Fear of Abandonment

Why do we fear abandonment? How do we balance dependency with self-reliance? These are the core issues of happiness in that if we can feel both self-reliant and dependent then we have reached a sweet spot of confidence and pride. Psychotherapy promotes dependency on the therapist, while at the same time, stressing self-reliance as a goal post. This duality, by its nature, supports the notion that dependence and self-reliance are not mutually exclusive. The fluidity of self-reliance alternating with dependency is an art, which throughout life, and particularly through traumatic experiences is the challenge. Too much tilt in either direction leads to pathology and unhappiness.

Marnie, twenty-eight, comes to mind. She is very anxious to have relationships such that she creates fantasies in her mind which stem from brief  “hook ups”. Each brief encounter with a man gives her a feeling of security, short-lived, leading to a persistent cycle of these very brief connections. She is aware that she feels desperate and this solves her problem, but like the alcoholic who knows that alcohol is a problem, this does not translate into a change in behavior. Marnie and I work together to help her see herself deserving more, more stability, more love, and more stimulation, while at the same time we work on her appreciating herself and all of the qualities that she brings into a relationship. The work involves both an in-depth approach to her judgment as well as an in-depth approach to her lack of self-esteem. The more she can appreciate herself, the more likely she will find someone who she can appreciate. The big picture is clear. The work involves helping her tolerate difficult feelings without acting them out, without seeking immediate gratification. Gaining frustration tolerance is the key towards her maturity. Marnie has a bright future, but she has to reflect and not act in order to reboot her emotional life.

When Should Psychiatry Residents Learn Outpatient Psychiatry?

Most psychiatrists leave academic medical centers and practice in the outpatient setting, and yet, many four-year training programs do not begin to expose residents to outpatients until year three. Medical education has typically been skewed towards the notion that if you can treat the sickest patients, then treating less acute folks will follow easily. This has never made sense to me, as although I think it is critical to see severely ill patients to learn the scope of illness, it is also critical to learn the skills of dealing with less intense, but still troubling symptoms. More specifically, in psychiatry, outpatient psychiatry is a very different skill set than inpatient psychiatry. With hospitalized patients, the goal is to stabilize them so they can leave the hospital, typically in three to five days. Stabilizing means getting symptoms under control. By contrast, with outpatients the goals are to improve functioning at work and at home. Here the skill set requires stimulating the patient to care about himself such that he makes good decisions which yield a sense of fulfillment, or “to love and to work,” as Freud would say. The goal post changes over time, as the patient gains greater self-esteem and confidence. To learn outpatient psychiatry one needs to take a longer view of health, and as such, continuity of care is critical for learning. If outpatient work began in year one, then the resident would have the opportunity to watch both patients grow, and watch themselves grow as a clinician. Utilizing time, the four years of training, as a way to emphasize that change takes time and as such, time is critical to professional development. Psychoanalytic training adds on, with a high-intensity clinical demand, but it is not a substitute for the challenging transition from medical student to psychotherapist. My rant continues. Psychotherapy needs to be a valuable part of psychiatric training and more pointedly, it needs to start when the student becomes responsible for patient care. I dream of this world where psychotherapy returns to psychiatric training in a way which builds confidence in the residents. I know it is a dream, but maybe, just maybe, it can get some traction.

Context

Drugs provide symptom relief, so a psychopharmacologist inquires about symptoms and provides medication. Yet, this makes no sense to me. Symptoms occur in a context, in a setting of relationships, childhood attachments and struggles of identity and meaning. If we, as psychiatrists, try to  put symptoms in a framework with personal meaning to the patient, and provide medication which offers symptom relief then we are providing comprehensive care. We must also understand the meaning of the medication for the patient.  On the other hand, if we only focus on symptom relief, we are making our profession narrow and limited. Yes, this is my rant. Yes, understanding context is time-consuming and expensive. And yet, if we do not attempt to help the patient have insight into his symptoms then we are colluding with the world of drive-through psychiatric care. We, as psychiatrists, must care about history, and we must encourage patients to care about that as well. I went into psychiatry because other specialists were too focused on disease and not the person with the disease. Psychiatry offered me a space to explore how the patient integrated his medical and psychiatric issues into the context of his personal story. Each symptom has a unique meaning to the patient, and inquiring about this meaning is the excitement and therapeutic aspect of my work. So, it is obvious why I am saddened that psychiatry, as a profession, has lost this curiosity. Symptoms, quite honestly, are not that interesting. How the patient manages with those symptoms never cease to be fascinating. Drugs are a great tool, as is good history taking. I am going to stick with that, while at the same time, mourn the change in my profession.

The Initial Interview: Structured or Open Ended?

When meeting a patient for the first time, in an outpatient setting, should the interview be structured or open-ended, meaning should the doctor have a list of questions, or should the patient determine the flow of conversation? Physicians are taught to have more closed-ended questions in an effort to get through a lot of “material.” Psychoanalysts are more curious how the patient constructs his/her narrative. Being in both camps, a physician and a psychoanalyst, I tilt towards being curious about how the patient creates an impression of himself. Does he start with where he is born, his siblings, his parents, or the “here and now” issues, as Dr. Yalom labels the current complaints. Yet, medical training fights against narratives as the pressure towards electronic medical records, corresponding to billing pressures, forces the physician to ask very specific and limited questions. This aspect of EMR (electronic medical records) is yet another unintended consequence in that EMR changes how the physician obtains a history and in so doing, the narrative is short-changed. This has been my fear for some time, but chatting with newly minted physicians, my fears are confirmed. The art of listening to narratives, like reading books, or watching movies, is diminishing in this time of monetizing clicks for billing purposes. Can we bring back this narrative, the opportunity for the patient to speak in ways which convey his subjectivity, his vulnerabilities, transmitted through changing eye contact, switched subjects and tone of voice. Dreams too, are another avenue of rich exploration, lost to the physician struggling to make sure he/she does all the right boxes on the EMR. A utilization review person will poke them if a box is not checked, but if they fail to ask about the nature of the patient’s dreams, there is no immediate consequence. My rant persists. The loss of the patient narrative, listening to how the patient wants the physician to hear his life story, is tremendous, both for patients and for physician satisfaction.