Advice to the Newbies: Give Your Heart, & Hold Your Theories Lightly

Sandra Steingard, M.D.

April 6, 2014

I was recently asked to give the commencement address for Goddard College’s masters program in psychology and counseling. This is what I said.

Thank you for inviting to share this exciting day with you. I am deeply honored and flattered. I asked what you might find most helpful. I know your experiences and interests are varied.

I was told that one student suggested “I like it when professionals give newbies advice. You know, sage wisdom from 20 years down the road.” You may be getting an added bonus since some of this advice will be from 30 years down the road.

It was suggested that perhaps I could tell a funny story from my own career.

Another asked for some encouraging words.

And I guess my favorite was “how to get some of the mind-boggling amounts of money that pours into the pharmaceutical industry and invest more for therapy supporting mental well-being for everyone.”

I know that the commencement speaker sometimes poses one more barrier to the true purpose of the day. I do not wish to make that barrier too onerous a burden for you all.

But, I have some dilemmas.

First of all, I am not known as a person of few words.

Secondly, I am not optimistic by nature (maybe as a final test I should have some of you help me with that).

Thirdly, I do not have an answer to the problem of the drug companies although I can tell you that they are getting out of the business. Their paradigms have not worked. And although the NIMH believes that it is required that they invest most of their research dollars into understanding neural mechanisms before we can figure out how to help people, the absence of pharma money opens the door a crack that we can try to widen together.

So we are down to the funny story.

How many psychiatrists does it take to screw in a light bulb? The classic answer is that the bulb needs to want to change. This is old but still true. Coming to grips with our limitations is a topic I will return to once I dispense with the humor.

And finally, we come to the classic part of the commencement speech – advice to the newbies:

1) Hold Your Theories Lightly

I know you have just worked very hard to accumulate expertise. The problem, however, is that our fields – and I include myself in this – are audacious in their attempt to offer help while we still are so much in the dark about so many things. It is an easy trap to deal with the uncertainty of clinical work by enclosing ourselves in theories. We then see the world from the perspective of our particular theory and we allow our observations to only confirm what we already know. We get blinded to observations that challenge our world view of “how things are.”

This has happened to me. No one should really come to me for advice because in truth I have been wrong so many times in my career. And while I am open to the possibility that this is perhaps reflective of a personal problem, I suspect I am not alone. We all benefit from the work of our intellectual forefathers – or foremothers – but we also belong to professions that have made many, many mistakes. For me, the only honest position is one of humility.

Holding that humility in balance with expertise and training is no easy task. For sure, you have learned something. It was not all for naught. But do not rely on your diploma to address your own needs for respect and validation at the expense of those we try to serve. For although psychiatry might own the lion’s share of potential to harm, we can all do harm and the advice – First Do No Harm – can aptly apply to all of us.

2) Do Not Lose Intellectual Rigor

Goddard has a fine tradition in the so-called alternative world. I suspect you have been encouraged to challenge convention. I support you in this. At the same time, I continue to value reason and critical thought. When I label myself and the work I am doing, I call myself a critical psychiatrist. My writing is geared to a critical evaluation of psychiatric diagnosis and treatment. Those of us who choose to question convention are nevertheless as obligated to maintain rigor as anyone else.

Read Daniel Kahnemann’s book, Thinking, Fast and Slow. He is a Nobel-prize-winning cognitive psychologist and his book is about the remarkable power of intuitive thinking but also about how it can lead us astray. Many of us who are drawn to this field have good intuitions that we need to use every day. The evidence base only gets us so far. But we have an obligation to actively question and look for our own blind spots.

3) Give Your Heart, But Protect It

I am a student of Finnish Open Dialogue. Jaakko Seikkula and David Trimble wrote a paper with the title “Dialogue as the Embodiment of Love.”  Honestly, for me this notion is both moving but also a bit uncomfortable. We understandably and appropriately need to be careful about our boundaries. But I also understand what they mean by this.

A couple of weeks ago, I went to meet a patient in the waiting room. I have known him for 20 years. He used to refuse to come to the office and even to talk to me. I would go to his home to see him. I have committed him to hospitals. Suffice it to say, he is doing much better. Despite his struggles, he has managed to be married for 20 years and to raise 2 kids. On this day his now teen-age son was with him in the waiting room. He turn to his son and said, “This is my friend, uh, my doctor.”

It is the relationships, the connections, we have to offer that may be most helpful. In the psychotherapy outcomes literature, only 15% of the variance of the outcome is accounted for by the particular technique one uses. Most of the variance is attributed to the therapeutic alliance and the qualities the person brings to the treatment. So we make connections. And this is fundamentally a paradox. For we are walking in the hinter land between professional and friend. This is not easy and it is often confusing. I have no easy answer to this other than to recommend that we at least acknowledge it.

But when you give your heart, it can be wounded. This can be very draining work. You need to take care of your self. A way to stay out of trouble is to be honest about your limitations. We can help the light bulb to change. We may even have ways to increase the light bulb’s desire to change. But in our world, in the end, the light bulb indeed does the changing.

We all need validation and when the bulb doesn’t change, we have a tendency to blame. Another aspect of Open Dialogue that appeals to me is that all conversations about the person are done in the person’s presence. I was at a conference with the Finns and someone asked if they always adhered to this and a senior psychiatrist said that they mostly do and she commented that she notices that when they begin to talk without the person present that the talk tended to veer into a negative and blaming tone. You may not operate in that model but you can think that way: talk about a person as if that person was present with you.

When I was a resident I worked in a VA hospital. We some times saw some very scary and angry guys. A senior resident once told me: if you are afraid to be in the room with someone, open the door, if you are afraid to be inside the room, talk in the hall, if you are afraid to talk in the hall alone, have someone stand with you. I am kind of a wuss. Those word stayed with me. I bring this up not so much to talk about dangerousness but to talk about acknowledging one’s limitations. By not thinking that I had to be someone who I was not, I could say to someone without rancor or blame, I am not able to be with you right now.

I once read that one secret of happiness is to be of service and to express gratitude. Although we are not laborers, this work takes a different kind of toll. But we are also privileged in being able to be of service. We are privileged to be part of people’s lives in the darkest times. This is a choice we made, not something that was imposed on us. Try to remember that on the tougher days.

So good luck to you all! Congratulations on your achievements!

Sandra Steingard, M.D.

Anatomy of a Psychiatrist: Dr. Steingard chronicles how she is integrating information from Anatomy of an Epidemic into her community mental health practice. She also discusses changes in Vermont’s mental health system and the influence of pharmaceutical advertising on clinical practice.


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4 thoughts on “Advice to the Newbies: Give Your Heart, & Hold Your Theories Lightly

  1. Thankyou! Appreciated all of it…every word…and especially these: “for me, the only honest position is one of humility” and these: “we can all do harm and the advice – First Do No Harm – can aptly apply to all of us.” Thankyou twice!

  2. “… do not rely on your diploma to address your own needs for respect and validation at the expense of those we try to serve.”

    Oh, yeah.

    Your point about boundaries is well taken, I can see today’s psychiatry being a reaction against vicarious trauma the way the war machinery of WW II was a reaction against trench warfare. Listening with empathy requires feeling pain, managing those boundaries is certainly work that requires a lot of time reflecting and checking oneself.

    Those big scary guys are the reason, I think, that people in a V.A. psyche ward aren’t condescended to and treated like children.

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