Analytic Stance

The patient comes in with a stomach-ache, many things could explain it, but the psychoanalyst wonders about the psychology, the historical roots, and the meaning of the  stomach-ache, while the patient wants her stomach to feel better. This cross-purposes describes the “analytic stance” where the therapist is thinking on multiple levels, even if the patient is not. The stomach ache could be present as a way to communicate that she needs nurturing, but rather than asking for nurturing, or saying she needs nurturing, she presents with a stomach-ache because as a child she learned that the only way she could get attention was by being physically sick. So now, as an adult, she experiences psychological distress through her body. In other words, her psychological stress transforms into a bodily complaint, because talking about how her body is betraying her is a comfortable way for her to communicate with a doctor, even if that doctor is a psychiatrist. To say, that she is lonely or scared, or at loose ends, are feelings that she is not at ease to discuss. By contrast, complaining about her stomach is familiar and, in the past, has rewarded her with attention which helps her feel cared for. To understand her stomach ache in context, as code language for asking for emotional support, is the beginning of a psychoanalytic process which might grow into a deep treatment, that is, a deep understanding of her distress. The patient may walk out with the same stomach-ache she walked in with, but at the same time, she is stimulated to consider her distress in different ways, and in so doing, the stomach-ache could gradually recede, and with further work to understand her issues, her stomach-ache may not  come back.  She will discover more direct ways of communicating her feelings and in so doing, her relationships with others, and with herself will feel fulfilling. The psychoanalytic process will pay off, but not in the immediate way of relieving her chief complaint.

Affective Intensity

 

And so begins again my class entitled “Building A Psychoanalytic Practice”. Some might call this a marketing class, in that the class is designed to help students deepen their work by transitioning some of their patients from once a week to multiple times a week. In so doing, an analysis, or deep psychological work, can occur. The focus of the class is to help students see the barriers, both conscious and unconscious, to working analytically, on both sides of the proverbial couch. One of these barriers is that more frequent visits invite an affective intensity which can be frightening to both the patient and the therapist.  Feeling shame or guilt, for example, can be deeply painful and de-stabilizing, and so there is often a strong desire to paper over these feelings with directives, platitudes and a lot of time between sessions. Increasing frequency makes the sessions less of a “dear diary” and more about “what is really going on here?” Looking down into the bowels of the mind, ultimately results in a more mature view of the world, but in the short-term increases anxiety and causes psychological discomfort. Dealing with difficult feelings, even if it is for the greater good, is the challenge of analytic work. Hence, as I said in my last post, this work is not a “lifestyle specialty,” but rather it demands the capacity to handle so many different types of feelings, the ability to listen and feel, in a way which is both empathic and thought-provoking. The therapist, the psychoanalyst, must facilitate the exploration, the archaeological dig, as Freud called it, in a way which titrates the associated feelings such that the patient is  stimulated to reflect on himself, but not overwhelmed and paralyzed by the experience. At the same time, the analyst needs to use his intuition to comment on how seemingly unrelated events, may, in fact, be related on a psychological level. It is this weaving of the affective domain with the cognitive domain which makes the work of the psychoanalyst challenging on many levels. Like starting chemotherapy, both the patient and the physician might be frightened about what untoward effects might happen, and yet, there are few other choices, for some, if they want to rid themselves of their poor judgment and self-sabotaging behaviors.

Psychiatry as a “Lifestyle Specialty”

With Thanksgiving approaching, I want to publicly thank my patients for giving me the privilege of entering their interior, knowing the courage and strength it takes to expose one’s deepest thoughts and feelings, both conscious and unconscious. My inner world is deeper and richer as a result of my work, and for that, I am eternally grateful. Having said that, I now return to my rant about the changing nature of my profession. Psychiatry is becoming a more popular specialty choice for medical students. The word on the street is that these students classify career choices based on how lucrative they are, and/or how “sensible” they are, meaning that certain specialties, are what they call “lifestyle specialties” in that the profession offers the opportunity to spend time doing other things, which usually means spending time with family. These “lifestyle specialties” contrast with surgical specialties, or life and death professions, like cardiology, where the commitment to one’s career has to trump other activities. Psychiatry, as a “lifestyle specialty” sends me flying with outrage and confusion. How does listening to physical and sexual abuse, deeply traumatic losses, and terribly self-destructive thoughts, create a “good lifestyle”? The emotional toll of getting down deep with patients is significant, thereby decreasing the bandwidth for listening to other important people in your life. This is a major occupational hazard, and as such, the “lifestyle” is compromised. When I challenge medical students with this notion, the feedback is the following: “I plan on just doing medications, so it won’t be so bad.” Oh my, I say to myself. How do I respond to that? First, I want to say that I do not understand what “just doing medication” means. I understand that they think they will be doing 15 minute visits in which they will be tweaking medications, for the most part. So, they are creating a superficial interaction, on purpose? They are signing up for boredom, in exchange for leaving the office by 6 pm? I am horrified. They, these students who claim that psychiatry is a “lifestyle specialty” are embracing the dullness of the work, when, in fact, by my way of thinking, psychiatry is the most stimulating field, in that one has no algorithms. The psychiatrist, at least in my day, must constantly be thinking on his feet. These “med checks” involve little thought, in that the medication is either increased, decreased, or stays the same, and in so doing, no deep conversation is had or sought after. And this is OK because the hours are good? I continue to be beside myself with a deep sense of grief, that the profession I entered is not the profession that exists today.  I know that with technology, with global trade and with clean energy, many professions of yesterday are gone forever. I am slowly accepting that mine is too.