Cocktail Parties and Psychiatrists.

I can’t see any deeper than anyone else.

I think most of the people I know now, friends and acquaintances, treat me like everyone else. They do not seem to consider me to be any smarter or insightful just because I am a psychiatrist. And that is certainly the truth of the matter. A psychiatrist is trained over a three or four year period to deal with certain psychological and medical illnesses that afflict people. We are instructed on how to deal with these relatively discrete problems. Our training does not have sub-specialties of “wisdom” or “smarts.” Psychiatrists are no better at figuring out politics or history than anyone else. We are sometimes asked to do things that are beyond our training and certainly beyond our capacity—such as determining who might commit a violent act at some point in the future; but studies indicate clearly that we are not capable of making that judgment any better than anyone else.

In fact, we cannot know anyone, even a patient, well enough based on his/her past to be able to predict with any reliability how that person will turn out in the future. There is something troubling about this. After all, we are trained, more or less, to deal with neuroses, which are conditions not much different from the ordinary ways in which ordinary people behave. We see lots of men and women who are simply worried or troubled in some general way. We would like to think we understand them. But if the meaning of understanding is what it is in the physical sciences, namely, an ability to consistently make accurate predictions, then we do not truly understand them. We often attempt to explain someone’s present on the basis of his/her past. If that were successful and accurate, we should be able to predict that person’s future in the same way. But we cannot. When we are charged with explaining the vagaries of personality we see on the basis, for example, of previous sexual abuse, we can get carried away and explain all sorts of behaviors; but we are likely to be superficial and wrong. These are retrospective judgments, and they cannot be falsified. They are a matter of opinion. Predictions, however, can be seen to be true or false; but we cannot make such predictions accurately.  No one can examine a child who is currently being abused and predict what problems that person will exhibit consequently as an adult. Not that we do not try; but the more experience a psychiatrist has grappling with this issue, the more modest he will grow to be. Some people are more sensitive than others; but that ability has little to do with the formal training of a psychiatrist.

When I was younger, however, and the people I met were younger too, their discovering me to be a psychiatrist made them draw back with exaggerated concern. “Uh, oh,” they would say, peering at me playfully over the rim of a martini glass, “I better watch my step before you reveal my deepest urges.” They imagine me looking around at the cocktail party and placing everyone within my ken in their proper niche. I have only to see the way they stand and hear a few words to know all their darkest secrets. Forget it. Putting aside the fact that a team of psychiatrists working together could not determine much about someone based on his/her cocktail behavior—other than, perhaps, that that person is an alcoholic, A PSYCHIATRIST IS NOT ACTING AS A PSYCHIATRIST AT SUCH TIMES. It is hard enough to figure someone out in a psychiatric office. At other times, the psychiatrist is not thinking like a psychiatrist.

To some extent, this is may be an embarrassment. What I mean is that most of the time in most ordinary circumstances the abilities that a psychiatrist does have are in suspension; but there are times when we really ought to know better.

An extreme example:

Many years ago I was the director of a psychiatric training program. There were fifteen or twenty residents in the program, one of whom came from India. He was a shy, soft-spoken young man who usually listened quietly, but volunteered little of his own thoughts. For that reason, when he began to assert himself in Grand Rounds, the Associate Director of the Department remarked to me that he was “really shaping up.”  The ability to speak up was considered a sign of growing self-confidence.

Later that same day, I was walking through the halls of the hospital when this young man stopped me and suddenly, for no reason that I could see, began telling me about a dream he had about his sister. This was surprising if, for no other reason, because I knew the residents were a little afraid of me—no matter how I struggled to be informal and helpful. It was not me, of course; they came from countries which were authoritarian, and they were afraid of my position as Director. This particular man had never approached me about anything, and here he was telling me about a dream.

I listened patiently but had trouble understanding him. He seemed upset. I smiled at him and told him, after all, it was only a dream. When I ran into the Associate Director a little later, I remarked to him about the incident. I went so far as to say that the fellow’s speech seemed to be “loose.” Loosening of associations in a sign of schizophrenia, but I did not put that two and two together because I was not thinking of him as a patient. I was not acting as a psychiatrist at that moment.

Later that day the head nurse in the emergency room called to tell me that this same resident, who was acting that day as the psychiatrist in charge of admissions, had discharged a woman who was, in the opinion of the nurse, flagrantly delusional; and now he was acting “funny.” When I came to the E.R. to see him, he got down on his knees and started kissing my shoes. Only a few moments of conversation made clear, despite my previous obtuseness, that he was acutely psychotic. I told him he had to come into the hospital, or I would admit him against his wishes. He agreed to admission, if he could be admitted to the same ward on which he had been working.

A relevant fact: not only did I not see this doctor as a patient, neither did the other patients on the ward. No one noticed that he was delusional and agitated—except one man who confided to me in a low voice that night: “There’s something the matter with that doctor.” The following day, I transferred our patient/doctor to a nearby psychiatric facility. I commented to the admitting resident at that institution that his new patient was the admitting psychiatrist at our institution the previous day; but he was unimpressed. It is very difficult to impress a resident.

This was an example of my being tuned out to an extent where I was, perhaps, negligent. But people do not see things unless they are looking for them. In cocktail parties I do not find myself inspecting the other guests. I cannot detect a hidden emotional problem any more than a surgeon could look around the room and spot someone with gall stones.  (c) Fredric Neuman