"The Worried Well"

Sometimes, the phrase "the worried well" is used to describe people with problems which are felt to be minor or which would resolve easily on their own.

In one recent lecture, the expert was extremely articulate, intelligent, and inspiring, discussing the importance of educating people about mental illness, as part of a public health campaign.  But then, while using terminology such as "the worried well,"  he finished his sentence in dramatic hushed tones, saying that people who requested, or demanded, more care for what he felt were minor problems were demonstrating "...narcissistic entitlement."  To be a member of the "worried well," I guess the view is that seeking external help would be wasteful, unnecessary, and inefficient for the health care system.  This speaker was very persuasive, for many reasons.  He obviously had a kind heart, a very altruistic disposition, a commanding intelligence, and excellent rhetorical skills. 


I agree that people with extreme, incapacitating symptoms and having extreme, harsh living conditions (such as experiencing severe psychosis while living in severe poverty) require very urgent help.  The health care system must attend to this type of situation with a very high priority.  Mind you, a big part of the health care would be addressing the poverty and other environmental dangers with similar urgency as treating any psychiatric or medical symptoms. 

But people who might be described as the "worried well" are not necessarily exhibiting "narcissistic entitlement" to ask for help.    Even if there are narcissistic issues, work with an experienced therapist could be difficult and long-term, but of great potential benefit to the person and to the person's community.  In some cases, a person with mild or short-term symptoms may not desire or need very much help, but even a little bit of professional attention can make a big difference.   Sometimes the help might prevent a failed relationship, a failed term in university, a slide into more severe mental illness, or a disastrous life choice.

In some cases of extreme severity,  a long-term complex care regime is often needed (such as a community team involving physicians, social workers, occupational therapists, etc.).

But in other cases of extreme severity, sometimes brief, focused help is adequate, and is all that the person desires or needs.

In cases of "mild" severity (such as a person with relationship stresses and generalized anxiety), sometimes minimal help is really needed...the issues may settle down on their own.  Other times, just a few visits with a professional may be sufficient to help the person pass through the situation more comfortably.

But in other so-called "mild" cases, people may benefit greatly from having more ongoing help, such as a course of psychotherapy.  Symptoms, as measured on symptom scales, may not lead to alarm bells ringing, and may not even change very much, but timely or ongoing therapy may make a difference between the person succeeding, flourishing, or failing in their schooling, career development, or relationship life.  The most common symptom scales do not tend to measure these things directly.

Nowadays, it is hard to discuss such matters philosophically, without dealing with a question such as "but where is the evidence?"  or "Are your ideas evidence-based?"  The best evidence base for any health care claim would have to involve a prospective, randomized controlled study with very clear outcome criteria.   It is expensive and difficult to assemble such studies.   Much of what I am talking about above is not based on some specific "diagnosis" (though nowadays it is quite easy to form a list of DSM-V diagnoses) but on a person's subjective wish to have help.  Treatment studies, due to technical difficulties and expense, tend to be brief, single diagnosis-based, and based on fairly simple quantitative measurements (such as symptom scale data).   For this reason, a strict requirement for evidence-based treatments in mental health care will tend to favour brief techniques which have very clear evidence of reducing acute symptoms quickly as measured by questionnaires.  This favouring is not because the evidence is invalid (in fact, the evidence from these studies is informative and excellent), but because most studies will necessarily be short-term in this way.  Longer-term studies with more qualitative measures are much more difficult to do, and therefore there is much less published data.

But in many situations, the benefit from mental health treatments is longer-term, and may be more qualitative than a symptom questionnaire could pick up.

I do not at all mean to disparage the focus on effective, cost-efficient, brief treatment of mental health problems.  I also think it is valuable to challenge wasteful or unnecessary expensive practices, especially those which lack any good evidence at all.

But mental health care sometimes requires a steady, longer-term commitment to really take care of people, to make the effort to know people very well for a long period of time, to understand a person deeply, not just in terms of symptom scores.  A therapist or psychiatrist need not be simply a "provider" or technician to relieve symptoms.  Sometimes this is all a person wants, and that would be fine.   But if this the only thing the profession focuses on, then we risk having a health care system which becomes more impersonal, disconnected, and mechanical.  For psychiatrists, a very short-term focus will naturally favour simple prescriptive approaches such as medication trials (I am not "anti-medication" but I strongly discourage the practice of prescribing medications without knowing people well, and without addressing other holistic strategies for health care).   A more disconnected or impersonal health care system is harmful for patients, and is harmful for the community of therapists and other professionals.

Let's not use phrases such as "the worried well."  Let's not diagnose people who are asking for help, with "narcissistic entitlement."    While it is important to prioritize urgent needs, let's spend the time trying to understand and care for all people, without judgment.

Medical Education

Medicine is a very strenuous professional program, but potentially full of incredible intellectual stimulation and personal challenge.

Having gone through medical school myself, and having gotten to know numerous medical students over the years, I have a few ideas about the medical education system:

The academic portion of medicine consists of an enormous amount of material crammed into a short period of time.  It requires students to prioritize study time with great care, to get the "big picture" of things.  Students with a very strong memory would have a huge advantage.  As a result, few students really get to savour the academic learning, to really think deeply about these important subjects.    For most, it is a stressful but superficial rush through vast areas of subject matter.  Students who are good with test-taking gamesmanship would have an advantage here.

Here are some ideas for change:

How about have a course system in medicine which allows people to gradually complete the academic section at their own pace?    This could allow people to take their time, master the material, and to enjoy it.

Some subjects in medicine, such as anatomy, are crammed into the first year, but then rarely touched upon after that, unless the student ends up doing a surgery residency, etc.  What about having some very basic subjects such as anatomy be reviewed regularly and immersively, with practical applications, so that students would deepen their knowledge and practical skill over time?

Practical skills in medicine, including interviewing, physical examination, and basic procedures, could be gradually introduced much earlier.  It is not necessary to understand biochemical pathways or histology, etc.,  to practice most clinical skills.   Many such practical skills improve, and become "second-nature," with years of practice, so why not start sooner?  This would make the work more interesting and relevant for the students, and ultimately would be very good for patients, because they would be dealing with medical students with better practical skills.