate to thoughts and emotions are elucidated, however this does not necessarily mean that the causes of thethoughts and emotions have thereby been elucidated. This has implications for treatment in that successfull treatmentcan address the non-material level[thinking and emotions] or material level[neurochemistry], regardless of whether theprimary cause of the psychiatric illness is non-material ormaterial.

Many patients are well aware of the existence of non-material processes and things. A patient may tell you that hisdeceased wife appeared to him.Another patient in the hospital may complain of difficulty sleeping at night because he sees a patient who had beenhospitalized in the same hospital many years ago. A third patient may explain that she ran out of her apartment nakedbecause a woman and a man had been appearing in her apartment andultimately touched her. Before concluding that such patients suffer from psychoses it is necessary to keep an open mindand broadly evaluate the entire clinical picture of the patient. The aforementioned patient who ran out of her apartmentnaked had just moved into the apartment. In discussing herexperiences with her doorman she reportedly had learned that the woman and man who had been appearing in her apartmentfit the description of the couple who had until recently lived in the apartment. The patient showed no evidence ofpsychosis during her hospitalization and was discharged without psychotropic medication.

In this context it is important to look at what constitutes valid science. The essence of science is keeping an entirelyopen mind. History is replete with examples of the “scientific” establishment clinging to scientifically unsoundprinciples in spite of clear evidence for other principles. If suchestablishments had been entirely successfull the planet earth would still be flat. Even if a principle is felt to bescientifically unproven, this does not mean that the principle is not correct; to assume so would be implementing faultylogic. It is understandable that some feel threatened by concepts which are unfamiliar to them and fearful of changingtheir world-view, however it is important for them to accept that such fear does not logically/scientificallyjustify the conclusion that such threatening concepts are incorrect.

PHYSICAL HEALTH: PHYSICAL HEALTH: Many psychiatric patients, especially those in public hospitals, suffer from physical illnesses. Comprehensive blood-work, a urinalysis, an EKG and, if appropriate, a chest x-ray are useful. On occasion the physical illness may be the primary cause of the psychiatric illness e.g. in hypothyroidism. As a psychiatrist you are a physician and it is appropriate to obtain a medical history and to physically examine patients yourself. Physically examining patients transmits the message that you see them as a whole person and are treating them comprehensively. Touchingpatients in itself generally improves the doctor-patient relationship by making it clear to the patient that you do not see them as “untouchable”; patients may have experienced others not wanting to touch them because the patient may behave bizarrely and exhibit poor hygiene. If a careful medical history has not been obtained and an adequate physical exam not performed major issues can be missed. A medical history and physical exam had been obtained on a young man and no significant abnormality had been noted; subsequently a nurse noted an elevated CPK in the blood and on further questioning the patient reported that he recently had been shot and that the bullet was still lodged in his thigh.

  • Review the patient’s lab-work and EKG yourself.
  • If a patient has a physical complaint e.g. a traumatic injury, back pain, abdominal pain, wheezing, palpitations, ahernia, lower extremity pain, ear pain etc. inspect, palpate, auscultate, examine the patient with an otoscope etc.
  • Maintain your medical knowledge as well as possible.
  • Make yourself available to e.g. insert an intravenous line or draw blood from the femoral vein in a patient who has poorarm veins[e.g. due to chronic intravenous drug abuse] if you have these skills and the occasion arises.
  • If available in your hospital, massage therapy can be very helpful for patients.

Poor hygiene and grooming can be outward signs of mental illness. The word “insane” is based on the latin word for”unclean”.
A healthy diet is important. For example rather than offering white bread and then treating the patient for constipationit may be wise to offer whole wheat bread.

DANGER: Psychiatric patients frequently represent a serious danger to themselves and/or others. You as a psychiatristcan not prevent suicide in a patient, because this choice is the patient’s; you can not choose for the patient, evenregarding suicide. The patient is a free human being with the freedom to make choices regarding her/his life. What Ihave just mentioned is not intended to suggest that no effort on the part of the psychiatrist be made tosupport the patient in changing her/his thinking and her/his life. On the contrary, the purpose of psychiatric treatmentis to support the patient inchanging her/his thinking and her/his life.

The above touches on the issue of paternalism. Truly successful psychiatric treatment is not possible unless it isvoluntary. To a large extent currentwestern society attempts to absolve itself of social, economic, family-related and criminal problems andresponsibilities by placing these problems and responsibilities into the lap of psychiatry. Sexual, physical andemotional abuse, social isolation, lack of education, unemployment, homelessness, poverty, malnutrition and criminalactivity are not themselves psychiatric problems, however exposure to them can certainly lead to psychiatric problems.Once a suicidal or violent patient has entered the psychiatric system, whether or not this is felt to be fair orappropriate, psychiatrists should not try to wash their hands of the patient; rather they should procede in an ethicallysound manner and do their best to achieve safety of the patient and others.

Very few, if any, people have never had a suicidal thought. Very few, if any, people want to kill themselves with totalconviction. Expressed differently,suicidal ideation is a big grey area, there is little, if any, black or white. If someone actually does kill themself itdoes not mean that they fully wanted to do so i.e. if someone does not want to kill themself they may still die from asuicide-gesture. A young man in the emergency room of a VA-hospital was calm and cooperative for half an hour whilebeing interviewed until I mentioned the word “shelter”[I felt that the patient did not require admission to the hospitalwhereas the patient wanted to be admitted]. The patient immediately rose to his feet and in front of me ingested theentire content of a bottle of medication. He was admitted to the medical intensive care unit.

Psychiatrists in hospitals are exposed to multiple pressures. Finances are a major concern and hospital administrationsand managed care companies want to minimize expenditures by having patients discharged quickly. Wards are frequentlyunderstaffed and nurses pressure psychiatrists to discontinue 1:1 observation in order to make staff available for othernursing duties. Use your best clinical judgement and accept the consequences, which may include conflicts with nurses,administrators and managed care companies. A young man was hospitalized after a very serious suicide attempt in which hesustained moderate physical injury. He denied suicidal ideation. His 1:1 suicide watch was discontinued in the morning.Later that day the patient was seen dancing enthusiastically to music in the hallway. 15 minutes after dancing thepatient was found unresponsive after trying to hang himself in his room. He died a week later.
Certain clinical constellations should raise a red flag. A hospitalized young man was depressed, but also irritable. Afew days later he killed himself. This combination of depression and irritability appears particularly dangerous. Ahospitalized grossly psychotic, large, muscular young man with physical brain abnormalities was receiving a low dose ofan antipsychotic medication. His behavior was bizarre. Within a few days he assaulted his psychiatrist.Inadequate psychopharmacological management of a patient can have dangerous consequences.

In a hospital setting large male staff members who, if necessary, physically ensure that a violent patient does notinjur others, are invaluable. Theirpresence alone makes violence less likely. A patient punched a psychiatrist in the jaw. A large male aide immediatelytackled the patient before he could deliver another punch. In this context the importance of helpful patients can not beoveremphasized. A young female patient was standing behind a corner on a ward holding a broomstick and about to hit meover the head when another female patient noticed this and engaged her in an altercation, willing to physically fight.There have been numerous occasions in which patients physically came to the rescue of other patients and staff-memberswho may have otherwise sustained significant physical injury. These rescuing patients have put their own safety on theline and have engaged in dangerous physicalaltercations with the attacking patients. It appears that staff-members who are seen by patients as having the patients’best interest at heart are less likely to be assaulted.

The fact that a patient e.g. a substance abuser with antisocial personality disorder is seen as not successfullytreatable in a hospital setting should not necessarily lead to the decision to discharge the patient if the patientdesires hospitalization. A middle aged man with a long history of substance abuse who had recently been released fromprison after serving time for murder returned to the hospital days after discharge because he felt unable to function inthe community and was afraid he might kill himself. He had been instructed by his psychiatrist to return to the hospitalif such a situation were to arise and the psychiatrist arranged for his readmission. Within a week however, while thepsychiatrist was away at a conference, an administrative decision was made to discharge the patient, who soon wasadmitted to the medical intensive care unit after a drug overdose and subsequently died.

Conversely, if a patient adamantly refuses treatment, this refusal should be respected as much as possible. Ahospitalized, pregnant, psychotic but notsuicidal or violent young woman refused to take psychotropic medication for fear of her fetus being harmed by themedication. A court order formedication over objection was obtained and the patient received antipsychotic medication. Soon after discharge from thehospital the patient killedherself. The antipsychotic medication which the patient had received may have been unlikely to harm her fetus, howeverthe patient believed otherwise and her suicide may have been based on this belief.

Similarly if a patient states that she/he will die from surgery, even though she/he technically consents to the surgery,take the patient’s statementseriously. A young woman on the surgical service was scheduled to undergo surgery, which was not expected by thesurgical team to be unusuallydangerous. However the patient herself was very anxious and agitated and stated that she would die from the surgery.Soon after the surgery the patient died.

The difficulties which patients struggle with are often daunting to both patient and psychiatrist. A patient in histwenties had cut off the distal part of his penis during a psychotic episode. While on the ward which was located on ahigh floor the patient clandestinely cut the cover of his mattress into strips, tied them together into a rope-likestructure and affixed one end of the structure in his room. He was able to open a window in his room. He then climbedout of the window and, using the rope-like structure, tried to lower himself to the ground. The rope-like structuresnapped and the patient fell to his death. This patient[A] was assisted in his escape attempt by one of his 3roomates[B] in the hospital. B, also a young man, chronically depressed, was HIV-positive, had a history of sexual abusein childhood and had been involved in pornographic films. Initially unbeknownst to staff, B’s wife, alsoHIV-positive, was hospitalized on the same ward at the same time. Within a few years B committed suicide in thepsychiatric emergency room of the same hospital.

TREATMENT APPROACHES: No treatment approach is inherently good or bad; treatment approaches are not automaticallyattached to judgements of their value. Any treatment approach, in a given patient at a given time, can be helpful or nothelpful. Psychotropic medication is currently likely the mostfocused-on treatment modality. Psychotropic medication is neither good nor bad, just as natural body substances e.g.epinephrine are neither good nor bad. Both psychotropic medication and natural body substances can have positive ornegative effects on mind and body. Psychotropic medication can be life-saving and life-changing, it also can be lethaland harmful. Like psychotropic medication, electroconvulsive therapy can be life-saving andlife-changing, but also lethal and harmful. Similarly psychotherapy can be helpful or harmful. Some patients requestpsychotherapy and reject the option of psychotropic medication. Others reject psychotherapy and request psychotropicmedication or electroconvulsive therapy. The patient’s wishes need to be respected.

Psychotherapy literally means therapy of the soul, the meaning of the greek word psyche. Therefore, in psychotherapy youare not treating anythingphysical; you are treating the psyche or soul. This distinction is crucial in understanding what you as a psychiatristare doing in psychotherapy. It is also helpful in realizing that a human being’s essence is non-physical/non-material,i.e. a human being is more non-material than material. In a dying patient who is alert you can interact with the patientright up until the time of death, however immediately after death no interaction is possible, even if the death occurredseconds before and all of the cells which constitute the patient’s body are still alive. As a human being’s essence isnon-material it exists before a persons “birth” and after their “death”. Before our “birth” we chose our parents.Therefore we ultimately need to forgive our parents, no matter how difficult our childhood was. In this regard we canlook at what was missing in our childhood and do our very best to now give ourselves what was missing then. Thispertains to anybody, psychiatrist or patient.

The material body of a person with all of it’s atoms and molecules is not static, i.e. there is a constant back andforth exchange with the environment in which atoms and molecules are incorporated into the material body while otheratoms and molecules leave the physical body. The material body which you have today is different from the material bodywhich you had yesterday. Therefore the enduring essence and identity of a human being is not the material body, butrather something non-material.

A basic tenet is the fact that people create their own experiences i.e. they are never victims. Different people in thesame external situation will create different experiences for themselves. You have observed this e.g. if you have everbeen stuck in an elevator with multiple people; externally everyone is exposed to the same events, however internallyeach person creates their own experience, which causes one person to cry, another to joke, a third toexpress anger etc. People create their experiences by their thoughts and beliefs; they make choices based on theirthoughts. We have control over what we think. Therefore negative thoughts should be avoided. For example we shouldtransform fearful thoughts into loving ones.

Another basic tenet is that you as a psychiatrist can not help your patients. You can support them and offer guidance,but only the patients can helpthemselves.

The goal is to live in the present moment and not cling to the past. On the journey toward this goal it is necessary toclear out unresolved psychological issues, which have been stored in the mind and ignored. Thereby one creates a clearmind. This clear mind then needs to be centered with theheart/emotions, thereby ensuring that the mind remains connected with feelings and perceptions.

All of us have female and male qualities. The qualities which enable us to heal are female[nurturing]. Therefore it isimportant for psychiatrists, especially male psychiatrists, to be aware of, accept and embrace our female qualities.

One psychotherapeutic technique involves viewing the patient sitting across from you as a mirror. For example if thepatient is angry, attend to your own angry feelings and clear them out e.g. by a few seconds of visualization during thesession. Your transforming your anger will effect a shift in the patient and make it easier for the patient to transformher/his anger. Simply put: a shift in your thinking causes a shift in the patient’s thinking.

As just alluded to, visualization is a crucial therapeutic process. Other examples of the use of visualization includevisualizing an angry patient in the color pink, a potentially self destructive patient in a pink bunny suit and apotentially violent patient as having holes from which violet steam is escaping. As noted above the underlying principleis that a shift in the psychiatrist’s thinking causes a shift in the patient’s thinking. We do not exist in a vacuum,separate from others; on the contrary the thoughts of people affect each-other back and forth.

DECISION-MAKING: Frequently many variables are worthy of consideration in a potential decision, so that it is impossibleto logically arrive at a decision e.g. by making a list of the pro’s and con’s. Ultimately the decision must be madebased on one’s general impression or gut-feeling of the gestalt of asituation.

DIFFERENTIAL DIAGNOSIS: It is important to keep an open mind and not automatically accept diagnoses which patients havepreviously been given.

A young woman had been diagnosed with schizoaffective disorder, however she described only hearing voices when she wasfalling asleep i.e. hypnagogic hallucinations. A sleep disorder appeared to be a more appropriate diagnosis for thepatient.

A young man had been diagnosed with schizophrenia during hospitalizations in another hospital. After a period of timehowever, based on observation of the patient and collateral information from the patient’s sister, it appeared that thepatient suffered from factitious disorder with both psychological and physical symptoms. Ultimately the patient admittedto feigning both his psychological and his physical symptoms. Antipsychotic medication wasdiscontinued and the patient showed no evidence of psychosis.

MISTAKES AND ADVERSE OUTCOMES: We all make mistakes every day and doctors should admit this to themselves and others,including patients. Because of an error patients were being offered, and to an extent received, each other’smedications. When an irritable, frequently hostile patient who had been offered the wrong medication was told the truthin an open manner he accepted the truth courteously and the matter was put to rest.

Adverse outcomes can occur regardless of whether a psychiatrist has made a mistake or not. A young female patient wasfound dead in her bed oneweekend morning. In Monday morning’s community meeting the patient’s psychiatrist expressed his feelings related to thepatient’s death as did all the others who attended.

LEISURE-TIME AND WARD-ENVIRONMENT: Leisure-time and the ward-environment are part of the hospitalized psychiatricpatient’s treatment. I have been impressed by the fact that the most frequently viewed television-program on wards whereI have worked appears to be The Jerry Springer Show, which is well known to largely consist of violent verbal andphysical altercations. It is important for staff to decide, which television- and radio-programs, videos, DVD’s, books,magazines and newspapers patients are exposed to, just as staff decides which medications and group-activities patientsare exposed to.
Patients respond very well to a dog or cat on the ward.

Physical exercise, if possible in nature, is important for anyone including psychiatric patients. Aside from basicphysical benefits, e.g. for the cardiovascular system and muscles, physical exercise can help release emotions such asanger.

PURPOSE: As a psychiatrist what do you see as your purpose? Why do you go to work everyday? It is essential that youenjoy yourself at work. Otherwise there is no point in your being a physician. Don’t be attached to outcomes. You cannotcontrol everything. Seemingly little things can make a bigdifference. An intern on the surgical service of a hospital was making rounds on a weekend morning. He approached ayoung man who had been stabbed in the neck and thrown out of a moving car in a drug deal gone bad. The patientreportedly had been rendered paraplegic. On a whim the intern asked the patient to move his toes. The patient was ableto move one of his large toes a tiny bit and began beaming ear to ear.

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