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.

Physician mistrust and the end of the doctor-patient relationship

KevinMD.com published a post a couple of days ago from medical student Joyce Ho in which she admitted to discomfort raising the topic of religion with patients.  As a "polarizing" issue that could make the doctor-patient relationship "more unprofessional," Ms. Ho imagined that patients would fear playing into their doctors' prejudices, particularly if the doctor were atheist, and that this fear would push some patients away from the inquiring doctor.  Despite her instructor's recommendation to ask gentle, open-ended questions about faith and spirituality in the context of a patient's support systems, "personally, I still will not actively ask about religious preferences if the patient does not bring the issue up." As a new reader of KevinMD, I was first to comment — a mistake, in retrospect.  I imagined her concerns were merely new-doctor jitters, a phenomenon as old as medicine itself.  I pointed out that students at first find religion, sex, and many other topics difficult to broach with patients.  Yet uncomfortable topics such as these are often important, and may go unmentioned unless the doctor asks.  Trying to be supportive, I noted that patients usually worry less about a doctor's own religious beliefs, or lack thereof, than they do about their doctor's care and concern.  Frankly, I didn't imagine my comment was controversial in the least.

To my dismay, comment after comment followed that a patient's religion is none of his or her doctor's business.  To some extent this was conflated with complaints of unbidden chaplains appearing at hospital bedsides, and awkward offers by medical staff to pray with a patient who wanted no such thing.  But even leaving aside those obvious blunders, there was rampant mistrust of doctors even inquiring about religion, spirituality, or faith.

Apparently, Joyce Ho was right.  Commenters on the blog assumed we doctors jump to false conclusions — "assume certain things about certain religions" — and are apt to over-interpret based on limited information; that we are "busybodies" to ask about such matters; that the information is irrelevant at best; that "doctors might judge you"; and that we cannot help but oversimplify the beliefs of any patient who has given religion or spirituality serious thought.  A self-identified atheist living in the Bible Belt was grateful no doctor had ever asked: "We in the South have enough problems ... without also having doctors who think they should be discussing religion with their patients...."  The comment with the most "agrees" was this anonymous one-liner:

I wouldn't want my doctor asking about my religion. That's not necessary. I'm glad mine don't do that.

How has it come to this?  Haven't patient advocates and caring doctors fought for years — decades — to retain humanism in a medical system that inexorably drifts toward the impersonal and mechanical?  What happened to the hope, if not expectation, that one's doctor sees the person behind the symptoms, the whole patient?  And what on earth happened to the premise that one's doctor can be trusted with sensitive personal information?  Religion, after all, is hardly the riskiest thing one might tell a physician in confidence.

A close look at the commentary reveals the sad truth.  The healing doctor-patient relationship is no more.  The Bible Belt atheist sees religion as a source of doctor-patient antagonism.  For the rest, the patient's relationship is not to a doctor, but to a "system of care."  This system aims to fill blanks in an electronic record; one commenter advised doctors to ask, "Would you like me to list a religious affiliation?" in order that this particular blank can be left unfilled if the patient desires.

Of course, antagonism and "listing" a religion in a database are not why medical students learn to take a patient's social history, including hobbies, interests, and social supports secular and otherwise.  It's to know their patients as people, to build rapport, to honor beliefs and relationships their patients hold dear, to appreciate their patients' strengths as well as weaknesses.  It's to offer personalized counsel, so that (to take the most basic example) the non-religious are not advised to seek solace in church, nor the faithful to neglect it.  Occasionally it's to develop a differential diagnosis for a medical condition unexpectedly related to a patient's social interests or behavior.  And often it's to learn a patient's values and preferences regarding end of life care, so that when that patient is unable to express them, his or her trusted doctor already knows.

All of this applies to a doctor, a well-meaning, trustworthy (if fallible) human fiduciary who listens in confidence.  In stark contrast, systems of care suffer diffusion of responsibility.  They spread personal information in unpredictable ways, outside the patient's control and awareness.  Thus, one commenter wrote, "I don't want that kind of information in my medical record," while another elaborated, "Blue Cross and the xray technician and everyone else who comes in contact with the chart have no need to know what religion the patient is unless the patient chose to share it with everybody."

Health reform provides long-overdue expansion of health coverage.  On the supply side, it promotes systems of care to enhance efficiency and decrease costs.  It's important to realize what we may already be losing in the bargain: the traditional personal relationship with a physician entrusted to handle intimate details of one's life with discretion and wisdom.  If it is no longer safe to divulge one's religion, what about one's sexual habits, recreational drug use, risky hobbies, and myriad other touchy subjects?  Widespread self-censoring of this information, to prevent it from entering large medical databases, may turn out to be more hazardous to public health than all the inefficiencies of the old approach.

Undermedicated

A patient I see for psychotherapy, without medications except for an occasional lorazepam (tranquilizer of the benzodiazepine class), told me his prior psychiatrist declared him grossly undermedicated in one of their early sessions, and had quickly prescribed two or three daily drugs for depression and anxiety.  He shared this story with a smile, as we've never discussed adding medication to his productive weekly sessions that focus on anxiety and interpersonal conflicts.  Indeed, the lorazepam is left over from his prior doctor.  I doubt I would have ordered it myself, although I don't particularly object that he still uses it now and then. Of course, there's a completely innocuous way to explain this difference between his prior psychiatrist and me.  My patient could have looked much worse back then, in dire need of pharmaceutical relief.  However, he didn't relate it to me that way, and I have no reason to doubt him.  There's also the possibility that I'm missing serious pathology in my patient — that I too would urge him to take medication if only I recognized what I'm now overlooking.  But... I don't think so.  I'm left to conclude that his prior psychiatrist and I evaluated essentially the same presentation rather differently.

In particular, I'm struck by the term "undermedicated" (more often spelled without the hyphen, according to my Google search).  This judgment most often comes up in speaking about populations, as in the debate over whether antidepressants are over-prescribed or under-prescribed in society at large, or whether children are diagnosed with ADHD and prescribed stimulants too often, or not often enough.  Under- and overmedication are also commonly mentioned when describing medication management of pain, a thyroid condition, mania, or chronic psychosis in an individual.  Here the terms express disagreement with a particular dosage, where the benefits of treatment and adverse side-effects or risks are deemed out of balance one way or the other.

"Undermedicated" also implies that adding medication is the preferred or only sensible treatment approach.  While this may always be true in hypothyroidism, it clearly isn't with regard to physical or emotional pain.  The term rhetorically denies non-medication alternatives.  I would also add that, to my ear, "overmedicated" and especially "undermedicated" sound dehumanizing, as though referring to a machine that is out of adjustment, or a chemical solution being titrated on a lab bench.  Since the natural state of human beings is not to be medicated at all, it sounds a bit odd to hear someone — as opposed to one's disease — assessed this way.  Perhaps I am especially sensitized to this after reading a controversial article by Moncrieff and Cohen that highlights the "altered state" induced by psychotropics and their lack of known, specific mechanisms of action.  There is often a supposition that medication dosage correlates with symptom relief.  This is not always true of subjective states, underscoring that the complexity of human experience often belies simple "over/under" judgments.

My patient's mood and anxiety vary with his interpersonal situation.  It wouldn't occur to me to turn his "thermostat" up or down in general, even if drugs reliably could do this.  Yet I know colleagues who'd argue that one, two, or even three daily medications could help him overcome his everyday challenges of dealing with people.  These approaches point to different fundamental viewpoints in psychiatry.  Does the patient have a disease, an as-yet-undiscovered chemical (or electrical, viral, inflammatory, etc) imbalance in the brain that is best remedied by a medical intervention, accurately dosed neither "over" nor "under"?  In acute mania or florid psychosis, as in hypothyroidism, it seems to me the answer may be yes, although this is unproven and time will tell.  Perhaps, too, in severe melancholic depression.  But in social anxiety?  Self-consciousness?  Feeling discouraged about one's career?  The field's perspective on these has shifted in recent decades, such that now a hidden biological cause is assumed by default, or at least held out as a rationale for treatment.  It is only by making this dubious assumption that one can speak of undermedicating such complaints, or the people who have them.

Do patients avoid psychiatrists for fear of legal holds?

Over on the Shrink Rap blog I got caught up in an off-topic debate.  The post was on why psychiatrists avoid insurance panels, something I've written about myself.  But the commentary wandered into exorbitant fees, inadequate mental health services for the poor, income disparity between psychiatrists and patients, a generation that expects something for nothing, and so on.  After a week, prompted by minor irritation with San Francisco's transit system the night before, I finally posted a comment.  I wrote that buses and taxicabs perform roughly the same service, but for many riders who can afford it, a cab is worth the extra money.  I acknowledged that the analogy to mental health care was flawed: bus and cab fares are both regulated, and psychiatric care is often more urgent and critical, and definitely more expensive, than an optional ride downtown.  Nonetheless, the comparison made the point that more affordable mental health services are inevitably "bus-like," and that there is a legitimate role for higher-cost "taxi-like" services for those willing and able to pay for them. It's important to realize that all analogies are flawed.  They only highlight certain similarities between two situations.  There will always be differences too, the salience of which are inevitably disputed by partisan debaters.  For this reason analogies illustrate far better than they convince.  One commenter noted that even "bus-like" mental health services are not always available.  A psychiatrist pointed out that many of us accept reduced fees or otherwise "come to some agreement" with cash-strapped patients in ways taxi drivers don't.  Then another commenter who frequently writes about forced psychiatric treatment argued that coercion never occurs with buses or cabs, rendering my analogy "shallow at best."

Going off-topic, I replied that forced treatment, e.g., being subjected to a 72-hour legal hold (the "5150" here in California), is uncommon in office psychiatry, and in any case didn't bear on the point I made.  I later added that a number of non-psychiatrists are also authorized to apply the 5150 in California, and in many instances would be far more likely to do so than a psychiatrist in a private office.  My interlocutor, and at least two others, pressed on: the mere possibility, however remote, of being placed on a legal hold is a threat that evokes fear in current and potential patients.  This fear keeps some who "truly need psychiatric intervention ... from even attempting to access 'help'."

I had already let it drop when our host asked everyone to return to the topic of insurance panels.  But it's a point that bears discussion, here if not there.  Do patients avoid office psychiatrists for fear of being placed on a legal hold?

I'm sure the answer is yes, at least sometimes.  In the first place, many patients do not know what triggers a 5150.  Movies, popular culture (such as the depicted t-shirt), and history itself prime the public to think a padded cell readily follows from a few ill-chosen words.  Often I've reassured patients that ideas or feelings, however destructive or horrific, never in themselves lead to involuntary commitment.  Patients are free to divulge fantasies of mass murder, elaborate suicide scenarios, gruesome torture, etc. without risk of being locked up.  Indeed, talking in confidence about disturbing ideas or feelings is a good way to defuse their emotional power.

But there's much more to this than simply not knowing the law.  In my experience a great many patients fail to distinguish feelings and actions.  They try unsuccessfully to control troubling feelings, and somehow equate this with uncontrolled behavior, a very different thing.  Yet the distinction is hugely important in life, and with regard to legal holds.  Feelings never justify a hold, whereas behavior, or its "probable" likelihood, does.  If this distinction is unclear, even feelings seem dangerous.

At a more subtle level, patients with hostile or self-destructive feelings often expect to be punished for them, or they unconsciously feel guilty, i.e., that they should be punished.  Indeed, people avoid psychotherapists of all types, imagining the therapist will condemn or humiliate them for the ugliness of their inner world.  Unconscious mixed feelings, i.e., simultaneously fearing and seeking a harsh response, are common as well.  A crucial part of dynamic psychotherapy is gradually trusting that the therapist won't fulfill this fantasy.  Seeing a psychiatrist evokes these usual fears of being judged and punished, heightened in some by the psychiatrist's power to diagnose and to initiate a legal hold — even if the risk of the latter is virtually zero.

I hasten to add that we psychiatrists don't make this any easier for ourselves or our patients when we are sloppy about applying legal holds.  Patients' fears of subjectivity and loose criteria are partly based in reality.  A casual "better safe than sorry" attitude may send the wrong message, trampling the treatment alliance and savaging trust.  Meticulous care in applying the 5150 is a "frame issue" as central to therapeutic success as any other treatment boundary.  As a profession we can never count on being afforded more trust than we have earned (and sadly, often less).

Of course, there are circumstances when we rightly apply a legal hold in the office.  A patient who believably voices, or behaviorally telegraphs, intent to die or to kill others should expect a trip to the psychiatric ER for further evaluation in a secure setting.  Conversely, there are presumably people intent on suicide or homicide who consciously avoid seeing psychiatrists who could thwart their plans, just as they avoid telling their family or the local police.  Such people, however, are not seeking psychiatric assistance to avoid dying or killing.  If they were, they would accept help, including inpatient treatment if needed.

I once had a patient who came to see me, he said, so I could convince him not to die.  If I failed, he would kill himself.  I quickly replied that I wouldn't play this game, although I was more than willing to talk with him about his suicidal feelings.  We met five or six times; he wasn't truly interested in overcoming suicidal feelings, and I wouldn't engage in the no-win challenge he set up.  He left — no hold applied — and months later I learned he was still very much alive.

Similarly, those who rail against the completely predictable response of psychiatrists to voiced threats of harm are enacting a "death by cop" scenario.  The paradigm is someone who brandishes a weapon in front of police, who then react the only way they can — and usually with great regret.  Fantasies of punitive authority, forcing the hand of those in power, and/or getting one's just desserts, are made real.  Patients who force their psychiatrists to take control of their behavior likewise sacrifice adult autonomy in order to enact a primitive unconscious fantasy.  Unlike most patients who are relieved to be protected from their own frightening impulses, these few harbor antagonisms that may feel more vital to them than life itself.

Loss of privacy and the new psychic numbing

I grew up in the era of the nuclear arms standoff.  Thousands of warheads on land, at sea, and in planes stood ready to obliterate most of the human race if the Soviets, Americans, or a rogue third nation launched a nuclear "first strike."  Authors of that era wrote of the psychological effects of living under such a threat (not that it is gone now, but it certainly felt different back then).  Some said it rendered life fundamentally meaningless.  Why indulge personal hopes or dreams when we, our community, our entire culture could be gone in an instant?  Psychiatrist Robert Jay Lifton coined the term "psychic numbing" for the denial we employed, individually and collectively, to allow us to live our lives while faced with the real and ever-present risk that our world might end that very day. Psychic numbing was curious yet undeniable.  We all knew the danger was real.  But because the unimaginable horror of World War Three was coupled with an apparent inability to do anything about it, we told ourselves the likelihood was low and somehow pushed it aside.  Instead of being the top priority it arguably should have been, nuclear annihilation lurked like an ominous cloud at the periphery of consciousness.  We and our comedians made nervous jokes about it.  A few idealists joined peace and disarmament groups.  Meanwhile, the rest of us watched warily out of the corner of our eye, weighed down by a pervading fatalism and learned helplessness.

The dynamic of psychic numbing is repeating itself today.  This time it is not the existential risk of nuclear war, but the reality of losing our privacy.  Revelations that our own government monitors our private telephone conversations and tracks our vehicles, allegations that a few years ago would have been waved off as paranoid rantings, are now headline news.  We now know that our email is scrutinized for keywords (and possibly collected and stored in its entirety), and our cellphones are used to track our locations.  Like the nuclear threat of the 1970s, it feels as if we can't do anything about it.  Our discomfort lurks like an ominous cloud at the periphery of consciousness.  We and our comedians make nervous jokes about the NSA.  A few idealists join activist groups to oppose the scrutiny of innocent citizens.  Meanwhile, the rest of us watch warily out of the corner of our eye, weighed down by a pervading fatalism and learned helplessness.

The theft of privacy has been opportunistic and widespread.  The 9/11 terrorist attack justified not only "security theater" at airports, but also a trading away of everyday privacy in the name of national security.  Video cameras monitor public areas in major cities; license plates of highway traffic are scanned en masse and recorded by local and state police; the FBI can activate your laptop's webcam remotely and secretly (with a court order).  Meanwhile, quite apart from national security or law enforcement considerations, internet privacy has become an oxymoron.  The social web, an aspect of Web 2.0, promoted living one's life in full view of "friends" and others.  Facebook and Twitter distribute micro-doses of fame to monetize the formerly private lives of their users.  Younger people post photos of themselves in compromising situations while failing to appreciate the permanence of these images.  Older people use online health and mental health support sites, not realizing their "private" conversations are archived and publicly searchable.  A great many advertisers and others track web activity for commercial purposes, amassing huge databases without users' knowledge or consent.  Whether on actual highways or the quaintly-named information superhighway, the distinction between public and private is quickly eroding away.

Is privacy passé, a luxury we can no longer afford?  Psychic numbing tells us to shrug and bear the new reality.  As many thought 30 or 40 years ago about the nuclear arms race, loss of privacy appears to be the price of living in our modern world.

Don't believe it.  The forces that now seek to strip us of individuality and dignity have always been here.  New technologies present novel challenges, but human nature hasn't changed.  It took decades to realize we weren't forced to live with Mutual Assured Destruction hanging over our heads.  When we overcome our psychic numbing this time, we will re-discover that nervous humor, wary sidelong glances, and helpless fatalism are not effective ways to deal with a real problem.  We will re-discover the value and honor in self-respect.