My Problem With Anything Vague

The question I always have in psychiatry relates to the psychodynamic area of psychiatry.

“If something is unconscious to the patient, then how can you be reasonably sure that THAT is the reason for how she is feeling at the moment? You are just the therapist. If it is unconscious EVEN to the patient who had experienced it herself, then how do you know that you are right when you point out, oh, the childhood experience of this and that are the reasons for what the patient is feeling now?”

I kind of feel unsettled by the vagueness of it all.

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I think many people who are involved in psychiatry DO have similar questions about psychodynamic stuff like this. But perhaps, unlike me, they don’t really feel the need to vocalize their confusions (or maybe they are not confused about it. Maybe I am alone in this bothersome affliction. Oh well…). 

I never get a satisfactory answer.

Or maybe… my benchmark for what is a satisfactory answer is higher than most. I was like that since I was a child. I would ask the same question to my parents repeatedly until I was satisfied. Of course, as I grew into adulthood, I learned to suppress my questions and pretend that I am satisfied with an answer… just to cut the interaction short. I suppressed my dissatisfaction at the answer that I received so that I could simply leave the discussion. And then I went back home, forever googling. Hahaha.

There are times, when I wonder, why should I bother being so open about my dissatisfaction? Orang lain belajar, jawab exam dan lupakan! Tak payah nak ruminate or question something that is already in the syllabus!

But questioning is how I learn! Debate, discourse, arguments… that’s how I learn. I need to know. Not with ABSOLUTE certainty; just with reasonable certainty that are backed up by scientific evidence.

Is-Arguing-Your-Childs-Learning-Style
I have to admit that my arguments can be very tiresome. Don’t take it personally, ok. That’s just my learning style. Convince me! Break my argument! Then, I will learn where I went wrong. If you cannot rebut me, then I will go away believing I am right.

When I was a teenager, I even questioned the so-called religious stories that were fed to me and my friends. And trust me, among traditional Malay community, questioning anything that sounds religious is taboo. They can jump to conclusion “Your faith is weak! Questioning something religious… you should make taubah and say astaghfirullah. It is the Satan whispering evil doubts to you.”

Kesian kat syaitan. Tak pasal-pasal dapat nama! When it is actually THEIR respresentation of religion that is faulty!

I had asked my naqibah, “Is that religious for her to ‘cungkil’ her eyes just because a man was attracted to her eyes? She had covered her aurat, even wore a purdah. But just because a man, who could not control his own self, was attracted to her eyes, she was supposed to ‘cungkil’ them out to demonstrate to us of her piety? Aku tak faham! How is that religious?”

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In one narration, this woman ended being dead! And this story has been propagated as the story of a pious woman that all women must aspire to become! And only MUCH later did I find out that, it’s a fake story!! And this story is still circulating in dubious blogs and among ustaz/ustazah who could not be bothered to check their references.

I was 18 at that time, doing my IB studies in KMB. I was just a teenager; albeit a curious one. When adults (like ustazah who endorsed the content of the ‘talk’) do not even question the ‘religious’ story, what authority did I have to even question it?

But question it, I did. 

I couldn’t help myself. It was deeply ingrained in my psyche to express my discontent at things that do not make sense.

I was SURE many students MUST have had similar thoughts, but they didn’t feel the need to voice them out. Kita dengar, kita balik, kita lupakan. That was the maxim!

And I used to be like that too. Religion was a mere ritual, separated from any logical understanding whatsoever. I prayed, I fasted… I was good enough, I thought. That was enough, surely! I would have been just like other teenagers….EXCEPT…. at that time, I was dealing with the death of my ex-classmate. I was interested to know – more than I ever did before – about religion, about philosophy, about life after death.

And they fed me these illogical stories?! (I knew it was not intentional on their part. They believed the story themselves! To them they were speaking the truth. But shouldn’t they have cross-checked their references before they gave talks to others. If I were the one being asked to include such a nonsensical story in my religious talk, I would probably ask about the authenticity of the story and investigate the sources until I was satisfied enough! You nak bagi talk, you prepare betul-betullah, kan!!)

If  they had known, how MUCH such fake stories would SHAKE!!! the foundation of someone’s faith, especially in the context of someone who was grieving and was searching for the TRUTH, they would NEVER think that their fake Israilyat stories were harmless and were just for  “Pengajaran saja. Bukan maksudnya kena cungkil mata. Kita nak tunjukkan potret seorang wanita yang berakhlak mulia.” Ugh!!

I was incredulous and very upset when I heard such an answer! What the hell, berakhlak mulia pi cungkil mata tak pasal-pasal? (In psychiatry, that is like deliberate self-harm! And we use the term deliberate self harm even for someone who simply cut their wrists. But this is cungkil mata, okay! Imagine if we have a non-muslim psychiatrist hearing this story, he would NEVER be interested in Islam kan! He would say Islam endorses deliberate self-harm! This is why the Prophet (PBUH) made it so CLEAR, that ‘sesiapa yang berdusta atas namaku, dia telah menempah tempatnya di neraka’. That is a huge warning, you know! Some people could not imagine how stories like this can turn intelligent people away from the religion! They could not imagine that …because in the first place, they were not deep thinkers! So why would they ever question anything, right? They assume everyone is as simple minded as them! And anyone who question them is just not religious enough!)

Glad INTJ argues

****

Let’s create a made-up scenario here to demonstrate how easily we can be wrong in our assumptions.

Let’s say… an imaginary psychiatrist, who is not well-trained in psychodynamic, finds out that when I was 11 years old, Ustazah S at my primary school was upset at me for secretly reading the school magazine in her class while she was teaching. This imaginary psychiatrist also finds out that Ustazah S had scolded me fiercely and took my magazine away from me and then she hurled the magazine out of the classroom door until it fell all the way to the ground floor of the building. (I was just flipping through that school magazine in her class because I couldn’t wait to find out whether my short story was placed in the ‘karya murid’ section.  Hahha. My fault for being unable to delay my gratification, I admit. But she didn’t have to throw my magazine down the building, right? Marah aku sudah cukupkan?! Tak payah lah nak rosakkan majalah sekolah aku, right? Hahha. I was ready to admit my mistake for reading the school magazine in her class. But when she threw my magazine all the way from the 3rd floor down to the school garden, I could feel my anger flare almost instantaneously. Instead of looking downward to demonstrate my remorse, I looked up and stared back into her eyes and refused to look away. It was a staring match I was determined to win. Hahah. She became upset and scolded me even more. “Kenapa jegil mata kat Ustazah? Tak puas hati!?” I remained silent but I held her gaze still. In my heart, I went “Memanglah aku tak puas hati! Kau baling buku aku kot! Kalau rosak, kau nak ganti ke?!” Haha. Seriously, I loved all my books! At that age, I had to collect my school money to buy myself any book and magazine that took my fancy. Every single book was precious to me at that time. So, of course I was angry! Ustazah S decided that I should stand at the corner of the class for the rest of the period because of my insolence for staring at her eyes. I defiantly held her gaze while walking to the corner of the classroom. In the end,  I won the staring match. LOL. Until now, my hilarious siblings who knew the story would take one look at me and said, “Weh…mata kak ngah dah mencerlang tu. Dia dah marah tu. Lariiii!” hahah.)

stubborn INTJ

 

intj stare
Hahah. I am not this bad. I don’t think I have a sinister smile.  LOL

The psychiatrist who finds out of my history with Ustazah S would probably say, thinking that he is applying his psychodynamic skill, “Hmm…maybe this is why you are hypercritical towards religious figures? Because of this ustazah? Maybe this is why you always like to question religious stories? Maybe this is why you don’t like anyone who speaks  like ustaz or ustazah? Because of what happened to you in your childhood with this ustazah….”

I would probably go…. “This psychiatrist is so ridiculous. He just didn’t get it! Such a faulty psychoanalysis!”

This imaginary psychiatrist is ignoring every other thing that was relevant to my behaviour in KMB when I questioned that ‘cungkil mata’ story. He is ignoring the fact that in the first place, the religious story was fake! When I questioned it, my question was right. I did not question it because the speaker reminded me of my childhood Ustazah S! I questioned it because I wanted to know whether the story was valid… because it sounded so dodgy, okay?! He is also ignoring the fact that, there ARE religious figures that I actually like especially those who are logical and sensible. So how does my terrible childhood experience with Ustazah S can explain my ability to like certain type of religious figures? Surely my sentiment and my dislike towards anyone is more logical than just being solely influenced by my brief childhood experience with Ustazah S. Human beings – when they are not psychotic, at least – are logical creatures!

This psychiatrist, if he jumps to such conclusion, is not being thorough in his assessment! For example, he might also be ignoring the fact that as teenagers, our formal operational stage was on the way to its peak! (Google Piaget Theory of Cognitive Development, guys!) Our logical sense was at its peak when we are at the teenage stage, especially when all our lives, we are surrounded by intelligent cohort from our previous school and all of them study science! Of course, we would question something as stupid as the ‘cungkil mata’! And do not forget the context of me dealing with the death of my friend. The urgency of me wanting to know existential, philosophical stuff like this was at its most passionate at that time. 

piaget-adaptation
Piaget Theory of Cognitive Development

 

When you put all those into context, the childhood Ustazah S really is not that significant to explain my abrasive manner in questioning religious authority, is it? 

So, my point is, not everything is about your terrible childhood, right? Childhood experience cannot explain everything that you are feeling or going through now! People who you have met and disliked in the past do not necessarily have such power over you that you would illogically and instantly dislike anyone who you meet in the future that reminds you of them!

I don’t believe that psychodynamic is that simple!

Oversimplifying things like this is an error in judgment!  We would be underestimating the power of our brain to learn from other non-childhood experiences. Our brains are always continuously learning, adapting, and assimilating our mental schemas (Piaget’s theory again) until we reach a cognitive equilibrium! And this process goes on for the rest of our lives.

You are not defined by your childhood alone. You don’t stop learning and adapting and accommodating… and you don’t always get stuck in a rut just because of your terrible childhood experiences. Our brain is so much better than that when it comes to adaptation!

Give our brains some credit!

I created that ‘imaginary psychiatrist scenario’ simply as an example of how easy it is to jump to conclusion and construct a connection which is NEVER actually there. And trust me, in those who practice psychiatry, sometimes they DO have the tendency to make assumptions, thinking that they are applying their psychodynamic theory that they learned VERY superficially during their Master days.

Heck, one case protocol….does NOT a psychodynamic expert make!

And yes, sometimes making assumption is necessary to help you direct your thoughts in formulating your case… but you MUST verify it! Otherwise, your assumption is pointless in the general scheme of things; your assumption would be worthless to the case and at worse, it only makes you come across as judgmental to the patient. 

If you have learned psychodynamic and you think assumption and interpretation can be made lightly, you don’t understand it enough! You don’t respect its grey complexity enough! And therefore, you should not be applying it haphazardly! I don’t like psychodynamic, but I have a lot of respect for it sampai aku tak berani pun nak guna that approach and pandai-pandai buat assumption pasal orang. Because I understood how very easy it is for me to be wrong when something is as vague and as unscientific as this! Psyhodynamic is an art…. more than it is a science. Some people are good and talented at this art… but for those who are not good at it, they shouldn’t even bother to make assumptions ‘tak semena-mena’, thinking that they are simply applying their psychodyanamic, ehem, ‘skill’.

I prefer the straightforward approach. If I observe something about the patient that I do not find the real origin for, I will clarify it with the patient. The patient deserves the chance to either confirm your assumption or deny it! You owe your patient that much. You owe it to your patient to make an effort to come to a correct understanding of their position!

“Afiza, for those who are well-trained in psychodynamic, I am sure they won’t simply jump to conclusion based on flimsy observation.  Psychiatrists who are trained in psychodynamic would take everything into context lah! Macam yang you nak dan macam yang you cakap tu!”said a friend of mine with whom I discussed the matter over. 

“Okay, kalau macam tu, we as psychiatry doctors should be trained very well first in psychodynamic.We should first KNOW which type of cases and which type of patient warrant psychodynamic approach. Kalau kita just psychiatry doctors biasa yang tak expert in psychodynamic, kita tak boleh pandai-pandai buat assumption kan? Some patients are intelligent, you know! And they might take it personally when we cannot connect the dots properly and simply repeatedly go back to her childhood yang mungkin langsung tak signifikan! Lepas tu bila dia annoyed dengan kita, kita cakap dia ada transference dengan kita pula! Padahal mungkin dia memang ada valid reason nak annoyed dengan kita!”

My problem is: I don’t like vague things! And psychodynamic feels vague to me. I will never be good at it, I humbly admit. And that’s why I just bought a book on psychodynamic. I want to settle these doubts in my mind once and for all. 

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I just bought this book via Book Depository. It cost me RM232. I wanna cry!

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I am just an MO. So if I said something or expressed my criticism towards a certain concept or worldview in psychiatry, I am just not credible enough, right? Not everyone is like INTP/INTJ who respects someone NOT based on position, but based on what you have to say. Some people need the stamp of titles and authority to push them to reevaluate their thoughts.

INTJ and authority

Kalau HO/MO cakap tak betul atau tak dipersetujui oleh orang atasan, mesti akan dikritik. Kalau specialist cakap, tak betul pun kita akan senyap. That kind of ‘yes boss’ attitude is prevalent everywhere and I have kind of adapted to that and have stopped expecting Malaysians to be less of a coward who can actually be honest with what they really think and just speak them out. (There is a lot of psychodynamic in this paragraph, and if you are the psychodynamic type you might be able to see it… But rather than going back to my non-existent childhood trauma, you can just go back to my first posting as a HO. Haha. See? Not everything is about childhood! My attitude towards authority began slowly as part of my INTP/INTJ personality but it escalated to this point after my first posting. Our brain is not so weak that they are stuck in childhood forever. Some people do get stuck with their unresolved childhood conflict… but some people get upset due to some recent things they genuinely and validly SHOULD be angry about. So, verify, verify and verify! Verify your assumptions with your patients!)

Imagine my delight when I read the book written by Jeffrey A. Lieberman (the former president of American Psychiatric Association) earlier this year, and he concurred with what I had always believed about psychodynamic. I don’t generally read a lot of non-fiction (I have been trying to increase my habit of reading them over the years) but this is one non-fiction book I actually enjoyed and I found it very relevant to my career.

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Well, Dr. Lieberman who was also one of the people involved in constructing DSM III which was a MUCH more systematic DSM than the previous two DSM…. well, he criticized psychodynamic quite heavily himself in this book.

Dr. Lieberman went through the history of psychodynamic and psychoanalysis in his book. He explained the history of how it came all the way from Europe to be practiced in the US, and how it then affected the psychiatry practice in the US.  He said that, initially Freud’s psychodynamic had brought respect to the psychiatry field until they feel they owed a lot to Freud/psychodynamic in general…. but as the sciences became more influential, as biological and behavioural approach took center stage, others started being openly critical towards this approach, and slowly but surely they departed from this approach.

I love this book! I have been having the same thoughts about the imprecise and unscientific nature of psychodynamic approach for so long (since I got into the psychiatry department) that when I stumbled across this book, I felt like “Yes! Finally there is someone who call a spade a spade. Finally, someone influential had written a book that concurred with my thoughts.” (I am sure there are others who have probably written the same thing over the years, but none that I have personally read myself. So yeah, I was pleasantly surprised when I read this book. I was so impressed by Dr. Lieberman’s book, so much so, that after I returned this book to my friend who had lent it to me, I went online and purchased it for myself so that I could have the copy of the book for my own keeping. So this book flew all  the way across the vast seas for me. I recommend this book for everyone interested in psychiatry!)

One of the best feeling that a  reader can experience  is when we read the written thoughts of someone else we have never met and yet…we can feel… “You and I could have been good friends if we are not separated by time and space. You explain my thoughts so precisely in a way that I would never be able to do. I would love to meet you.” (I feel that way towards Charlotte Bronte, Anne Bronte, Jules Verne and Jane Austen. And many many more authors. I have had hopeless crushes on book characters for so many times that I have lost count on how many different ways my heart is divided. Haha.)

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I am not saying that psychodynamic approach should not be practiced. Some of the theories are actually understandable (id, ego, superego is one example of psychodynamic aspect that I can understand…well, sort of. Fruedian slips do make sense in a way. Free associations can be useful in therapy, I suppose. The negative therapeutic reaction described in psychoanalysis is comprehensible enough.)

I am saying that when it comes to making assumption about our patients (or about other people in general), we have to keep in mind that psychodynamic is not precisely accurate. There is a high chance that we are wrong in connecting the dots especially when we are not trained! I repeat, “when we are not trained!”

If we want to practice it, we should do it properly.

Further your training in psychodynamic if you like it so much. Do it right. Don’t just make assumptions in every case you see thinking you are applying your psychodynamic approach, and at the same time you never even make the effort to actually verify what you assume about the patient. Because people who really know what psychodynamic is about would find our casual manner of doing it as quite haphazard and an insult to the REAL way psychoanalysis is supposed to be done.

I am sure that psychodynamic psychiatrist would inwardly cringe when they hear their colleagues jump to conclusion improperly and would feel “this people would give this approach a bad name; more bad name than it already has.”

Some assumptions are not psychodynamic. Some assumptions are just nonsensical baloney. And we in psychiatry should know that. If we want psychiatry to gain some semblance of elite status in medical field, we can start by being serious and methodical in how we come up with our thoughts about our patient.

My take home message is this: If you want to practice psychodynamic, you do it right and do it properly. Intelligent people can hear what you say and they can break your assumption to smithereens when they are annoyed by your jumping to conclusion and they will walk away thinking psychiatry is full of baloney. Is that what we want? For intelligent people to feel psychiatry is bogus? Just because we are psychiatry doctors and are ‘supposedly’ an expert in human behaviour and motivation, it does NOT mean that we are correct in our assumptions all the time. It does NOT mean that we can make assumptions based on flimsy anecdotes when we are not properly trained. And then, we go around giving excuses “oh, this is psychodynamic approach.” *shakes head* Aku rasa psychodynamic psychiatrist pun akan bengang! Be fair to the patient…. be fair to the reputation of psychiatry. Be fair to yourself! 

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