Attitude 1 says that patients know what they want but not necessarily how to get it, and psychiatrists are there to advise them. So a patient might say “I want to stop being depressed”, and their psychiatrist might recommend them an antidepressant drug, or a therapy that works against depression. This is nice and straightforward and tends to make patients very happy.

Attitude 2 says that people are complicated. Sometimes this complexity makes them mentally ill, and sometimes it makes them come to psychiatrists and ask for help, but there’s no guarantee that the thing that they’re asking about is actually the problem. In order to solve the problem, you need to unravel the complexity, and that might involve not giving the patient what they want, or giving them things they don’t want. This is not straightforward and requires some justification, so let me give a few cases where Attitude 2 seems to me obviously correct.

1. A mother brings her 6 year old son to the doctor, complaining that he gets nauseous every morning. She wants the doctor to prescribe an anti-nausea pill. The doctor probes further and finds the kid only gets nauseous on school days. In fact, he only gets nauseous on school days when he has a particular gym class. The doctor asks the kid if there are any problems in that gym class, and the kid is reluctant to say anything. After a while, he finally admits there is a bully in that class. The mother calls the school, and the school takes care of the bully. After that the kid is no longer nauseous in the mornings.

2. A woman goes to a plastic surgeon asking him to fix her nose, which she insists is hideously deformed. The plastic surgeon thinks the nose looks perfectly normal and asks her to be cleared by a psychiatrist before surgery. The psychiatrist diagnoses the woman with body dysmorphic disorder, a delusional belief that one of their body parts is unbearably ugly. The psychiatrist advises the woman and her surgeon that plastic surgery does not work for this disease; if the woman gets her operation, she’ll inevitably either think that the new nose is just as ugly as the old one, or she’ll switch to focusing on something else like her ears or her mouth. He suggests she get psychotherapy instead. After several years of psychotherapy, the woman learns not to worry so much about her nose.

3. A woman goes to her doctor asking him how to taper off her birth control pills. The doctor is surprised at this request because he knows she is planning to break up with her boyfriend. The woman says that this is true, but she wants a child as a way to remember the relationship. The doctor probes deeper and finds the patient is very anxious and ambivalent about leaving her boyfriend and feels like if she has his child at least she will always have “a part of him” with her. The doctor refers her to therapy for her anxiety, and she is able to sort through her conflicting feelings about leaving her boyfriend. She chooses to stay on her birth control.

4. A man goes to his doctor asking for the strongest antipsychotics that exist, saying that he’s crazy and he’s going to hurt someone. The man converses very logically, and tells the doctor he’s felt like this for a year now and never hurt anybody. The doctor suggests that he’s not actually psychotic or violent, but might have an obsessive-compulsive disorder where he worries about becoming that way. The doctor recommends therapy for OCD.

5. A man comes to the psychiatric hospital saying that he’s suicidal and needs admission. The doctor knows him well, and remembers that he has been admitted five times in the past six months, each time after a life crisis, and that the patient has never actually attempted suicide and never even planned how he might do it. The doctor suggests that the man is using the psych hospital as an emotional crutch, and that instead of threatening suicide and going to the hospital whenever he is upset, he needs to learn more adaptive coping mechanisms.

Attitude 1 would have been the wrong choice in these five situations. If the doctor had just given the mother the anti-nausea pill she’d been asking for, the son’s stress about being bullied probably would have just caused some other symptoms. If the surgeon had just given the woman the nose job she wanted, she would have been dissatisfied with the surgery and wanted it changed again. If the third doctor had just told the woman how to get off birth control like she wanted, she might have had a baby for the wrong reasons and regretted it later, leading to heartache all around. If the fourth doctor had just given the man an antipsychotic, he would have unnecessarily exposed him to a potentially life-long course of very strong medication. If the fifth doctor had admitted the man to the hospital, he would be using up scarce resources and discouraging the man from learning better coping strategies.

Any halfway decent psychiatrist uses both attitudes at different times, but most people I know tend to lean to one side or the other. The 2-leaning doctors stereotype the 1-leaning doctors as simple-minded and gullible. The 1-leaning doctors stereotype the 2-leaning doctors as antirational paranoiacs with sledgehammers.

I remember a textbook talking about a case study by a famous psychiatrist. The patient had come in talking about how her husband was being borderline-emotionally-abusive to her. The psychiatrist interrupted her and said that she was perpetuating this dynamic to feed her own narcissism. The patient said this was absolutely not true and she wasn’t narcissistic. The psychiatrist said she would never be able to get over her provoking-her-husband problem until she admitted the depth of her narcissism. The patient refused to keep seeing the psychiatrist after that, and the psychiatrist commented that it had been a hopeless case from the beginning – the extent of her narcissism was so great that she would never acknowledge that somebody else might know more than she did.

And the textbook was very wishy-washy about this – it acknowledged that the famous psychiatrist was brilliant and was doing the right thing in trying to confront the woman with evidence for her narcissism, but then it said that maybe he should have taken a more compassionate tone. Meanwhile, I couldn’t help thinking that the famous psychiatrist was a jerk, that his only evidence the woman was narcissistic at all was a snap judgment from one or two easily misinterpretable things she said, and that call me narcissistic if you want but I wouldn’t have kept attending therapy with this guy either.

That right there is the failure mode of Attitude 2; when we get out of the perfectly safe cases I mentioned above and into the more extreme versions, it starts looking a lot like making snap judgments about how all of a patient’s problems reduce to a single personality flaw, and then interpreting everything about the patient in that light. Narcissism is probably the most popular, but other such flaws include “patient is regressing and wants to act like a child and have other people take care of her”, “patient is just looking for attention”, and “patient is obsessive and demands complete control over everything”. The problem is, once you make one of these judgments every possible piece of data becomes further confirmation.

For example, suppose that a patient says he is having side effects on his new medication.

If you already believe the patient is a narcissist, you can dismiss the patient by saying that he wants to be special, he’s not happy on the same medication as everyone else, he’s trying to control the interaction by making you feel bad because you gave him an inferior medication. The solution is to teach the patient that he can’t always have his way by continuing the medication.

If you already believe the patient is regressing, you can dismiss the patient by saying that he’s throwing a temper tantrum, that instead of dealing with the side effects like a mature adult he wants someone else to step in and make everything magically better. The solution is to teach the patient to deal with his own problems by continuing the medication.

If you already believe that the patient is looking for attention, you can dismiss the patient by saying that they’re just trying to get the doctor’s attention by complaining. You can teach them that this is a maladptive social strategy by continuing the medication.

If you already believe that the patient is obsessive, you can dismiss the patient by saying that he’s getting all neurotic over minor side effects and has worked himself into a frenzy over perfectly ordinary minor hiccups because he can’t tolerate anxiety. The solution is to reassure the patient that everything is fine and continue the medication.

If you already believe that the patient is a witch, you can dismiss the patient by saying that they’re trying to confuse and upset you so that you will be easy prey when they try to kidnap you and sacrifice you to their lord and master, the Devil.

So it’s pretty easy to dislike 2-leaning doctors. Also, fun. Also, quite often justified. So sometimes I give in to the urge and dislike them.

The problem is, sometimes they’re right. I remember one time I had a patient who complained that Geodon was making her hallucinate. Geodon is an anti-hallucination medicine, so the chance that it makes someone hallucinate is pretty slim – but I’ve read all the usual social media posts where people complain about their evil psychiatrist who just dismisses their deeply felt pain as fakery because they had a problem that wasn’t listed in the textbook, and I didn’t want to be that guy, so I went along with it. I asked her to take some Geodon right there in my office. She swallowed the Geodon pill, and sure enough, about two minutes later she said she was starting to have all of these terrible hallucinations.

So I explained to her that oral Geodon takes at least an hour or two before a reasonable amount gets into the bloodstream, and there was no biological way that it could cause hallucinations two minutes after she took it. Then we talked about why she might be scared of the Geodon, and whether she felt any ambivalence about really wanting to get better. Eventually she agreed to try the Geodon again and didn’t hallucinate any more.

Here I felt okay because I had biological impossibility on my side. But I always wonder how many cases I’m letting slip just because my patients’ stories are merely possible-but-unlikely.

Everything’s a tradeoff between Type I and Type II errors. If I err too far on the side of Attitude 1, then my patients will like me and I’ll never inspire a “my doctor said I was just making up my side effects for attention, and later on I got neuroleptic malignant syndrome and died!” horror story. But I will occasionally be doing the equivalent of doing plastic surgery on a body dysmorphic disorder patient, giving unnecessary and harmful medical care while ignoring the true problem.

If I err too far on the side of Attitude 2, then I always get to feel like a hard-headed non-gullible investigator digging down to the root of the problem – but occasionally I’ll end up like that famous psychiatrist in the textbook and tell people that the reason their foot hurts is because they’re narcissistic, and it has nothing to do with the fact that they stepped on a nail and the only reason they’re even bringing up the nail is their deep-seated narcissism.

I tend to lean way toward Attitude 1. I’m not sure I can justify it. Part of it is my personality: conflict scares me and I want to be liked. Part of it is that I read too many horror stories on social media about how much patients hate their Attitude 2 psychiatrists. Part of it is that Attitude 2 has a lot of its philosophical grounding in Freud, and I really don’t trust Freud.

This is a lucrative attitude nowadays. We are all supposed to be biological psychiatrists, all the old psycho-babble is no longer covered by insurance, and The Customer Is Always Right. I am lucky insofar as my natural tendency is also the socially more acceptable one.

(I suppose an Attitude 2 psychiatrist would say I’m not lucky at all, and that my unconscious desire for social approval and success has led me to adopt Attitude 1, and also I am a narcissist)

I may or may not be a narcissist, but I am definitely neurotic. And when my neurosis gets to “maybe I’m a terrible psychiatrist”, this is what it usually settles upon to worry about. Attitude 2 and the various arts associated with it are opaque to me. I can pass tests on them when I have to, but I don’t feel them in my bones. When I’m with a whole conference of doctors nodding their head and going “Yup, that guy’s a narcissist”, I’m always panicking, thinking “Wait, I’m not even close to convinced he’s a narcissist, and also nobody really knows how to treat narcissism, and I would feel a lot more comfortable if this conversation would shift to comparing and contrasting the various subtypes of dopamine receptors.” I am bad at it, and what’s worse I don’t even know if I should be better at it, and I don’t know how to solve the bad-at-it part without worrying that I’m sending myself and my patients down a blind alley.