Posted by: thealienist | October 2, 2014

The Psychiatrist as Scout

When I was in residency, my attending psychiatrists sometimes described psychotherapy as two people walking together. The patient is in the lead, and the psychiatrist has a flashlight with which he can point out and illuminate interesting or useful objects or processes. I like this image, though I prefer the image of the old west scout who was hired to guide explorers and settlers through the mountain passes and wilderness paths of America’s frontiers.  Still, this image brings up some questions.  How did this unlikely pair come together?  Where are they walking?  What does the psychiatrist bring that is of value to this pair?  Who is in control?

As to how this pair came together, it has happened in many different ways.  Most of the time the patient has sought out help.  He has tried many different ways to navigate his way through life but has come up against obstinate and seemingly intractable obstacles.  Other times, he has been lost and endangered, and society finds him in need of rescue.

As to where the pair is walking, ideally it is the domain of the patient’s life.  The patient sets the destination and may even suggest the proper trail to take.  He will tell the psychiatrist about past attempts to reach his destination and the difficulties that have thwarted his progress.  Their walk together will take the pair through various areas of the patient’s life.  Some terrain will be easy, but much of it will be strewn with anxiety, fearfulness, almost overwhelming hindrances, exhaustion, confusion, bewildering wildernesses, and wreckage from previous failed passages.  The walk will be hard, and the patient may doubt at times whether the effort is worth it

And how is a psychiatrist equipped to help his patient?  His best equipment is his experience.  He has walked similar paths before.  He knows the terrain.  He has helped others clear the obstacles they will likely encounter.  He knows what paths others have taken to continue their journey.  He knows the signs that suggest that a path is good.  He knows the signs of danger.  He has seen others overcome hardship to reach their goals.  His next best supply is courage and encouragement.  He is willing to stand with his patient has he confronts his challenges.  He sees his patient’s goals and desires as worthy of endurance and effort.  He sees his patient’s emotions as honest expressions of his inner life and worth understanding and experiencing.  He will not retreat from the difficulties they face, nor will he accept the responsibility for completion of the journey.  Instead, he will encourage the patient to exert himself, accept challenges, and persevere until the journey is complete.  The psychiatrist is also equipped with strategies and supplies for the journey.  These may include psycho-therapeutic approaches or medications.  In the end, though, the success will be the patient’s.

One issue that sometimes gets confused in this relationship is, “who is in control?”  In the long run, and in the vast majority of cases, the patient is in control.  It’s his journey, after all.  (If another party, such as the courts, gets involved, then neither the patient nor the psychiatrist is likely to be very happy.)  Still, the psychiatrist remains in control of himself.  He remains free to assist in ways that he sees helpful and to refrain from helping in activities that he sees as harmful.  In this way, both the patient and the psychiatrist negotiate what each is interested in doing and not interested in doing.  Neither is in absolute control, though the goals are the patient’s, the efforts are the patient’s, and the chosen means of attaining the goal are the patient’s.  The mental health expertise and certain resources are the psychiatrists.

In a successful expedition, the patient attains his goals — a new way of living, the discovery of some important meaning and significance in his efforts, or some peace of mind and contentedness.  The psychiatrist has earned his pay and been given the privilege of accompanying him on the journey.

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