Tuesday, December 02, 2008

Shrunken Shrinks?

Midwife with a Knife writes:

"Hm... so I'm not sure it's fair to make psychiatry residents have psychotherapy. After all, nobody made me have a gyn exam or give birth as part of my ob-gyn residency!"

It's been a common theme in our comments, this idea that one needs to walk in the shoes of the patient to truly empathize. One commenter even wanted all med students to have a couple of electroconvulsive therapy (ECT) treatments!

So let me talk for a moment about the whole concept of psychiatric residents having their own personal psychotherapies. It started as part of psychoanalytic training (and remains a requirement in order to become a psychoanalyst). The idea isn't to empathize, or to experience what the patient feels, the idea is that the analyst must understand and work through his own unconscious conflicts in order to effectively work with the patients. He must be able to recognize his own counter-transference, know which issues are his so he isn't projecting them on to the patients, and be aware of his own unconscious motivations and conflicts. It sounds good, I have no idea if it works. I'm also not a psychoanalyst and I've never been in psychoanalysis, so my knowledge is limited, and this whole last paragraph may be a bit off or misstated.

Some residency training programs encourage residents to have their own therapeutic experiences. Where I went to medical school, residents would openly post that they were off to therapy or analysis, and it was both expected and encouraged, and trainees would leave the hospital four and five times a week to lie on the couch. Where I trained as a resident, I was aware that some residents were in therapy, but it was never openly announced in public-- it was something that was either done quietly or on the residents' time-- I believe if a resident working on an inpatient unit announced they had to leave for therapy, it would have been frowned upon during working hours. The residents were expected to be doctoring and leaving th for the hospital for treatment in the middle of the work day was not encouraged.

It's hard to learn therapy. It's a process over time and there's not a great mechanism to watch it unwind. Having it oneself probably provides at least one example, and that can't be bad. Most supervision occurs based on notes or the resident's report and so it is skewed, the supervisor can't always be sure the reporting is accurate or necessarily get a great feel for an unseen patient. Yes, there is "mirror" supervision (where the supervisor watches the resident with a live patient), and this is a terrific learning experience, but there isn't really a way for a trainee to be a fly on the wall of an older, more experience psychotherapist over time. Being your own experiment may help with the learning curve, but I'm not aware of any programs that require it. Is therapy required (as opposed to encouraged) to become a social worker or a psychologist? If so, does the program pay for it, does health insurance, are there discounted ways of getting treatment, or does the trainee pay for it? And for how long and how often?

Does one need to have therapy to be a sympathetic human being? Absolutely not. In fact, one can have years of therapy and still be a creep, while another person can be a wonderful therapist even without having been a patient. Nor does one need to have chemotherapy to understand that cancer sucks, or have AIDS to treat it with kindness. As MWAK has pointed out, many child-free people have delivered wonderful healthy babies and rendered terrific care to their pregnant and delivering mothers without ever having had the experience themselves. And if one has never psychotic, can one truly appreciate the pain it causes: I doubt it. Is it necessary to feel that pain in order to render good care? Of course not.

Sometimes it brings people comfort to know their doc has been there. Substance abuse counselors are often open about their own past histories with drugs. A friend with cancer is now seeing a therapist who is a survivor, and she feels very comfortable with this. I have always been comforted by the idea that my children's pediatrician is himself a father.

But you don't have to have panic disorder to treat it. You don't have to have suffered with depression or schizophrenia or obsessive compulsive disorder to treat it or to appreciate that someone else is suffering.

Should psychiatrists undergo their own psychotherapy?
Oh, everyone knows what I'll say: yes, if they want to.
I believe that most people who are drawn to being psychotherapists have a somewhat analytic nature. They like to look at patterns and relationships (maybe they even like to blog about them). They are curious about what makes humans act the way they do, and by extension, they are probably interested in what makes their own psyches tick. Furthermore, people who practice psychotherapy tend to believe in it's power, they feel there is value in articulating emotional life and in examining the internal world. Given this, a personal therapy may have some appeal, with or without the presence of a psychiatric disorder. (I'm not going to even touch the question of who should pay for it if the psychiatrist doesn't actually have an illness...). If the psychiatry resident wants to have a personal psychotherapy, he should. If he has a psychiatric illness, he should get treatment. But a psychiatry resident who is not ill, who is not suffering emotionally, and who is able to work and to love and who doesn't want to have psychotherapy should not feel compelled to do so for it's own sake. And, by the way, if he later decides it might be helpful, there's no time limit on when, it's not just for trainees.

Are there studies? I don't know of any that randomly divide shrinks who've been shrunken from shrinks who are unshrunken and then looked at their treatment successes with patients....


Rach said...

If the psychiatry resident wants to have a personal psychotherapy, he should. If he has a psychiatric illness, he should get treatment. But a psychiatry resident who is not ill, who is not suffering emotionally, and who is able to work and to love and who doesn't want to have psychotherapy should not feel compelled to do so for it's own sake. And, by the way, if he later decides it might be helpful, there's no time limit on when, it's not just for trainees.

Thought provoking as always, Dinah.
Are psychiatrists more likely to have a diagnosed mental illness than a different specialist physician, or this a myth perpetuated by the specialization in itself, along with the type of people that are sometimes drawn into the specialty?

Has there ever been studies done about the rates of pervasive, chronic mental illnesses (diagnosed of course) in physicians (or other professional career people for that matter)? I know my psychiatrist constantly reminds me that X% (and I can't remember the statistic at this moment) of CEOs of fortune 500 companies have bipolar disorder...

This interests me particularly because I try to manage my life as well as possible and when I finally confide in someone that I have the illness they say something like "that can't be, you're so good at everything", etc, etc... It seems that as a society we're really good about making the public aware of people on the down and out, but those who are successful just don't want to share how they struggled to get the top (and how they continue to struggle to stay there).

Midwife with a Knife said...

For the record, my comment was in response to Dr. Shock's comment about Netherland psych residents being required to have therapy or some such. :)

Gerbil said...

I think it's useful to have therapy while in training if you need it for your own issues. If you truly don't need it, it might be a waste of two people's time.

And then there are supervisors who (unwittingly or not) confuse supervision with therapy. Oy.

(If ob/gyns had to have a gyn exam or give birth as part of their training, then only women could be ob/gyns...)

Anonymous said...

If there two people in the room, and only one of them is sane, it should probably be the psychiatrist.

Being flippant, but I vote "yes" on therapy (was this subject to a vote?) for reasons very close to those stated.

Anonymous said...

I got turned down for a Personal Trainer job. They said being unfit and 130kilos might get in the way.

Some jobs seek a certain level of complementary characteristic or attribute.

Some demand it.

I don't know if it is demanded in this instance.
An RCT on shrunk shrink vs unshrunk shrink - outcomes and burn out etc. would be interesting. But likely to demonstrate a need for further research - and promulgate two opposing hypotheses.

Anonymous said...

In Australia,

Psychologists have to complete university qualifications. From what I know generally most of these institutions don't require psych students to have personal therapy.

The training is often (sometimes) quite clinical and there can be a bit of an us (Psychologists) and them (patients) attitude. So if one is to become a patient then you would become on of them and that may mean that you could no longer be one of us!

This is certainly not always the case though.

Psychotherapists and counsellors can obtain an advanced diploma by any organization that wishes to set up as such a training institution. These are quite regulated and audited often by government. It is here where you get the wide array of different psychotherapeutic approaches and thus they vary considerably in requiring students to have personal therapy.

The one scenario that I have considerable trouble with is when the trainer requires the student to have him as their psychotherapist. They cannot choose someone else. To my mind that is very wrong to not allow a person to have completely free choice of who they want as their psychotherapist.


Roia said...

I agree that personal therapy should be the choice of the psychiatrist/psychologist/music therapist in training. That said, though, I would personally prefer to go to a therapist who has done his/her own emotional and internal work.

As a music therapist, I haven't had the opportunity to experience my own music therapy sessions (largely because of lack of availability of music therapists who work with "normal neurotics"; however, I've had a good clinical supervisor who is both a music therapist and a psychologist (and who, happily, recognizes that there are boundaries between therapy and supervision). Along with having my own (verbal) psychotherapy, having had the opportunity to work through my own garbage has made a huge difference in the type of therapy I provide to my clients.

Ladyk73 said...

I think I am rather "special" in the sense that I have a wonderfully severe mental illness and I am in training to be a clinical social worker.

My MSW program is very highly skewed to clinical social work. I have had training in basic CBT, DBT, motivational interviewing, schema therapy, solution focused therapy, skills based group designment and a million other things. I personally do not want to go into the clinical side of social work, except maybe to design and do skills-based group work.

In our area, clinical supervision is very much like mini-psychotherapy. Of course someone can purely deconstruct sessions or treatment plans. However, it is often work on countertransferance issues, but often "real-life" issues. This supervison is suppose to be more about 'you' as the therpist. Having nighmares about forensic clients, having personal difficulties with agressive clients are more focused on self-care and vicarious traumization.

Personally, my training has spoiled my own work. I decided to join a group (me as a patient) with the college councelinmg session. I spent more time noticing the actions of the therapist and never went into my issues (until the very second to last session). I am still struggling to bring up issues in my own therapy.

Anyways, I think my own issues and therapy has helped me be a good therapist. I have been told I am talented and should pursue it. I still thjink I am too ill myself to do that....

Ladyk73 said...

And obviously...I am a wonderful speller and make no typos when commenting!


Anonymous said...

Great post.
I wouldn't go to a male doctor to have a pap smear, because no way can he know what it feels like. With something so intimate and invasive, I think the empathy is very important.

Psychotherapy is similarly intimate and potentially invasive, so I would prefer to see a therapist who knows what it feels like.

Not that I think it should be a training requirement, but I'm not sure they can do the job properly if they haven't undergone it.

harry103 said...

panic attacks are common and becoming more recognised and diagnosed but most psychs have never experienced one and the few who have, often before delivering a speech to their colleagues,consider themselves experts
but its easy to cause a panic attack with an injection and I suggest every trainee psych should br required to experience an induced panic attack, this has caused howls of outrage when Ive suggested it to a few psychs

Anonymous said...

As someone who has done psychotherapy and then years later went into therapy, not for any axis I disorder but more for personal reasons, I say there is nothing like having the experience of transference personally. I say if people are not interested in taking a psychological approach, including in their own lives, then why did they go into psychiatry in the first place? Btw all of the Dutch psychiatrists I know feel that their therapy was an important part of their training. That said, if all you want to do is give drugs, which is fine if you have a therapist partner, then you probably don't need therapy.