Wednesday, February 20, 2008

Shrinking the Shrink

Roy asked me to comment on Dr. Richard A. Friedman's article in yesterdays New York Times, "Have You Ever Been in Psychotherapy, Doctor?"

Dr. Friedman talks about a psychiatry resident-in-training who becomes uncomfortable when asked by a patient if he's ever been in therapy. He moves from the patient's question to the broader, much-discussed issue of whether it's necessary for a therapist to have been in therapy. Friedman reviews the issues that every psychiatry resident has heard and discussed--You don't need to have had brain surgery to be a neurosurgeon. Psychotherapy, it's said, is different. "One way to think about it is that a therapist should not start exploring a patient’s mind without really knowing what is in his own." He talks about understanding one's own feelings and being aware of counter-transference.

But even as we have been swept off our feet by sexy neuroscience, my field
is in danger of losing touch with the rich psychological life of patients, something that is reflected in the waning popularity of therapy during residency training.

All true, but we are far from understanding the ultimate cause of most psychiatric disorders, despite the promise of brain science. We can effectively relieve symptoms and increase functioning, but we still have to help our patients live with illness.

Psychiatrists who have had the humbling experience of therapy themselves know something of what it feels like to be a patient — the sense of frustration,
anxiety and dependence it entails. As such, they can better understand the emotional reactions patients have to their illness — and to their doctors.

So do I think a psychiatrist needs to have had his/her own psychotherapy to be a good psychiatrist? Do I think the "humbling" experience of psychotherapy, or any other version of patient-hood, is necessary to create a good therapist?

Honestly, I have no idea. I'm not aware that anyone has every asked this question in a useful way. We'd have to survey patients and survey their shrinks, find measures to calculate good versus bad versus adequate docs and then we'd have to ask how much therapy, how often and by whom for it to "count." The psychoanalysts have made it a given, every psychoanalyst-in-training has to have completed a full psychoanalysis with a designated, experienced, "training" analyst. I'm not sure there's any reliability to who spends 4 years on the couch and who spends 10, but they've all been there. And are psychoanalysts "better" psychotherapists? I don't know.

I went to medical school in New York City when and where psychotherapy, and especially psychoanalysis, was still considered necessary for would-be psychiatrists. Part of "The unexamined life is not worth living," (thank you, Socrates) theory, I suppose. Still, when I started to see a psychiatry resident for my own therapy, I told no one and I worried about who would see me in the halls and what they might think. I was a medical student and I knew I'd be applying to that same department for residency ), so I worried about which supervisors talked about me with my resident doctor.
I only went for a little while, and this is what I can say about that particular psychotherapy experience: It was absolutely, and without a doubt, the most valuable experience I had in learning to become a psychotherapist.

Now, let me tell you about the psychiatry resident I saw. He was horrible. He wasn't a mean person in any way, but he wasn't a good therapist. No matter what I said, he'd say, "How would that make you feel?" Before I'd go to a session, I'd think about what I was going to say, and I'd think about how it would make me feel, and so I thought I had the bases covered. He'd still ask, "How would that make you feel?" I'd already told him! It was exasperating. I felt like he was a puppet of his supervisors, that he was wasn't thinking for himself. Years later, a classmate who was also going to be a psychiatrist and who was also in therapy with a resident in training, told me what safeguards were in place for student treatment, how the records were segregated and locked, and exactly who had access. Why hadn't my resident shrink just told me this? When I told him I worried about running into my advisor in the hall (who could have cared less that I was in therapy, I'm sure) why did he repeatedly ask "How Would that Make you Feel?" Why didn't he just tell me that my advisor didn't have access to my file?

I learned a lot about being frustrated as a patient. I learned an awful lot about what not to do, about how it leaves a patient feeling like you're not there with them.

Therapy is a kind of secretive mission-- perhaps why we enjoy the voyeuristic aspects of In Treatment and Jennifer Melfi's therapy with Tony Soprano. You can watch cardiac surgery. You can do it with a more experienced cardiac surgeon in the room. And Mirror Supervision for therapists is invaluable but often hard to arrange for. Mostly, we just try our best to report what happened to a supervisor, read books, try our best. What Dr. Friedman didn't mention is that being a psychotherapy patient is one of the very few ways that a therapist ever gets to see what goes on behind closed doors.

P.S. The resident who treated me for that brief period of time later went to work for a drug company. I'm sure he did a great job.


Anonymous said...

I hate not having blog access. I've been following the email comments at work. The NYT site registration is free. I love the shrink in therapy post! One of my supervisors kept telling me to just keep asking the patients how they feel; I thought that was stupid advice and that post confirmed it. Unfortunately I can't add that comment, arghh...waiting on comcast to dig up my boulevard.

April said...

My shrink told me he's had several years of intensive therapy in his M.D. education/training and honestly that makes me feel better about the process somehow. Mostly, maybe, because he's rather newly licensed so it gives me confidence that even though he's kind of new at this he will have the experience to help with countertransference, etc.

Anonymous said...

You might have read this article in the NY Times (sorry I forget when it was written) about a psychiatrist who self diagnosed herself with depression. She put herself on Wellbutrin XL and had all sorts of nasty side effects when on it and in trying to get off of it.

After that experience, she vowed that she would never say to her patients to tough out side effects. She was aghast at how insensitive she had been.

By the way, I am not inferring that you three are insensitive as you don't seem that way at all.

But my point is that unless a doctor has experienced what the patient is going through, no matter how caring and empathetic they may be, it just isn't the same.


HP said...

I think it's extremely valuable to have experienced therapy from the other side. It gives greater understanding of the struggles the client may go through in therapy. If asked the question, I would definitely be open about having been in therapy and be parepared discuss it very briefly (dependent on the usefulness of that in the situation) but I wouldn't disclose the details.

Anonymous said...

It makes me feel better knowing that my psychiatrist has been through his own psychoanalysis because I want to be with a therapist who knows the process from the patient end, and who hopefully has worked through his own issues.

Years ago I had a therapist who was a Marriage and Family Counselor and not only was she a LOT less capable but it was clear that she had her own problems and her own issues which tended to bleed into her interaction with me. Ultimately I left her because of this. I felt I could not trust her advice and opinions because her own life was in such disarray.

My current psychiatrist is terrific and I know from the things he says that he HAS examined his own background and issues and has overcome a less than perfect past. He knows himself thoroughly and uses that self-knowledge to understand me with amazing clarity.

I don't know HOW any psychiatrist who did NOT fully understand him/herself could ever adequately understand his/her patients.

Gerbil said...

I think it's valuable for a therapist to have had the experience of being "on the other side of the couch," but not just for the sake of the experience itself. I would venture that it's more useful for the therapist to have had some reason to have been (or to still be!) in therapy, other than just fulfilling a training requirement.

Also, I used to think it would totally ruin everything if it got out that I had not only been in outpatient treatment, but also (for several months when I was 18) in higher levels of care. Though I doubt I would ever disclose that part of my past to a client, I've mentioned it to supervisors without incident... and, in terms of my professional development, knowing what it's like to be in the hospital and in PHP is a lot different from knowing what it's like to be in outpatient therapy.

Anonymous said...

OK, so I saw my new therapist today. She's a social worker who specializes in compulsive behavior.

She asked me why I thought I overeat. I said, "stress, and I like the feeling of being full."

She asked about my job. I told her it was stressful, but no more stressful than any other profession.

Then I told her about a personality conflict I'm having in my department. I was very matter of fact, no whining. She asked, "If you get fired, what would you do?"


I told her I had no intention of getting fired. She actually argued with me, saying it was possible, even probable, as my adversary has a position of power.

Then I left and went to Taco Bell for a quickie binge before my evening shift.

I knew this was a bad idea. Haven't given up on her yet, but that was a bizarre first session. :)

I'm wondering if her therapist when she was in training used that sort of approach -- picture the worst thing happening and figure out a plan, then nothing else is that bad. Do ya think?

Rach said...

Did you ever read "Mount Misery" by Samuel Shem? (same author as House of God) - I'm reading it right now, and despite the fact that it's fiction, and far out fiction at that, I think it gives some (at least) adequate insights into this topic.

NeoNurseChic said...

I told my psychiatrist once that I wondered if he had ever been in therapy. Because I didn't phrase it as a question, he had the out to not answer the question without it seeming weird. Instead it turned into something along the lines of why I wanted to know that about him, and why it was important to me. I still don't know if he has ever been in therapy or not. Because he tends to be sort of like a psychoanalyst, I wonder if he has or has not. He seems to be pretty good at what he does, so I don't know if that just came naturally to him or if he has been on the other side of the "couch" himself or if he just had really good training.

I have spoken before about past therapists I went to. One of which kept asking me "How does that make you feel?" And the best question of all from him was, "What do you feel in your life went wrong?" I looked at him and wanted to say, "Uh...I was born..." Didn't click with him well. Then the one girl I went to who was training to be a school psychologist, she was just endlessly trying to set goals. So even though I was going to her to try to develop coping skills to cope with chronic illness, I kept having to set these ridiculous short term goals. Once I achieved the one goal, I said (after 3 sessions with her), "Well I guess that goal is achieved and I don't need to come back." She made me feel like everything had to be so goal oriented that I couldn't just relax and talk about what was on my mind - there had to be some goal and action plan for everything.

As I've said many times, I started seeing my current psychiatrist when he was a 3rd year resident, but something just seems really different about him. I never had all the "therapist-in-training" feelings that I had about the others. He just seemed more experienced at it right from the start. I do still wonder if this came from him being in therapy at any point. Honestly, I speak differently to other people sometimes because of the fact that I am in therapy. When at work, I use some of those skills in certain situations. Even though I'm not a therapist, being in therapy has helped me with communicating with my own patients.

I can't see that there would be any harm to it - really only benefit. Maybe I will bring the subject back up again with my psychiatrist some day. I wonder if he would ever really tell me or not. Curious...

Take care,

Mel said...

I often wonder the same thing, as I have been seen by psychiatry residents in recent years as well. The concern isn't because I work with them (I'm not a doc), but because my husband is, and is a resident that they know very well. It took me a long time to even mention this subject to my pdocres, but since I did, she understands a little better why I used to be so evasive when we talked about my relationships.

Anonymous said...

Oh yeah, and off topic a bit, but you might find this interesting...

Anonymous said...

To Fat Doctor:

I am not a therapist, just a patient with an excellent psychiatrist, but I can't imagine he'd ask that "If you get fired" question in the context of what you said to him/her.

I am a "Fat" Therapy Patient, and my (thin) psychiatrist's perspective is that I won't (would not) get my eating under control until I solve a couple of life issues. I have just made huge strides on the biggest issue (left my husband of 30 years who has been neglectful/abusive).

I was somewhat concerned because immediately after leaving him my eating got worse, not better and I decided that at least I would be fat and happier eventually if not happy and thin. However, an amazing thing has happened now that I am 7 weeks down the road and starting to inhabit my own body and live my own life for myself instead of for someone else: my eating has relaxed and I have started dropping weight. No more compulsive eating.

It might not work that way for everyone, but I think that examining my whole life was important for me. I did not start with the goal of losing weight, however. I had resigned myself to living life "large".

Anonymous said...

My therapist would totally ask me, "is it important for you to know that and why?" And she would never really answering the question... Lol, it's pretty bad when you've shrinked your shrink.

She's also easily a size 2 (just tiny), which is absolutely obnoxious to someone who's been struggling with serious med-related weight issues for the last 4 years. Some days I walk in and just want to turn around and walk right back out...

Anonymous said...

I wouldn't go to a therapist who hasn't been on the patient's side of the room, any more than I would choose to go to a male doctor for a pap smear.... Stands to reason that if you know what it feels like you'll do it more sensitively and gently....

That said, I briefly saw a psychologist when I experienced postnatal depression, who spent an awful lot of time telling me about her own PND when she had twins, and that that experience had led her to become a therapist. I think this was meant to make me see her as human and make me feel better about what I was experienceing, but it had the effect of making me shut up about my problems - after all, I didn't have twins, etc.

I think the thing is maybe to disclose 'yes i've been in therapy' but to say that you wouldn't disclose the reasons.