There is a moment about 10 minutes in the interview when we understand each other. A teenager admitted against their will to a psychiatric ward and a psychiatrist four times their age, seemingly holding all the power.
I have been a psychiatrist for 30 years; I have seen thousands of kids and their families, and I cherish this feeling every time.
It is a moment when their shoulders relax a little, eye contact becomes more consistent, and I may glimpse a smile. I feel warmth radiating from the kid, and they let some of my warmth get through their defenses. From that point onward, it stops being a psychiatric assessment and becomes a conversation.
I call it finding the essence.
I learned this concept for the first time when I was finishing my residency in Buffalo and was preparing for board certification. Our director flunked me on a mock exam because I “failed to capture the essence” of the patient I saw.
It was an actual patient, a 17-year-old. She was admitted after a suicide attempt triggered by a breakup with her boyfriend. I had 30 minutes to complete the assessment, so naturally, I focussed on symptoms and timelines. She spoke about relationships.
I was pissed at the director. No one had taught me how to assess “the essence”. We learned diagnosis, therapy, medications, risk management. They taught us everything but “the essence”. Indeed, finding the essence of the patients was not part of the actual exam that I passed later with flying colors.
Now, finding the essence is all I do day in and day out.
I work on a psychiatric inpatient ward. Our patients are mostly admitted involuntarily because they are a danger to themselves. It is as acute as it gets. Our hospital is the last resort for a teenager in crisis. Regularly, we meet them after a suicide attempt. Sadly, over the years some of them died.
How do I assess the essence? Most of all, I want to understand their thinking the minute before they decided to end their lives.
For some, it is a fear of loneliness, failure, or poverty. For others, being in pain, suffering forever. But it is always about the future. It is a fear that they will not be fine.
The essence of a person is a feeling; it is indescribable. We can only approximate it by observing their choices and the values behind those choices. It is one human trying to understand another human.
By now it is a little more obvious what my personal values are, but understanding myself is still a process even after five decades of life experience. It is impossible for a teenager to see the values that will survive the test of time.
I remember being a fresh immigrant to Canada 25 years ago. I could only get a minimum-wage job at Radio Shack. It was a small fraction of my current salary, but I enjoyed it just the same. Later, I realized why. It is one thing that a sales rep at Radio Shack shares with a psychiatrist — solving puzzles, helping actual humans. It turns out there is no big difference in solving a puzzle of diagnosis and treatment versus connectors and cables.
Most often the kids say, “I value my family”. But family is not a value. It’s a scene. I dig deeper to ask what it is about the family? It could be loyalty, connection, shared history.
Teens need competent adults in their lives who will ask them challenging questions. They need walls to push against to show what actually matters to them. One person tells me they want to go home because their dance crew is rehearsing for a competition and they cannot miss it. But another wants to escape the hospital because they are bored.
Suicide is always about the future. So when the teens are brought in, they see none. Our job is not only to find a working coping skill or adjust their meds but also to help them find a reason they would even swallow it.
Their essence is the why.
What Happened to Our Kids’ Future?
In the Soviet Union, paths to success were relatively predictable—put your head down, work hard, and you get rewarded with stable income and a state-sponsored apartment. Engineers, lawyers, and teachers were paid the same because their education took about the same time. Professors and PhDs were paid more than regular doctors because they had to study m…
Brilliant piece, Ruben!
I absolutely love your distinction between a "scene" and an actual core value—that’s a profound shift in perspective that a textbook simply can't capture. It’s a beautiful reminder that our clinical frameworks only work if we build that genuine human bridge first.
We learn the most from a failure we can’t forget. Most of our truest lessons didn’t come from the curriculum but a personal interaction. The connection after we find the “ essence” is certainly one.