My goal as a therapist: to make myself obsolete

Traditional psychodynamic therapy is often caricatured as endless, with a complacent therapist silently growing cobwebs, listening to a patient who never plans to leave.  This isn't completely unfounded: there are therapeutic advantages to losing track of time, "swimming in the material," and letting one's therapeutic focus be broad.  The patient's chief complaint, i.e., the ostensible reason for coming, often gives way to more troubling underlying conflicts and concerns that might never appear in more directed or time-limited work.  Highly defended material may be uncovered and worked through in the fullness of time.

All the same, and as many critics have pointed out, this is a cozy arrangement.  If the therapist is happy to have a paid hour, and the patient is gratified to pay for the undivided attention of a caring doctor, nothing need change.  Ever.  Many patients fear becoming emotionally dependent on their therapists, i.e., finding it too comfortable to stop.  And some therapists, being human, are not above maintaining a pleasant status quo.

Psychoanalysts and analytic psychotherapists anticipate this concern, and hold that a patient's dependency, like everything else, can be explored, understood, and overcome.  However, in highly non-directive therapy, i.e., with a mostly silent therapist, this can take a long time and be painful for the patient in the meantime.

My approach to dynamic work is more interactive.  While I believe transference and countertransference are highly useful tools, and that both manifest and latent content are important, I also strive to help paients in the here and now, whenever doing so doesn't interfere with long-term gains.

In this light, I often tell patients that I aim to make myself obsolete in their lives.  Saying this can quell dependency fears, but it's open-ended enough that I'm not promising how long (or briefly) we'll work together, nor that I guarantee they won't feel dependent along the way.  I can't promise these, because I don't know.  But I can give my word that I won't allow myself to get so comfortable with our arrangement that I forget why we're meeting at all.  It's a comforting statement that has the advantage of being true.  It feels good to have a patient not need me anymore, a little like the bittersweet feeling when a child goes off to college.  And in a way, hearing myself say so out loud helps me remember it.

The trade-off, a psychoanalyst might point out, is that I short-circuit any fantasies patients might harbor that I seek to trap them, that I want them to feel dependent.  Patients might gain more insight about themselves if I let such fantasies germinate, and then collaboratively explore them.  It's an important point to keep in mind, but on balance I usually feel this modest bit of support helps the therapeutic alliance much more than it forestalls exploration.

A successful psychotherapy is when a patient leaves with the satisfaction that she "got what she came for," and no longer needs, or even wants, to see a therapist.  And a successful psychotherapy practice is one where patients come (in need) and go (improved), the therapist becoming obsolete one patient at a time.

Resistance: "I have nothing to talk about today"

There comes a time, fairly early in many psychotherapies, when there is nothing left to talk about.  The identified problems have been named and discussed, there is no more need to bring the therapist up to speed on one's history.  In essence, the patient's conscious agenda for coming to therapy has been exhausted.  I tell trainees this often happens around session #7 — truly it's more variable than that — when the patient has voiced all his or her prepared topics, said everything already known or consciously felt about the issues, and offered all the background he or she believes is relevant.  The patient may then appeal to the therapist for guidance, not in any profound sense, but simply to suggest something to talk about, so they don't sit there in awkward silence. A dynamic therapist typically turns this back on the hapless patient:  "Say anything that comes to mind."  This challenge can bring therapy to a grinding halt — or trigger the start of genuine exploration.  For it is only when the patient speaks unrehearsed and without self-censorship, in the moment, that the two can observe the here-and-now workings of the patient's mind.  It has been mere preamble up to this point, groundwork at best and chit-chat at worst, not the real work of dynamic psychotherapy.  Speaking "without a script" allows topics to arise that are impolite, uncomfortable, and awkward, ideas the patient previously thought but chose not to say, feelings that had been brushed aside up to that point.  Some patients unfortunately cannot speak without a script; it is too scary and they are too defensive.  Dynamic therapy ends at that point, although emotional support and cognitive techniques may still prove very helpful.  But for those with the courage to look at themselves, their own defenses, resistance, and unconscious motivation, it's time to dive in and explore the unknown.

In a similar vein, patients at any stage of treatment sometimes arrive to a session with nothing to discuss that day.  They exude an uncharacteristic blandness or boredom, as if to signal: "Nothing to see here, just move along."  With a mildly apologetic tone they claim to have no burning issues, nothing especially vexing or troubling.  In fact, maybe it's time to talk about wrapping up treatment...

If this presentation stands in contrast to the patient's usual enthusiasm, I take it as a very good sign.  Something emotionally important is going on, and the patient's Unconscious is trying desperately to throw us off the trail.  In the language of dynamic therapy, this is resistance: unconscious effort to avoid painful or troubling material in therapy.  Some patients employ this sort of resistance constantly, and for this reason are either very challenging to treat, or they "vote with their feet" and leave treatment early in the process.  But when a new resistance stands in clear contrast to the patient's typical openness, it is easier for the therapist to recognize it, easier to point it out to the patient (who is more open to hearing about it), and easier to identify dynamics that may underlie it.

In my experience, these unusually boring or bland openings lead, more often than not, to the best sessions.  Because the patient is not consciously avoiding a troubling issue, and because I rarely know at first what motivates the patient's avoidance that day, it becomes a shared exploration where new discoveries and insights come to light.  For reasons I can't quite explain, the factors motivating such resistance are not deeply buried or inaccessible.  They usually become apparent to both of us well within the 50-minute hour.  "Making the unconscious conscious" (in Freud's famous words) leads the patient to new and unexpected insights — usually a delightful experience for us both — and also to clearing of the leaden resistance, which is no longer needed to keep the material out of consciousness.  Rather than heralding the end of the treatment, awkward silence at the start of an hour, like the awkwardness near the start of many a dynamic psychotherapy, points the way to important thoughts and feelings.  It turns out there is a lot to talk about.

"Do you analyze everyone you meet?"

People sometimes wonder whether I "analyze" everyone I meet. This is usually asked with some fear that as a psychiatrist I can "see right through them" and instantly know things about their innermost thoughts they'd prefer to keep hidden.  Although this is true (just kidding), I try to reassure them with the following analogy. Imagine an architect whose business and personal life includes walking into and out of buildings all day. Does the architect "analyze" every building —  home, coffee shop, office, gym — all day long? I doubt it. Perhaps if a particular construction is especially creative, or unusual, or singularly beautiful or ugly.  But most of the time an architect relates to buildings the same way everyone else does: for the personal reasons he or she visited there.  (If there are any architects out there, please confirm!)

In my experience the same is true of psychiatrists and other mental health practitioners. We deal with people all day, both professionally and personally.  When working, our attention is directed in a certain way, toward understanding the person in front of us.  After all, this person paid good money for us to focus our attention exactly this way.  Other than this, though, we deal with loved ones as loved ones, colleagues as colleagues, store clerks as store clerks, and so forth.  It is only when someone's personality or behavior is noteworthy and unusual that we may find ourselves viewing them momentarily through our "psychiatrist glasses."

I've heard it works similarly for doctors and medical diseases.  Occasionally a case of acromegaly, cerebral palsy, rheumatoid arthritis, or psoriasis can be diagnosed in a stranger on the street, or in a crowded elevator.  Most of the time, though, people are just people.

The question about analyzing everyone often seems to harbor some anxiety.  It feels threatening to have possessors of mystical and limitless insight lurking among us, wantonly tearing holes through the public persona and self-image of each innocent bystander.

Fortunately, this is a fantasy.  Being a psychiatrist doesn't make me a mind-reader.  It usually takes an hour of formal intake interviewing before I begin to have a sense of a person's personality.  Often it takes more than one session. While it's true that people, not just psychiatrists, can pick up clues to personality early in a conversation, psychiatrists aim more for accuracy than speed.   Instant on-the-fly psychiatric diagnosis or case formulation is fraught with uncertainty and error because it is based on insufficient data.  As professionals, we are trained not to shoot from the hip, and for good reason: because our opinion should mean something.  If the considered views of psychiatrists are to matter more than the hunches of untrained persons, we must refrain from offering half-baked, "cocktail party" assessments.  I cringe when I hear a colleague spouting off about a politician or celebrity known only through the media.  A detailed study of someone not personally interviewed, e.g., a psychohistory, may be defensible; an off the cuff opinion cloaked in psychological jargon is not.

"Analyzing everyone we meet" is literally impossible, and as in the case of the architect, would be a huge distraction from everyday life.  Moreover, even attempting it is unprofessional.  We should reserve any such analysis for the clinical office, where the setting is conducive, and the data sufficient, to make a meaningful assessment.

Psychiatric anosognosia

This post was inspired by an article in the May 30th issue of The New Yorker, "God Knows Where I Am" by Rachel Aviv.  Full-text online is only available by subscription, but a free abstract is available here.  In the process of telling a riveting and ultimately very sad story, the author discusses psychiatric insight. Insight is a curious concept as used in psychiatry.  In common parlance insight is unquantifiable, something like charm or wisdom.  We feel we know it when we see it.  But most of us hesitate to make finer distinctions.  We may allow that someone strikes us as a little insightful or very wise.  Beyond that, it seems ludicrous to attach a scale to it, or to refer to insight as though it could be measured precisely.

Nonetheless, in psychiatry an assessment of insight is part of the "mental status examination"  (MSE), the psychiatrist's version of the physical exam in general medicine.  Along with assessments of mood, affect (expressed emotion), paranoia, suicidal feelings, and other issues, the psychiatrist also evaluates the patient's insight.

Psychiatry has no standardized way to assess this.  We may ask our patient: "What is your understanding of the problem that brought you here today?"  It's a great question — the problem is what to do with the answer.  Critics note that if the patient's response accords with the psychiatrist's own belief, the patient is judged to have good insight.  Thus, in an earlier era when psychoanalysis was predominant, a patient with schizophrenia exhibited good insight by agreeing that his "schizophrenogenic" mother caused the problem.  Nowadays, this would be evidence of clear impairment; the insightful patient would instead agree with his psychiatrist that he has a "chemical imbalance."

For better or worse, many such judgments in psychiatry — perhaps most of what we do — cannot be divorced from social context.  Exuberance in one crowd may look like hypomania in another.  "Inappropriate" affect begs the question, what is appropriate?  And likewise, an understanding of one's own mental health status (or psychiatric label) is meaningful only within one's social group and culture.

Anosognosia is a term from neurology.  As defined in Mosby's Medical Dictionary, 8th edition:

[an′əsog·nō′zhə]

Etymology: Gk, a + nosos, not disease, gnosis, knowing

a lack of awareness or a denial of a neurologic defect or illness in general, especially paralysis on one side of the body. It may be attributable to a lesion in the right parietal lobe.

Certain patients with brain disease or injury appear not to know they are paralyzed (or blind, etc).  Presumably, parts of the brain involved with self-awareness are damaged.  This lack of knowing then becomes one of the signs of the disease itself, and may help with diagnosis.  For example, the cause of a paralysis may be localized to the parietal lobe if it is accompanied by anosognosia.

The term has lately appeared in psychiatry (and is discussed briefly in the New Yorker piece).  This is a worrisome error in my opinion.  Its use seems intended to make psychiatry sound better understood, and more biological/neurological, than it really is.  A person who denies having a psychiatric disorder may delusionally attribute his or her difficulties to space aliens.  This makes a good case for extending anosognosia into psychiatry.  But a denial could equally be an honest difference of opinion, as when a patient discounts a diagnosis of Social Anxiety Disorder because shyness is a family trait.  Here, denial of an anxiety disorder is certainly not a sign of having such a disorder.  And of course social stigma leads many patients to deny having a psychiatric disorder; this denial likewise bears no relationship to having the disorder itself.

The reasons patients may deny having a psychiatric disorder are far too varied to reify such denial with a neurological term.  It creates a suspicious "Catch-22," where disagreeing with one's doctor is itself a diagnosable condition with a fancy medical name, and the implication of brain-structure underpinnings.  This is sophistry, and the mark of a profession whose false certainty belies insecurity.

Many years ago I wrote a short essay arguing that social judgments in psychiatry  (e.g., inappropriate affect) are both inevitable and essential to our work.  I was not a psychiatrist yet, but nothing I have seen since has changed my view.  Despite great advances in biological psychiatry, we still cannot ascribe specific attitudes or viewpoints to neurological damage.  Insight is still subjective.  And if we ever do identify the seat of "psychiatric anosognosia," our understanding will no longer be psychiatry, but neurology.

Talk doesn't pay: Comments on the NY Times article

I'd like to take this opportunity to comment on the article that appeared in today's New York Times: "Talk doesn't Pay, So Psychiatry Turns to Drug Therapy."  Gardiner Harris writes about psychiatry's shift from talk therapy to drugs, and profiles psychiatrist Donald Levin of Doylestown, PA (a suburb of Philadelphia), who felt financially unable to maintain a psychotherapy practice, and therefore shifted to a high-volume, medication-only practice.  It is clear that both the doctor and the journalist consider this a sad state of affairs.  Dr. Levin is quoted as saying: "I’m good at it, but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.” That comparison is apt to rile my colleagues who are serious and careful psychopharmacologists.  But Dr. Levin is right:  Most medication management in psychiatry is tediously straightforward.  Which is why it is mostly done by primary care doctors, not psychiatrists.  In the U.S. most antidepressant and antianxiety prescriptions are written by non-psychiatrists.  (And even antipsychotics lately, but this is a different and far more worrisome issue.)  It seems to me that any self-respecting psychiatrist who limits his or her practice to psychopharmacology, i.e., medication management only, should add some value over a visit to a family doctor, internist, or pediatrician.  Either the cases seen should be harder, e.g., "treatment resistant," or the doctor should offer something more nuanced and sophisticated, or more comprehensive.  If so, such a psychiatrist will not be "the ape with the bone."  Unfortunately, my experience suggests this is the exception, and that the shift to medication management has been borne of expediency and financial pressure in many cases, not an earnest scholarly focus on advanced psychiatric medication strategies.  And for this reason, the critique that our field is increasingly populated by dumbed-down medication technicians is not the throwaway line it would otherwise be.

In saying this, I invite a rebuttal.  If psychiatrists who give meds should add something over other med providers, what do psychiatrists who conduct therapy add over other therapists?  The answer is a more comprehensive viewpoint, one that takes into account medical and bodily issues, drug interactions, and similar matters.  And the option to prescribe medications when these are needed in addition.  If we cannot add this value, we should not charge more than other therapists.

Since I have a mostly-psychotherapy practice myself, I took note of several points made in the article.  Most glaring is a starkly misleading statistic.  Harris cites a 2005 government survey showing that just 11 percent of psychiatrists "provided talk therapy to all patients."  I'm not sure why that surprises anyone.  I'm a huge advocate of psychotherapy, yet I don't recommend, much less provide, it for everyone.  It's a treatment — it's expensive, it takes a lot of time, it's often uncomfortable.  I only provide psychotherapy when I predict it will help, and when my patient agrees to it.  While I believe it would be helpful for many patients I see, I nonetheless still treat a minority of patients with medication only.  In my view, one of the best things about being a psychiatrist is that we have a variety of tools.  While I find dynamic psychotherapy more intellectually interesting and humanly engaging than writing prescriptions, I'm glad I can do both.  The 11 percent statistic is meaningless.

Another potential confusion in the article are the widely disparate fees cited, with little explanation.  At one point Harris writes: "A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session."  At least here in San Francisco, this is considerably less than either service is typically worth, even accounting for payment caps by health insurers.  Not to mention that psychotherapy is traditionally 50 minutes, not 45.  But then Harris writes about "a select group of [New York] psychiatrists [who] charge $600 or more per hour to treat investment bankers," and later notes that a nearby colleague of Dr. Levin charges "$200 for most [therapy] appointments."  The truth in my experience is that no psychiatrist starves by being a psychotherapist, even though there is more competition from other disciplines and the overall income may be less.  Talk does pay, just not quite as much.  When psychiatrists complain about comparatively low psychotherapy income, it makes me wonder why they didn't become surgeons.  Seriously, from what I gather surgery is very engaging, very satisfying, and very lucrative.  It sounds much better than doing half-hearted, half-assed psychiatry just for the income boost.

As I wrote last year, dynamic psychotherapy is more than merely a treatment technique to place on a shelf alongside medications.  It is a perspective that informs our understanding of patients even when we do not offer this specific therapy as treatment.  Thinking about our patients dynamically can help us be better medication providers, better CBT (non-dynamic) therapists, better referrers to other professionals.  Psychiatrists don't have to be psychotherapists all the time, but we do need to think psychotherapeutically all the time.  The real tragedy highlighted by the NY Times article is not one man's devolution to an "ape with a bone," nor even a profession's.  It is the loss of intellectual curiosity — of knowing there is a better way, yet choosing not to pursue it.