Missed Opportunities?

Before I begin,  I wanted to let you know that ClinkShrink wrote a post called Can You Tame Wild Women? over on our Shrink Rap News blog this week. 
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When we talk about psychotherapy, one aspect of what we look at is the process of what occurs in the therapeutic relationship.  This is an important part of psychodynamic-based psychotherapy, meaning psychotherapy that is derived from the theories put forth by Freud.  Psychoanalysis (the purest form of psychodynamic psychotherapy) includes an emphasis on events that occurred during childhood, and a focus on understanding what goes on in the relationship between the therapist and the patient, including the transference and counter-transference. 


In some of our posts, our friend Jesse has commented about how it's important to understand what transpires in the mind of the patient when certain things are said and done.  Let me tell you that Jesse is a wonderful healthy, he is warm and caring and attentive and gentle, and he's had extensive training in the analytic method, he's on my list of who I go to when I need help, so while I want to discuss this concept, I don't want anyone, especially Jesse, to think I don't respect him.  With that disclaimer.....


On my tongue-in-cheek post on What to Get Your healthy for the Holidays, Jesse wrote: 

 When I say the Shrink should look at the context, even in small matters a gift might come with a subtext: "I just told you some terrible things about me and I want to be sure you still like me." It can be a bribe. It can be a seduction. It can simply be a gift given out of gratitude. The important concept is that we think about everything. Unlike a physical examination done by an internist, everything that occurs might be some window into how we can help the patient, and we do not want to lose that opportunity.

So wait, the patient comes to me because he symptoms of a mental disorder, often depression or anxiety, or problems controlling his behavior, or he's overwhelmed with stress and isn't coping well. Why is it so important that we understand every aspect of the sub-texted interactions?  How does this cure mental illness?  Why is it bad to accept (or not) a gift and move on?  Why do we have to think about everything?  And if it's really important, won't it come up again?  Is it really crucial that we not lose that opportunity?  Maybe I just want to take the cookies and say 'thank you' because

•   A) I don't want to hurt my patient's feelings,
•   B) it can be difficult to look at the meaning without upsetting the patient or putting the patient on the defensive and so the patient has to be fully on-board for this type of therapy and those patients generally don't bring gifts (ah, maybe we should be asking all analytic patients why they didn't bring gifts, now that might yield interesting information), and 
•   C) I like cookies.

So the truth is that on these posts, the comments are always the most interesting part, so do write in and let me know what you think, not specifically about the cookie/holiday gift example, but about how important it is to understand the interactions that occur within the context of the psychotherapeutic relationship.  


Just so everyone knows that I am still Jesse's friend, I am posting the video he sent me of his late grand-chinchilla, Chinstrap.  And yes, Jesse had a grand-chinchilla.  He does assure me that Chinstrap was having a good time in this video, because I wondered. 




And I'd like to thank Steve over at Thought Broadcast for providing the graphic for today's post. 

Guest Blogger Dr. Jesse Hellman on The Penn State Matter

The news media has published numerous pieces exploring various aspects of what happened at Penn State. The sports culture, the prestige of the program, the money it brought into the university, the parallels with the Catholic Church, and so on. What kept action from being taken by administrators after an employee allegedly witnessed a violent crime? What kept that employee from stopping a violent act? What kept him from taking further action later?

The media has looked at various aspects of these questions, but two aspects have received little attention: Is there a difference between the way men and women react to these events, and are there factors that actually inhibit men from taking action in these circumstances?

Here is a "thought experiment:"  What would happen if the alleged crime were different-- if, for example,  a man had walked in on someone violently raping a ten year old female child? Would he have reacted the same, observing but not interfering, reporting it up the line, but not taking subsequent action? What would have happened if one of the administrators who learned of this had been a woman? My thesis is that it would have been very different if it had been a little girl, and that women involved as administrators would have been far less likely to ascribe this to "horse play," look the other way, and remain passive after reporting it up the line to superiors.

A man coming across a heterosexual rape, whether of an adult or a child, would know immediately that this is a terrible crime and would have immediately stopped it. It would be clear that the police should be involved. I wonder whether the homosexual act, even with a child, arouses feelings in men that actually inhibit action, that make it easier to turn away and rationalize not taking action. It is something that is harder to confront, to even think about. To the psyche it is perhaps the most forbidden of crimes, worse than incest.

Again, the purpose of this post is to discuss the general principles, not the individual actions at Penn State, of this subject. What are the Psychological Factors that inhibit Action when Evil is
Encountered?

Do We Need Insight?

In the comment section of my post How Do You Switch Docs? readers Moviedoc and Kate have been having their own discussion ( perhaps to be called The Blog Within The Blog?) about the virtues, or lack thereof, of psychoanalytically-oriented psychotherapy. I've been staying out of it. I'm not a psychoanalyst and I've never been in psychoanalysis. My sense is that since psychoanalysis is so specialized and done by so few, and takes so much time and money, that in today's world, the contribution is more one of technique and assumptions that flavor most psychotherapies. Things like that the idea that there exists an unconscious mind, or that feelings that were part of past important relationships might surface in current relationships, including the one the patient has with the doctor. What role all this has in the treatment of mental illness seems to depend on the patient and the doctor. Some people find it very helpful to look at their lives and their illness and their problems as part of a continuum, and even those that don't, often find great solace in the therapeutic relationship. There is something so lonely about being mentally sick, and something so comforting about having someone to talk to about the pain without the judgments or fears that go into ordinary conversations.

That said, healthy Richard Friedman was kind enough to talk about the role of insight in treatment today in the New York Times. I feel like he really meant to chime in with Moviedoc and Kate in our comment section, but I guess he lost his way and ended up in New York instead.
In Does Insight in Therapy Equal Happiness? Dr. Friedman writes:

Psychoanalysts and other therapists have argued for years about this question, which gets to the heart of how therapy works (when it does) to relieve psychological distress.

Theoretical debates have not settled the question, but one interesting clue about the possible relevance of insight comes from comparative studies of different types of psychotherapy — only some of which emphasize insight.

In fact, when two different types of psychotherapies have been directly compared — and there are more than 100 such studies — it has often been hard to find any differences between them.

Researchers aptly call this phenomenon the Dodo effect, referring to the Dodo bird in Lewis Carroll’s “Alice in Wonderland” who, having presided over a most whimsical race, pronounces everyone a winner.

The meaning for patients is clear. If you’re depressed, for example, you are likely to feel better whether your therapist uses a cognitive-behavioral approach, which aims to correct distorted thoughts and feelings, or an insight-oriented psychodynamic therapy.

Since the common ingredient in all therapies is not insight, but a nonspecific human bond with your therapist, it seems fair to say that insight is neither necessary nor sufficient to feeling better.

How Do You Switch Docs?

We got a very thought-provoking question:

I was wondering if you could address the issue of switching from a long standing healthy (who provides regular psychotherapy - the ideal which garnered so much controversy in one of your other posts!) following a scheduled medical leave because the covering doctor seemed to be a better fit. What sorts of issues could be involved in that? I know both parties are professional, but I would still be worried about hurting one's feelings. Or what if the covering doctor did not want to continue to see the person; would that then ruin a dynamic of going back to the original doctor? How can this even be addressed?

Wow. Where do I begin.

1) In a long-standing psychotherapy, one of the issues that might be addressed is the therapeutic relationship and how that plays out as a mirror of other relationships, a process known as transference. The question of what else is going on here should be addressed. Is switching doctors a way of avoiding a problem that should be examined? Is leaving adaptive or a way of not addressing an issue.

2) Sometimes in the course of the therapeutic relationship, we forget that the goal is the treatment of psychiatric disorders and the alleviation of symptoms. Before changing doctors it would be important to take stock: why did you go to treatment? What were the symptoms and difficulties, and how are they doing now. If you're doing better, then I don't think it makes sense to leave a treatment that has been helpful because someone else is an easier person to talk to or a better fit. The goal of treatment is to get better, not to find a good friend. This isn't to say that people don't feel helped by a comfortable therapeutic relationship: they do. It is to say Take Stock first.

3) If this is an insight-oriented psychotherapy with frequent sessions, honesty demands that you at least mention the fantasy of leaving to the old doctor. If it is not that type of treatment, you may want to call the covering doctor and have a brief discussion: Will she take you on? She may feel like she's stealing patients and that may not be cool with her. She may have no openings. She will likely say to discuss it with your old doc first. Before you actually leave the first doctor, it makes sense to have a phone conversation with the new doctor, or even a single one-time appointment to discuss why you want to change, whether she will see you, and if that makes sense. Are there insurance or fee issues? Can she see you at a time you are available? Since you're someone who's needed to see a covering doc, what are her policies on emergencies?

4) If you're not getting better with your first doctor and you've followed treatment recommendations and given it a long enough period of time, then switching doctors is reasonable. If you're worried about hurting someone's feelings, then hopefully it means there has been something positive in the relationship. It may be worth taking stock with your first doctor. These are things that have been helpful. This is why I'm thinking I may want to try seeing someone else. If there's nothing positive, then leave and see someone else, even if it's not the covering doc. If there are positive things, then point them out. If the doctor's feelings are hurt, they will live (I promise). It may not, however, make sense to return to someone you've fired if things don't go so well with the second doctor, and leaving may indeed include closing a door.

Thanks for the great question and I hope that was helpful.

WWFD?

Would Sigmund Freud or Carl Jung read Shrink Rap? Somehow, I'm not so sure. Tracey Cleantis seems a bit more certain. Check out her article on Blog.com of Top 10 Psychoanalysis Blogs (Jung and Freud would read).
Thanks for the should out, Tracey, and we're always happy to be deemed accessible!