Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Monday, April 14, 2014


Sometimes, when I'm in a session with a patient, I wonder how to address beliefs I don't agree with.

It gets pretty complicated. There's the whole issue of religious beliefs. People are entitled to believe in a deity, if they're so inclined. I am curious about these beliefs, particularly if they are significant in a patient's life, and I will certainly ask about them, and encourage the patient to discuss them. But is it appropriate for me to "reality test" when it comes to religious beliefs? Like, "Come on! Do you really believe in resurrection, or weird things happening to large bodies of water (splitting, turning to blood, etc.)?"

Let's assume I lay off religious skepticism. Religions are, after all, culturally acceptable and common phenomena. But what about related ideas, like ghosts? Lots of people believe in ghosts. Is it my place to say, "You're an otherwise rational person, so what's up with the ghosts?"

I don't know the answer to that, but the bigger problem for me is, what about when it comes to health related issues. Like homeopathy. Or crystals.

What if I think these beliefs are dangerous? Like, "My 15 year old son has been having leg pain that's waking him at night and causing him to limp, so I'm taking him to a chiropractor who's giving him orthotics to correct his alignment. No, he didn't have an x-ray, the chiropractor said that would be too much radiation exposure." (A variation of this happened to someone I know, not a patient. Luckily, it wasn't neoplastic, but it did require surgery, and months of pain could have been avoided with a simple, inexpensive x-ray.)  If I were a pediatrician, I would never let that one go unchallenged. But as a shrink, doing therapy, or analysis, I'd be crossing a boundary to say, "Your kid needs an x-ray. Take him to his pediatrician. If he's cleared, then you can go ahead and spend lots of money on useless shoe inserts."

In general, I take the position that if my patient is about to do something I think is a mistake, if I believe it's dangerous, I say something. Otherwise, I don't. But "dangerous" can mean a lot of things. And even when I do say something, I try to be as neutral as I can.

In practice, this is difficult. "Have you discussed this with your pediatrician?" certainly implies that I think my patient OUGHT to discuss this with the pediatrician, so it's not so neutral, but it's better than osteosarcoma that could have been caught early on if only I had said something.

Lately, the issues that have been making me think about this topic have to do with diet. Gluten. Organics. Supplements. Toxins. What is WITH the whole gluten-free thing? Yes, some people have celiac disease, and THEY shouldn't consume gluten products. But just because gluten is bad for them doesn't mean gluten is bad for everyone! It drives me crazy.

And hey, if a hemp oil, flax seed, kale, pomegranate, agave smoothie is your thing, go for it! But if you're drinking it because your current guru claims it will "cleanse you of your toxins", maybe we need to examine why you're so willing to believe this.

I think there are a couple of take home points here:

1. It's a good exercise for me not to feel like I have to agree with everything my patients think or do, or to "correct" them.

2. It's good for my patients to feel safe enough that they can share their beliefs with me, and question the ones that may be causing them problems.

3. Belief is a remarkable phenomenon. People are so willing to believe in the latest health fad, even with poor or no scientific evidence to support it. Bad Science by Ben Goldacre is a good read on the topic of pseudoscience.
I think it goes beyond "sciencey" sounding ideas, though. I think what it comes down to is that we all worry about our well-being, our health, our diet, and by extension, our mortality. And in the face of this worry, we long for certainty. Doctors don't provide certainty. Likelihood in some cases, but not certainty. In fact, I consider it part of my job description to help my patients learn to tolerate uncertainty.
People hawking homeopathic remedies or miracle cures sound pretty sure of themselves. THIS will definitely help you live longer, feel better, boost your immune system (why doesn't it occur to most people that we'd die pretty quickly of an immune system boost?), improve your life. What a comfort that is.

'I love you" is a scary three word phrase.

"I'm not sure" is scarier.



  1. You ever wonder if people took their spiritual beliefs seriously perhaps their incessant worry about their health, their diet, their mortality, etc would be greatly reduced?

    Personally, I don't worry about my mortality because that is a certainty. I never worried about my diet either until started getting sick. It started with dairy products over ten years ago. Back then, no one was talking about dairy being terrible. At least not to my knowledge. No, I don't mean lactose intolerant; all the lactose edited products made no difference.

    I hate being put in the same category with those who adopt whatever fad idea is making the rounds. I certainly don't fit that description. I am the type of person that deliberately goes in the opposite direction of the crowd on subjective matters, I only read up on the common side effects before taking a medication [it is only after I have a symptom that I look it up and this generally involves some digging since they tend to be the uncommon ones such as fatigue from lisinopril, not the cough], and I am always suspicious of someone selling something, especially when they sound so certain it will help me.

    The reason I wrote this was only to point out that you may have a patient here or there like me in your world. You'll know them by the fact that they don't jump from one fad to the next, they prefer to experiment and observe what happens vs just being told something, by anyone, and they will have things that don't help them as well as things that do in their list of experimental results.

    My type greatly appreciates physicians keeping an open mind in regards to our subjective experience. As I wrote on the skeptics blog once in regards to my reactions to vaccines, it is more limited in thinking to believe that it could not possibly have happened to me, as to accept that maybe it did. However, as long as I can maintain autonomy over my body and am not harangued about my choices, I am perfectly fine with whatever you believe.

    1. For the record, I've received all my vaccinations and boosters even though they all make me feel miserable in some way for days after. Once, I even enrolled in a drug study to get the Hep B vaccination when my employer wouldn't pay for it because I didn't have direct patient contact,