Freud supposedly understood himself as a surgeon of the mind, dissecting his patients’ mental anatomy through the process of psychoanalysis. I found this comparison appealing, so when I started the psychiatry clerkship in my third year of medical school, I approached the interview in psychiatry as analogous to a surgical procedure — efficient, scripted, precise. I thought that psychiatrists employed a masterful tapestry of words through which they could build models of other minds within their own, identify what is broken and fix it.
On our rotation in the inpatient psychiatry unit, each student conducts an interview while being observed by our attending physician and the rest of our cohort. Likely because of my expressed interest in psychiatry, my attending decided that I would be the first to interview. He tasked me with interviewing Mark, a patient admitted for a suicide attempt after he discovered his wife’s affair. Following a quick glance at his chart, we stepped into his room and met a middle-aged, disheveled white male. Forthcoming and long-winded, Mark essentially developed the rapport himself. He spoke with candor even about private matters of his life, so I probed into his suicide attempt without fear of inducing restraint. However, shortly into his story, he began weeping uncontrollably, then hid under the sheets of his bed. I asked if he was all right and if I could do anything for him, but he remained silent. I looked to my attending and classmates with desperation, hoping for assistance. Instead, my attending thought it best that we give Mark some privacy, so we left his room and discussed his case in my attending’s office.
My mind wandered during the discussion. Though my attending and classmates assured me that I did nothing wrong, and though I knew that I had asked Mark about a sensitive topic, I felt convinced that I must have committed some misstep to provoke his reaction. For the rest of the day, I replayed each part of the interview in search of the mistakes I made but found nothing definitive; I only hoped that Mark would find someone in whom he felt safe to confide.
After Mark, I met a few patients who shared similar stories in which their impression of someone close to them was shattered by an unexpected discovery. They found that no matter how well they thought they understood someone, there were still secrets and hidden details. Be it an affair or some other form of betrayal, the discovery subverted their understanding not only of the person they thought they knew, but also of themselves. Some patients began to believe that they were unworthy of close relationships, while others questioned the value of human connection in its entirety. Often, I found that patients distanced themselves from close friends and family members out of fear of being rejected again. This begged the question: how do psychiatrists connect with patients who have been damaged by broken relationships?
Later in our rotation, my classmates and I observed how our attending conducted an interview. This time, the patient was a teenager named Kim who self-harmed with suicidal intention. She initially resisted sharing the reason behind her self-harm, so my attending pivoted to questions about her personal life. He always responded to her answers with unconditional positive regard. When she shared that she often thought about running away from home, he would acknowledge the legitimacy of her feelings. She grew more comfortable with opening up until, finally, she shared that she self-harmed because of feelings of worthlessness after a close friend betrayed her confidence.
This interview revealed to me that the content and character of a psychiatrist’s responses can change the patient’s understanding of themselves. My attending’s unconditional positive regard imparted in Kim the comfort to share her most shameful or embarrassing feelings without fear of rejection. The interview then became an experience of recognition for her, of having her thoughts and feelings acknowledged as valid even if she herself believed them not to be so. Effectively, my attending invited Kim to understand herself as he did — as someone who, despite deeming herself as defective, is worthy of being heard.
Such a delicate, yet potent dimension of interaction with the patient strained my understanding of the interview as akin to a surgical procedure. Thus, I now understand the interview no longer as a procedure, but as an invitation to a place where nothing is broken, where nothing needs fixing, where stories are received without reservation.