Myopia

Stacy, thirty-two, wants to travel world for a year and then decide how she wants to make a living. Her aunt Mo thinks she is making a horrible mistake. Stacy and Mo love each other, but now they cannot be in the same room. “She called me myopic,” Stacy says, bewildered.  “What does she think you should do?” I ask. “She thinks I should get a career path, get married and have kids. I want those things. I just don’t want them now.” Stacy says, with a sound of protest which resembles an adolescent. “It sounds like Mo hit a nerve,” I say, implying that she has some insecurities about her travel plans. “Well, yes, I am really not sure what I want to do with my life and so traveling postpones that decision for a year, but I don’t want to admit that to Mo.” Stacy says with candor and shame. “You don’t want to admit that to Mo because you want her to believe that you feel more confident than you actually do.” I say, pointing out her embarrassment over her uncertainties. “Yea, and I don’t want to tell her that she has a point.” Stacy says, as if she and Mo are at war. “Why can’t you tell her that you understand and appreciate her concern?” I say, pointing out that people who are interested in your welfare are hard to come by. “I have told her that, but I also think she should trust me that I will figure it out.” Stacy says, with the irony that she does not trust herself to “figure it out.” “You mean that her questioning your decision makes you feel that she has no faith in you?” I say, trying to show her that Stacy is projecting her insecurities on to Mo. “Yes, when she questions me, I question myself and I don’t like that feeling.” Stacy says, revealing that the problem with the question is that it makes her uncomfortable because it hits on unresolved issues for her. I repeat, “So Mo hit a nerve and now you are in pain.” “I guess so,” she agrees, but still confused about how to handle her relationship with Mo. “Maybe you can tell her that your life is uncertain, and that you can live with that and you hope she can too.” I suggest, hoping that an honesty about her internal state might be helpful. “I will try that,” Stacy agrees, with a hopeful tone.

Do Child Psychiatrists Still Play With Kids?

I have a new job-a volunteer job, that is! On July 12, 2012, I will begin teaching “Clinical Practicum,” which is a six month child psychotherapy course to first year child psychiatry fellows at UCLA. I will have seven students with varying degrees of interest in doing child psychotherapy. “Can I give my students articles to read?” I ask, my new boss. “You can do whatever you want,” she tells me with a smile. I am excited to walk into an environment in which psychopharmacology is the dominant modality, with the hope, that maybe, just maybe, I can remind my students, budding professionals, that listening and explaining are still valuable skills. Maybe, I can encourage play. By that I mean, maybe I can inspire them to play with their patients as a way of getting to know them.

I have a goal, but my question to myself is how best to achieve that goal. We can read and discuss articles. I can talk about my clinical experience, by disguising identifying features in order to preserve privacy.  If I choose that path, should I pick one patient and go into depth about his treatment, or should I discuss vignettes of multiple patients? I can have them bring in their clinical experience, and we can have a group supervision group where we share ideas about how to get into the inner workings of both the child and his/her family. If I have the child psychiatry fellow bring in a case, then should I divide up the 26 weeks among seven fellows so that everyone has an equal opportunity? Should I limit the class to the treatment of pre-pubertal kids, since treating adolescence is a very different skill set? The best path is not clear to me.

I need to connect with them in a way which expands their experience, but does not seem “outdated.”  I fear that they will see the idea that one must  spend a lot of time with a child and his family before plunking down a diagnosis  as “unrealistic.” To help them see that understanding and explaining is a journey contradicts the notion that parents need immediate answers to their concerns about their child. On the other hand, this is a University, so a multiplicity of ideas should be embraced by both students and faculty. I hope that my exploration of different ways to approach this class will be in line with my goal that different approaches all have value. The more one learns, the more tools one can draw upon. This is a simple notion, but even in the most open minded families, I mean institutions, this idea gets lost. Am I too grandiose to think that I can bring back a discussion of family dynamics to a scene which is so heavily based in neurobiology? Or, do I need that grandiosity to enter into this adventure? As always, I welcome your thoughts.

Psychiatry Residents: Thinking About Psychoanalytic Training

This is not the group I spoke to today, but the picture gives you an idea of psychiatry residents, physicians who decided sometime in their medical career to specialize in psychiatry. These folks, graduates of medical school,  have decided to spend four years doing adult psychiatry training and they can then decide to add-on another one to two years to do child psychiatry training. At a noon-time talk, we discussed why I did psychoanalytic training and whether it makes sense for them. “I felt when I finished my adult residency and my child psychiatry fellowship that I needed more psychotherapy training.” I said to astonished faces. “After all this training you did not feel competent?” One resident asked me. “First, you have to remember that I trained in the eighties where we had a lot of psychotherapy training in residency and we did not have as many psychopharmacological tools, which means that we did not have psychopharmacology clinics like you have now.” I say, emphasizing that doing psychotherapy in residency made me appreciate the depth of knowledge necessary to do deeper work, such that more training seemed mandatory to me.

On the one hand, I understood that from their perspective, they are about to graduate from ten years of education, many of them saddled with substantial debt. The idea of further education must seem both financially and academically absurd. On the other hand, the work of a psychiatrist/psychotherapist can be so deep that training is never finished. This is a field of ongoing in-depth analysis of the human mind, which requires expert consultants, ongoing study, along with group training experiences to fully appreciate the nuances of motivation. “The end of residency is not the end of learning,” I say to a group that continues to look stunned.

I am left to reflect on my own classmates in residency. We knew that psychoanalytic training was in our future. We accepted that as part of our professional development. Psychopharmacology was a nice addition to our tool box, but it was no substitute for studying how the mind navigates a complicated world. I fear that my cohort is a dying breed. “The one thing I am sure about is that I cannot be replaced by a computer.” I say with confidence. “Oh yes, you can” the residency director  says. “One day a computer will study your every move and then be able to do exactly what you do, except that you keep learning and the computer cannot do that,” he corrects himself with a good point, supporting my point. Psychoanalytic training, as a lifelong process, makes my work deepen with time. Each patient adds to my experience and my wisdom, along with consultation with colleagues and study groups, such that replication of my work is nearly impossible. “I work in a personalized way and I am grateful for that opportunity,” I tell the residents. “No one else thinks like I do, and so I bring something unique to each session,” I say, without modesty, emphasizing the privilege of being a psychiatrist. I am not sure these residents will be able to say the same thing, but I sure hope they will.

Job Security

  Nora, https://shirahvollmermd.wordpress.com/2011/01/13/i-am-glad-that-is-not-happening-to-me/, fifty-two, has worked for CIGNA, an HMO,  for twenty years as a pediatrician. She likes her job, but she has no job security. Management changes and she is vulnerable to a lay-off. Sure, she has transferable skills, but Nora comes to me complaining of anxiety which “no one understands.” “Tell me more,” I say, wanting to hear both about her troubles at work  and about her feeling alone with her anxieties. “I have a year to year contract, so every year, I am never sure if I will get renewed.  I don’t want to go into private practice, but I guess I could if I had to. I could join another HMO like Kaiser, but they tend to hire people straight out of residency and I have twenty-five years of clinical experience.  When I complain, most of my friends look at me like I am a doctor, so I have nothing to complain about. Of course, I understand that, but I also think that it is terrible that I work in an environment that I like, but I am always worried about the future.” Nora says, with a tone which conveys a sense of inner struggle and discontent. “It sounds like, at the very least, it would help you if your friends and family could empathize with your dilemma,” I say, highlighting Nora’s earlier point of needing to be understood. “Yes, that would help a lot, since I feel like on the one hand, I can’t complain since I have had the same job for twenty years, but on the other hand, job security, like my friends have who work for the County, seems really nice to me,” Nora says, again displaying a twisted feeling in her tone. “Maybe I can help you decide if you want to stay in your job, given the uncertainties, or if it makes more sense for you to be proactive and find a new job where you will have a longer term contract,” I say, with a practical tone which is not consistent with my usual search for underlying meaning. “What does Liam say?” I ask, thinking about her hives. “Well, he tries to be supportive, and sometimes he is, but mostly he says he does not know what to say. He does not really get my dilemma,” Nora says in a way which exudes a great deal more patience with Liam than she had when she had her skin problems. “So you are looking to me to show some understanding of what it is like for you to go to work, knowing that this chapter in your life may pass more quickly than you would like.” I say, stating Nora’s dilemma in my own words. “That would be nice,” Nora says with, what seems like, is a new found calmness.