What Does It Mean To Be Spiritual?

 

Spiritual is a word that confuses me. It is not that I do not appreciate the right-brain and all of the fantasies and creative thinking that results, but the word “spiritual” makes me wonder what the patient means when he says it. Do they mean that there is more to life than the mundane aspects of showering, eating and sleeping? Do they mean that the word “religious” troubles them, and so they compromise by using the word “spiritual”? Jay, seventy-one, comes to mind. He was brought up in a devoutly religious home, in which he feels did not “suit him”. He raised his children without any religion, and by his account, he suffers “tremendous regret” about that. In the last decade, he has become “obsessed” with yoga, which he feels to be very “spiritual”. My hunch with Jay is that yoga has allowed him to access the part of his brain which is non-linear, the part which is not focused on competition or comparisons. The “spirituality” of yoga seems to have given Jay the ability to relax, to not worry about his future, to not worry if he will be the next one of his friends to get a cancer diagnosis. It allows him to be “present” as he would say. How do I, as Jay’s psychiatrist, work with his “spirituality”? First, I try to understand the meaning it has for him, and how he integrates this word into his mental space. In other words, I try to understand how he connects this word to other ideas and fantasies in his mind. Second, I try to see how his “spiritual” side might help, and might hinder, his personal growth. This new-found love of yoga might open mental doors for him and allow him to get access to parts of his mind which were previously shut off, but it also might serve as a protective shield, in which he goes to yoga seven times a week as a way of avoiding having relationships with those he cares about. It is our job to explore this together, to try to add historical context to his newly discovered passion. The ambiguity inherent in the word spiritual is our open window into his mind. “Tell me more,” I like to say, truly curious about what it means to him.

Working With Perception: Learning Counter-Transference

 

What happens when a therapist needs to be liked, needs to feel like they matter, and/or needs to feel like they are nurturing and the patient does not meet the therapist’s need for such gratification? Often, the work grinds to a halt. The patient gets “busy” with other things. The therapist, suddenly, must cancel multiple appointments. These unconscious resistances on both sides of the couch is the meat of psychoanalytic teaching, and yet, the most challenging concept to grasp in psycho therapeutic work. In other words, the beginning therapist must put aside the layman’s notion that “this work is so gratifying” as the need for that gratification can impose a burden on the patient to say they are well, when, in fact, they are still suffering quietly. The therapist’s unconscious need for affirmation can replicate the patient’s role in his/her family to make sure that their parent is happy, at the expense of knowing their own true self. In this scenario, the patient is not only not getting better, but in fact, is being re-traumatized by the alleged therapeutic situation.

Ty, a forty-year old female patient, and Tro, a forty-four year old female beginning therapist start to work together. Ty keeps telling Tro how much she is helping her. Tro reports the gratification is seeing Ty develop and suddenly, after 6 weeks, Ty drops out of therapy, while Tro is aware that Ty remains in a difficult relationship and she has occasional substance abuse issues. Tro is bewildered. On the one hand Ty expressed gratitude at every session, and on the other hand, Ty stopped the work prematurely, according to Tro. “Could it be that Ty unconsciously had to tell you how much you were helping her,  because she sensed your need for affirmation, but that deep down, Ty knew that she was not finding her sense of agency, her sense of her own voice?” I say, to my student, to her amazement and somewhat alarm. “You mean that I am letting my own stuff get in the way?” She asks, astutely. “If by stuff, you mean, your need to feel validated by others, then yes, that could be getting in the way of Ty being more authentic. She may feel she has to care for you and make sure that your ego is intact, as she had to do that with her mom.” I respond, pleased that Tro is quickly grasping the concept of counter-transference. “It is hard to be in a field, where positive reinforcement can be a defense,” I say, trying to make light of this challenging topic. “The holy grail of reward is seeing a patient become less defensive, which does not necessarily translate into holiday cards, or presents. In fact, gifts become a complicated subject, layered with meaning, and sometimes, “you guessed it” I say, a defensive act.

Borderline Personality Disorder: Bah

 

Primitive mental state-that is what I strongly prefer to say when my students tell me that their patient, or their patient’s mother has “Borderline Personality Disorder.” My reasons are many, which begin with I find this diagnosis misogynistic, given to women who exhibit colorful or spirited emotional responses to stress, thereby imposing a judgment in which emotional reactions are somehow pathological. I accept that women and men, as a general rule, express themselves differently, but to say that a woman who describes dark moments in her feelings a “borderline” is to inhibit the facilitation of emotional expression. Second, I find this diagnosis a way of saying that the doctor does not like the patient, and finds the patient’s emotional experience objectionable. It is as if the doctor perceives the patient in a compassionate way, then the doctor diagnoses Major Depression, but if the doctor starts to feel uncomfortable with a patient, then he/she is more likely to throw the personality disorder label on the patient. Third, the terminology “Borderline Personality Disorder” does not convey the process in which the personality needs help. I prefer the developmental model of personality in which some of us fail to develop, or we develop and then we regress to more primitive expressions of our feelings which often involve rage and bodily and/or property destruction. If we were to use the term “primitive mental state” then we convey a certain hopefulness, that with all states of mind, they are fluid and subject to maturity and emotional growth, whereas “Borderline Personality Disorder” implies a life-long struggle which borders, pun intended, on hopelessness.

My students, taught this diagnostic system, are almost always taken aback by my objection to our language, which shapes our thinking, and hence our interventions. The advantage of a big institution, like UCLA, for example, is that students are exposed to multiple ways of approaching this complicated organ, we refer to as the brain. This seems to give little comfort, when I encourage them to challenge their rock stars. Students, like patients, have a transference to their teachers, and so learning new information, in such an intimate setting, is not an emotionally neutral experience, but rather it is an experience filled with identifications and defensiveness. Therein lies my challenge. I need to work with both the conscious and unconscious aspects of my student’s brain, while at the same time, not go too deeply into their own personal dynamics. Like psychotherapy, this is a delicate dance, which most of the time goes well, but occasionally I need to be mindful, not only the layers in treatment, but the layers in teaching as well.

Psychiatry In Transition

 

 

 

 

http://blogs.scientificamerican.com/mind-guest-blog/can-psychiatry-turn-itself-around/

 

Many people ask me whether I exaggerate the issues in my profession, so I am always glad to read works from psychiatrists who have similar concerns. In this article, Nathaniel Morris MD, a psychiatry resident at Stanford outlines similar concerns of how we sabotaged ourselves by getting greedy with regards to “medication management” and in so doing we have lost the trust of our patients. Can we turn ourselves around, he ponders. I hope so, because if we don’t we will get folded into Neurology, and the curiosity about the unconscious might get lost in the profession.