By Mark D. Rego, MD
One of the most important things I try to impress on clinicians in training is to learn which questions patients can easily answer and which ones are difficult. For example, when you ask a patient about a symptom they know very little about, like a symptom of psychosis or mania, they may not be sure what to say.
On the other hand, there are questions that everyone knows the answer to. These are invaluable in helping to understand a person’s experience.
The main question applies to any disorder, and, as I mentioned above, everyone immediately knows the answer. Simply put, the question is, “Do you feel like yourself?” After working hard trying to figure out what may be wrong, or if the treatment has had a strong effect, I have asked this countless times and, in an instant, both the patient and I know where things are.
Feeling like yourself is like having a jacket that fits perfectly. Only you can tell that every inch of that jacket conforms to your body, and you know as soon as you put it on. Feeling like yourself is similar in that every inch of internal being feels just right and normal. It does not have to be feeling good or bad. For example, you may be feeling sad about something and still feel like yourself.
This is, in my view, is the most important symptom in the mental health world. It is really the basis for what we do. We aren’t looking for something physically abnormal or out of range on a blood test. Even if we have such tests someday, the most important starting point is how the person feels inside. Only their mind has access to this.
Despite this, this question is rarely seen in admission or discharge summaries.
This question should be used at the beginning of any new treatment if the person is not quite sure what’s wrong. As we know, there are also people who may not feel quite ready to say what is bothering them, yet they felt compelled to come for help. Asking this question can be an excellent way to get things started.
If the answer is “no,” the follow-up question makes it easy for a patient to focus in on what is bothering them. Once there is a “no” answer, the follow-up question is, “if you are not fully yourself, what is missing that would get you back to feeling fully like you.” Because the person’s mindset has already been focused on the universal feeling of being yourself, it becomes easy to say why you are or are not at your usual baseline.
Similarly, when a person has had therapy or medicine treatment, there is often a discussion of just how much better the individual feels. Are they all the way better or only partially? This can be hard to know for the clinician and the patient. Once again, “Are you yourself?” can break through the ice.
If the person is not all the way better, the answer will be “no,” which is the clinician’s cue to ask, “in what way are you not yourself yet?” or “what is missing to get you back to your full self?” Once the person’s mind is primed with thinking about selfhood (or feeling if the jacket fits), they will know what is missing.
I’d like to add a final group of questions that helps when the patient and clinician are trying to decide if the treatment made the person merely better or fully well. In many cases, a person will be so relieved to not feel as bad as they did initially that they will say — in complete honesty — “I feel great!” We want people to return to their whole selves in order to live their lives as fully as they choose, but there is another reason to look for “well” not only “better.”
When people are fully remitted, they are more stable and less likely to have a recurrence of their disorder than if they are only partially better. For that reason, I ask the following questions: “Do you have the capacity for interest, fun and relaxation?” Unlike our first question, this needs some explanation.
First, in practice, I ask each item (interest, fun, relaxation) separately. Second, notice I say “capacity.” What I am stressing here is, is this something that you have the ability to do, not that you are necessarily doing it. Perhaps with a job and kids, you do not have the time. But like with our first question, people will know themselves and know the answer to this.
This whole process starts with the question, “are you yourself?” (or “does your jacket fit?”) and if it doesn’t, working together, person and clinician, to figure out where you can help it to fit better in the future.
Mark D. Rego, MD, is a psychiatrist with 25 years of experience in community practice. His focus was on special groups, such as people resistant to standard treatment, the elderly, people with developmental disabilities and the medically ill. His areas of expertise also include psychopharmacology and psychiatric pathology. Dr. Rego has taught psychiatrists in training at Yale, and he is now writing a book about the effects of modern life on mental illness.
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