Posted by: thealienist | September 16, 2014

Foundations of Mental Health: The Truth

There are many people who don’t believe that there is any “Truth.”  There are also many who believe that, not only is there “Truth” but that they know this “Truth” absolutely and need to make everyone else believe it.  Some people don’t believe in “Truth,” but believe that there is something called “truth” that may appear differently to different people and may even be contradictory to different people.  Some people base their “truth” on science.  They believe that everything that can be known can be known through science.  Anything that cannot be known through science must then be false.  Others believe that science can show us many things, but that there are things that science cannot know that are nevertheless “true.”

With all the philosophical confusion about what is “true.”  I wonder what the role of truth is in psychiatry and mental health.  I must admit that I am a believer in “Truth.”  Still, I don’t think I have a monopoly on it, though I continue to strive to see more of it.  I also believe that there is more truth than science can reach.  Not that I think that scientific findings are false — I just think that there are things that science is not equipped to speak about.  So, what about truth in psychiatry?

I think that truth is a matter that is important for both the psychiatrist and the patient.  Still, it is a slippery concept in some forms of therapy.  Let’s start with the psychiatrist.  The psychiatrist needs to know the limits of his knowledge.  There is a vast quantity of knowledge in the field of mental health, but most of it needs to be interpreted very carefully.  For example, we know a great deal about the brain (though much, much more remains to be discovered).  We know a great deal about medications that work for many people to decrease depression, reduce anxiety, increase attention, and control psychosis.  We know how certain patterns of thoughts, behaviors, and emotions produce clinical syndromes.  We also know typical courses of illness for these syndromes.  Given all this knowledge, it might be tempting to assume that we have the “Truth.”  However, there is much that we don’t know.  We don’t know exactly how brain function (or dysfunction) produces most types of mental illness.  We don’t know exactly how our medications improve functioning.  We cannot yet predict which types of treatment will be best for our patients.  It seems to me that a certain amount of humility is appropriate for our profession.

We do not do our profession any favors by pretending to know more that we actually know; however, we don’t do our patients any favors by pretending we don’t know what we actually do.  Do I know that SSRI’s increase serotonin levels?  Yes.  Do I know that increased serotonin levels are what decreases depression and anxiety?  No.  Do I know that depression is a “chemical imbalance?”  No.  Can I guarantee that SSRI’s will not cause a particular pregnant woman’s child to have a birth defect?  No.  Can I make an educated evaluation of the likelihood that her untreated depression will cause harm to her child?  Yes.  I know many, many things that can be of use to my patients, but there are just as many things that I do not or cannot know.  This is my truth as it currently stands.  I think my patients should know this.

Just as I need to acknowledge the limits of my knowledge as I use the truth I have in service of my patient, my patient needs to be wrestling with the truth as well.  So many patients live their lives in the shadows of lies.  They have been told that they are “worthless,”  “a burden,”  or “screwed-up.”  They have convinced themselves that they are failures or are incompetent to deal with what life gives them.  They passively wait around for financial payoffs that will not arrive.  They see stalkers who are not there.  They hear voices that are not there.  They are convinced of bodily defects that make them “ugly” or that will lead to their deaths.  They believe that they have no hope and no help to deal with their misery.  They tell themselves they are “unlovable.”  In the midst of their deception, they feels the need to lie to themselves, to their families, and to their psychiatrists.  They don’t trust anyone (often including themselves) with the truth.  They don’t want to see who they truly are.

Sometimes my patients have come to their mistrust by actual bad treatment from others.  Sometimes they create them all by themselves.  Regardless, they seldom get better (or stay better for long) as long as they prefer the false to the true.  It can take a long time for patients to get comfortable enough with me to risk the truth.  They need to be sure that I will not use the truth as a weapon against them.  They need confidence that I can handle the truth, that it will not hurt me, and that I will not use it to hurt them.  They also need to know that, when the truth comes out, I will not throw their previous lies back in their faces.  They need to know that they are safe being who they really are when they sit with me.

In their sessions, psychiatrists and patients wrestle with truth.  The psychiatrist has more legal power than the patient.  The psychiatrist generally has more knowledge of mental illnesses, treatments, and mental health.  But, he is also unable to make the patient do anything.  The patient, on the other hand, is the expert on himself, his values, and his goals.  He is the only one who can decide whether to participate or not in the therapy.  He has also, unfortunately, been unable to find a solution to his problems by himself.  The truth of a psychiatric session is that the psychiatrist has knowledge and tools to offer his patient, but only the patient can take these tools and use them to live a meaningful life.  Both will likely find the truth to be a slippery subject in the therapy session.  The psychiatrist will often wish that he had more knowledge, more skill, more tools, and more control to improve his patient’s life.  Some of these wishes may be possible, but others are false hopes.  The patient will sometimes wish that the psychiatrist could take control and improve his life or that his problem would simply vanish overnight.  He might wish that his past no longer mattered or that he would get another chance to correct past mistakes.  He may wish that his weaknesses would go away or that he would develop some strength that he has seen and admired in someone he knows.  Some of these improvements might be within his reach, but others are unrealistic and unlikely.  Still, if both the psychiatrist and patient prove trustworthy, it will become easier for both of them to see the truth and to cope with the truth.

Even when the psychiatrist and his patient are working well together, however, the truth can be slippery.  Sometimes as they play with ideas, they will talk about things that are not true as if they were.  In this, they occupy a special space where things are treated as true even if they are not.  It is a “transitional space” where the psychiatrist and patient can “make believe” and try out roles to see how they fit.  In this space, shy people can practice acting brave.  Confused people can pretend to be decisive.  Passive people can assert themselves.  Anxious people can be adventurous.  It’s a place where both participants agree to suspend the rules of “normal reality” and see how it changes their lives.  In some way, it is like little children playing dress-up.  In the play, when I dress up as a pirate, I am a pirate, and my friends interact with me as if I were a pirate.  We both know that I am not “really” a pirate, but we agree to pretend.  Just so, in the office, the patient tries on different thoughts, understandings, behaviors, and emotions.  If he likes them, he may take them with him out of the transitional space and make them “true.”

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Responses

  1. It seems to me that far more fundamental than the distinction between theists and atheists is that between those who believe in truth and those who do not (also known as psychopaths). To believe in truth is to believe that there are values that transcend our mere preferences. I find that my confidence in such values is pretty much untroubled by psychopaths, just as my love of color is not negated by the physiological occurrence of blindness; that is, I can reason that psychopaths are unable to perceive transcendent values.

    It is far more disturbing when genuine truths are diametrically at odds with one another. For instance, from what I have read and for all that I know, members of the Islamic State authentically believe that ruthless violence toward infidels is the best and most authentic way to honor God. Of the executioner who beheaded journalists in those videos we must surely say that he is evil, but we have no way of knowing that he is mentally disordered.

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    • I agree. I will look back over my post and see if I implied that people who commit some kind of evil thinking it to be good were mentally disordered. If I did, I did not intend it. I think that many of the mentally disordered have at the heart of their problem a misperception of some important truth. I do think, however, that there are many people who have misperceptions of the truth who are not mentally disordered.

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