Over the Holidays, I attended a neighborhood get-together. There I started chatting with a woman who turned out to be a clinical social worker. As we started talking about working in the field of mental health, she asked me, “… what are the main lessons I’d convey to residents to help them become more effective psychiatrists.” Hmmm. I tend to think about such things so I wasn’t completely unprepared. But still, I had to give it some thought. Here was my two-part answer:

  • Learn to establish a relationship with a patient. Learn to harness the power to effect positive change in another person.
  • Learn to help the patient unpack their problems. Once you can clearly identify and define a problem, the solution becomes – nearly – self-evident.

Today I share with you my thoughts on the second point, leading patients through a process of “unpacking” their most anguish-inducing problems. One known method for doing this is called “The Five Why’s.” The concept is that whenever a person tells you they want something different than what they have now, whether it’s to have a million dollars, to be happy, to stop arguing with their spouse, whatever is their desire, the approach is to keep asking, “Why?” – consecutively five times, or more, if needed. This approach works for anyone and everyone and is even used by companies to identify next steps. This iterative process of exploration / investigation help individuals and entities identify their underlying motivations, thus providing a clear target for goal-setting and problem-solving.

Try it for yourself. Choose something that you want, something new to add to your life or something old to subtract from your life and keep asking yourself why you want that. The answers may surprise you.

Let me give an example of a (semi-remembered but illustrative) conversation between myself and a patient loosely applying this approach:

  • Jack: What is your main goal for treatment? That is, what change would you most like to see from our work together?
  • Patient: I’d like to be happier; I’m really depressed right now.
  • Jack: To be happier. That sounds like a worthy goal. Tell me in as much detail what you being happier looks like.
  • Patient: Well… To start with, I’d be able to sleep through the night…
  • Jack: Why is that important?
  • Patient: Right now, I wake up really early, like when it’s still dark…
  • (The patient now looks out of the window, focused on the mid-distance. So I know the patient is re-experiencing the state he’s speaking to me about. Thus, I know not to interrupt with the next question. Rather I wait…and wait…and wait as the patient struggles, apparently with whether he should tell me more. As time goes by, it seems that the side that wants to tell me is losing, so finally I ask the follow up question.)
  • Jack: Waking up so early… When it’s dark.. When everyone else is asleep. I imagine that’s a difficult time. Tell me what it’s like when you wake up in the dark?
  • Patient: It’s very lonely… I feel most alone then… I feel like.. Like I should be dead…
  • Jack: Please tell me more.
  • Patient: I feel like I don’t deserve to live.
  • (Here I strongly resist my urge to ask the patient if he has thoughts of suicide. Rather I hew close to his last comment. I nod and say…)
  • Jack: Please tell me more why you feel that way… I know it’s hard to talk about, but I think you will experience some relief when you’re able to tell me.
  • Patient: I know why but I’ve never told anyone before… I’ve done some bad things in my life… I’m sorry I can’t just blurt it out to you right now… Maybe next week…
  • Jack: I understand and respect your decision. I appreciate that you’re willing to talk about it after you’ve had some time to gather your thoughts. I’d like to suggest you consider writing down what it is that makes you feel like you deserve to be dead. Give it a try. It might make it easier to talk to me about it next time.
  • (I pause. The patient nods.)
  • Jack: I do have to ask you something very specific before you go: is there any danger that you will do something that will bring about your death… Or harm yourself in any way?

I went on then more formally discussing suicide risk factors. And asking the patient what he would like to do now about his sleep. We agreed he’d take a longer acting hypnotic, one indicated for sleep initiation and maintenance.

What I remember most about this conversation was that the patient started opening up about his suicidal thoughts and urges that started with a discussion about his sleep difficulty. He had not previously admitted to me the presence of suicide-related symptoms.

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What took me a really long time to figure out in my work with patients was that I needed to show more humility regarding what I understood about patients when they presented information to me. I was so confident in thinking I knew what they were talking about and in understanding their experience, that I would not actually follow up and ask in enough detail the exact nature of their problems, their fears and desires, and why all this was so important. Rather, I wanted to show off how good I was in empathizing, in thinking I understood what it was like to be them.

I am good at empathy and often have been able to establish great rapport with patients quickly. But I sometimes misuse this ability. I try to remind myself to not assume and to dig deeper. “Respect the patient’s story” is one of my mottos.

If you have an example of digging deep with a patient that led to a more complete understanding of their problems and suggested a path towards solutions, please write me. I would love to share such a “clinical vignette” with our readers.

Until next time,

Dr. Jack


Today’s Quotes

“Your pain is the breaking of the shell that encloses your understanding.”
– Khalil Gibran, Lebanese-American writer, philosopher, and poet (1883 – 1931)