Psychotherapy: the Down Side

In my review of Lou Breger's book Psychotherapy: Lives Intersecting, several readers commented that they felt injured by psychotherapy.  It's a favorite topic of ClinkShrink who wrote the section for our Shrink Rap about how therapy can be harmful, and likes to note that any treatment with the potential to heal also has the potential to harm. 


So I got to thinking Why Would Psychotherapy be harmful?
There's bad therapy, like those mentioned by ClinkShrink and by Dr. Breger, where the therapist has their own belief system and thrusts it upon the patient, whether or not the patient feels the interpretations resonate.  We've talked before about what makes a good therapist.  Maybe we should talk about what makes a bad therapist?
I'll give you my list, please write in and add to it.
A bad therapist:

• Falls asleep during the sessions
• Forgets to show up for the sessions (repeatedly, we all have emergencies or calendar/technological failures).
• Does not return phone calls (or other communications) or is generally not responsive.
• Over-emphasizes money issues with patients who have traditionally paid.
• Makes interpretations that don't feel relevant to the patient and insists they are true even when this repeatedly upsets the patient.
• Takes non-urgent phone calls during sessions routinely.
• Is generally disrespectful of the patient (curses at him, eats pizza during the session, berates or belittles him).

• Is preoccupied and not attentive on a regular basis.

These were my thoughts off-the-top of my head, certainly not a comprehensive list, but this list is more inclusive and includes a list of more obvious red flags like licensing issues, the therapist initiating a physical relationship, revealing the identities of other patients, etc.  
 
 I want to say that there are always exceptions, and so these "bad therapist" ideas need to be general.  If the therapist just found out his wife has cancer, he may be less sensitive than usual or preoccupied, it doesn't mean he's a bad shrink.  And therapists have their own bills, and their own individual financial issues which may or may not permit them to be flexible or reduce fees, but some ways of talking about fees are more sensitive than others. 

 Finally, there is no perfect therapist: Someone who does everything wrong and has an awful reputation may be seen in a totally different light by a patient who feels very helped by his/her style, and the most wonderful of shrinks will still see patients who don't like them--- there's an element of chemistry that can't be ordered off the menu.



So tell me your list of bad shrinky things to do.
 
 
 

Guest Blogger Dr. Jesse Hellman on "Acting Professionally."

 

Psychiatrists “friending” their patients or interacting with them on Facebook led to the discussion of professional boundaries on Podcast #62. I thought of expanding the discussion because the oft-advised “act professionally” is less than truly helpful: how does one know what is professional? That does not elucidate the underlying principles. I’m talking about one aspect of this below, and am posting this to see what ideas others have. If possible, try to look below the concrete example to expose the underlying principle. 

The psychiatric relationship is a special extension of what is considered proper in all relationships in which one engages someone for professional ends. A mechanic, accountant, electrician, each has access to certain information and he is to use it only for the purpose intended. When you invite an electrician into your home he is to concentrate on the task at hand, not dwell on your art or the design of the home, and certainly not on how beautiful you are. 

A psychiatric patient opens up extremely sensitive personal information, potentially much more embarrassing and intimate than that seen by other physicians. The psychiatrist needs to behave in a way that not only takes no advantage of the information but also keeps the focus on what will help the patient. 

The more the psychiatrist holds to this dictum not only is it easier for the patient to speak openly but the psychiatrist may learn of things that the patient has revealed to no one, perhaps information that he has had trouble admitting even to himself. 

Keeping to proper boundaries is very important in psychiatry. Certain remarks which are common in ordinary social situations would be quite seductive in a psychiatric session. We do not use our patients for our own gratification. That is the basic principle and it is essential if we are to help them.

The Ethicist On Whether Shrinks Should Lie to Keep Their Clients

I hope everyone had a wonderful holiday! We've been busy brining, basting, baking, eating, and visiting with family. Sad to go back to the daily routine.
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In today's NY Times Magazine the ethicist entertains the question of whether it's okay for a psychiatrist to lie to keep his clientele. (!)

I am a psychiatrist who happens to be an atheist. Occasionally a patient asks me what religion I follow and, displeased by my answer, seeks another psychiatrist. I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s. Nevertheless, candor sometimes costs me a patient. May I claim a belief in God to avoid damage to my credibility and business?

VAIDYANATH IYER, THE WOODLANDS, TEX.

If you want the ethicist's answer, check out the column here.

I think that most of us would agree that it's not okay to lie with the intention of keeping business. What if a patient asks how long you've been practicing, and your sense is that the patient wants an experienced psychiatrist-- would it be okay to say 10 years, rather than 1 year? Clearly not.

Personal questions can be awkward, however. In traditional psychodynamic therapy, the therapist doesn't answer personal questions---the "blank screen" is necessary for the treatment, and the meaning behind the question is explored. This can be very off-putting to some patients, and for myself, I find that it feels disingenuous, and I prefer to simply answer questions. It helps that I don't get many questions: Do you have children is the most common, I've been asked my religion a couple of times, if I have a dog (Yes, two, would you like one?). Here and there, I've been asked rather unusual questions (Do I have a cook? Who has a cook? No, but I'd like one!)

It seems to me that if something like this is essential to the patient's comfort level, then they should ask this on the phone before the first session. Does it all matter? Who knows---they make good therapists in all shapes and sizes and the interpersonal fit often is found in the least expected place. And my guess is that the ability to accurately diagnose and treat a mental illness has relatively little to do with any of these matters. Probably people are more picky about the personal lives of their shrinks than their brain surgeons, but maybe they shouldn't be.

Related Posts:

Self Disclosure and Being Genuine

A Shrink Like Me

My Friend, My Shrink

I just finished reading Dr. Gary Small's book, The Naked Lady Who Stood on Her Head. I talked about it during our podcast, and maybe, someday, that podcast will be posted.*

In the final chapter of the book, Dr. Small talks about his mentor, friend, and father-figure who has been mentioned throughout the book. The mentor approaches him on the golf course, where they meet to talk, and says he needs psychotherapy and Gary is the man to do it. The author is surprised, hesitant, and a bit uncomfortable with the demand (it comes as more than a request). His wife likens it to the need for a plumber or a dentist, and Dr. Small takes on the task. The mentor calls all the shots: where the meetings will be, what pastry they will eat, the form of his payment. The author initially misses the diagnosis and uses this as an example of how one can be blinded.

So is it okay for a friend to treat a friend?

I was in an institution where the resounding feeling is that psychiatric disorders are medical diseases like any other: the patient should go where the care is best. Obviously, our institution gave the best care, and so there was no taboo about faculty being treated (or even hospitalized) within the department. This is not to say that everyone treated their friends, but people might not move their care as far away as one might imagine (and sometimes people treated their friends).

At the same time, the standard professional boundaries suggest that friends should not treat friends, and that such arrangements are not kosher, especially after the fact if the treatment is called in to question.

Dr. Small talks about a delay in diagnosis. He doesn't talk about the fact that the patient here is dictating the care in a way we generally don't view as being helpfu to patients-- even VIP patients-- or that the desire to please authority figures can be very powerful.
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* Regarding the My Three Shrinks podcast: We've decided that I, the non-geek, should try to produce the podcasts for the near future. Roy said he'd rather stick a fork in his eye than teach me to do this. Clink is trying, but even the process of transferring the recordings to my computer has been rough, not to mention that our podcast programs don't sync. Soon... we hope.

What to do when your Patient Friends you on Facebook or Follows you on Twitter

I participated long-distance in a social media workshop for the 2010 MedInfo conference (#medinfo2010) in Cape Town earlier this week. Kate Anthony and DeeAnna Nagel from the Online Therapy Institute were also participants, and the provided and excellent discussion of professional ethics, dual relationships, and good therapeutic behaviors as they relate to online interactions with patients and prior patients.

Excerpt:

Jane is your client. Both of you live and work in the same community. Jane is the director of a local charity. She sends you an invitation to be one of her contacts on LinkedIn.

Marcie is a former client. She was a teenager when you treated her. Several years later she has friended you on Facebook with a private message thanking you for being such a positive influence in her life. 

John is a current client who has begun following you on twitter.  He has send you a direct message and has also sent you an @reply to one of your tweets. He recently posted a tweet stating what a great therapist you are with a link to your website.

Mary has been your client for over a year. She has a history of childhood abuse and you have encouraged her to write in a journal. You receive an email from her asking to change times for her next appointment. She closed her email with “By the way, the journal writing has been so helpful, I have decided to start a blog. Here’s the link! www.maryrevealsinherblog.com. You open the link to discover that her first blog entry contains emotionally charged and highly graphic information about past childhood sexual abuse she has not previously revealed in therapy.

Kim was your client for over a year. You have not heard from her in at least that long. She was often hostile during sessions and would call between sessions feigning crisis and then apologise for her behavior during the previous session. The reason for termination was due to her move out of the area. Today you do an internet search for your name and you see that Kim has created a website, www.bewareofbadtherapy.com. Your name is on the website’s blacklist with links to excerpts of verbatim chat transcripts from sessions you held with Kim online.

To listen to their responses to these scenarios, watch the video at http://www.onlinetherapyinstitute.com/ethical-implications-for-therapists/ (the weird sound effects at the beginning last about 20 seconds or so... just wait for them to stop, it's worth it... and you get to hear input from their Second Life cat, Reva).


It would be great to hear your experiences with this issue in the comments, whether as a patient or as a therapist.

Weird Social Situations.

Thank you all so much for your input on my Intrusions post. I'm going to sit with the chapter and your comments and try to get it all put together. Soon. I hope.

So I want to talk about a weird social situation. I have to confabulate this one, you'll bear with me and not get too involved with the details, because they aren't real.

There's this woman I know sort of vaguely. We've had a few conversations over the years, and she has always greeted me very warmly. We were never friends, but I like her, and like I said, the vibes between us were good. She called me at work one day and asked if I'd treat one of her family members. She's not a friend--- I said yes-- but I did make the comment to Family Member that I knew Warm Woman and asked if this was a problem. It wasn't. I saw the family member for a while, the treatment was successful and Family Member has left treatment with the understanding that my door remains open. Nothing that was said in the therapy changed my opinion of Warm Woman....Family Member cherishes her and didn't reveal any skeletons in any closets.

Yesterday I went to a small event for a group I belong to. Warm Woman was there, seems she's also a member of this group. She ignored me. I followed suit and did not approach her-- seems as the relative of the patient, it's her call. And I do know she's been in treatment herself, and that she understands all about boundaries. It felt weird though. I wanted to say Hi, and I wanted to tell her to give my regards to Family Member who has not seen me for a while. I almost felt like I was in the room with my own uncomfortable patient, but Warm Woman was never my patient. I even wondered if I should drop out of the group, but I like going, and I joined, in part, at the request of someone else in the group, someone who has no idea this interaction is happening.

Just thought I'd share a day in the weird life of a shrink.

In Treatment: Season 2, Mia's Sex Life & April's Cancer Treatment

Mia bursts in with breakfast and charges into Paul's kitchen despite his objections. She talks quickly and tells of her sexual escapades over the weekend. No sleep, she's drinking a lot, has acrobatic sex with a young band member and then David the cop, a guy she met at a bar. Paul wants to return to the office and Mia says, suggestively, "So you want me on the couch?" I'm wondering how safe Paul is alone with her.

Mia talks about her relationships with men, it moves back to her relationship with her father. "I'm 43 and I'm entirely alone. Who do I have in my life-- You?" She talks about her loneliness.

I guess I'm wondering if Mia has untreated bipolar disorder? --She's gone days without sleeping, she's intrusive, talks rapidly, promiscuous, maybe hypersexual, and her mood is labile. Paul looks at her behavior from a psychodynamic perspective only, and I'll wonder if there isn't something biologically driven to it all.
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April is back, she hasn't told her mom she has cancer and she hasn't gotten any treatment. She's sick, she's tired. Her autistic brother, Daniel, tried to commit suicide, again. She talks about Daniel. April thinks she's depressed. They talk about this and Paul tells April when she feels badly, she should call him, any time of day or night.

April sounds like the neglected child, her mom "gets overwhelmed, she needs to vent." April sounds hopeless about Daniel's prognosis. Paul points out that April will eventually be responsible for caring for Daniel, a burden she clearly doesn't want, but oops, she may be dead long before such a day arrives.

Paul wants to talk about chemo but Daniel calls and April needs to go get him. She faints in Paul's office. Paul gets angry, he screams at her. She tells Paul, "It's okay that you can't handle this, you panicked." They scream and shout at each other. The phone rings, it's April's mother, April stands up to her and says she can't go get Daniel, and mom hangs up on her.

They run over on time, April keeps pointing this out and Paul keeps saying there is more time. "What if I come with you to the hospital?"
"Would you? Now?"
"Yes, now."
He leaves with her and shuts out the lights.

The episode is advertised in it's TiVo'd blurb as Paul crosses a boundary. I thought the boundary was screaming at the patient. But he leaves with her, takes her to negotiate cancer care.
Paul is portrayed as human, he's frustrated and feels helpless. His patient is a ticking bomb. She's destined to die if she doesn't get care now (oh, and maybe even if she does). So off to the hospital they go. Yes, I think it's the 'right' thing to do, or at least I don't think it's 'wrong.' What do you think? Yes, Clink, I know it's a TV show.

Self Disclosure and Being Genuine

In the comment section to the post below on Sally Satel and Stigma, mysadalterego writes:

I am rotating through psychiatry now (family practice traning) and really enjoying it, yet I feel terribly inauthentic treating bipolar patients ("I know what you mean, it is hard to give up the highs...") while being so secretive myself.

My first thought was, well, if in a given situation it seems like it would feel more genuine to the doctor and might be helpful to the patient, then why not? It got me thinking about the reasons a physician might self-disclose a personal diagnosis to a patient, or not.

Pros:
-- It really is destigmatizing when successful people 'come out' and let people know they've been treated for an illness. On a person-by-person basis, this is not any individual's obligation, but I believe it does help when public figures discuss their mental disorders and treatment with the press.
--In illnesses where the prognosis is in question, it offers hope. So yes, I think it's helpful to a patient if a doctor says, "I had the exact same type of cancer and I got treated and I'm doing great." and I think it may well be helpful if a doctor says, "I have bipolar disorder and I've been able to manage it and I'm able to function well."
--The patient may feel better able to be helped by someone who has had similar struggles.
Do note that having the same illness does not always make for the best mix: the clinician may think "I didn't think/feel/behave that way when I was sick, so you shouldn't" and the clinician's views of treatment may be narrowed if some treatments were helpful or harmful to him.
--In substance abuse treatment, clinicians are often people who've had problems and often they are quite open about their own struggles.

Cons:
--There is no right to confidentiality on the part of the physician, so the doctor must be willing to forgo his privacy if he reveals personal things to a patient.
--There is the risk that the doctor's issues/stories will become a prominent focus of the treatment if the patient uses this as a door to ask questions and compare and contrast symptoms/treatment responses. This can detract from the patient's treatment, and the physician may have trouble setting boundaries with regard to his own privacy (but may be not?)
--The patient's response is not predictable. The patient may feel comforted by the like diagnosis, or the patient may feel angry: "How come your illness is under control and you get to be a doctor while I keep going in and out of the hospital!"
--Revealing personal information to patients can be considered a boundary violation. In and of itself, a single revelation like this is simply a single revelation. But if the doctor is ever in legal/disciplinary proceedings over a boundary violation (for example, if a patient alleges sexual improprieties), the fact that he revealed highly personal information may well be used as further evidence of poor boundaries.
--It's important to keep in mind that the goal is to help the patient as much as possible. Being completely 'genuine' isn't necessary and isn't always desirable.

Any thoughts? Are there mental health professionals out there who've told patients their own psychiatric diagnoses? And what's it like from the patient's point of view?

[Edit 7/18/2011: See also Self-Disclosure: To Patients Versus to the World]

Things to Ponder

I've decided to start a series of thought-provoking (I hope) scenarios. These aren't real patients, they're just food for thought. Please chime in.

So how much should one psychiatrist say to his patient about another psychiatrist? Here's the specifics-- a patient wants a referral for her friend. The friend is having difficulties related to his sexual orientation and the patient asks for the name of a gay therapist to give to her friend. She's only asking for a name, nothing about insurance or the specifics of any mental illness. Is it okay for the psychiatrist to give her the name and phone number of a gay psychotherapist to give to her friend? What are the assumptions that are being made here and is this a reasonable thing to do?

Stories From The Office

I'm not sure where I'm going with this story or even why I'm telling it. I've convinced myself that it's okay to tell it, even though it's a real patient story, and I'll confabulate some details, but basically it's true. I haven't seen the patient in over ten years, I don't recall his name, I'm not sure if he's even alive. It's one of those stories, however, that sticks in my head; one I think about from time to time, one that makes me wish I could tell it to the people it involves.

So John (not his real name) was an elderly, but not old, gentleman. He laughed easily and found joy in many things. He and his wife of 53 years had many wonderful things going on in their lives.

He talked about his father who had come to this country from Europe. His father had very definitive ideas about how John should live his life and the rules were spelled out quite clearly. As a young man, John had fallen in love with a young woman and he'd wanted to propose-- his father disapproved and wanted him to put his education first. The young woman married someone else and my patient met his current, and only, wife. He'd long ago lost touch with his first love, but he did know what had become of her-- she'd become quite prominent in her own career and John knew that she still lived in town.

He had spent 54 years thinking about this woman, feeling he'd made a mistake, pining for the one that got away. His wife was kind and attentive, and they got along well, but he'd lived out his adult life quietly wondering 'What if?'

And why is this a blog-worthy story? In fact, I've wanted to write about it for 2 years, I' m not sure what has quite stopped me.

So the patient told me his first love's name. I knew this woman-- she is the mother of one of my friends. I didn't know her 54 years ago, but in the here and now, she's a cranky soul and, if you ask me, my patient is better off with the lovely wife he has. The funny thing is that my friend's dad is a lot like my patient.

I wondered then if I should say something. What would I say and would it help? I didn't, by the way-- I was afraid it might make things worse and that I would regret having opened this door. It's always a little awkward when my worlds intersect.

In Treatment: Episode 11....the sub-blog

Mike Huckabee was on Meet The Press discussing how he cooked squirrel in a popcorn popper in his college dorm. That is so weird.

Okay, back to our show here:
Paul is sleeping on the couch in his office, fully dressed, rudely awakened by the alarm. His idea or Kate's?

Laura is 25 minutes late, she asks for water (also a common theme on this show, no wonder they all have to go to the bathroom). She's come in a cab and she watched a dog get hit by cars, repeatedly. "I had to get him to a vet. You would have pulled over?" Paul responds, "I wouldn't have pulled over, I'd have assumed he was dead and there was nothing I could do."

He points out that she would have been late, dead dog or not, "I would have appreciated a call." She accuses him of being "anti-me."

"What do you think your being late is trying to say to me? Maybe you think I'm not doing my job?" "Are you angry with me? Maybe we need to talk about what good this therapy is doing you." She talks about her distress at the end of the last session. "You're trying to make me angry. I can't win here." She curses him out. "You don't have to love me in return."

"Now I see why they laugh at shrinks and their ridiculous interpretation." She talks about her helplessness as the patient, about having an idiotic theory thrust on her.

"Maybe I'm not helping you at all," Paul says.

They talk about Laura's upcoming marriage, how she hasn't told her father, though her husband-to-be has blasted his whole e-addressbook. He returns her to the issue of her being late.

"You want to kick me out of therapy." He says absolutely not, but then says they should think about winding down. "You don't want me to treat you as a psychologist (he really garbles this, did he say ologist or iatrist?)....I'm the one who says No, who humiliates you. Therapy should not be a source of constant humiliation for you."

"Am I the first patient to be in love with you, Paul? Maybe you can't treat me because you're in love with me Paul?" She's breached the boundaries. He ends the session despite her pleas for more time and Laura storms off while Paul tries to hand her the bill. Laura bumps into Alex, who has arrived for his session a day early. They flirt on the street and they drive off together.

Oh my, so we've got early patients, late patients, popping squirrels and dead dogs. Patients in love with shrinks ramming unwelcome theories at them, and an uncomfortable doc who wants the patient to leave.

Okay, so I still don't know What Paul is. Laura made a reference to med school, so I thought a psychiatrist, but there's never any mention of meds. Of course, with all that water, one might think everyone has dry mouth from their medications. One of our commenters has said he's a psychoanalyst, but I don't think so, his patients come weekly, not daily, and he doesn't have an analytic set up with a chair behind an analytic couch (these are rather specific couches).
Paul and Laura have a discussion that epitomizes the type of power struggle our commenters often worry about. Another episode where no one feels heard. You know, the whole point of psychotherapy (or at least one major point of psychotherapy) is to feel heard. These people are getting it all wrong, and I don't blame Laura for feeling cornered. Seems like Paul takes turns with his patients being painted against the wall.

Why can't Paul be honest? It's hard to have a patient declare that they're in love with you, the boundaries are a mess, he's feeling uncomfortable and he CAN'T have a relationship with her, it's simply unethical and he would lose his license. So he went to see an old supervisor, to get another opinion of how to handle a situation that's uncomfortable for him and that is obviously uncomfortable and painful for her. The supervisor wondered if they shouldn't consider transferring her care and he feels that now that that option's been brought up, they should look at it. Laura would be mad, she'd feel betrayed, but at least it's honest, it gives the sense of consultation and propriety, and instead he's pushing Laura away, treating her unfairly, being unnecessarily cold.

And a final thought here-- Sarebear asked if anyone here worries about being sued (I think it was Sarebear)--between making tea and having one's wife dress one's patient in their daughter's dry clothes. Really, there's nothing to be sued for here--- there are only a few boundaries that are set in stone (don't sleep with your patient and don't kill them, for starters). A patient could lodge a complaint that her therapist made her tea, but why? And since he makes tea for everyone, and the question is milk or sugar, not Red or White, there isn't a boundary violation. And giving an injured wet and cold young patient dry clothes, well, it's hard to find harm here. The boundary issues become salient if a patient ends feeling injured, and then the doctor's behavior gets scrutinized. If Laura feels jilted, and she sues Paul, then things like whether he extended the time of the sessions, what he gave her to drink, whether they'd ever met outside of the office, then and only then is it an act that has relevance. Even if a patient and a therapist were to go out for a meal, yes this is a boundary violation, but in the absence of something more, a patient can't sue a doctor simply for going out to eat a meal. It's just a suspect thing to do, and becomes a part of the case against the doctor, if the patient then alleges they had sex.
ClinkShrink, I hear, shares her squirrels with her inmates.

In Treatment: Episode 8...the sub-blog

Sophie's back, she's all washed up, in from the rain. Paul gives Sophia some of his daughter's clothes and offers to dry hers. She tells him he has to help her change, with two broken arms she can't change by herself. Kate the wife is brought to help change the sopping teenager.

"You could learn a lot from your wife about how to talk to people."

She's angry that he hasn't written her evaluation. "WTF." "Are you a quack?" Oh, we shrink rappers like ducks. Why are all this guy's patients so tough on him? Oh and by the way "Your daughter's clothes are hideous. This is stupid. Are my clothes dry yet? Can you check? You people are such tools, I can't believe you get paid for this!"

Sophie talks about life at the gym, how you have to be anorexic, how everyone follows Cythe gymnastics coach around. It sounds like a pretty hostile environment. "They're leaving tomorrow for California for training camp and I can't go." Sophie picked a fight with Cy, it wasn't his fault. She was looking forward to training camp. Sophie talks about her relationship with Cy and his daughter, Dana, the one she babysits for.

"My dad was right, I'll go to therapy and end up a psycho. Just like your daughter, she's a freak. Shrinks kids are psycho. Everyone knows that." Great. Just what I want to hear. Let me go check in with my psycho teenagers.

Paul asks if she's trying to hurt him. Paul talks about how people are afraid of therapy, of opening wounds. He asks about Cy and Sophie asks about the status of her wet clothes. Can you check? She wants to hear her evaluation. He reads to her, all his comments are positive. He calls her mature and independent. He doesn't mention that she's guarded, inconsistent, and he never says to her, "Look, in order to evaluate you, I need to ask you some questions." Paul goes with the flow better than I do, I ask a lot of questions at the first visit.

Paul tells her he thinks someone in her life has broken the rules and when she asked him to help her change into dry clothes, she was testing him. Sophie talks about how after the accident, the world was soundless, how the noise came back. She talks about her anger at her mom, how they can't get along. And while Kate the shrink's wife helps her get dressed, she throws her arms around Kate. Never mind transference to the shrink, this kid has transference to the shrink's wife.

Who is the wife? She looks so familiar-- What else has she been in? I like her, I hope she isn't cheating on Paul. You can feel their tension, but I want them to be okay. My TV-viewer transference, perhaps. And you know, when you blog about a show like this, the characters somehow feel more like they're more Mine then when I just watch like every other TV viewer.

Paul is hot. Is that the right word? Warm, maybe. He's becoming less sexy as he becomes more human and flawed. I may have to go back to George Clooney for hot. I like Paul's office, it feels like a place I could sink into. I like the space, the clutter, and I'd like a cup of tea, please, while I pour my heart out. I would go along with the script better, though, so my sessions would never make it to TV. One of our commenters compared Paul to a bowl of crusty oatmeal left in the sink. What a great metaphor, and the same commenter didn't like the house, the decor, the clutter.

I ask my husband what the show is about. "I'm your beta test for the proletariat interpretation? It's about a girl who doesn't belong anywhere. " Sophie is my husband's favorite.

So patient Laura brings Paul's marital discord to the surface. When do we hear more about Rosy the weird shrink's kid, and Paul's relationship with her?

Anyone want to chime in?

Why Does Laura Need A New Therapist?

The sub-blog post on the episodes of In Treatment where Laura, the patient, announces her love for her therapist, Paul, have gotten a number of comments. I fueled it with my subsequent post, You Don't Have To Say It All. I ended by saying that Paul needs to document what's going on, seek professional consultation, and end therapy with this patient.

Yup, if this were a real life case, it would be both upsetting and extreme.

I don't want to talk here about transference or counter-transference, they may feed into how things have played out, but psychodynamic terminology is not what the treatment setting is about at this point.

What is it about? I think it's about everyone's safety.

A quick recap. Laura is obsessed with her therapist. She's been seeing him for a year, she has a serious boyfriend who's proposed, she shows up to her first session after sitting outside in the dark for 4 hours, dressed in an outfit she'd worn to go to a bar and nearly have sex with a stranger in. She announces that she's in love with Paul, has been since the beginning. The next session, she arrives in her anesthesiologist uniform and announces her engagement along with her fears of becoming a domesticated animal (I may be reading too much into that). Paul is shocked at the engagement, less than enthused for her, asks why, when the week before she was presenting it as an unpleasant ultimatum, and Laura says, "I said yes because you said no." She talks about how Paul looked like a dead man when he first met her, implies she's brought him to life, pushes every boundary, and says--and please excuse my R-rated bluntness here-- "I want you to fuck me." We know from Paul's therapy session that his marriage is stale, that maybe his wife is unfaithful, that he is resisting looking at his own feelings towards Laura. We, as viewers, are probably meant to believe that Laura is just a bright young woman with a sixth sense and an ability to judge people. We hope and believe that she doesn't have have access to information about Paul's marriage and stale sex life (was she lurking at his session?), and because we know there's some truth there, it comes off a bit differently than if Laura said all these things but Paul was oh-so-happily married.

So here's the deal: there's a young woman who loves (real, transferential, does it really matter?) her psychotherapist and she's pushing for sex, for the bathroom inside the house, for a glimpse of his wife ("is she lying on the couch watching TV and drinking beer?"). She's raw and vulnerable, and she's decided to marry her boyfriend not because she loves him but because her psychotherapist won't have her. Perhaps she's angry, or desperate, or who knows what. But she's making a major life decision unwisely and tossing it onto the therapist (--seems to be a theme with Paul's patients). And she's not exploring her feelings with curiosity or respect for Paul's marriage, their doctor/patient relationship that absolutely forbids a sexual relationship, or as a therapeutic endeavor. She's saying "I want you to fuck me." She's trying, rather successfully, to make him uncomfortable, and right or wrong, she's making it about him and his needs/insecurities/feelings as well. Maybe she's got it right, or maybe she's projecting onto him her desire that he love her back (oops, I did it, I mentioned a defense mechanism, forgive the psychobabble). At any rate, we now know we have two raw, vulnerable, and hurting people and if this isn't a set-up for disaster....well, it is.

How does therapy continue from here? Does Laura even want to get better or is her goal to get laid? At any rate, she's been rejected from a pretty hard push proposition, and I'm guessing she's angry and her feelings are hurt. She's alone in an office with Paul, and so far we have no reason to believe that he's done anything unprofessional, and he's said point blank, "I'm your therapist, I'm not an option."

Laura has assured Paul that she won't boil his kids' rabbit. Oh good, but it's an unnerving reference to Fatal Attraction and violent unstable stalker women. It's not that I think Laura is a violent stalker woman, but I don't know and Paul may not know. At this point what I do know is that no one is safe.

From Paul's perspective, he could end up in bed with his patient--she's gorgeous and we know he's thinking about sex all the time. Such things unfortunately happen. This would not be a good outcome for anyone, it would ultimately injure the patient in unspeakable ways. Paul could also do everything absolutely right, continue to work therapeutically with Laura, refuse her advances, hold tight on reasonable therapeutic boundaries, and hope he can help her and that she has the strength to bear the pain of her unrequited love, to work in therapy, and to uphold the integrity necessary for the process. But these two people are alone together in an intimate setting-- if she decides to complain about her care, or to accuse Paul of any sexual wrong-doing, the issue becomes one of He Said-She Said and Paul's career, professional reputation, and marriage are a step away from ruin. The doctor isn't always in control-- when two people are alone together the issue of trust and safety goes both ways. The reality is that both the patient and therapist are vulnerable-- she is vulnerable to being used in a sexual way, he is vulnerable to the possibility of both his own misbehavior or that she might lie.

I've said that Paul needs to document what's going on, certainly for his own protection. He sought consultation, but he resisted talking about this patient. Now, however, with her new engagement, her statement of distress over his rejection, and her blatant "I want you to..." (oh, I've said it enough)... Paul needs to seek a consultation with more honesty. Do I think he should call Laura and dump her before the next session? Of course not. I do think they need to figure out what might make the sessions safe-- another person in the room would do it. Maybe Paul could borrow an office at a hospital clinic to see Laura in-- a little less intimate, two chairs, no couch. If he can get her to quickly cease her advances, to be willing to look at her feelings and the distraction and disturbance they create, and to address the issues of safety that they both now have, maybe it can be salvaged.

Please don't get me wrong here-- I'm not in any way saying that a psychotherapy needs to end if the patient becomes attracted to the doctor. It happens all the time. I'm not saying that it shouldn't be addressed in the therapy and looked at in whatever way works for both parties (--Hey, Tony professed his love for Dr. Melfi, lavished her with gifts, and moved on when she said "No, it's part of what happens in treatment.")

It's hard to get it to work, though, if it's more than a discussion of feelings. Laura's session was a full-court press for intercourse. In real life, these things end badly.

You Don't Have To Say It All

Last night's episode of In Treatment got us thinking about how uncomfortable it is when the patient falls in love with the therapist. LadyAK47 wrote in to say that it's very awkward when clients tell her she's attractive. She says, with an tone that I think conveys a hint of guilt, that sometimes she just ignores them and she hopes she'll learn to deal with it better.

Anonymous wrote in and said:

I just ended eight years with my therapist. I started leaving about two years ago. Five years ago, I told her I was sexually attracted to her. No discussion about it except an "Oh that's natural, it will pass once we work through your transference issues." It was never discussed again. I got a very brief description of transference with the explanation of me being bright and I would understand it. I thought I did except I wanted to f**k my therapist not my mother. I never shared anything significant with her again and did my therapy by writing but I was still silent as I shared it with no one. I thought this episode was so painful to watch but totally unrealistic, or maybe she is just narcissistic. I would never say to my therapist, "I want you to f**k me" because I would worry how uncomfortable that would have made her and myself. I am betting this is true of most people who find themselves in that situation. Of course therapy is supposed to be the place where it is safe to say anything but I really think that after a time with your therapist, you do start monitoring what is said and their comfort level other than your own (the client). -- ** mine.

So we've all heard that therapy is supposed to be uncensored free association, no holds barred. If it pops into your mind, it should be said, and perhaps the psychoanalysts want it that way. But let's be real here: shrinks/therapists are people, and while therapy should be a safe place to share intimate, uncomfortable, and embarrassing thoughts and feelings, and behaviors, there are limits. And as with any relationship, there are consequences. Many people have very successful psychotherapies without sharing their every thought. And if the patient's feelings are expressed in a way that makes the shrink feel threatened, uncomfortable, totally miserable, completely and irrevocably insulted, or sexually vulnerable, then one consequence may be that therapy becomes un-workable.

LadyAk47, sometimes the best, easiest, and least hurtful thing to do is to ignore an uncomfortable comment.

And to anyone who wants have sex with their therapist, maybe it's just fine if it isn't expressed in crass and threatening terms, but caged in gentler and subtler ways.

In real life, if a patient comes on to a therapist as strongly as Laura did to Paul the sequence of events is clear: Paul should document Laura's advances, he should avoid doing anything that she might misread as leading her on, he should seek formal consultation, and he should end the therapy. A psychotherapist can't be alone in a therapy session with a patient who is asking for sex. The risks of real or imagined abuse get too high and the repeated requests for sex get in the way of any real therapeutic work getting done-- instead it becomes a paradigm for frustration, discomfort, and sometimes for inappropriate sexual activity.

Onward to Episode 7

The Shrink Next Door

This is our 600th Post!
Lately my neighbors have been apologizing to me, which feels a little bit weird. We'll have brief (OK, sometimes not so brief) conversations and they end them by saying something to the effect of, "I'm sorry to chew your ear off," or "I know you're off duty, so I'm sorry about that," or words to that effect. They know I'm a psychiatrist so I guess they think they're burdening me when they do the normal problem-sharing thing that goes along with being a friendly neighbor. Now, it's possible that I get more than the usual share of mental-health related problem sharing because they know what I do for a living. And it's true I know lots of stuff about who in the neighborhood is on which medication, or who would never in their life take that particular medication, or who is looking for a psych referral (I give them names but they rarely follow through), just because of what I do for a living. But it doesn't feel like they're burdening me. I like my neighbors. I've never had a bad one, and that's pretty unusual considering how long I've lived here.

That being said, I can't say that I've ever gone to my mechanic neighbor for car advice or to my hair stylist neighbor for coloring advice (although Dinah probably thinks I should) but that's not because I don't think they'd help me if I asked for it. It just never occurs to me to ask. It is nice to know though that any one of those folks who apologized to me for "problem dumping" would be just as quick to listen to me if the tables were turned. That's just being a good neighbor.

Who's Your Mama?

You know it's a bit confabulated.....

So one of my patients happened to mention today that her son is a coach in a league one of my kids plays in. I must have known this, she must have mentioned it when I first took her history, eighteen months and two playing seasons ago. Today, at the end of the day, hours after she left and as I was writing progress notes, it suddenly hit me: her son is my kid's coach. It was this funny, disconcerting feeling.

Now the fact that a patient's son coaches my kid isn't really a big deal. Only I wish I could say that my kid is the ideal player, the coach is a wonderful coach, that I've never actually had reason to speak with the coach, or if I did, that it was a warm and rewarding experience. Let's just say that's not the case, the coach is a little weird, my kid once had an issue and I'd felt a need to intervene.

And now I can wonder, who knows what? This particular patient has no qualms about announcing her struggles with psychiatric illness. I know the son knows she has shrink, I can't imagine my name doesn't get uttered here and there-- she comes to sessions and sometimes says "Little Howie said to be sure I tell you such-and-such." Only I have a fairly common last name and like my patient, my family members all seem to have different last names (--Max has requested that I not publish his last name on the blog). I now can wonder if Coach related to me, Neurotic Mom, all the while thinking You're My Mom's Shrink. Or maybe he worried that she tells me personal things about him. Maybe we've had a whole unspoken relationship that I just missed. So, Coach Howie, if you're out there, rest assured that Mom says all nice things about you.

It's fine that I treat Coach Howie's Mom. This is the part that's disconcerting-- I realized that I relate a bit differently to different people in different places in my life. With patients and their families, I keep it pretty even and I try to remain professional (I hope). No ducks at all. Without even trying, I'm a slightly different person when I'm the doc than when I'm the mom. In my non-doc role, I talk more, I listen less, and I tell raunchier jokes. I might look to Coach Howie for wisdom or understanding. If I'm frustrated I might be more sarcastic than I'd ever be with the family member of a patient. I'd never complain to the family member of a patient, even in a non-clinical setting, that he was an idiot for not starting my kid when the kid he did start was clearly an inferior player. (--oh, I didn't really do that, but it was fun to confabulate).

Coach Howie, you have a lovely mom.

My Patient, Myself

I saw this abstract and wanted to post it. Entitled Psychiatrist Attitudes toward Self-Treatment of Their Own Depression, it's a survey conducted of Michigan psychiatrists regarding their opinions toward self-prescribing. A survey of more than 500 Michigan psychiatrists showed that more than 40% would medicate themselves for mild to moderate depression and that 15% had actually done so in the past. Seven percent of psychiatrists said they would treat themselves for severe depression or depression involving suicidal ideation.

The AMA code of medical ethics states: "Physicians generally should not treat themselves or members of their immediate families...It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems."

So why or when would a doctor consider treating himself? I don't know Michigan well, but I'd guess they probably have the same shortage of psychiatrists that other Midwestern states have. If you're a depressed psychiatrist you may be the only game in town. Maybe he'd be concerned about privacy and information-sharing among colleagues.

Or maybe the AMA would consider mild clinical depression to be a "short-term, minor problem" for which the self-treatment exception would apply. There are probably hundreds of physicians who at one time or another have written antibiotic prescriptions for themselves or for family members. I wonder if this also applies to prescribing for family pets? Should a psychiatrist prescribe Prozac for his obsessional cat? Thorazine for the nervous dog? A recent survey of neurologists showed that more than 90% agree that it would be appropriate to self-prescribe for acute minor illnesses. Another survey of young Norwegian physicians found that 90% had self-prescribed in the past year.

Don't ask me what Michigan surgeons would do...

You Order Salad Like A Shrink

Or: working towards the MNP (see posts below)
Warning-- Plot Spoiler



So I went to see Reign Over Me with the connected Judge and my connected now-13-year-old daughter. I think Carrie recommended it some time ago in a comment on an old post. It was my second attempt this weekend to see The Namesake, the first go around I ended up at The Hoax with my husband.

So Reign Over Me Was a shrink blogger's jackpot. Here's the drift:
Alan Johnson (Don Cheadle) is a dentist, he lives in Manhattan with the perfect wife, the perfect life and two lovely daughters. His job and family define him, he longs for friendship, maybe even adventure, his life is perfect but sterile. In a boundary-violating maneuver bordering on stalking, he lurks outside a psychiatrist's office to bombard her with questions about "a friend" as she leaves her office--he can't hear that he should schedule an appointment, and the poor beautiful Dr. Angela Oakhurst (Liv Tyler) gets question after question.

Enter scooter-riding, unkempt, can we pleeese give him a haircut, Dr. Charlie Fineman, Alan's long lost college roommate and dental school pal. Charlie is a walking talking post-traumatic mess from the aftermath of the 9/11 terrorist attacks in which his wife, 3 beautiful young daughters, and poodle (?) Spider, died in on one of the planes. By day, he compulsively and repetitively remodels the kitchen (--an apology, we later learn, to his wife who's final conversation with him was about the kitchen), by night he plays video games on a giant screen, goes to Mel Brooks flicks, collects vinyl from the 70's and 80's. He remembers nothing from before 9/11, has written off his in-laws, given up dentistry, doesn't recognize roommate Allan who reminds him how he used to sleep naked. Oh, good, another penis on the blog; hold on, there's more.

The two re-connect, their relationship becomes meaningful for both of them, their needs almost palpable. Charlie, however, has this little quirk that when someone mentions his past, he gets violent. Oops. Alan, however, is kind enough to overlook a few big outbursts, even one where Charlie grabs him by the neck, slams his diplomas to the wall. And Alan decides that Charlie needs help and he's going to be the one to get it for him.

So Alan has this other little sub-plot problem: a gorgeous patient, Donna Remar (Saffron Burrows) offers him a blow job (see, I told you, more penises), he tosses her from the office and she's sent off with orders to get a new dentist. Only jilted, she then sues him for sexual harassment, ridiculous, but how does one prove what goes on behind closed doors? Office partners just aren't happy. Eventually, he agrees to see her and she apologizes, explains she was mistreated by her ex, drops the lawsuit, turns out to be a patient of the lovely Angela, and will eventually be cast as the will-be girlfriend of the traumatized and violent Charlie the former Dentist.

Okay, so Alan wants to get help for Charlie, who wants no one and nothing that will touch on past memories. In a record store, they bump into the nerdy Nigel who invites them to join them for lunch-- Charlie quickly sniffs out the deception and yells over lunch "You're a shrink, you even order salad like a shrink." A man close to my heart, Nigel responds, "How does a shrink order salad."

Next, Alan introduces Charlie to Angela, who Charlie agrees to continue seeing, in part because she has great breasts, something he doesn't hesitate to tell her. He talks for a few minutes then ends each session abruptly. Finally, Angela confronts him with the fact that he needs to tell his story to someone or there's no point coming. He leaves, and tells his tragedy to Alan in the waiting room as Angela listens. It's one of those tear- jerking breakthrough moments that one hopes will lead to a cure, or even the end of the movie. But Charlie goes home, loads a gun, ends up pointing it at a police officer (this, my real-life judge friend tells me, is called Suicide By Cop), ends up tackled and spending 3 days in a psych unit, where Angela and Alan lobby for his release, and Angela insists what he needs is outpatient care which she can provide-- and ohmygosh nobody mentions that her last great intervention just days before nearly got the patient, or a cop, killed. Charlie goes free, there is another hearing a few days later in which the judge (Donald Sutherland) decides that his in-laws can dictate if he needs further inpatient commitment for up to a year, warning them harshly, "think about whether your little girl would want her husband to go to a place like this." Give me a break.

So Charlie moves out of the apartment with the now gorgeous kitchen, Angela the shrink and Donna the sexually harassing patient bring him root beer and pizza, everyone lives happily ever after.

So PTSD Adam Sandler style, with lots to think about, and while Dr. Angela is actually pretty good at times, there are all the boundary-blasting usual shrink things we've come to know and love in the movies.