Wednesday, October 06, 2010

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.

* 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.


Anonymous said...

"such arrangements are not kosher"A touch of iron from a site that offers bacon on the side.

Anonymous said...

make that irony

Retriever said...

Interesting post. Reminded me of some seminary flip flopping roles many years ago... Will link to it. But the example Small gives (haven't yet read the book) is of being a shrink to an authority figure not a friend. A friend would not boss one about, dictate, call the shots. If they do, they should expect it to become the subject of therapy.

Although I could imagine that with a friend one might also miss a diagnosis because one might treat a person gently , cushion blows, make excuses, look for the most socially acceptable explanation: eg: he isn't an alcoholic, he just appreciates fine wine because he grew up in wine country.

I think that if you live in a city, you should refer a friend to someone else. Especially if it's a university community with many psychiatrists and psychologists. But several names.

I think that in a small town, you may have sometimes to treat a friend. Or a friend's kid. But it may become the stuff of much of the the therapy and involve a lot of discussion setting up boundaries. So the person feels safe that this therapeutic relationship really is separate. Not everyone can handle it. It would depend on the friend.

If you were just writing a prescription and giving some encouragement to keep taking meds, probably no different than being a GP. But if you were treating a truly dreadful mood problem or a life threatening crisis that would take a long recovery and need long term therapy, a lot would depend on your own training. I'd be inclined to say that the needs of the patient should take precedence. There are so many places where there are only a couple of shrinks in an area and one is a jerk and the family knows the other one from the kids' school. In that case, the shrink who knows them from school should probably be the one.

I could also be flip about this and say I have a personal stake in this: we have a family house in a rural area and I have a kid with serious issues currently in remission. Should he suddenly go ballistic, the only mental health professional I know for fifty miles in the area is a blogging friend. I think I know what I would do if I were up against the wall...:)

moviedoc said...

Anon: Just as I was thinking of the blogger as Iron Dinah... Nah.

Wasn't this already discussed as "friending" on Facebook? Either way it's a bad idea. It cheats the patient. We like to think of psychiatric disorders as medical, but that model fits variably along a spectrum with schizophrenia at one end.

The exception might be in a rural area with no other psychotherapist. And it might be less of a problem with CBT than with a psycho-dynamic approach.

Sunny CA said...

Mulling through the eyes of the patient: I wonder if having a friend become one's psychiatrist might make it harder to disclose the hard-to-disclose things? It would be for me. There have been things that I finally told my psychiatrist I doubt I would ever tell a friend. If a professional relationship were established, would one then feel uncomfortable socializing with the shrink considering the shrink perhaps knows everything that others do not? I know my shrink talks to his partner and sometimes his friends about his patients. I suppose he would not do that if the patient was part of that group. In my case our lives are completely separate.

snoring solutions said...

This site is great.I think that in a small town, you may have sometimes to treat a friend. Or a friend's kid. But it may become the stuff of much of the the therapy and involve a lot of discussion setting up boundaries. So the person feels safe that this therapeutic relationship really is separate.Thank you for bringing such nice posts. Your blog is always fascinating to read.

Anonymous said...

My bf emails his therapist on the side, and clearly tries to 'lure' her into his world outside the chair...
I find it to be absolutely breaking the boundaries...
Therapists are the only adults in most of these situations, the ones who must keep the charge of holding these boundaries steady