Psychologists, whether they be in private practice or community clinics, rely on such a telescopic interview. Of course, this interview is alleged to be "biopsychosocial," as it makes inquiries into the past of the patient, including such things as where they live now, contact information, relationships with parents and sibs, both now and then, education, alcohol and drugs, activities of daily living, and serious relationships, past and present. It relies on the patient's presentation of self--what they wish us to know AND--what they wish to keep opaque. It is based on a limited peek into their conscious awareness. It is an opportunity for hypothesis testing. It is not diagnostic per se.
We used to encourage patients to describe, not to use clinical terms as "obsessive-compulsive, depressed, bored." What does that mean to you? What does it mean that you have "insomnia?" Everyone says they have "insomnia." But few actually have it. No one falls asleep the moment their head hits the pillow. Except maybe in Nancy Drew books. And surely no one relies on her as the epitome of mental health. C'mon--she has no legal standing, she drives around in a sports car at all hours (except school ones), she breaks and enters, contaminates crime scenes, etc.
But I digress. Mostly, the biopsychosocial interview as a diagnostic tool is a packet of lies in the service of an exagerrated, emotional presentation of self, in order to indicate a need for treatment and garner the therapist's sympathies. The biopsychosocial, or initial interview, is mostly useful as a packet of testable hypothesis, to be augmented by clnical data. Or more falsehoods.
For example, I always used to ask children to use their words to draw me a picture of their household. Where did they sleep. Where did they do their homework. I used to ask their mothers who was regularly in the house. Mothers routinely denied anyone was in the house, besides the children and them. No other grownup. No other relative. No "friends," with or without benefit. So the pregnancies that they routinely had after placing the child in therapy of course were the result of immaculate conception. I ask, not because I am there to condemn their activities. I want to know who the child regularly interacts with and how they all get along. Of course mothers are allowed to have friends, and the more benefits the friends bring along, the better for the future of that child, I would imagine. And children protect their mothers. And they are groomed as to what to present in treatment ("Don't tell that lady this. Don't tell her that").
But all I ever received was a packet of lies. The parents wanted the child medicated. They wanted a passive child whom they put somewhere and the child stays put. They don't want an actual human being, but a doll, who will give them love when they need love and has no other human emotions.
The house you reside in is an indicator of mental health. I wish I could require patients to bring in pictures of their house, as it usually is. Especially if they describe themselves either as "OCD" or slovenly and disorganized in their ways. Most people who claim they are "OCD" are not. They are tidy. They are organized. They are not pathological. They are appropriately germ-phobic. Most cultures require people to take off their shoes when they enter the house and put on house slippers. Most individuals in other cultures reside in small houses. Mattresses are put out at night and rolled up in the morning. Kitchens are living spaces. It is rare that people have their very own room to sleep in all by themselves. Possessions are limited. Cleaning is regular, perhaps done by servants or women, but the homes are clean and tidy.
So, is the person just tidy and organized, or are they actually OCD? How many hours do they spend tidying up? What isn't being accomplished, due to their endless tidying. Is there a function to this organization (making weekly dinners on Sunday evening, so that throughout the week, one need only defrost and eat)?
And of course, the pendulum swings the other way. The patient who comes in regularly, she (usually a she) is depressed. She can't do this or that. She takes the medications, but she is still depressed. She refuses to make any plans that would give her a sense of purpose to life. What don't you know about her? What don't you see? What sort of home does she go home to?
Well, this weekend, I meant to go kayaking with friends. I did go apple-picking (no, I'm not digressing, I'm just leading up to some pointless pithying about). After the apple-picking, it was cloudy and apparently raining in Cold Springs. So my friend and I visited his cousin-in-law, a Chasidic woman residing in Rockland County with her husband and brother-in-law. She 50something, with adult children and young grandchildren (the oldest is 9). At least one of the adult offspring lives in the Midwest, so far away from quotidian contact.
I accept that she recently moved into the bungalow six months ago. The house is a two bedroom, with living room, dining room, eat-in kitchen, a wooded backyard complete with two back decks, one with a swimming pool. There is also a finished basement,where her brother-in-law resides. She works as a taxi driver--which means she drives other Chasidic women and their children about, and receives bupkes, perhaps just enough to keep up the car. Accepting the religious life for such women is akin to the vow of poverty nuns take. A life of hard work, with few monetary rewards. Most of these Chasidic women go about, furbischena faced and furious, with little outlet except for studiously stuffing sorrows seriously into their stomachs, a psychiatric symptom of their quotidian quarrels. Internalize bubbe, internalize.
There are only two things such a woman can control: her figure and her household.
Only one a psychologist will see.
They see her quiet obese frame. They hear her tell of her depression. They don't see her house.
Let me describe such a house. Every single room looked like Dorothy's Kansas hurricane landed in these rooms. The kitchen had boxes of food stacked up over the counter spaces and on the floor. The dining room had a table, with no room to eat upon it. There was unwrapped slices of bread, open packets of rice-cakes, juice-bottles, Jewish newspapers, ArtScroll books, some opened to specific pages, opened boxes of kitchenware, boxes of paper plates and plastic cutlery. The floor likewise, filled with opened boxes of books and durable goods. The living room strewn with toys occupying the floor, and more opened boxes which had yet to be unpacked. But at least the living room had a couch and a rug which could be used. The dining room had a table, though it could not be used, and four chairs, which could be used. The spare bedroom had a bedframe upended in the corner, and many opened boxes. There was an empty bookcase, also upended in the middle of the room. The bathroom had a toilet whose inner rim was solidly encrusted with unflushed fecal matter. The sink worked, and had a counter lined with Lysol, but no hand soap or sanitizer. The shower had shampoo and conditioner on the shelves, but likewise, no soap or sanitizer present. I did not test if that was operational.
The place looked like it hadn't been cleaned since they moved in last April.
I found the whole place just contributing to many hypothesis. She is married and has a brother-in-law in the basement. Why don't the men folk put away one box per night? Clean one room a week? How about the brother-in-law, in exchange for the spare room upstairs, unpacking and organizing and cleaning up?
It's diagnostic for a Chasidic woman to live among such a maelstrom. And her psychologist, if there be one, would never know. They would never see her interior. And it doesn't impact on the exterior. The outside of the house looks typical of a bungalow house built in the 1960's. The backyard is leaf-strewn, as would be expected from a wooded acreage. The driveway is paved, the cars of recent vintage.
It is also diagnostic that she does not wear a wedding ring. We ate at a local kosher restaurant, and since I sat next to her, I had ample time to observe her hands. Usually religious women have gorgeous wrist watches and great wedding rings. She had neither. I looked for the ring assidously. Each pretty finger unadorned. Not a cocktail ring or friendship ring rung her digits. There was no tan lines, no indentations indicating a recent removal. I could understand the cheap wristwatch--perhaps she only wears the good one on special occasions. But no wedding ring? She wore a shmatte which covered her entire head. She wore a long three-quarter sleeve shirt which was not tucked into her ankle length skirt with sneakers. No wedding ring? What meaneth this? Is this a situation where she cannot get a get? Where she and the husband live separate lives and make (or don't make, in her case) separate beds?
In other news, I enjoyed all the attention I received in Rockland County. Children and their parents staring at me unabashedly. I had come to apple-pick and kayak. I wore a blue hat, a black fleece-lined jacket, black yoga pants, and blue sneakers. I was their day with multicultural pluralism. Yea me. For their mental health, I can do nothing. I have no standing in their community (just like the Wicked Witch). For my mental health, it was something. I had real agency to receive awesome amounts of attention.