Wednesday, August 16, 2006

Couch Time

Reading Dinah's post about Talk Therapy inspired me to think about my view of what it means to be a psychotherapist. The people who have been reading this blog for a while will now exclaim, "Wait a minute. You don't do psychotherapy." Well, that's kind of the point. Let me begin with an illustration. Over the weekend I went to a party where I got involved in a conversation with a friend's wife. As these things happen, the topic turned to what I do for a living. The conversation went something like this:

"So, you talk to criminals to find out why they did their crimes?"

"No, I'm a psychiatrist. I treat brain diseases."

"Oh, so all you do is give them medicine."

(Yeah, like all an anesthesiologist does is put a tube down the patient's throat so he can breath.) "Well, that's pretty important."

"Don't you ever get to talk to them?"

"I don't do psychotherapy. I treat brain diseases."

"Oh, so they don't get counselling. Isn't that sad?"

I've had this conversation with people so many times that I no longer have the impulse to run screaming from the room. I can resist the temptation to say, "No, all I do is give them medicine so they don't rip their clothes off and stand masturbating all day or curse and attack the officers or break the windows out of their cells. That's all I do." They are civillians. They have no clue. They can't help it.

We had a therapeutic prison fad back in the 1950's and '60's. When Thorazine was first invented and we suddenly had the ability to treat psychosis it seemed like anything was curable. Criminality became a disease. And so they were given therapy in Therapeutic Prison. Sentencing laws were modified to allow for indeterminate sentences---no fixed endpoint---so that release was dependent upon the treatment team. Ah, the unintended consequence of how to determine when psychotherapy ends! Inmates discovered that the sentence, like the psychotherapy, became endless. So they did the logical thing that all inmates do in these situations---they sued. They sued for the right to end psychotherapy and leave Therapeutic Prison. The court agreed that indefinite involuntary confinement was unconstitutional even when it was for well-intended therapeutic purposes. And so we are back to our starting point.

Today inmates still want to search for the Answer to "why I do the things I do." And they insist, coincidentally, that this can only be done in Therapeutic Prison. They don't want to hear that the Answer to why they repeatedly use drugs and drink is because they're addicted to it. It must be because of trauma X or dual diagnosis Y, or some other Answer that is the key to never coming back to prison. Honestly, I'm a bit skeptical about the utility of psychotherapy in these situations. I'm of the opinion that if a trip through a 200 year old prison isn't enough to convince someone that breaking into houses and robbing people is a Bad Thing, then all the couch time in the world isn't going to do it.

Fortunately, it is possible to be therapeutic without doing psychotherapy. A good therapeutic relationship---of any kind---can keep an inmate alive. People with personality disorders have a lot of trouble staying alive. They die from medical diseases because they don't take care of themselves. They use bad judgement and take risks that get themselves killed. They are annoying to other personality-disordered people and end up getting murdered. And then there's the suicide issue. A therapeutic relationship involves being available to answer questions and explain how the system works. It involves treating the inmate humanely and with respect. It involves explaining to the inmate what their disease is and how to care for it. It involves giving the inmate a safe place to sob away from the other prisoners when needed. Sometimes it means I walk down the street and hear a voice calling from a distance: "Doc! Hey doc! Remember me? How ya doin'?" and then the former inmate tells me about something I did years before during a brief med check that "really helped".

And yes, I also give medicine.

11 comments:

Dinah said...

You know, I was just looking for you!

So you're wrong: psychotherapy does help your criminals not commit crimes when they are out in free society (and therefore my patients). Why? Not totally sure, and I do see a select group of patients (ah, ones who can pay me, mostly) for psychotherapy. I do listen sympathetically to stories of victimization, but I don't think that's it. I think what helps, in the case of a criminal who doesn't want to be a criminal (or any other type of misbehaving soul) is the regular Accountability. It's hard to walk into your doctor's office each week and have to start with "I robbed another house..." and if it isn't offered, I ask: "So how's the house robbing thing going this week?" Not everyone is perfect (oh, no one is perfect), but the folk who can pull it together to show up for regular psychotherapy do better with the demand for frequent accountability for their behaviors. Just my thoughts. And I was going to post on how you DO DO psychotherapy.

ps thanks for finding your own couch, it's lovely

On the Same Page said...

It's interesting that Irvin Yalom, I believe in the introduction to Existential Psychotherapy (it's to early to go looking for the book, but I'm pretty sure) talks about surveying patients as to which therapeutic "technique" they found the most helpful. He was surprised to find that patients found things like reassurance, acknowledgement, a pat on the shoulder as they left, a hand shake, or a smile to be the most important aspects of "psychotherapy." I have always taken this to mean listen, pay attention, and listen again.

Several years ago, I was asked by our then program director my opinion of the evaluative process used by the Dept. I told him that I am my own evaluator in the sense that I attempt to make a therapeutic "impression" on every patient I encounter: if a man walks away with the thought that it is possible not to recidivate, that there is a chance of making it on the outside, or if they leave, if only for the moment, with the feeling that the interaction was positive, I am satisfied that a psychotherapeutic intervention has occurred.

I believe Dinah is correct. Don't underestimate the nature of what you do (do do, Dinah?).

Shiny Happy Person said...

What a great post.

I've bugger-all to add, incidentally.

But I liked it a lot!

Dinah said...

What does BUGGER-ALL mean?

ClinkShrink said...

Dinah, thanks for the compliments on the couch. I searched long and hard for it. I agree that accountability can do wonders and taking responsibility for meds/appointments is the start of that. I think many folks would probably not consider what I do to be psychotherapy---I'm not trying to develop insight or interpret psychodynamics or encourage introspection. I'm just there, being somewhat helpful with practical things. Occasionally, I strongly encourage my patient to "buy a clue". Rarely, they may listen. I think Foo described it well---a therapeutic technique but not necessarily a therapy itself.

And I thought it was inevitable that at some point FooFoo and "do do" would get linked in the same sentence.

Aw, thanks SHP. I totally agree with your approach to therapy by the way. Which is I guess another way of saying you're doing exactly what I would do, so you must be right. (And I'm working on your Hair Mood Scale, with Dinah's help. We're working off that $10,000 cheque. Keep an eye on the blog.)

Dreaming Mage said...

I'm not a criminal, but I think what you do is very valuable. I am bipolar, and I doubt I could get by without my meds.

And what you do keeps people alive. I dont' know the statistics for other illnesses, but I know that 1/3 of bipolars die indirectly from the illness. Suicide, drug abuse or accidents from risk-taking behavior, it doesn't matter. The disorder killed them.

Thanks for being part of the force keeping us alive.

Mage

jw said...

I'll tell a little story about my at one time best friend that applies here. The person in the story is someone you may well know so I'll be carefull to hide some of the details.

X had a violent alcoholic step father. When X was 12 his step father, in a rage, started beating X's mother in a very severe way. X picked up a sledge hammer and killed his step father.

X was placed in Penetang, Canada's maximum security mental hospital: He was placed on F ward, where Canada keeps our worst of the worst psych-offenders.

The media got him out when he was 15. The home he was sent to was run by a particularily violent woman. She molested & beat him for two years ... he ran away at 17.

X, like me raised his kids as a lone father. X, like me, fought for rights for lone fathers and for male survivors: Also like me, X worked his way through university as a lone father.

I talked with X a few years ago, just before he died.

X said that out of all the "help" he was supposed to get (and never did) the one thing which actually did help him came in a few minute meds consultation back when he was in his twenties.

The doc looked at him and said "X, if we plotted you on a 1 to 10 unfairness-out-of-life chart you'd be off the top of the scale. You can spend time thinking about that or you can get on with life. Your choice ..."

That little --tiny-- statement was the difference which moved X from a loser to a winner. That statement stayed in X's mind from then on: It made all of the difference for him and through him for his children and for many other people.

That statement brought X to a point where I worry that the little bit of ID I have provided is enough for an unknown psychiatrist to ID him.

hmph!

Don't doubt the time spent on meds consults. YOU, you may say something which will ripple over time into help for a great many people!

Shiny Happy Person said...

Thanks, clink. I really appreciate that.

Dinah - "bugger all" is a British way of saying "nothing".

NeoNurseChic said...
This comment has been removed by the author.
Roy said...

Clink,
This is called supportive psychotherapy. It's a real form of therapy. I even have a whole book devoted to it.

Planting a seed, like JW described, is something I try to do with each encounter, no matter how brief.

Sorry I haven't been around much... I've been working late every day, and bugger all else.

NeoNurseChic said...

He lives! Hope you have the weekend off to rest and relax, Roy!