"The experience of learning to know another’s inner self is one of the most difficult, but most gratifying parts of our clinical work," writes Allan Tasman, MD.
FROM THE EDITOR
With one breath, with one flow
You will know Synchronicity
A sleep trance, a dream dance,
A shared romance, Synchronicity
A connecting principle, Linked to the invisible
Almost imperceptible, Something inexpressible, Science insusceptible.
Logic so inflexible, Causally connectible
Yet nothing is invincible. . . .
If you act, as you think,
The missing link, Synchronicity.
Sting and Sumner Gordon Matthew
In a brief experience of synchronicity, just before I sat down to write this last editorial in my capacity as Editor in Chief of Psychiatric Times, I saw an article in the New York Times about the author’s feeling privileged to speak with several individuals who had written a Psychiatric Advanced Directive (PAD).1 The writer felt humbled by those individuals’ willingness to speak with her about their illness. Having had few such discussions, she was struck by how much the individuals she interviewed were aware of their own mental states. To me, though, it was clear that something about the relationship the writer had developed with those individuals fostered their willingness to share their inner worlds with her.
The experience of learning to know another’s inner self is one of the most difficult, but most gratifying parts of our clinical work, and I’ve written about this in Psychiatric Times and elsewhere and lectured about it, on many occasions. To me, this capacity is at the heart of successful work with our patients and learning about it is the most difficult but important skill for psychiatrists.
One of my first experiences as a third-year medical student during my first rotation, in psychiatry, was learning that it is possible to understand a patient even in the most severe psychotic state. When the chief resident asked a patient with schizophrenia how he was doing, the patient responded with an angry tirade about how Lyndon Johnson was burning and killing defenseless babies in Vietnam. I was taken aback at the patient’s vehemence, but our chief resident calmly asked if our patient felt someone had been mean to him that morning. Yes, the patient replied, he thought the nurse was angry when she gave him his medications. Our chief said that the nurse was very busy and wasn’t angry with him at all. The patient visibly relaxed with this brief reality testing, nonpsychotic interchange.
A few weeks ago, I had a similar experience with being in synchronicity with a patient. I was asked to join a resident in speaking with a young man who had been unsuccessfully treated with medications for an acute onset of depression and anxiety several months following the shooting death of two close relatives. After speaking with him only for several minutes, I felt there was likely something that he hadn’t spoken about that was bothering him.
Was it his body language, open, but holding back at the same time; his affect, the worried expression on his face; or something more? I can’t really say. But I felt something was missing and I asked if he knew why he felt so bad, even beyond the fact that the two deaths were so understandably and horribly upsetting. Yes, he said with no hesitation, he felt guilty.
“Why?” I asked. “Because I should have been able to prevent it,” he responded. This led to a brief conversation in which I began to better understand the origin of his ongoing guilt. As he told me the specific details of what had happened, I thought his guilt was in reality unjustified. His response to my subsequent question about whether he had told anyone about his guilt led to his revealing that he had not because he felt so ashamed.
I’ve been doing clinical work for over four decades, and I still can’t explain how at certain moments with certain patients I feel in tune with them. It’s my and their state of consciousness within our relationship that in some way seems to help them to reveal something about their inner lives to me. When I teach residents and students, I talk about this state as learning to listen not as an external observer but as an empathic listener. I’m not sure, though, that description completely captures what is happening.
I still can’t really explain what allows us to inhabit, even though briefly and incompletely, the hidden self of another person. Is it a finely tuned mirror neuron neural network, or quantum mind and entangled electrons, or something else? I just don’t know, although I do know that we can enhance our ability with time and effort and self-reflection. And, it may be that Heinz Kohut was right when he asserted that empathic connection and understanding, this sharing of souls, this synchronicity, is the curative transmuting component of our psychological treatments. And, that it is likely to affect the outcome of all treatments.
Outside of a science fiction story, we still don’t have an expeditious way to enhance the capacity for developing empathic connections. At present, developing this skill requires lengthy practice. But, who can say what the future holds. Our neuroscience research findings about brain function are growing too fast to keep up with. What the near and distant learning path will be for this and other related and critically important aspects of the curative process is hard to predict. I think there’s a long road ahead, one that may take another generation to travel. I’ll likely not be working, or perhaps not even alive by the time the full understanding is discerned.
So goodbye yellow brick road . . .
I’m going back to my plough. . . .
. . . I’ve finally decided my future lies
Beyond the yellow brick road
Goodbye Yellow Brick Road,
Elton John and Bernie Taupin
There are so many issues we deal with and so many barriers, from too few psychiatrists, to lack of knowledge and inadequate skills, to societal, governmental, and health system matters, that an apparently unending array of work remains to be done. I am honored and appreciative, and fortunate, that I’ve had a chance to highlight some of this ongoing work through my position at Psychiatric Times.
There are still many patient populations that have little access to psychiatric care, including children, the elderly, those living in urban core or rural areas, service veterans, and members of minority racial, ethnic, gender, and immigrant groups. Of great concern is that suicide rates continue what appears to be an inexorable rise, including those at both the younger and older ends of the life cycle. And, the CDC just reported that that gun deaths were the highest in the 2017 reporting cycle than in decades, or possibly ever in the US. On the other hand, the government, although not nearly quickly or thoroughly enough, is beginning to take concrete steps to address the opiate addiction and overdose death epidemic.
Over the past years, Psychiatric Times has addressed all these issues and many more. And, I’m proud that during my tenure as Editor in Chief, we’ve begun to implement a number of initiatives to continue improving the quality of the articles you read both in print and on our website. It has been gratifying that the publishing staff have been responsive to a number of ideas from Michelle Riba, our deputy editor who also is stepping down from her editorial leadership position, and me.
We’ve taken steps to diversify the editorial board in keeping with national best practices to improve equitability, diversity, and inclusiveness of historically underrepresented voices. We instituted an editorial advisory board comprised of residents and recent graduates to open editorial access to the newest generation of our colleagues.
We also are quite proud of the formal alliances we’ve formed with a number of important subspecialty organizations in psychiatry. The expert contributions that have come from these relationships have clearly raised the bar for our content. In addition, we’ve benefitted from regular contributions from psychiatrists with a very diverse array of interests and expertise such as Fuller Torrey, Allen Frances, Harvey Greenberg, Tom Kosten, and Ron Pies to name just a few. David Pollack and his colleagues, as another recent example, have begun what will be an ongoing series on the psychiatric issues related to climate change. Ongoing work will assure that Psychiatric Times continues to achieve greater diversity in our regular contributors.
One of the most important collaborations I’ve been fortunate to have over my career has been the one with Michelle Riba. I know that her creativity, diligence, advocacy, and commitment to excellence in every aspect of her work have helped make me a better psychiatrist, scholar, editor, and person than I would otherwise have been. While I know we’ll both miss working together at Psychiatric Times, we also know there will be other collaborations down other roads.
Another important reason my work at Psychiatric Times has been so meaningful to me is not only the opportunity to help advance our field, but also to work with such a terrific and dedicated professional staff. I continue to feel lucky that Susan Kweskin, our former staff leader who I worked with through most of my tenure, convinced me to take the role of Editor in Chief. Although Susan left her position at Psychiatric Times in the spring, we have a connection that is ongoing.
As you may be aware, the ownership of UBM changed recently and that time of transition has seemed to me a good time for me to make my transition from the Editor in Chief role I’ve filled since 2014. In addition to that transition, and Susan Kweskin’s departure, there have been other staff transitions. Guiding the ship through all these changes have been three talented and hardworking people whose behind-the-scenes work rarely gets public notice.
Natalie Timoshin has done an incredible job steering the Psychiatric Times ship as executive editor since Susan’s departure. Heidi Duerr has always done an amazing job with our special reports and other major content and now is outdoing herself. And, Laurie Martin has used her magical skills to oversee our website’s incredible array of content, a job which normally would need to be carried out by several people.
The most important acknowledgement and thank you goes to my wife Cathy. My appreciation reflects not only her tolerating the many hours I’ve spent on Psychiatric Times that otherwise would have been spent with her. Cathy has been my most supportive (and critical) editor since I began to write lectures, editorials, and other publications four decades ago. The quality and readability of my work is due to her unflinchingly direct and honest editorial review and advice, well before I submit anything for publication. One of the things I’ll miss the most about stepping aside as Editor in Chief of Psychiatric Times is the time we’ve spent together fine tuning (and sometimes more than that) my monthly editorials.
There’s so much more work remaining for our field, and Psychiatric Times will, I trust, continue to play an important role in both highlighting our progress and reminding us of what still remains unfinished. I have unbounded pride that Psychiatric Times remains the most widely read psychiatric publication by psychiatrists in the US for a good reason.
There are so many of our readers I’ll never meet and benefit from through personal contact, but the relationship with our readers is something I already miss. I’ll simply close with this:
I did my best, it wasn’t much
I couldn’t feel, so I tried to touch . . . .
I’ve told the truth, I didn’t come to fool you.
Hallelujah, Leonard Cohen
1. Belluck P. Gaining Access to a Subject’s Mind. New York Times. Dec 17, 2018.