I was musing while driving this week about how my attitude and approach to patients had changed over the course of my clinical career. I was recalling some of my unsuccessful patient interactions over the years and internally wincing with variable levels of embarrassment and regret. Just then, the word “humility” crossed my mind. I realized that there seemed to be an inverse relationship between my sense of clinical and personal humility and patient outcomes, that is, the more humble my approach, the better the outcome for my patients.

The converse was equally true: The more I assumed, jumped to conclusions, or was showing off, the less successful were my efforts to help the patient change in the ways they sought to change.

“Brilliant” Interpretations

Early in my career, starting in my residency, there were many times I wanted to “prove” myself to my patient – and myself, I guess – and would share with them some “brilliant” interpretation that came to my mind regarding the source of their difficulties. Some of these insights may have had some validity to them, but I noticed that often my “brilliant” insight, made with a flourish, did not make a difference; the patient went on as they had before, my insight sinking into the never ending stream of new events and experiences, one among the thousands a person lives through each day, barely leaving a ripple in its wake.

I was often left confused and even, at times, underappreciated by my patient, questioning my competence as well as the patient’s level of perspicacity and commitment. It took many disappointing “brilliant” interpretations for me to realize that what I was saying and doing was not so much wrong, as more or less irrelevant. Change can, but usually doesn’t, come from someone drawing a connection for you between some life events in your life, like for instance, hearing someone tell you that you have commitment issues because your parents’ marriage sucked. Even if true, now what? Or, as one patient once told me, “Tell me something I don’t already know!” Haha.

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So, if interpretations are, at worst, irrelevant or, at best, not enough, what else is needed to help someone make desired changes in their lives?  As you may have heard me say before, I now see myself as a facilitator of a person’s self-healing. Based on this view, I think the relationship between clinician and patient is foundational. Making “brilliant” interpretations, does not necessarily lead to a more engaged and trusting patient and can, at times, lead to the opposite.

Competence and Ignorance

The times I believe I have been most useful to a patient were when I practiced humility, when I did not assume anything about the person in front of me, and did not seek to “show off.” I came to the realization that a high level of clinician competence was not at odds with ignorance about the patient. My job was first to understand, and this humble quest was what most endeared me to my patients and built their trust in me. To understand is to keep my eyes and ears open, to not assume anything about the person, but rather to ask and observe, and ask and observe again and again. Certainly, as a competent clinician, I make hypotheses about why the person in front of me engages in certain behaviors. But I don’t want to fall in love with my hypotheses, which are only a step that guides my continually unfolding assessment.

These are some of the simple questions I learned to ask:

  • What would successful treatment look like to you?
  • What are your goals you imagine I can help you with?
  • What should we do if you find you’re not progressing towards your goals?
  • What’s helped you the most in the past?
  • What experiences have you had with psychiatrists and therapists that weren’t helpful, or even harmful, to you?
  • What am I doing that isn’t helpful to you?
  • How are we doing, as in, you and me working together?

Cultural Humility

In the process of writing this post I searched for “humility in psychiatry” and “humility in therapy.” I found there is substantial literature in cultural and multicultural humility in health care. (If interested, you can search for the Cultural Humility Scale.)

Certainly, a person’s experiences are affected by their multiple identities. As a married white male, in my mid 50’s, and a child of immigrants who has never served in the military, I have experienced the world in specific ways, ways that differ substantially from many of the persons who have been in treatment with me. The more my identities differ from those of the person seeking help from me, the more humble I need to be when seeking to understand their life experiences, expectations, concerns, sources of succor and threat, and idioms of distress and healing. What this means in practice, for me, is that I ask even more questions, and open-mindedly seek to learn.

An additional point should be made: I have found, both in my own work with patients and when supervising trainees, that that same humility and quest to understand is crucial when treating a patient who shares important similarities with the clinician. Paradoxically, a patient who shares the same ethnicity, social class, immigrant experience, religious tradition, military status, etc., as you do, may more easily inadvertently lead you to assume the patient is more like you than they really are. Your similarities may hinder your ability to see them and their needs in their uniqueness. And, after all, everyone has a right to be themselves.

Until next time,

Dr. Jack


Today’s Quotes

“The complex mix of unique people rising from different identities, beliefs, education, gender, upbringing, point of views, and ethnicity have unequal sense in their impact in other’s status, opportunities, resources, talents, skills, and productivity. It is very good to live with cultural humility that complements competency and proficiency.”
– Angelica Hopes

“The goal of competency is to equip you with the right answers, as if the culture you are experiencing is a language you have learned to interpret. The cultural humility approach, on the other hand, is meant to equip you with the right questions. Cultural humility, then, represents a shift in focus from confidence in one’s own knowledge to deference to another’s knowledge.”
– Jason Bilbrey