Missed Opportunities?

Before I begin,  I wanted to let you know that ClinkShrink wrote a post called Can You Tame Wild Women? over on our Shrink Rap News blog this week. 
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When we talk about psychotherapy, one aspect of what we look at is the process of what occurs in the therapeutic relationship.  This is an important part of psychodynamic-based psychotherapy, meaning psychotherapy that is derived from the theories put forth by Freud.  Psychoanalysis (the purest form of psychodynamic psychotherapy) includes an emphasis on events that occurred during childhood, and a focus on understanding what goes on in the relationship between the therapist and the patient, including the transference and counter-transference. 


In some of our posts, our friend Jesse has commented about how it's important to understand what transpires in the mind of the patient when certain things are said and done.  Let me tell you that Jesse is a wonderful psychiatrist, he is warm and caring and attentive and gentle, and he's had extensive training in the analytic method, he's on my list of who I go to when I need help, so while I want to discuss this concept, I don't want anyone, especially Jesse, to think I don't respect him.  With that disclaimer.....


On my tongue-in-cheek post on What to Get Your Psychiatrist for the Holidays, Jesse wrote: 

 When I say the Shrink should look at the context, even in small matters a gift might come with a subtext: "I just told you some terrible things about me and I want to be sure you still like me." It can be a bribe. It can be a seduction. It can simply be a gift given out of gratitude. The important concept is that we think about everything. Unlike a physical examination done by an internist, everything that occurs might be some window into how we can help the patient, and we do not want to lose that opportunity.

So wait, the patient comes to me because he symptoms of a mental disorder, often depression or anxiety, or problems controlling his behavior, or he's overwhelmed with stress and isn't coping well. Why is it so important that we understand every aspect of the sub-texted interactions?  How does this cure mental illness?  Why is it bad to accept (or not) a gift and move on?  Why do we have to think about everything?  And if it's really important, won't it come up again?  Is it really crucial that we not lose that opportunity?  Maybe I just want to take the cookies and say 'thank you' because

•   A) I don't want to hurt my patient's feelings,
•   B) it can be difficult to look at the meaning without upsetting the patient or putting the patient on the defensive and so the patient has to be fully on-board for this type of therapy and those patients generally don't bring gifts (ah, maybe we should be asking all analytic patients why they didn't bring gifts, now that might yield interesting information), and 
•   C) I like cookies.

So the truth is that on these posts, the comments are always the most interesting part, so do write in and let me know what you think, not specifically about the cookie/holiday gift example, but about how important it is to understand the interactions that occur within the context of the psychotherapeutic relationship.  


Just so everyone knows that I am still Jesse's friend, I am posting the video he sent me of his late grand-chinchilla, Chinstrap.  And yes, Jesse had a grand-chinchilla.  He does assure me that Chinstrap was having a good time in this video, because I wondered. 




And I'd like to thank Steve over at Thought Broadcast for providing the graphic for today's post. 

Guest Blogger Dr. Jesse Hellman on The Penn State Matter

The news media has published numerous pieces exploring various aspects of what happened at Penn State. The sports culture, the prestige of the program, the money it brought into the university, the parallels with the Catholic Church, and so on. What kept action from being taken by administrators after an employee allegedly witnessed a violent crime? What kept that employee from stopping a violent act? What kept him from taking further action later?

The media has looked at various aspects of these questions, but two aspects have received little attention: Is there a difference between the way men and women react to these events, and are there factors that actually inhibit men from taking action in these circumstances?

Here is a "thought experiment:"  What would happen if the alleged crime were different-- if, for example,  a man had walked in on someone violently raping a ten year old female child? Would he have reacted the same, observing but not interfering, reporting it up the line, but not taking subsequent action? What would have happened if one of the administrators who learned of this had been a woman? My thesis is that it would have been very different if it had been a little girl, and that women involved as administrators would have been far less likely to ascribe this to "horse play," look the other way, and remain passive after reporting it up the line to superiors.

A man coming across a heterosexual rape, whether of an adult or a child, would know immediately that this is a terrible crime and would have immediately stopped it. It would be clear that the police should be involved. I wonder whether the homosexual act, even with a child, arouses feelings in men that actually inhibit action, that make it easier to turn away and rationalize not taking action. It is something that is harder to confront, to even think about. To the psyche it is perhaps the most forbidden of crimes, worse than incest.

Again, the purpose of this post is to discuss the general principles, not the individual actions at Penn State, of this subject. What are the Psychological Factors that inhibit Action when Evil is
Encountered?

Do We Need Insight?

In the comment section of my post How Do You Switch Docs? readers Moviedoc and Kate have been having their own discussion ( perhaps to be called The Blog Within The Blog?) about the virtues, or lack thereof, of psychoanalytically-oriented psychotherapy. I've been staying out of it. I'm not a psychoanalyst and I've never been in psychoanalysis. My sense is that since psychoanalysis is so specialized and done by so few, and takes so much time and money, that in today's world, the contribution is more one of technique and assumptions that flavor most psychotherapies. Things like that the idea that there exists an unconscious mind, or that feelings that were part of past important relationships might surface in current relationships, including the one the patient has with the doctor. What role all this has in the treatment of mental illness seems to depend on the patient and the doctor. Some people find it very helpful to look at their lives and their illness and their problems as part of a continuum, and even those that don't, often find great solace in the therapeutic relationship. There is something so lonely about being mentally sick, and something so comforting about having someone to talk to about the pain without the judgments or fears that go into ordinary conversations.

That said, psychiatrist Richard Friedman was kind enough to talk about the role of insight in treatment today in the New York Times. I feel like he really meant to chime in with Moviedoc and Kate in our comment section, but I guess he lost his way and ended up in New York instead.
In Does Insight in Therapy Equal Happiness? Dr. Friedman writes:

Psychoanalysts and other therapists have argued for years about this question, which gets to the heart of how therapy works (when it does) to relieve psychological distress.

Theoretical debates have not settled the question, but one interesting clue about the possible relevance of insight comes from comparative studies of different types of psychotherapy — only some of which emphasize insight.

In fact, when two different types of psychotherapies have been directly compared — and there are more than 100 such studies — it has often been hard to find any differences between them.

Researchers aptly call this phenomenon the Dodo effect, referring to the Dodo bird in Lewis Carroll’s “Alice in Wonderland” who, having presided over a most whimsical race, pronounces everyone a winner.

The meaning for patients is clear. If you’re depressed, for example, you are likely to feel better whether your therapist uses a cognitive-behavioral approach, which aims to correct distorted thoughts and feelings, or an insight-oriented psychodynamic therapy.

Since the common ingredient in all therapies is not insight, but a nonspecific human bond with your therapist, it seems fair to say that insight is neither necessary nor sufficient to feeling better.

How Do You Switch Docs?

We got a very thought-provoking question:

I was wondering if you could address the issue of switching from a long standing psychiatrist (who provides regular psychotherapy - the ideal which garnered so much controversy in one of your other posts!) following a scheduled medical leave because the covering doctor seemed to be a better fit. What sorts of issues could be involved in that? I know both parties are professional, but I would still be worried about hurting one's feelings. Or what if the covering doctor did not want to continue to see the person; would that then ruin a dynamic of going back to the original doctor? How can this even be addressed?

Wow. Where do I begin.

1) In a long-standing psychotherapy, one of the issues that might be addressed is the therapeutic relationship and how that plays out as a mirror of other relationships, a process known as transference. The question of what else is going on here should be addressed. Is switching doctors a way of avoiding a problem that should be examined? Is leaving adaptive or a way of not addressing an issue.

2) Sometimes in the course of the therapeutic relationship, we forget that the goal is the treatment of psychiatric disorders and the alleviation of symptoms. Before changing doctors it would be important to take stock: why did you go to treatment? What were the symptoms and difficulties, and how are they doing now. If you're doing better, then I don't think it makes sense to leave a treatment that has been helpful because someone else is an easier person to talk to or a better fit. The goal of treatment is to get better, not to find a good friend. This isn't to say that people don't feel helped by a comfortable therapeutic relationship: they do. It is to say Take Stock first.

3) If this is an insight-oriented psychotherapy with frequent sessions, honesty demands that you at least mention the fantasy of leaving to the old doctor. If it is not that type of treatment, you may want to call the covering doctor and have a brief discussion: Will she take you on? She may feel like she's stealing patients and that may not be cool with her. She may have no openings. She will likely say to discuss it with your old doc first. Before you actually leave the first doctor, it makes sense to have a phone conversation with the new doctor, or even a single one-time appointment to discuss why you want to change, whether she will see you, and if that makes sense. Are there insurance or fee issues? Can she see you at a time you are available? Since you're someone who's needed to see a covering doc, what are her policies on emergencies?

4) If you're not getting better with your first doctor and you've followed treatment recommendations and given it a long enough period of time, then switching doctors is reasonable. If you're worried about hurting someone's feelings, then hopefully it means there has been something positive in the relationship. It may be worth taking stock with your first doctor. These are things that have been helpful. This is why I'm thinking I may want to try seeing someone else. If there's nothing positive, then leave and see someone else, even if it's not the covering doc. If there are positive things, then point them out. If the doctor's feelings are hurt, they will live (I promise). It may not, however, make sense to return to someone you've fired if things don't go so well with the second doctor, and leaving may indeed include closing a door.

Thanks for the great question and I hope that was helpful.

WWFD?

Would Sigmund Freud or Carl Jung read Shrink Rap? Somehow, I'm not so sure. Tracey Cleantis seems a bit more certain. Check out her article on Blog.com of Top 10 Psychoanalysis Blogs (Jung and Freud would read).
Thanks for the should out, Tracey, and we're always happy to be deemed accessible!

The Cab Driver Story: Single Session Psychotherapy

Another story came out of the APA conference that Dinah wanted me to blog about.

I was in a cab going to pick up Dinah for dinner. The cab driver found out I was a psychiatrist so he told me about his life-changing experience with therapy. At one time he was having an incredible problem with his life. He was using cocaine, couldn't keep a job and his relationships were going down the tubes. Therapy helped him quit cocaine and change all that. (Which was good, since he was the driver of my cab. I really wanted him not to be high or in distress.) This kind of turn-around story isn't unusual for me; parolees will often come back and tell me about things they've done in free society that they're proud of.

The unusual part of this story is the fact that he made all of these changes after a single one hour session.

OK, that got my attention. What was it about this therapist?? What happened in the session?? I had to ask all the questions.

The cab driver told me that it wasn't so much what the therapist said, but rather who she was. She was a kindly, older woman who was sincere and compassionate. She told him he needed to start taking care of himself, eat better, get enough sleep, etc etc.

And that worked. Geez, I was impressed. It changed his life. The last remaining habit he wanted to fix was his smoking. He wanted to go back and see his therapist again, but she had retired. He was sorry he couldn't go back, and so was I.

That's my cab driver story.

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Wait, says Dinah (who added the pic and subtitle): you told it in a more dramatic fashion at the time. He was running 8 miles a day now. There was a religious/spiritual component, something profound about the experience and about the therapist. Oy...we'll never make a novelist of you, Clink.

What Should I Do?

A reader asks if we give advice. I hope it's okay if I copy and paste the question from the comment section of another post, I'll leave the commenter's handle out:

I went to a psychologist 7 or 8 years ago and all she did was tell me what I should do. “Go there, do this, etc.” She didn’t listen to me at all. If she had, she would have known that the things she was telling me to do were things that I would never ever do. I quit after 2 or 3 sessions. I decided to try therapy again about a year and a half ago and my psychiatrist is the complete opposite. She has never given me a single word of advice and even when I directly ask her opinion, she will only occasionally give me a straight answer. I appreciate the fact that she isn’t trying to force off-the-wall ideas on me, but sometimes I wish she’d put in her 2 cents. Where do you guys stand on this? I’m just curious as to what’s the “norm” since my 2 experiences have been so drastically different. Thanks.

Traditionally psychotherapists don't give advice--- perhaps this differentiates "therapy" from "counseling" which does imply that one person knows what's best. Psychodynamic psychotherapy is about delving and understanding unconscious conflicts, and it's done by looking at the process of the material a patient brings to the session. Rather than go for the superficial and concrete, perhaps there is something to be gained in understanding why a patient wants the therapist to give them advice. It's about understanding the mechanisms that guide the patient, not the specifics.

So I'm not an analyst, I'm particularly quiet, I tend to say what I think, and I'm a physician who treats conditions that I believe have some biological input. To some extent, I have to give advice: Take this medicine at this time. Don't take that medicine with this one, it'll kill you. Don't drink alcohol when you're taking Xanax, that'll kill you, too. I believe that when someone is suffering from a problem in a way that up-ends them, they should make it their job to do what they have to get well. What helps depression: medicine, exercise, sleeping enough, not sleeping too much, structure, being empowered. There was a study recently that suggested a link between Mediterranean diets and lower rates of depression--- so I tell people to eat hummus (if they like it!). I even suggest a brand because I've personally taste tested them all and have a strong preference. (Is it awful to admit this?)
Do I give advice otherwise? Yeah, sure. Sometimes I tell people who need more structure that they should get a dog. Dogs are good--- ya gotta get up and walk them, they're interactive, they're entertaining, you have to feed them, they pull people outside of themselves just a little, and they are object of passion-- passion, I think, is good.

What have I discovered? People come to their appointments, mostly. They take their medicines, mostly. No one really does much more of what I suggest. No one has bought a dog because I've told them to. And people who don't want to exercise rarely do so because a psychiatrist tells them the research says this will help. I'll let you know how it goes with the hummus. I don't think Freud would have liked me.

So I tell my patients what to do sometimes. The more salient question would be: Do you tell Roy what to do?

Carl Jung in Tomorrow's New York Times Magazine

Ya gotta love the internet--- you get to be "the most emailed" before you're even published. So tomorrow's NY Times Magazine has an article about Jung and the little red book. I started, but I'll save the rest for the joy of Sunday mornings and coffee (and the dream of lox and fresh bagels if anyone would like to drop them by my house). Here's an excerpt from Sara Corbett's "The Holy Grail of the Unconscious":

THIS COULD SOUND, I realize, like the start of a spy novel or a Hollywood bank caper, but it is rather a story about genius and madness, as well as possession and obsession, with one object — this old, unusual book — skating among those things. Also, there are a lot of Jungians involved, a species of thinkers who subscribe to the theories of Carl Jung, the Swiss psychiatrist and author of the big red leather book. And Jungians, almost by definition, tend to get enthused anytime something previously hidden reveals itself, when whatever’s been underground finally makes it to the surface.

Zen and The Art of The Psychoanalyst's Couch

This weekend's Sunday New York Times Magazine featured a piece by Chip Brown titled Enlightenment Therapy where Brown discusses the coming together of psychoanalysis and Zen Buddism. It's a long piece, and I looked at it several times. I read for a while, but it was long and I can't say it held my attention well. I went back several times. I'm missing something here: Why is this a featured article? What's said that's worth taking pages to say? What am I missing here? Someone want to enlighten me?

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.

The Silent Psychiatrist

This morning, I woke up and got ready for work. Time to go and I called to the kid to come. Only nothing came out. Nothing. I felt fine, but I'd lost my voice. Completely, barely a whisper emerged.

It was just before 8. Kid announced she felt sick and went back to bed. I fetched the carpool kids (--the issues of what to do about carpoolers when one's own child is sick could be its own entire blog). My first patient was for 9:00 and it seemed like too short notice to cancel. I did croak out cancellation calls to the next couple of patients with the thought that they might have a hard time conducting the session without my input; some people don't come in and just talk spontaneously, they look to me for direction, a little more than I sometime wish and a lot more than my voice could tolerate today.

As shrinks go, I talk a lot. As people go, I talk a whole lot. I think I'm probably in the top ten percent for talkativeness in the general population, though I quiet down when ClinkShrink tries to monopolize the podcast.

So suddenly, I couldn't talk. I figured it would be a good experiment, or at least a good blog post. I listened and I let the sessions flow a little more organically. There were places I'd normally interrupt to ask questions-- I didn't. At the end of the session, I asked how it went. The first patient said it was fine once he realized I felt okay (I felt fine). With that, I called the rest of my patients and left the choice to them-- a couple came, a couple didn't. There was one session I'd wondered about, and I did end up having to do a fair amount of talking/croaking.

I wondered if I would be a better therapist-- I sometimes think I talk TOO much. I don't think it was better. I don't think it was particularly worse, either. I'll be happy when I can just talk again. Camel says to rest my voice, Roy says to gargle with salt water. Off to hot tea with honey now. Thank you for letting me croak here.

Stolen from The New York Times

Today's post is a cop out. I'm stealing, verbatim, from the Social Q's column in the NY Times.
I've somehow missed the social Dear Abby column, but today's is shrinky, so why not?

"

Social Q’s

My Shrink (Gasp!) Has Shrunk

By PHILIP GALANES

Published: January 30, 2009

After not seeing my therapist for several months, I returned to find her a wisp of her former self. She was never fat before, but she looks like a marathon runner now. It seems strange not to comment on such a significant change. But even my most innocuous questions — like “How are you?” — are either ignored or turned back on me. Should I be quiet, or can I mention the weight loss?

Christoph Niemann
Elizabeth, Berkeley, Calif. "

And the Social Q person responded:

"Oh, how I envy you! My therapist hasn’t changed so much as his shoes in all the years that I’ve been seeing him. And there’s only so much hay you can make with a scuffed-up pair of Bass Weejuns.

So speak up. Successful therapy requires you to share your thoughts. It may be the one office on earth where unedited candor is a good idea.

There will be consequences, though. If you compliment her on her weight loss, you will spend the balance of your session dissecting your body image. And if you sound a note of alarm for her health, the subject will turn to mortality — either fear of yours, or how the prospect of hers triggers your abandonment issues."

-----------

So I think I practice another brand of psychiatry. When patients comment on my appearance, I usually just mutter "Thank you" (or whatever might be my version of socially appropriate) and move on. I'm not sure I've ever cured anyone by insisting they fully understand their motivations behind noticing that I've lost weight, had my hair blow-dryed to a different style, or am wearing a new outfit. I'm not saying there is nothing to be gained from exploring these issues, I'm just not sure that it's worth the trade-off of taking the time away from talking about things going on in their lives.

Everybody Lies

Back in the Dark Ages when I applied to medical school, all applicants were required to take the Minnesota Multiphasic Personality Inventory or MMPI. This is a personality test designed to identify psychopathology by examining the answers to literally hundreds of questions, many of them innocuous-sounding or not clearly related to any pathological answers. For example, one question that stood out in my mind was "I like to paint flowers." Now, I happen to like flowers and paintings of flowers but never in my life have I ever even tried to paint flowers. You're supposed to answer "true" or "false" to this question. Keep in mind that the answer to this question was going to have some bearing on whether or not I got accepted to medical school. OK, you make your best guess on the "right" (non-pathological) answer, whatever that's supposed to be, and then you run into this question:

"I always tell the truth."

Oy. Talk about your wife-beating question. (In other words, "Sir, when did you stop beating your wife?"). If you answer "yes" then you're obviously lying because everyone fibs now and then. If you answer "false" then you look like a dishonest person who couldn't be trusted to hold a friend's purse much less a scalpel.

So anyway, that brings up the issue of truth-telling in psychiatric treatment.

No patient ever tells the truth. Not the whole truth, not at first, and not in the way they want you to hear it. It's not a matter of intentional dishonesty or deception and it's not a character flaw, it's just being human. I've had friends (not my co-bloggers) who have told me, "Oh, only your patients lie." Well, as Dinah puts it, in my little bubble world it would be nice to believe that the only misleading people were the ones inside the prison walls.

There are many reasons not to tell the whole truth, or to tell it in a way that puts the best light on things. Self-deception (or therapist/psychiatrist) deception is a way to look your best to help the therapeutic relationship form. It's a defense mechanism for people who are feeling self-conscious about their problems or embarrassed about their background or humiliated by their real or self-perceived failures. In extreme cases, it's a way of protecting oneself from negative consequences (eg. "If I tell my doctor I'm suicidal, I'll get 'put away'.") For my patients inside the walls, it's the way they've found to cope with life and get their needs met because they learned early on that simple requests for help often didn't work.

The gradual unfolding of truth, the step-by-step admission of distortions, is part of the treatment process. It's a positive sign that trust is growing between patient and doctor. In psychiatric treatment, at least in my clinic, you don't get punished for admitting you lied.

So now in all honesty, I'll admit that I'd love to paint flowers.

(Wow, this is a first in the history of the blog---I've posted over myself!)

I Forgot

I was driving home from work the other day and I heard a piece on National Public Radio about professional musicians who forget their instruments. I didn't hear the whole thing, but they mentioned stories about symphony musicians who leave expensive instruments somewhere (the Stradivarius left in the cab, for instance).

They asked a mental health professional who also happened to be a musician why people do these things. The mental health talking head said it happened because the musician was "hyperfocussed" or so concentrated on the upcoming performance that everything else was driven out of the mind. He also speculated that performance anxiety was expressed as an unconscious wish to lose the instrument. What he didn't mention, but the first thing that popped into my head, was sleep deprivation or just simple absent-mindedness.

We all do absent-minded things at some time in our lives. We lock our keys in the car, or ourselves out of the house, or we forget to pay a bill or to mail a bill that's already been paid. We forget birthdays and anniversaries and other important dates that we (and our loved ones) really expect us to remember. Fortunately, we also forget anniversary dates of things that are better left forgotten, although I think it will be a long time before anyone forgets dates like 9/11. (Do young people know the date 12/7? Isn't it amazing what we, as a collective national memory, forget?)

Yet we don't consult mental health professionals about why these things happen. Remembering things, and forgetting, are a natural mental process that happens continously outside our awareness. If the problem becomes too severe---if we start forgetting the names of our spouses or children or where we live, or if the memory problem becomes associated with other brain problems like writing or reading or talking, then it becomes a disease.

Age-related memory changes may concern older people, but they are not necessarily a sign of progressive disease. It can also be a sign of clinical depression, in which case memory problems are temporary and reversible.

Of course, none of this explains why I keep forgetting to take my iPod out of my my car when I get home. It must be an unconscious fear of listening to My Three Shrinks. What I want to know is, what's the unconscious wish for forgetting to pick up your kid?