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 like schizophrenia, 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.