‘Have You Ever Been in Psychotherapy, Doctor?’

By RICHARD A. FRIEDMAN, M.D.
A curious thing happened to one of my psychiatric
residents not long ago. One of his patients caught him
off guard with a challenging question: “Have you ever
been in psychotherapy yourself?”

He was uncomfortable answering the question directly,
so he spent some time trying to discover why it
mattered to his patient. “He wanted to know if I knew
what it felt like to be ill and helpless,” the
resident said.

It was an interesting question, and it made me wonder
whether one could be a good therapist without having
been in psychotherapy. If the answer was no, it would
appear to be at odds with what we do in the rest of
medical practice.

After all, we don’t require neurologists to have a
spinal tap or cardiac surgeons to have undergone
bypass surgery before performing these medical
procedures.

But there is something special about psychotherapy, I
think, that sets it apart. Of course, the
doctor-patient relationship is important in any
clinical encounter. But in therapy, the relationship
is the very instrument of the treatment.

If your cardiologist does not have the best bedside
manner but effectively treats your hypertension, you
might not be happy, but at least you are heading in
the right medical direction. In contrast, if you do
not have a rapport with your therapist, then the
treatment is useless.

To be any good, a cardiologist should be an expert in
the use of his instrument, whether the stethoscope or
the cardiac catheter. But how does this principle
apply to psychotherapists?

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. Therapists, just like
their patients, bring their own life experiences into
treatment, which influence their feelings about their
patients — a process called countertransference.

Therapists who do not understand their own
countertransference run the risk not just of
misunderstanding their patients, but of confusing
their own hang-ups with those of their patients.

Once a resident asked me to help him deal with a
difficult patient, whom he actually dreaded seeing.

It was easy to see why. The patient, a 35-year-old
man, told me that my resident was incapable of
understanding him and then angrily dismissed his
therapist as inexperienced (right) and unfeeling
(wrong).

My resident turned out to have plenty of feeling that
he did not know what to do with. He felt angry,
humiliated and trapped. This patient, who felt
disappointed and mistreated by the world, was simply
giving the therapist a taste of his own narcissism.

It did not help that this patient bore a striking
resemblance to my resident’s older brother, whom he
found critical and demeaning. The resident had never
had therapy himself, but just realizing the origin of
his negative feelings helped him deal with this
difficult patient.

Nowadays, most psychiatric residents finish their
training without having had any personal
psychotherapy. This is a departure from the past, when
psychotherapy reigned supreme and a personal
psychoanalysis was a rite of passage for trainees.

The explosion of neuroscience, along with the pressure
of market forces, has had a powerful effect on the
training of young psychiatrists. Not all of it is
good.

Being a psychiatrist and psychopharmacologist, I could
not be more thrilled with the promise of brain
science. And there is no question that we have more
effective biological treatments for the major
psychiatric disorders than at any point in the past.

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.

Does it really matter? After all, psychiatrists are
too expensive and too few to treat the vast majority
of patients who need psychotherapy. Psychiatrists of
the future are more likely going to be consultants in
the treatment of patients with the most serious mental
illnesses likeschizophrenia, mood disorders and
complicated substance abuse.

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.

I don’t know about you, but that sounds like the kind
of psychiatrist I would want taking care of me.

Richard A. Friedman is a professor of psychiatry at
Weill Cornell Medical College.





________________________________________________________________________________\
____
Be a better friend, newshound, and
know-it-all with Yahoo! Mobile. Try it now.
http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ