A patient needs some extra support over the weekend. I suggest I get the Crisis Resolution Team to visit her every day. ‘What’s the point’, she says. ‘You know, they just ask the same questions again and again. It makes me worse’. I have no answer. I know this is true.
For several decades, since the days when I was a patient, I have seen and heard how an obsession with questions damages psychiatry. Many of us have been asked the same questions day after day, year after year: ‘Do your thoughts seem faster than normal?’, ‘Do you ever have thoughts in your mind which are not your own?’, ‘Do you feel anxious?’, and so on.
What does this feel like? As ever, my patients describe it best. One locates it as “like a machine gun into my brain”, another “an attack, an intrusion, a knife into my body”. A socially anxious man appeals “Did I say what I was supposed too? Did I perform OK?”. A woman with a long history of childhood abuse says the questions felt like “a penis going into my body, again and again”.
These type of descriptions are the norm not the exception. For the structure of being asked questions is a specific one: it places the desire of a powerful other (the nurse, the psychiatrist, the social worker) as primary. This echoes an interactional pattern so familiar to so many who have been bullied, shouted at, beaten, tortured, sexually abused. The feelings from these past times can return in the body – anxiety, paralysis, disconnection, anger – none of which are articulated to the professional, trumped by the desperate life or death task of getting out of the room in a vaguely ‘together’ way. So the doctor gets thanked for his time and doesn’t learn any better, and it is the student nurse on the ward, or the parent at home who sees the person in bits. Hearing only what a patient says under questioning when frozen by paralysis, or subject to the hyper-arousal of anxiety, the professional misses the opportunity to hear the threads of something new, the possibility of weaving with the patient a narrative of hope and recovery.
To be with someone in real distress can be incredibly difficult, and we can perhaps empathise with the professionals unconscious desire to cling desperately to the diagnostic manual, to the crib sheet of mental state assessment questions, as someone drowning clings to a rock. Hearing a person’s real history, rather than the history of their symptoms, makes explicit the limits to what psychiatry can do – the drugs don’t often work, and they rarely get rid of what triggered the problem in the first place. As both parties have some awareness of this, they can only perform ‘the doctor who asks questions’ and ‘the patient who answers questions’. This is deeply depersonalising and means neither party will quite be there, both alienated by a set of rules of how they should be, as Tom and Jerry are obliged to perform Cat and Mouse. Yet, it’s perfectly possible to rip up the implicit rule book, and have a real encounter. It doesn’t mean the psychiatrist can’t check in on any risk questions right at the end, it doesn’t mean no medication to dampen down the physical, but it does mean the patient gets to dictate what the space might look like for the overwhelming majority of the time.
The need to fight for space so something of one’s distress can be heard becomes ever more important as even psychotherapy spaces becoming colonised by form filling, much of which is a response to the professionals internal judge who screams ‘show you are doing something!’ as opposed to a task related to patient care. For a barrage of questions about symptoms obliterates the possibility of the joining patient and professional to explore: ‘symptom of what’. This is especially tragic when going mad can unconsciously be a way to try to communicate something that hasn’t been put into words. Mania can be a desperate attempt to flee hopelessness, voices the still heard words of an abuser, rage an understandable response to being downtrodden, depression unspoken grief for a baby, lost. The ‘what’ here is not connected to anything that can be found in one of the heavy diagnostic manuals, or got rid of by a small change in medication dosage. Every meeting that fails to explore this ‘what’ solidifies the psyches defences – it repeats what is often a common theme in a patients life ‘you are alone with this’.
How, then, can we construct a space that isn’t dominated by colonising questions? Both parties may think anxiously of the comic blind date sketches that originate from the horror of being asked outright ‘What do you want to talk about?’ Instead, professionals need to learn how to carve out an open, space in a gentle manner. This must involve thinking about how power, emotion, and social conventions may be present in interaction. Consider the question ‘How are you?’. A health professional will often ask this before proceeding to do a mental state exam, taking a simple response as meaning its time to start on their agenda. However, in any scenario, ‘How are you?’ nearly always needs to be asked twice. For at first, we tend to give a smudged response (‘ah you know, so so’) to allow us to ask the questioner how he or she is, the rules of normal discourse. We do this so often it’s automatic, so if a professional asks it we default into the same pattern.
Yet, if we ask someone ‘how are you?’ a second time, and really mean it, something more singular always emerges. The text of the person’s response nearly always provides some clues we can pick up on. So, if someone says “I’m alright, you know, things aren’t always easy”, we can repeat “things aren’t always easy” with a questioning tone and we’ll get an elaboration on how present the voices are, how impossible it is to open the post, or whatever it may be. Or we might pick up the ‘you know’, insisting perhaps with a dollop of humour, that its actually the patient who knows. And then we hear how tough its really been. We ask one simple question and then position ourselves as subservient to the discourse of the patient, attending to the silences, and pauses, and body language. It is this which gets to direct the conversation. Questions only become useful when they are about something idiosyncratic that has slipped into the conversation – an interest in a particular band, an old dream to be a footballer. Curiosity on this can often allow new expanses of our experience to reach discourse, can remind us of things its worth getting better for.
Rather than the dominance of the voice of the most powerful person in the room, we need a psychiatric practice that privileges and gives real space to the service users voice. It is madness to expect healing to occur if a space is colonised by standard often heard psychiatric questions, with the service user only asked what they wish to talk about in the snatched last few minutes, expecting them to express their needs whilst a professional shuffles their notes and makes to leave the room. Though psychiatry brings up metaphors of the brain to justify its practices the whole time, the evidence base actually supports such an approach. The diagnostic system is being revealed left, right and centre as an unscientific system still waiting 100 years on for evidence, the promised improved wave of new atypical antipsychotics now revealed as no more effective than the ones that went before, and the talking therapy beloved of the market place, CBT, is shown to be no more effective than befriending for psychosis . In contrast, the best outcomes in the world, using the most rigorous randomised controlled trials, are from a Scandinavian programme called ‘Open Dialogue’. With this approach, when someone becomes acutely distressed, everyone involved meets within twenty four hours – the patient, their family, any neighbours or friends, and professionals. They talk about what may be happening. The professionals do not ask questions, they are more there to witness what emerges, and make sure everyone’s voice is heard. The professionals talk about the power their titles may seem to bring, and how it is is dwarfed in the face of the lived experience of those present who know what’s been happening. All the professionals do is listen for the truths, the islets of hope, the forgotten traumas and dreams, which inevitably leak out in the act of speaking.
I write “all the professionals do is listen for the truths” but the ability to do this, to stay with distress, is something that has to be cultivated through gently guiding the professionals hand away from the book, so they can actually be with the person in front of them. If the professional can stop using questioning as a way not to be there, they will be able to join with the patient to hear something new and emerging in the conversation that may be a surprise for all. It is when we have the space and safety to surprise ourselves with hidden knowledge of where we are, and where we have been, that the seeds of recovery are sown.