Wednesday, February 20, 2008

Shrinking the Shrink

Roy asked me to comment on Dr. Richard A. Friedman's article in yesterdays New York Times, "Have You Ever Been in Psychotherapy, Doctor?"

Dr. Friedman talks about a psychiatry resident-in-training who becomes uncomfortable when asked by a patient if he's ever been in therapy. He moves from the patient's question to the broader, much-discussed issue of whether it's necessary for a therapist to have been in therapy. Friedman reviews the issues that every psychiatry resident has heard and discussed--You don't need to have had brain surgery to be a neurosurgeon. Psychotherapy, it's said, is different. "One way to think about it is that a therapist should not start exploring a patient’s mind without really knowing what is in his own." He talks about understanding one's own feelings and being aware of counter-transference.

But even as we have been swept off our feet by sexy neuroscience, my field
is in danger of losing touch with the rich psychological life of patients, something that is reflected in the waning popularity of therapy during residency training.

All true, but we are far from understanding the ultimate cause of most psychiatric disorders, despite the promise of brain science. We can effectively relieve symptoms and increase functioning, but we still have to help our patients live with illness.

Psychiatrists who have had the humbling experience of therapy themselves know something of what it feels like to be a patient — the sense of frustration,
anxiety and dependence it entails. As such, they can better understand the emotional reactions patients have to their illness — and to their doctors.

So do I think a psychiatrist needs to have had his/her own psychotherapy to be a good psychiatrist? Do I think the "humbling" experience of psychotherapy, or any other version of patient-hood, is necessary to create a good therapist?

Honestly, I have no idea. I'm not aware that anyone has every asked this question in a useful way. We'd have to survey patients and survey their shrinks, find measures to calculate good versus bad versus adequate docs and then we'd have to ask how much therapy, how often and by whom for it to "count." The psychoanalysts have made it a given, every psychoanalyst-in-training has to have completed a full psychoanalysis with a designated, experienced, "training" analyst. I'm not sure there's any reliability to who spends 4 years on the couch and who spends 10, but they've all been there. And are psychoanalysts "better" psychotherapists? I don't know.

I went to medical school in New York City when and where psychotherapy, and especially psychoanalysis, was still considered necessary for would-be psychiatrists. Part of "The unexamined life is not worth living," (thank you, Socrates) theory, I suppose. Still, when I started to see a psychiatry resident for my own therapy, I told no one and I worried about who would see me in the halls and what they might think. I was a medical student and I knew I'd be applying to that same department for residency ), so I worried about which supervisors talked about me with my resident doctor.
I only went for a little while, and this is what I can say about that particular psychotherapy experience: It was absolutely, and without a doubt, the most valuable experience I had in learning to become a psychotherapist.

Now, let me tell you about the psychiatry resident I saw. He was horrible. He wasn't a mean person in any way, but he wasn't a good therapist. No matter what I said, he'd say, "How would that make you feel?" Before I'd go to a session, I'd think about what I was going to say, and I'd think about how it would make me feel, and so I thought I had the bases covered. He'd still ask, "How would that make you feel?" I'd already told him! It was exasperating. I felt like he was a puppet of his supervisors, that he was wasn't thinking for himself. Years later, a classmate who was also going to be a psychiatrist and who was also in therapy with a resident in training, told me what safeguards were in place for student treatment, how the records were segregated and locked, and exactly who had access. Why hadn't my resident shrink just told me this? When I told him I worried about running into my advisor in the hall (who could have cared less that I was in therapy, I'm sure) why did he repeatedly ask "How Would that Make you Feel?" Why didn't he just tell me that my advisor didn't have access to my file?

I learned a lot about being frustrated as a patient. I learned an awful lot about what not to do, about how it leaves a patient feeling like you're not there with them.

Therapy is a kind of secretive mission-- perhaps why we enjoy the voyeuristic aspects of In Treatment and Jennifer Melfi's therapy with Tony Soprano. You can watch cardiac surgery. You can do it with a more experienced cardiac surgeon in the room. And Mirror Supervision for therapists is invaluable but often hard to arrange for. Mostly, we just try our best to report what happened to a supervisor, read books, try our best. What Dr. Friedman didn't mention is that being a psychotherapy patient is one of the very few ways that a therapist ever gets to see what goes on behind closed doors.

P.S. The resident who treated me for that brief period of time later went to work for a drug company. I'm sure he did a great job.