About That Mean Streak of Yours: Psychiatry Can Do Only So Much

About That Mean Streak of Yours: Psychiatry Can Do Only So Much By RICHARD A. FRIEDMAN, M.D.
When have you ever heard of a therapist telling a patient that he is mean or bad? Probably never.
It’s not fashionable in our therapy-friendly nation, where people who behave obnoxiously are assumed to have a treatable psychiatric problem until proven otherwise. Nothing in the human experience is beyond the power of psychiatry to diagnose or fix, it seems.
But even for me, an optimist and a proponent of therapy, things have gotten a little out of hand.
Not long ago, one of my psychiatric residents called in distress about a patient who was demanding a different therapist. “This guy is in my office shouting at me and telling me how bad I am,” the resident said.
Sure enough, the patient in question was very hostile and demeaning in talking about this young doctor. Jabbing his finger in the air, he told me how unsympathetic my resident was and how rude the staff at the front desk had been.
“This kid doesn’t know the first thing about treating patients,” he said with derision. He clearly meant to hurt and humiliate his new doctor in front of a supervisor.
I listened for a while to his litany of complaints and found it easy to understand why people didn’t like him. “It’s no surprise to me that people aren’t nice to you if this is a sample of how you behave in the world,” I said to him.
This remark did not go over well.
“I’m basically a nice guy who has a terrible problem with anxiety,” the patient said resentfully.
He in fact did have a major psychiatric disorder; he had been struggling with obsessive-compulsive disorder for the last decade but had shown a pretty good response to antidepressant medication.
There was something else about him, however, that could not be neatly explained by psychiatry: he was simply mean-spirited.
At this point, most therapists might go in search of a cause for the patient’s behavior. Was there something in this patient’s life experience that might explain his nastiness? Not really. Life had not been too unkind to him; he’d suffered no major deprivation or trauma, and he had had all the benefits of an upper-middle-class upbringing.
Many of my colleagues would argue that he could have a personality disorder, a category that is broad enough to encompass nearly every variety of human misbehavior. Of course, everyone has personality traits, but when they cause major problems in relationships and work, they cross the line into disorder.
On the other hand, maybe he was mean by nature, a concept that may sound heretical coming from a psychiatrist because it seems dangerously close to rendering a moral judgment on a patient’s soul, something doctors should doubtless leave to theologians and philosophers.
But if some people turn out happy and good despite a lifetime of withering hardships, why can’t some people be mean or bad for no discernible reason?
There can be a relationship between nastiness and mental illness, and many therapists assume that when patients are mentally ill and mean, the illness is probably the cause of the ill temper.
But human meanness is far more common than all the mental illness in the population combined, so the contribution of mental illness to this essential human trait must be very small indeed.
Don’t get me wrong. There is plenty of undesirable human behavior that falls well within the rightful domain of psychiatry to understand and treat. But must we turn everything we don’t like about our fellow humans into a form of psychopathology?
Not long ago, we had a patient in the hospital who was psychotic and frightening to the staff. After several weeks, his psychosis cleared beautifully with antipsychotic medication, and we all thought he was ready for discharge.
Then early one morning, he used the pay phone to call one of my female residents at home, threatening her and talking in a sexually provocative way.
When I confronted him, it was quickly obvious that he was no longer psychotic or manic. In fact, he was cheeky and unrepentant about his behavior. And he left no doubt in my mind that psychiatry had done all it could for him.
He said it better than all the clinicians who had treated him on the inpatient unit: “I’m not crazy now, but I guess I’ve never been a nice guy.”
To put it another way, some mentally ill patients can be mean or bad just like anyone else, and this is not a problem for psychiatry to fix.
Copyright 2007 The New York Times Company

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