We only see a slice of a person’s life. We focus on the patient’s "history of present illness," the narrative history told in that moment, and the mental status exam. We rely heavily on collateral information to corroborate as much as possible. We use this to measure accuracy and distortion, always holding a skeptical lens against our patient!
While we want to believe our patients and take their histories at face value, we can’t fully do so because we know, instinctively or through training, that fantasy permeates the human mind and transforms meaning. Yet, at the same time, we assess that very idiosyncratic meaning for what it is, because that meaning stays with patients as they move from our ER to the street or the unit. And it is that meaning, embedded in an individual’s coping strategies and character that partly predicts what and how the person will do. It is an inherent consideration of risk and resilience, and we instinctively factor that into our decision making. This is the art of psychiatry at its best.
The CPEP is the frontline of psychiatry. Some residents dislike it because it vibrates with anxiety and responsibility. It is a place in which clinicians tend to come unglued behind the scenes, joking as if at a party, talking loudly and blurting out inane and obscene lines from TV shows and real life. In the back room, the burdened frontline psychiatrists and staff attempt to regain control and wrestle back their own meaning in life, in the face of withstanding traumas, distortions, and psychosis – the delinking of meaning – while rendering verdicts of risk and resilience based in rapid assessments of social, cultural, characterological, and biological factors that make up patient lives.
We swiftly analyze our patients and decide their immediate fate – street, home, unit, extended observation, needles, blood, medications, even visitors and babysitters. We hold them, or we jail them, depending on your view. But we do it with benign and perhaps grandiose intentions to protect, comfort, and quickly "know" them in order to progress them to the next most right place. And we do this almost without knowing that and how we are navigating a delicate and profoundly intricate path of evaluation and decision-making that is uniquely human in its intellectual and emotional nuance.
It is a job full of sharp edges and soft curves, a job that makes a bouncer an analyst and an analyst a bouncer. It is a job never to be reduced to algorithm or computation.
Dr. Pula is a psychiatrist at New York–Presbyterian/Columbia University Medical Center. He also is in private practice and is a psychoanalytic candidate at Columbia.