Defensiveness in Clinical Work

How do we talk about our work without worrying that we will be seen as fools? Do we only talk about the success stories, with a good dollop of embellishment about how we changed a patient’s life, or do we fall on our sword and admit defeat, that despite years and hours of treatment, the patient is not only not better, but worse? Hearing case presentations, then opening the discussion to feedback, there are two kinds of responses from the audience. There is the “you should have taken this approach” comment, or there is the “you really did and said everything right, but the patient just did not respond.” In the former, the presenter can say “thank you very much for that feedback,” and/or he can say, “you are not in the room with him, so you don’t know how hard it is to take that approach.” Learning psychotherapy is a constant dance of “showing off one’s skill set,” alternating with looking at therapeutic impasse with an open mind, which can easily lapse into a defensive posture. There are no rights and wrongs. There are two people in a room, and when this is discussed amongst professsionals, than there are many minds, but nothing can replicate that experience of the struggling dyad, trying to make sense of their therapeutic relationship, trying to find ways in which the pain and suffering can be alleviated. Teaching involves the same dance. Trying to give feedback without making the student feel humiliated and hence defensive. As a student, the challenge is to feel humiliated as a means to growing as a therapist. Running away from that humiliated feeling, like patients who want to grow emotionally but cannot take the pain of regret, stifles the learning curve. Teaching psychotherapy and doing psychotherapy are a parallel process. Both involve creating pain for the sake of a future gain. The challenge is both the need for diplomacy and emotional maturity. The margins are thin, and the feelings can be explosive. On the other hand, watching someone grow as a therapist, like watching a patient go through the journey of metabolizing their pain, is a fulfilling experience. Like hiking a steep mountain, the path is hard, but the end is glorious.

Picking A Supervisor

Residents, psychiatric residents that is, pick supervisors to help them learn psychotherapy. From medical student to hard-working internship to inpatient psychiatry, these residents jump off a cliff into outpatient psychiatry land, which requires learning a completely new skill set. Acuity decreases, and the long journey of psychotherapy begins. The skills required to manage emergency situations, skills which are honed over many years, are no longer needed. Instead, the skills of patience, careful listening, thoughtful hypotheses, and a cerebral mode of being, rather than an action mode of being are required. For some, this transition is the reward of many years of training. For others, it is simply terrifying. And for a few, this is “old fashioned psychiatry” with skills that are “hardly useful.” As their second academic year comes to a close, they are faced with the uncertain task of finding a supervisor, a psychiatrist who can shepherd them through their development as a psychotherapist. They want to learn, but they do not want to feel the shame of not knowing. They are faced, as they hover thirty, with the humiliation of being a student, a pupil who knows little, but is expected to grow rapidly. The anxiety, for some, is large, whereas for others, it is yet another hurdle in their long road of professional development. So, how do they choose their teacher: by reputation, by their curriculum vitae, and/or by the chemistry they feel when they have seen these teachers in other settings such as journal clubs or lectures? Or, is the system broken? Maybe the supervisor should choose the student, based on the supervisor’s judgment of which student would have the most growth potential? Or, as I said in a previous post, maybe supervision is not the best way to teach psychotherapy. Maybe they need to have a psychotherapy boot camp, where, with the help of a facilitator they can rely on each other to struggle through the fog of psychotherapy. Or, maybe they need to learn some basic concepts of technique before launching into seeing outpatients? Maybe they need to read, and write papers, to demonstrate knowledge of psychotherapy before seeing outpatients? At the moment, that is not how the system works. The resident picks their teacher, making it so charismatic teachers, those who the residents perceive to be nonjudgmental, are highly sought after, leaving the less assertive residents with the quieter, less charming supervisors. Maybe the system works, despite its flaws. Maybe, though, this is a time for big data, a time to be more scientific about what works. It is a thought.

Supervision

How do you become a psychotherapist? How do you become a teacher for psychotherapists? Who should be the students? Is it necessary to have a science background? How many years should it take? How many internship hours should one put in? Who should license psychotherapists? Should this be a State license or a federal license? What about lawsuits? What can people sue for? What is evidence that things went wrong in psychotherapy? These are the endless questions in which my field is dazed and confused. Psychoanalytic institutes have a model for training; a model hotly contested, since there are no empirical studies. Traditional institutes have a tripartite model which includes a personal psychoanalysis, four years of classes, and three cases under weekly supervision, where the student goes for one hour a week to report on a patient who is seen four times a week. The lines between supervision and psychoanalysis blur, because since the student goes to his/her own psychoanalyst four to five times a week, then maybe the student should bring his/her questions to his/her therapist and not a separate supervisor. And who becomes a supervisor is yet another question?

Currently, I am working towards passing an examination which will, in one boutique of psychoanalytic training, consider me both a training and a supervising analyst. The training analyst part means that I will see therapists who want to become psychoanalysts, in psychoanalysis. The supervising part has those “fifty shades of grey” which can, as the movie suggests, contain an erotic component. The boundaries in psychoanalysis are clear. The patient comes at a particular time, they pay a fee, and the subject of discussion is the inner workings of the patient’s mind. The boundaries in supervision are subject to interpretation, and hence not clear. The student is supposed to talk about his patient and the supervisor is supposed to give thoughtful feedback, but as with all dyads, unique dynamics develop and the utility of the process is open for question.

In my new study group, we are reading articles about the controversies around supervision, and once again, I am struck at the arbitrariness of the process. Howard Bacal MD writes “a pedagogic ‘big bang’ occurred within the psychoanalytic universe. The ‘tripartite’ system of analytic training officially came into being with the strict separation of its three modalities.” In other words, a model appeared, and it has stuck, and so I am stuck in it. I do not mean that I do not have options, but I do mean that understanding the history enlightens me in that I can work within the model, or I can try to change it. For now, I am working within the model, while generating fantasies about how to change it. The jury is not out whether group supervision is superior or inferior to private supervision. The jury is also not out whether a supervisor should “graduate” to this status by passing an examination, or whether a supervisor should be defined by years of practice. For now, I am growing by learning, even if I am learning just how random professional development can be.

‘I Am Willing To Talk To You’

“I am willing to talk to you,” Marla responds to Monte upon his request for supervision. The arrogance overwhelms Monte. The words reverberate in his head. Monte, disturbed by this interaction seeks help from me in psychotherapy. “Yep, it sounds like arrogance,” I affirm. “Why does the grandiosity bother you so much?” I ask Monte. “We are colleagues. I am asking for help, but she treats me like she is doing me a favor.” Monte says with internal turmoil which appears to exceed the current interchange. “You are so disappointed with Marla, over and over again. Why do you keep going back for more disappointment?” I ask, thinking that Monte might be replaying an experience in his life where he gets his hopes up, only to be met by crashing devastation. “I really don’t know,” Monte says, almost pleading with himself to come up with an answer. “Maybe you feel you deserve to be disappointed.” I say, trying to gently suggest that he set himself up for this by calling her up. “Maybe,” Monte tentatively says, with a sense of personal disgust in his voice. “I am willing to talk to you too,” I say, trying to make light of this situation as the time comes to an end. We laugh, but we know the pain is still there.

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