Saturday, May 05, 2007

A Shrink Like Me!

We're back to our regularly scheduled program now.

It was April 24th, back when Roy was having Grand Rounds mania and Shrink Rap was under lock and key, when the New York Times printed an article by Dr. Richard Friedman,
Understanding Empathy: Can You Feel My Pain. Dr. Friedman begins his piece by quoting a patient who asks if he's ever been depressed; does he know where she's been?

It's a funny question. Why does a doctor need to have suffered from an illness to treat it? We assume our oncologist hasn't had lung cancer or metastatic colon cancer, he hasn't gone through what his patients are going through, and yet we'll assume he's sympathetic and competent. If the doctor has had the disease, or has had a close relative with it (why is that never the question?) then perhaps he is more understanding, but really, how would this help his competence to treat a given disease? In fact, sometimes those who've conquered something are less sympathetic, sometimes those who've conquered say an addiction, or lost weight, or stopped smoking, or have somehow suffered, develop a bit of condescension toward those who aren't doing as well-- a bit of I did it Why can't You? Maybe it's better if the doctor is an outsider, a technician there to make the proper moves without the burden of his own history or agenda.

Friedman goes on to talk about patients who come with requests for specific flavors of therapists: gay, feminist, African-American, Jewish. These patients want a shrink who identifies with their lifestyles, who better knows what it is to be them.

I think there are two different issues here. Clearly, one can treat an illness if one hasn't had it; mental illnesses really are no different and plenty of patients get treated for schizophrenia by docs who've never been psychotic. Having been depressed doesn't change one's ability to write the right prescription, to imagine what it is to suffer, to listen, learn, and appreciate a patient's distress. If anything, it may color the doc's view. Want more? See my post from last September, A Taste of Our Own Medicine.

The second issue is more about therapy-- does it help to have a therapist who is familiar in some ways with the patient's world or culture or core beliefs? Dr. Friedman says No: "What is critical to understanding someone is not necessarily having had his or her experience; it is being able to imagine what it would be like to have it. Thus, I do not have to be black to empathize with the toxic effects of racial prejudice, or be a woman to know how I would feel about being denied promotion on the basis of sex. "

And what do I think? It seems to me that just as some patients respond to one medication and not another, some people have very strong feelings about who they are comfortable speaking with, while many don't care. I've had many calls from patients who want to see a female psychiatrist. I don't question it (what am I going to do about it anyway?) and I've come to take it at face value. I imagine there are women who prefer to talk to a man or who just don't care about their shrink's gender. The reality is this: if a patient lives in a place where there are options for who will be their therapist, and the patient has means to pay for it, they will select who they want to see--- there is no means for telling someone who wants to see and pay for an available female/gay/Jewish/Hindi psychiatrist, "No, don't do it." For those who go to clinics, where there may or may not be choice, the clinics vary in how responsive they are either willing or able to be to such requests.

In an ideal world, I suppose I think that anything reasonable that makes a patient more comfortable should be accomodated so long as it doesn't make someone else uncomfortable. It's not an ideal world, and some orders are hard to fill.

Any thoughts? I, of course, want a therapist with a blog.