Saturday, May 05, 2007

A Shrink Like Me!

We're back to our regularly scheduled program now.

It was April 24th, back when Roy was having Grand Rounds mania and Shrink Rap was under lock and key, when the New York Times printed an article by Dr. Richard Friedman,
Understanding Empathy: Can You Feel My Pain. Dr. Friedman begins his piece by quoting a patient who asks if he's ever been depressed; does he know where she's been?

It's a funny question. Why does a doctor need to have suffered from an illness to treat it? We assume our oncologist hasn't had lung cancer or metastatic colon cancer, he hasn't gone through what his patients are going through, and yet we'll assume he's sympathetic and competent. If the doctor has had the disease, or has had a close relative with it (why is that never the question?) then perhaps he is more understanding, but really, how would this help his competence to treat a given disease? In fact, sometimes those who've conquered something are less sympathetic, sometimes those who've conquered say an addiction, or lost weight, or stopped smoking, or have somehow suffered, develop a bit of condescension toward those who aren't doing as well-- a bit of I did it Why can't You? Maybe it's better if the doctor is an outsider, a technician there to make the proper moves without the burden of his own history or agenda.

Friedman goes on to talk about patients who come with requests for specific flavors of therapists: gay, feminist, African-American, Jewish. These patients want a shrink who identifies with their lifestyles, who better knows what it is to be them.

I think there are two different issues here. Clearly, one can treat an illness if one hasn't had it; mental illnesses really are no different and plenty of patients get treated for schizophrenia by docs who've never been psychotic. Having been depressed doesn't change one's ability to write the right prescription, to imagine what it is to suffer, to listen, learn, and appreciate a patient's distress. If anything, it may color the doc's view. Want more? See my post from last September, A Taste of Our Own Medicine.

The second issue is more about therapy-- does it help to have a therapist who is familiar in some ways with the patient's world or culture or core beliefs? Dr. Friedman says No: "What is critical to understanding someone is not necessarily having had his or her experience; it is being able to imagine what it would be like to have it. Thus, I do not have to be black to empathize with the toxic effects of racial prejudice, or be a woman to know how I would feel about being denied promotion on the basis of sex. "

And what do I think? It seems to me that just as some patients respond to one medication and not another, some people have very strong feelings about who they are comfortable speaking with, while many don't care. I've had many calls from patients who want to see a female psychiatrist. I don't question it (what am I going to do about it anyway?) and I've come to take it at face value. I imagine there are women who prefer to talk to a man or who just don't care about their shrink's gender. The reality is this: if a patient lives in a place where there are options for who will be their therapist, and the patient has means to pay for it, they will select who they want to see--- there is no means for telling someone who wants to see and pay for an available female/gay/Jewish/Hindi psychiatrist, "No, don't do it." For those who go to clinics, where there may or may not be choice, the clinics vary in how responsive they are either willing or able to be to such requests.

In an ideal world, I suppose I think that anything reasonable that makes a patient more comfortable should be accomodated so long as it doesn't make someone else uncomfortable. It's not an ideal world, and some orders are hard to fill.

Any thoughts? I, of course, want a therapist with a blog.


Anonymous said...

It can be a double edged sword, this desire for a therapist who shares a similar history, religion, whatever. It may feel more comfortable in a sense, but there is a danger that the both parties will assume too much. The therapist can assume they know more than they really do about the client's unique experience because they "have been there". The client can assume that this therapist will be the one who truly understands, but if I am a woman and half the rest of the world are women, that does not mean that half the rest of the world is going to get what I am about.
Someone else could have said this a whole lot better but hopefully the point gets across.

DrivingMissMolly said...


I understand and see where you are coming from. Perhaps certain people have certain preferences for reasons that are not readily apparent.

I found out that my aunt, who is in her 60s, never sees anyone EXCEPT women for ANYTHING. She told me with a laugh, "even my stockbroker is a woman." Her reason? When she was 14 years old, the dentist she was seeing rubbed up against her breasts.

I feel lucky that nothing like that ever happened to me. The worse things that ever happened to me were; 1)A therapist making me hug him when I didn't want to, and 2) being undressed, placed in a gown, and thrown in seclusion by a mixture of women and men.

Before I started seeing this shrink, I had a list of good shrinks that I had gotten from a resident. One of them was a woman. I hesitated about choosing her, and then I thought that seeing her would prove a good opportunity to discuss the role of female hormones on depression, something I have never discussed with my all male psychiatrists.

In my case I believe it is very significant. I got my period the day after my fist suicide attempt and I believe it was due to PMS.

Anyway, the female psychiatrist had a long wait for an appointment because she was the only one that took insurance, so I went with the man I am seeing now. My therapist is also male.

I NEVER foresee the time that I would ever discuss periods, hormones or anything remotely sexual with either of these men. NEVER!

Part of it is the fear that they would think I was "putting the moves" on them. Most of it is thinking it just isn't appropriate.

For some reason women think women gynecologists and women doctors are better. My view is that both men and women get the same training. The women aren't sent to the "sensitivity" class and the men aren't sent to the "jerk" class.

I once went to a female gyno and hated her. I liked my male gyno and preferred him to even his nurse practitioners because he was gentler.

I disagree when it comes to race and possibly religion, however. Can anyone but a Catholic understand Catholic guilt? Can anyone but a Jew understand anti-Semitism? I'm not sure. However, I think it is a matter of perspective.

It might be good to see someone who is "different." In that way, maybe you'll get an outside view from someone who is really free to be objective.

I've been through many therapists and psychiatrists. There was also a period when I went through many primary care physicians. I know what I want and I think that anyone could be a possible candidate.

I want;

1) Experience
2) Compassion
3) a "spark"
4) a good listener
5) someone who I think is moral, just and kind and NOT judgemental

My psychiatrist is Jewish. I have been so fascinated by this fact that I have been reading and watching movies about Judaism and the Holocaust. This fascination has lasted since September. This interest pleases me because I want to go back to grad school and Judaism is the spark that has led me to believe that I have the curiosity to continue my studies.

Anyway, good post, Dinah.

Rach said...

Dinah, such an interesting and thought provoking post. As I am currently looking for a new therapist, I've spent a lot of time thinking about the qualities I want in a therapist... When asked by my current Shrink, I replied that gender wasn't importnat (which he couldn't understand - but honestly, if a person is empathetic, a good diagnostician and listens well, I dont care if it's a male or female), and that I wanted someone Jewish.

Judaism for me is so much a part of my being, I would hate to have to explain myself, and the little eccentricities that often come from my religious and cultural background.

I don't think it's a matter of having a similar history (as anonymous suggests). I think it's a matter of knowing that I'm getting the most out of 50 minute therapy hour - and in my particular case, knowing that I can actually get to the heart of matters rather than just trying to explain the surface of them.

Gerbil said...

Heh. Although I've never actually asked my own mental health providers about their sexual orientation, in my mind they have always been gay until proven straight. Even before I came out to myself, I made this assumption. Yup, I've been wrong... more than once.

I don't actually care, most of the time, whether I see someone "in the family." The only time it ever made a difference was right after I was seriously screwed over, in a most phenomenal way, by white religious conservative male heterosexist patriarchy. It was really important to me to have a lesbian therapist. ('Twould have been nice if she were also Jewish, but I guess you can't have everything.)

Then again, I once worked at a place where I was assigned all the Jewish lesbians, just because I was the only Jew and the only lesbian. Then they found out that I like working with Axis II issues, and my caseload filled up with Jewish lesbians with personality disorders.

I guess if it matters to the client and there isn't a therapist shortage, it can't hurt to do a little bit of therapist-client matching. But what gives me the heebie-jeebies is when a match is done without consulting the client. That sort of thing assumes not only that the client has a preference which he/she may not actually have; but also that only a therapist with a particular background can help him/her.

Don't get me started on "cultural competence." It won't be pretty.

Sarebear said...

Dinah, other medical professions aren't nearly as involved with the inner workings of a person's emotions, experiences, and processes, as is psychiatry.

That is why I think people ask iatrists if they've had it, or something, even though of course empathy doesn't require having had the same illness as the client.

On another issue, with me being LDS (Mormon), I think if I was seeing a therapist who didn't understand the culture and religion, it would be . . . difficult to touch on anything that touches on spiritual things, in therapy.

Especially when it comes to issues of sorting out when I am being prompted by the Holy Ghost, vs. sorting that out from manic, depressive, anxiety, and/or phobic impulses, thoughts, feelings, desires, etc. That would probably be an issue for anyone who believes in the promptings of the Holy Ghost, but it is a very large part of Mormon religion and experience.

Priesthood blessings being another; having priesthood holders (worthy men who hold a particular office or level of the priesthood, the keys of which were restored to Joseph Smith by divine inspiration and visitation) give me a blessing of comfort or healing, when one is distressed or ill . . . one might wonder if a non-LDS person might think I am crazy, or something.

Also especially when it comes to issues of, well, feeling like . . . . well, being terrified of eventually going through the temple (I know what ordinances are done there, but that's it; I do not know the content, as it is very very sacred to us and so not discussed outside the temple), being scared of the unknown. Tell me, how could a therapist help with THAT if they had no idea? There are also some strange things about the temple ceremonies put forth on the web, too. (My therapist, who is formerly LDS, but not in a bitter or anti-Mormon way, as many former LDS can be, reassured me that there is nothing to be afraid of in the temple.)

Anyway, probably way TMI, but I thought I'd use a few examples.

Roy said...

I think part of the reason for these preferences (sometimes) is that it is a shortcut... a way to get a jump-start to trusting that someone has the empathy to understand them. It can be hard to take this on blind faith without a reason to believe.

Rach said...

This raises another question in my mind, and that is, what do you say when a patient asks you if you've ever experienced blank [- depression, anxiety, suicidal ideation, psychosis, etc]? Where does a professional cross the line between empathy and boundary-slipping/crossing?

NeoNurseChic said...

I can see this from a few different angles, which is interesting. My personal journey in medicine started with wanting to become a pediatric pulmonologist because my cousins have CF. Then, when I had a benign tumor at age 16, I wanted to work with kids who have cancer. After getting headaches, I wanted to go into adult neurology. And then it all came crashing was too much. I don't want to work with adults with headaches. Ever. I don't mind helping them - I don't mind being there for them. I don't mind listening to them, educating them, whatever - but I don't want to be the provider. It's too hard for me. I don't think it's because I came through it and would look down on them. I think rather that it's because mine has not responded to anything at all, and so it's difficult for me to relate to people who are complaining about episodic headaches twice a month. (Can't believe I admitted that in public, but I may as well be honest...) I also don't like to face the attitude that I can't possibly understand the position of those who have headaches so badly that they had to go on disability. I can't tell you how many times people have come to me and said, "Well you can't have it that bad because you still go to work and go to school...." That's offensive to me. Yes, I push myself to work under extreme conditions, but my doctors have pushed me to go on disability dozens of time. I can't do it - and I have my own reasons for that - it doesn't make my pain less bad. If I don't have insurance, then I can't afford to live. So I must work. And work serves as some sort of distraction from focusing on pain 24/7.

So that's why I chose not to work in headaches. (Although I do plan to work in pediatric headache - that is different for me - afterall, I'm no longer a kid, so it's not like looking in the mirror.) Interestingly enough, when the American Headache Society did a survey of why neurologists went into headache, a vast majority had personal experience with headaches themselves.

In terms of psychiatry - I don't really want someone who is unstable. I want someone who is understanding. I don't care if they have or have not battled with depression and anxiety really. I did say to my psychiatrist once that I have wondered if he has ever personally been in therapy (I still don't know the answer to that - and I wasn't asking - I was saying that I wondered), but that was for a different reason. I have run into 3 blocks so far in being able to talk about things, and 2 of these blocks are because he's a male. I really think that I would be able to share the 2 things without any problem talking to a female - but I can't in talking to a male. So we've gotten into quite a discussion as to why I feel I can't share certain things - only 2 of them are because of the gender issue, however. His theories are related to various issues of transference - I haven't decided if I agree 100%, but I think this is at least partially true.

My former neurologist never had headaches like I do. My friend and I asked him once, and he said he gets tension headaches, but nothing like my headaches. My current neurologist suffers from migraine, as do a number of the employees at the headache center. I like that. I find that people who have never had headaches basically don't think they are important/problematic/significant/and so on. I literally just ran into a problem with someone the other day where I was supposed to present on women and migraine and she kept cutting down on the time she was giving me, and she said she doesn't get headaches - basically admitted that by not having headaches, she can't see why it's important that I do a public information session on women and migraine. But after I did the session (which took 10 minutes), she thought it was great. She just didn't know. So having a provider that has suffered from headaches in some way is helpful.

I do not feel that way about any other condition that I have - reflux, AVN, arthritis, and so on. Whatever - I just want a good doc who works with me as a partner instead of just telling me what to do. I want someone who is excellent in their field, and I want someone who is empathetic with good bedside manner. And at this point in my life, I really won't settle for less - I really can go somewhere else. That probably sounds very picky, but I have managed to find providers in each field where I seek treatment who fit that description.

Take care,
Carrie :)

NeoNurseChic said...

Oh and one more thought. I have spoken many times about how lucky I feel to have a psychiatrist that I work so well with. So when I started seeing him, I didn't pick him - and I didn't make any requests about who to see. My friend was chief resident (female psychiatrist), and she is the one who set it up so that I could see this particular psychiatrist at the clinic. I have brought up in appts somewhat recently that I sometimes wonder why my friend picked him for me. She knew me, and she knew him - what was it that she thought would make us work well together? Or was it nothing and just the fact that he became chief resident the next year so she knew he was good? I don't know...

I tried to get another friend into the same clinic once. I didn't know that you have to go on a waiting list and that you really don't have much choice in who you see. I thought you might at least have a choice of gender, but I found out that the only reason I got to see someone specific was because my friend was chief resident. Again - I was lucky.

I don't think I'll ever know the real reason why she lined me up with him. I guess I could ask her - but even then, that might be weird, and I'm not sure she would answer. But it is definitely something I think about. I didn't request anything other than that I needed someone who had reasonable fees and could prescribe my concerta. Actually trying to find someone with reasonable fees is not as easy as it sounds - that's why I went to her for help. She is a firm believer in residents' clinics!

Take care,
Carrie :)

Sarebear said...

Hey, Carrie, finding a psychiatrist who will take a new patient at ALL, never mind finding one you can work with well, is being a major PITA. If I run down the list of 35 or so that are within 50 miles, and none will take me, then I'll taper off meds and be done with it. It's stupid, and it's ridiculous.

It also makes me feel, should I get another as bad as Dr. Derry Brinley, that I won't have any choices, any options, no matter how abused I feel.

Gerbil said...

Rach--no one has ever asked me about my personal experience. (My sexual orientation, relationship history, and [ahem] personal behaviors, yes.) But if someone did ask me, I would not lie; but neither would I go into any great detail. For me, this is part of genuineness.

Unknown said...

We discussed this over at Dr. Helen: I MUST make the same point here that I made there: Martha Mitchel error can get BADLY in the way of therapy and that must matter above other considerations.

OK, I've never made it a secret that I was badly hurt as the result of a female offender sex assault. The problem with that is that almost without exception psychs will take that as proof I am delusional: This because EVERYONE KNOWS there are no female offender sex assaults against males.

The thing is, what everyone knows is just plain bigoted and wrong.

So, some patients, me among them, have very good reason to be picky about who is our Dr. or pscyh or ...

Thus, for me, asking for a men's movement psychiatrist is not a matter of convenience, it is a SERIOUS matter of safety and the only possible way to get communication. That's something I have rarely had a therapist of any stripe understand: Sad to say ...

Alison Cummins said...

Shortcuts, definitely. If I'm paying someone 30% of my income (as I have in the past) to save my life in 50 minutes once a week, I don't want to spend that time explaining what my sexuality means to me. I want to focus on what I can do to stay alive.

Another way of putting it: if I am depressed and in a draining lesbian relationship, I don't want to have to say that the relationship isn't that bad to avoid judgement for being in a sick twisted lesbian relationship. If my therapist is a lesbian in a healthy lesbian relationship, then we can tackle why I am in a *sick twisted* lesbian relationship without getting diverted into the sick twisted *lesbian* relationship. And I don't have to worry about my therapist's perceptions, or do regular check-ins with the therapist to be sure we are keeping the sick-twistedness separate from the lesbianness, or keep up a good front for the sake of the cause.

There's a lot more to being a woman or black or lesbian or jewish than being discriminated against. Shortcuts are great.

About being depressed: depressed people are often very judgemental of themselves. Wanting to be reassured that the therapist really understands this seems perfectly normal to me.

Roy said...

Alison, GREAT explanation! Thx

Anonymous said...

Two thoughts

1. Depending on the role of religion in your life, I think it can be important to have a nutdoctor who is at least familiar with your religion. I didn't know that my psychiatrist was a Christian when I first started seeing him, however I did know that he had been very helpful for various Christians I knew of. As a lot of my problems are either caused or amplified by church stuff, it makes an enormous difference to have someone who understands why healing is not as simple as stopping or changing church - there is an awful lot of guilt and angst and despair and doubt that probably wouldn't be there if, for example, it was the Scrabble Club causing the problem.

2. The other bit (that I will be discussing today - I'm sure I could come up with some others!) of finding "a shrink like me" is a bit harder to define. Looking at it backwards, one of the reasons that I went to med school was that I'd noticed that the doctors I'd had useful clinical relationships with, had all been the sorts of people who I'd get along well with in real life. Going to university with a bunch of other people "like me" sounded like a good move (and it indeed has been - I have friends who are just as nerdy as me!!).

But back to the topic at hand, if my psychiatrist weren't like me in this hard to define sense, I don't know that it would have worked out to be the long/rewarding/tumultuous relationship that it has been. For me, perhaps a good marker of this warm and fuzzy aspect of "self" is sense of humour. If someone laughs at the right time, chances are that things will work out. Also, for me, intuition is important. I know that it could be argued that psychiatrists are prone to above-average intuitive skills, but I really appreciate not always needing to spell out that there is a problem, what it is and why it is a problem. And for that to happen, the shrink really does need to be able to think like I do. Which is definitely not a learned skill :D

Alison Cummins said...

More thoughts about "a shrink like me": way back when I couldn't afford either talk therapy or medication for depression because I was too depressed to secure an income, my GP (covered by Medicare - I'm Canadian) gave me a list of psychiatrists affiliated with an outpatient clinic who I might be able to make appointments with.

From their names they all appeared to be foreign-born men gaining re-accreditation in Canada. I imagined the following scenario: I meet with a man whose family sacrificed to put them through med school back home, and who dropped everything to start again from the bottom in Canada because they'd had enough of the wars/corruption/ethinic-religious conflicts/poverty in their country of origin. And I say, "Hi, I'm white, middle-class, educated, born into the dominant culture, and I feel too discouraged to make anything of myself."


I didn't call any of them. Not that none of the hard-working, disciplined men on the list wouldn't have been able to empathise (or even to un-empathetically write a script). I just didn't want to put either of us through the humiliation, certainly not if it meant going through the whole list to find one I could work with without feeling insulting.

Maybe it would have been fine with the first one I met. I just didn't feel up to taking the risk.

Anonymous said...

I believe that having a therapist that comes from the same culture and speaks the same language I do is very important. Write English is not the same as the American english we use on the streets. I am not saying they have to be the same race, religion or sex as me, but someone that was not raised in our culture and does not speak fluent English is definatly the therapist I do not want to see. Some of my experiences with foriegn born therapist have been funny, like the time I had a talk to me about my cat for half the session. I did not own a cat at the time and didn't like cats back then. Some of left been woundering which one of us was really crazy, like the one that yelled at me for applying for unemployment after just being laid off from a job. Others have been near fatal when they have not been able to understand that I was having a bad drug reactions or that they just handed a sudicial patient more than enough of a drug to overdose on. I don't even want to imagine what happens when they meet people like the people I work with that use street english.

I have had both male and female therapists, some have shared my religion some have not, some have been black some have been white, but if they are not raised in our culture and english is not their native language, I am not going to see them. If it means going without care, so be it. The risks of interacting with these proffesionals are way to high.

Anonymous said...

Depending on the role of religion in your life, I think it can be important to have a nutdoctor who is at least familiar with your religion. I think this point made by yay can be applied to many aspects of identity, sexuality, gender identity, and race/nationality included. The key here is how big of a role any given identity factor actually plays in ones life. To be honest, sexuality just isn't much of an issue for someone struggling with MDD in many cases.

At some MHCs I've been asked whether I have a gender preference. At others I have simply been lucky to snag an appointment with one of two psychiatrists serving medicaid patients in a country of over 50,000. Circumstances like this have taught me that I will only marginalize my care by specifying my preference for anyone more particular than "the best who will see me."

Sometimes, the "empathetic" professional is one of the worst people to do the job. I do not believe that those with an hX of anorexia/bulimia should treat eating disorders, for example. Under no circumstances should an MHP disclose h/or/sh/its eating disorder history to such a client. Perhaps affective disorders, personality disorders and whatnot demand their own criteria, though. My old doc probably would have been a much better psychiatrist had he personal experience with rapid titration of Zoloft/Effexor. Come to think of it, Paxil probably would have worked, too.