Sunday, August 12, 2012

What Kind of Work is it I Do, Anyway?

I'm blogging during the closing ceremonies for the London Olympics.  As if there's not enough stimulation going on here....  

In Shrink Rap: Three Psychiatrists Explain Their Work, we talk about psychotherapy as a process that occurs over time where the talking is an integral part of the actual treatment; that is, it's the talking itself that facilitates the cure.  Traditionally, psychotherapy happens on at least a weekly basis -- sometimes twice a week -- and for psychoanalysis 3-5 times/week. Sessions are 50 minutes long and patients are often seen at a set time, for example, every Friday at 1pm. 

I think of myself as a psychotherapist because I see the majority of my patients for 50 minute sessions and people generally tell me about the events going on in their lives.  Unless someone is acutely symptomatic, very little of the sessions are devoted to symptoms, side effects, and medications, though certainly that is part of what gets discussed if there is a problem.  The assumption, however, is that there is more to the psychiatric treatment I'm doing then checklists of symptoms and medication adjustments that take place in a vacuum that does not include the patient's life events, past events (including childhood) and their emotional reactions to their world.  

Okay, so several readers and Amazon reviewers have commented on typographical errors in my e- novel, Home Inspection.  I recently got the paperback proof back, and with the help of one of our readers,  I've been re-reading it and going through the novel trying to see the words (and errors) my eyes (now on their zillionth reading) tend to simply not see.  

For those of you who haven't read Home Inspection, it's a story told by a psychiatrist through the sessions of two of his patients.  Dr. Julius Strand's life is a bit of a disaster: he continues to mourn the death of his first wife, his second wife kicked him out, he's living with his cat in an apartment full of unpacked boxes, his career has a crisis, his health is not good, and his relationship with his daughters is strained.  Patient Tom is a cardiologist who is having panic attacks as he starts building his dream house with a woman who is certainly not his dream woman, and Patient Polly feels 'stuck' in her life.  She struggles in her relationship with the psychiatrist and talks about her past begrudgingly, asking repeatedly if it will set her free if she talks about those past secrets.    Through a series of coincidences, their paths all cross, and somehow, the patients help to cure the doctor.  

The therapy that Dr. Strand does is a very conventional, psychoanalytically-informed therapy.  His patients come at the same time each week.  They talk about how past events inform their current behavior, and he thinks a great deal about how their relationships with him are relevant.  

It occurred to me as I was reading my own account of treatment (fictional though it may be), that I don't do really do this type of therapy anymore.  I'm not sure I ever did.  When people start therapy and are feeling badly, they generally come weekly, but as soon as a patient's symptoms get better -- often a matter of weeks to months -- they ask to come less often, and most patients come every two to four weeks.  Some I see on an irregular basis -- they call when they have a problem and want to come talk.  Therapy is expensive, and in our harried world, most people don't have either the time, money, or inclination for sessions once or twice a week. While there are people I tend to see on specific days or at specific times, most patients don't have a fixed regular session -- I think this is because I like having some flexibility to my schedule.  And while people do talk about what is going on in their lives, and I often will ask about how past events and emotions have impacted them, I don't spend much time focusing on the therapeutic relationship.  I won't say never -- and certainly,  the fictional Dr. Strand thought about it much more than he talked about it -- but it is not a major focus of treatment for most people.

So I think of myself as a psychotherapist, and I think of psychotherapy as a crucial part of treatment, but if I don't see most people for weekly sessions,  then what exactly is it I do?

And if you don't feel like talking about psychotherapy, by all means, tell me what you think of the closing ceremonies!


Anonymous said...

Sounds like people pay you a lot of money to unload without having to feel bad not reciprocating. If they still come to talk after "feeling better," than I doubt they actually got much from the experience of therapy (besides the passage of time), but just got accustomed to the idea that feelings are commodities that require paying someone to talk about.

Sarebear said...

I'm underwhelmed by the closing (and to a degree, the opening) ceremonies.

Unless they're doing something really neat, who cares about a bunch of people dancing in a stadium? And the older singers, that either can't sing anymore, or are so off key that what's the difference . . .

Part of it though is NBC's coverage. They are 80% of the time zoomed in too close or too far, and you can't get a good sense of things, it's too scattered.

Plus, the biggest negative is ;D where the heck is Dr. Who? They gotta have Dr. Who . . .

As for psychotherapy, the therapeutic relationship and stuff, I could say a whole host of things. Some of which I've said over the years, at my piebolar blog and now at my typepad blog. Therapeutic relationship is one of the largest tags in my blog tag cloud. I actually have recently described for myself, what therapy is for me (though it doesn't cover it all, it hits most of the big stuff).

Anonymous said...

Interesting post. Emotional triage?

rob lindeman said...

What kind of work is it you do?

You write books (DUH!)

I agree psychotherapy is essential. Psychotherapy's major drawback, it seems to me, is not the expense, although it is considerable: it's the inability of some clients to "do" psychotherapy. My understanding is that the client has to have a modicum of insight and not a trivial amount of intelligence to make psychotherapy work. Correct me if I'm wrong.

A Girl said...

Therapy has been many things for me over the years. Initially, I went for the once-a-week, fixed-slot kind of thing. For me, it was awful. It meant that I'd keep things bottled up inside for days on end, until the session rolled around, at which time I had nothing to say, because it was all forgotten as soon as I walked through the door.

Today, I wouldn't mind going once-twice a week. But I can't: Between money, family, work, leisure, and a whole host of other factors, that possibility does not exist. Instead, I have a therapist I can call and book with when the mood strikes - I see her roughly once a month, and it suits me fine. I love the flexibility of being able to walk in for a dobble-session when my mum calls me up and tells me she's being spied on again, and then not comming for a month when I'm just dabbling in the shallows.

Incidentally, my current therapist does play-therapy, which I initially thought was waaay to fluffy and hippy-like for me. I chose her anyway, because lets face it: The usual stuff wasn't working to well. And now I love it. Funny how going for something totally different can totally change your life :D


Reed said...

I pretty much agree with anonymous. Often, people want a place where someone will listen to them. We live in a society in which we tend to have people who "love" us but who cannot bear to listen to us for fear they may hear something they didn't want to know. Love is so conditional that folks are willing to shell out the bucks to pay a stranger to listen. This is not to confuse seeing a shrink with love. It is business. In some sense, it does seem similar to a visit to another sort of professional by a man who then goes home to the woman he loves but she doesn't give him everything he was looking for.
I don't know if people feel understood after they leave the shrink who listens for 50 minutes or it just felt good to get something off their chest. A lot of the standard shrink responses are designed to make people believe someone understands. I am not so sure that it is really the case.
People move around, families break up for a lot of different reasons, friends are often situational ones and everyone is busy with working, raising kids, dealing with their own stuff. A person can go to a shrink, pay a fee and have their ear for a bit. It is not that surprising that you don't think about the relationship too much.I wonder about the shrinks who focus so much on the relationship when the truth is that relationship is not a good descriptor of the transaction.

Anonymous said...

I think therapy is very different for different patients and maybe your patient population self-selects for people not interested in talking about the relationship they have with you.

My husband and I have both spent several years in therapy but very differently because of our very different difficulties. My husband is like your patients in that he goes once a week when he can or less frequently when he is busy. He talks about problems he has in his current life and how they relate to his past. He rarely talks about his relationship with his therapist because he trusts that the therapist likes him and is trying to help him. He is willing to listen to suggestions and try new strategies easily. I spend hours talking about why I can't trust my T. What a minor lapse in attention or change in tone means. I have those reactions to everybody in my life including my husband. It isn't surprising to me that therapy is very different for each of us.

I enjoyed the closing ceremonies if only to remind of some great British music (even if it didn't sound great last night).

Jane said...

I agree with what Rob said about some people not being able to "do" psychotherapy. But I think it's for different reasons. I don't think it's all about intelligence level high personal insight. I don't think either of these things are the reasons that I don't do well with psychotherapy. I really believe that some people, for whatever reason, do not respond to psychotherapy. And it has nothing to do with some inner flaw within the patient (intellectual or emotional).

And I have always wondered what your clientele is like. You are very expensive compared to other psychotherapists, because you are a psychiatrist who performs psychotherapy. I wondered how people could afford that kind of therapy frequently It turns out you don't have very many people in your practice who do see you as often as they might see an MFT, psychologist, etc.

Dinah said...

di345 points out that therapy is very different for different patients. This is absolutely true.

I don't think most people feel they come to "unload." There is something about therapy that helps some people maintain their balance, and certainly the relationship (even if it's not discussed) is important.

Why do some people talk and not others? I wish I had an answer. Certainly, I've noticed that when some people decrease the frequency of their sessions, they have less to say-- it's counter-intuitive. Some people who struggle with what to talk about early on become talkers as time goes by.

I do believe that combining therapy with medication management makes it so that the patient ultimately takes fewer medications, that relapses are caught earlier, that the psychiatrist knows and understands the patient in a context besides "rate your mood on a scale of 1-10 and how are you sleeping." Every symptom is not a relapse and knowing the patient and the context of their lives makes it easier.

Jane: many of my patients are people who have failed treatment with a split treatment model.

Anonymous said...

I've found the therapeutic relationship generally isn't an issue when the therapist is skilled at what they do. The one time it took center stage in the psychotherapy process for me, the psychiatrist didn't seem to have adequate training or experience with talk therapy and frankly hadn't gotten a handle on his own issues. The Olympics? Gosh, I haven't watched them since the late 90's!

Anonymous said...


Replace the word client with the word therapist and you will have hit it on the head. Some of them charge for it but really cannot do psychotherapy.

Journalist on Call dot com said...

I have written an article for Harvard's Nieman Foundation on the Casey Anthony trial and I am in the middle of a book being written with the intention of breaking new ground. I would like to find someone who will share a conversation on legal issues
from the case. Please let me know if you would be interested in discussing these issues. Keith Long

Journalist on Call dot com said...

I have written an article for Harvard's Nieman Foundation on the Casey Anthony trial and I am in the middle of a book being written with the intention of breaking new ground. I would like to find someone who will share a conversation on psychiatric issues generated from the case. I have read two depositions from court appointed psychiatrists who interviewed the subject and have some questions in order to faithfully report and write about their findings. They were deposed by the prosecution. Please let me know if you would be interested in discussing these issues. Keith Long

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Anonymous said...

Hi Shrink Rappers--

I have been reading your blog for some time and was wondering if you guys could address a problem that I am having with my therapist.

To make a long story short. My therapist is very truthful. Things are said how they are-- and although this can be helpful--- the truth seems to just keep me feeling a bit hopeless.

So I bring this up with my therapist and it is met with a large amount of defensiveness. There is never an apology even if I ask for one and specifically describe what and why I feel i deserve it, very rarely is there any type of acknowledgement that my therapist did anything wrong and I hardly feel as if my distress and feelings of hurt are understood at all.

Also when I do this I normally get a response which focusses on what I am doing wrong and how I should have done something better or not taken it so personally etc...

It is so hard! I don't really want to switch therapists because we have so much history... but how do I help my therapist get through her own defenses which she puts up because of her own insecurities.??

(If any of you have felt perhaps scrutinized by a patient for being a bit too harsh in some circumstances how would you like constructive feedback given to you?)

The reason I am dwelling on this is because this conflict between us is growing and I feel it is not helping my therapy or our alliance.