Recently, I listened to an audio interview with a journalist named Michel Martin. She has reported for the Wall Street Journal, Washington Post, and has been a host of programs on NPR. In 2014 she was interviewed by Krista Tippett of the radio Program “On Being.”
Sometimes I need to take hour long car trips and look for podcasts to listen to while driving. I’m glad I stumbled on this one featuring Ms. Martin, a truly wise person, who said something that struck me. She was describing how so many people, coping with poverty and violence, seek to be noticed, to have their voices heard. Halfway through she said, “I think sometimes what we do as journalists is, if I could use this expression, a ministry of presence.
Hmmm. Ministry, of course, often refers to a religious endeavor, a ministering to people’s spiritual needs. The word ministry, however, has a broader meaning, as service to people and, as one might hope, faithful service to the people, in which the needs of the people being served are kept as the primary goal of the ministry’s actions. In many countries government agencies are called ministries, like the Ministry of Health or the Ministry of Finance. Now, regarding the ‘faithful service’ that ministries are tasked to provide, clearly many fall far short of that ideal. Nevertheless, the ideal stands. Given this definition, it is appropriate to define what journalists do as a ministry of faithfully reporting the truth to the world, of letting people’s concerns be identified and broadcast to others.
I began to think that what we do as psychiatrists also can be considered as a ‘ministry of presence,’ of providing our patients with the solace that comes when one’s pain, disappointments, fears and desires are listened to, understood, accepted, and validated.
It is no accident that the foundation of DBT is acceptance and change: One cannot guide a person toward change without first accepting them and their best efforts the way they are now.
Over all the years I held the Psychiatry Oral Board courses, I witnessed between two and three thousand psychiatrists interview patients and / or present cases. One pattern I noticed was what occurred in an interview when a patient felt they were not being heard: they would repeatedly return to the point they struggled to get the clinician to ‘hear’ and respond to in some way. The interviewing psychiatrists felt extreme time pressure due to ‘having to get all this data in 30 minutes.’ It was understandable that sometimes they would relentlessly ‘drive’ the interview in directions towards what they deemed important for a board-style interview. That meant many often rapid-fire questions about symptoms and risks, all important information, no doubt.
But what often got lost in the interviewing psychiatrist’s focus was what seemed to be the most important topic the patient wanted to discuss. Such topics usually related to something that continued to be a source of pain for the patient. This could include death of a child or spouse, declining health or loss of function, or disappointment in someone important to the patient who let them down. After the interviewing psychiatrist was able to ‘check off’ that issue as representing some symptom from the DSM – depressed or anxious mood, for example – they often lost interest in further discussion of that topic.
But the patient didn’t. They kept returning to that topic, often resisting the interviewer’s lead onto other topics. My advice in those situations was, “the quickest way to gain the patient’s cooperation to follow your lead into the areas important to you is to first address their need to share with you what is most bothering them. What seems like the slow way is actually the faster way.”
Those were the oral boards, of course, but this concept of listening to, demonstrating an understanding of, acknowledging and validating a person’s pain is even more pertinent to the real world of caring for people with psychiatric conditions. Allowing a person to feel they are ‘present’ to you is the quickest way to establish a therapeutic alliance and gain commitment from a patient, and the easiest way to provide succor to a person. Allowing someone to be present to you is therapeutic in and of itself. Someone whose suffering and struggle are heard is in a stronger position to overcome the hurt.
If interested, here’s the link to the transcript of Michel Martin’s discussion:
Until next time,
“Let others see their greatness when looking in your eyes.”
– Mollie Marti
“There is no good singing. There is only present and absent.”
– Jess Buckley
“From the beginning the focus of DBT has been a ‘life worth living.”
– Marsha Linehan
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