Is Your Dogma Hurting Your Patients?

September 13, 2011

Psychoanalysis was my first love in medical school; really the only one. I briefly considered surgery but couldn’t bear either surgeons or the idea of standing up all day. In psychiatric training my favorite instructors and psychotherapy supervisors were analysts. I became determined to become one. It took me many years to recover from that decision.

I learned valuable lessons in psychoanalytic training and in my years of practicing it but ultimately realized that the orthodoxy required to go all the way, to become a full-fledged psychoanalyst and strive to become a training analyst, the top of the analytic food chain, was not my cup of tea. The simple, commonsense topic of this piece was verboten in that world.

Whereas the analyst strives to foster a process in which the patient may live out their inner demons and defenses against conscious awareness of them, I now try to directly promote the optimal development and functioning of my patients. You know all this: regular exercise, healthy diet, optimal BMI, good sleep, robust engagement in a community of others, the embrace of spirituality or mindfulness, and having plenty of fun. Make all these things important priorities for both yourself and your patients. I naturally perform a careful psychiatric evaluation and work with my new patient to tailor a treatment plan. But I now see the clinical process as embedded in the larger perspective of our ongoing development. A healthy brain is essential for success. Psychoanalytic techniques do come in handy in resolving or removing obstacles for engaging in healthy or optimal development. However, we can promote our patients’ development more directly. The following are examples of what I attend to as we engage in treatment.

We are what we think. A chief source of our distress is our thinking; assumptions we make; interpretations of events or other peoples’ actions or speech; fantasies, day-dreams. I have practiced mindfulness skills enough to, some of the time, find a bit of “thinking space” that is relatively clear and calm. I encourage my patients to find a mindfulness practice that suits them – meditation training, tai-chi, yoga, or prayer and reflection. As Merlan, one of my favorite old, wise teachers would say, “the only thing we control is our voluntary muscle system.” His point was the impossibility of controlling what happens in thought generation – but we can effect a shift of attention.

Nutrition and one’s weight are incredibly important. A physiology instructor in medical school claimed that a cheeseburger is the shining example of the perfect meal; maybe, maybe not. We are what we eat. Become curious about your patients’ eating habits. There is good evidence that we function optimally when slightly underfed. It’s not hard at all to tell if your patients are overweight. After all, most Americans are.  Eat foods that take trouble to prepare or at least chew. Use a few supplements – omega 3 fatty acids of good quality at around 3 grams per day, a good multi-vitamin, and extra vitamin C.

Run – work up a sweat every day. There is a clear correlation between regular running and increased concentrations of BDNF and other factors crucial for general brain health and memory in particular. Just a brief web search reveals a wealth of information about this aspect of self-care. This topic is especially pertinent for us psychiatrists since studies demonstrate a tight correlation between initiation of antidepressant medications, increasing concentrations of BDNF, and remission of depressive symptoms.

Learn. I read long ago that learning a new language or a new musical instrument are two excellent ways to boost brain health. Brain imagining studies demonstrate recruitment of surrounding cortical “real estate” of the motor areas innervating the muscles of the fingering hand of violinists. A more efficient brain is a healthier, more resilient brain.

Be careful with whom you associate, as mom used to say, but by all means, talk, interact with other humans. We have evolved as social animals. E. O. Wilson, a specialist in the lives of ants, claims that the unit of the organism, the super-organism, is the group. I suggest that this also holds for us. As individuals, our American rugged individualism notwithstanding, we fall; in association with our faithful group, we stand and prosper. So, make friends, pair up. As an individual you are incomplete, therefore stressed.

Avoid toxins – stress, especially that of the chronic variety, results in steady state concentrations of cortisol and other compounds that are literally toxic to our brains. Make sure that the stressors in your life are not the kind that linger. Alcohol and other “recreational” drugs, if present chronically in too high a concentration – kill brain cells.

Sleep – most people need 8 1/2  hours of sleep per night.  We need to be asleep by 10 and awaken at 6:30.  We should sleep at night and be awake during the day. This sleep should be uninterrupted. We should awaken refreshed and ready to tackle the day. This is the amount most of us need but the distribution is a bell-shaped curve. Some need more, others less. Sleep acquired with sleep promoting medication is better than sub-optimal sleep if non-medicated. In my experience many people will experience a decreasing need for sleep aids as they establish good sleep-wake cycle rhythms.

Do nothing – at least some of the time. It is madness that has most of us thinking that every moment of our lives should be filled with “productive” pursuits. Coast. Look at our beautiful Chicago skyline, the amazing play of light and shadow in our alleyways. Nap. Breathe. Enjoy it.

This approach to treating patients is a long way from the therapeutic neutrality my psychoanalytic education taught. I really want my patients to get better and leave my practice healthier. If you see that they are not taking good care of themselves, tactfully broach the subject and help them learn to do so. Engage them in the fight against the enemy that confronts us all – apathy and ignorance. It must start with you. If you are not in good shape physically, you know what you must do. Get started now. Think of these simple things as the very foundation of your practice in self-care and of the treatment of your patients. If this is unclear to you and you want to exchange ideas about it, email me at


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