Luan Hassett

One of the big misconceptions about psychiatrists is that you have to primarily work in a cognitive way. Meaning you make intellectual decisions, requiring your awareness to reside primarily in your head rather than the rest of your body. I want to illustrate how this has not been the case in my practice.

Last Thursday I had a patient come into my clinic who was having a dreadful time with a family member abusing her emotionally and making physical threats. This relative had the history to make the threats credible, and my patient was distraught when she talked to me about it. She was too scared to go to the police because she was afraid of what he would do to her if she did. She sat in the chair opposite me and with tears flowing began to disgorge information about conversations and arguments and the chronology of the falling-out.

I had 15 minutes to spend with her. There was no way I was going to be able to help her situation because my only recommendation would have been to go to the police. From a psychiatric point of view there was nothing I could prescribe her which would meaningfully improve her life. She was already seeing a therapist, with limited results. Previous psychiatrists had been over the same story with her. She continued divulging and what I did was keep some awareness in my body and soften any tension resulting from feeling like my time was being wasted. And when the impulse came, somewhere in my gut, I interrupted her.

I apologized for interrupting her, not to appease her but just to acknowledge that she had a lot to say and I wasn’t allowing her to fully say it. She was okay with it. She soon resumed her divulgences, because this was obviously a core pattern for her especially with anyone in a helping role. Again I interrupted her, allowing a note of exasperation to enter into the tone of my voice while maintaining an open heart. Once more she received this well and the whole interaction ended up being quite brief. I didn’t change anything in her management plan. She left the room praising my kindness.

You could look at this story and you could think, well, okay, you didn’t prescribe anything, or make any other kind of important decision, so you didn’t really need to go into your head. Aside from the fact that any patient in distress makes a psychiatrist think about risk assessment, the point is that if I had approached the interaction headfirst I’d have gotten badly lost in the details she was giving me. The appointment would have run over time. I’d have been stressed and off centre and my head would have felt tight and dense. It would have been difficult to think through the next cases that came in the door.

Psychiatry has many such situations. If you live in your head you will get badly lost in the morass of detail and emotion which certain patients point at you. It’s not their fault and they’re not necessarily deliberately trying to cross boundaries or upscuttle you, but this is just the way that certain interactions go, more so in the emergency department where patients tend to be sicker, but also in clinic betimes. If you don’t know how to act and even to think and decide from your gut, I think your most likely experience will be to leave work with a tangle of uncomfortable sensations plus cognitive slowing/heaviness, and you will likely blame the nature of your work itself rather than the approach you’re taking. Meanwhile in work there might be some stuckness between finding the correct answer and carrying it out.

As for how to make difficult and complex prescribing decisions, I would say again, study the theory until the point where this too can move from your gut. Or if you’d like, just from your body. Sometimes it’s helpful when you speak about embodied decision-making to be less precise about where in the body it’s coming from, rather than going looking for a sensation specifically in your gut region. It may be that your heart is a more appropriate point of focus for a given decision, e.g. if there is counter-transference.

But yeah, your body is still going to tell you how certainly the symptoms meet the criteria to prescribe a medication, and your body will also tell you when it’s a bit too complex to make a quick decision and when you need to go talk to someone or look up guidelines. To illustrate Alexander Lowen’s claim that there is no effective thinking without feeling concomitantly, I would also say that when you sit down to study, you’re looking for a feeling of opening, one might even say wonder, (although that can be too strong a word at times), but even the subtle openings into the information, the subtle heightening of focus that doesn’t feel like a shear force within your system, but instead actually feels relaxed while the focus heightens. There’s maybe warmth and softness there too, and this is a good feeling to follow. It is the feeling that makes it so that study doesn’t have to be a form of self-coercion.

All of this is to say that Psychiatry can be an embodied practice. And I would even go so far as it should be, in the sense that if it isn’t you are going to run into unnecessary problems.