Critical Thinking: A Therapeutic Goal

 

 

 

Critical thinking — what the philosopher John Dewey called the ability “to maintain the state of doubt and to carry on systematic and protracted inquiry,” is the goal of reflection. To modify Dr. Dewey’s quote, psychotherapy/psychoanalysis aims to help the patient develop critical thinking about one’s own mind and about the minds of those that influenced them. “I am not interested in symptoms” I say, in a provocative manner, to my class, knowing that saying that contradicts all of their previous education in psychotherapy. “I am also not interested in symptom-relief,” I say, taking it one step further. “What I am interested in,” I say, “is how the patient is thinking about his life and why those symptoms are manifesting at the particular time, and in the particular way, in which they do. ”

Karen, sixty-two, comes to mind. She has what could be called Generalized Anxiety Disorder, and I prescribe her medication, so in that sense, I am interested in symptom-relief, but mostly I am curious why she has to worry. I am helping her be curious as to why her mind is preoccupied with worry. The key words are “has to”. As I understand anxiety, it is often a symptom of a deeper issue of insecurity and loneliness  and I would like to explore that with her. I want to explore that with her in a way that makes her curious about it in a way which generates a  “systematic and protracted inquiry” and which carries on both inside and outside my office. This is what I do, and this is what I teach. Sure, I tell patients with anxiety to try yoga, meditation, and dietary interventions, but that is merely the beginning, because as time progresses, the issue becomes, “so what is really go on here?” To that question, there are endless answers, requiring a “systematic and protracted inquiry.” Dr. Dewey, may he rest in peace, is my hero.

Patient Sculpting

 

Hans Loewald  discusses the idea of patient sculpting, meaning that the therapist imagines the patient without his neurosis, and in so doing, imagines the patient having a more fulfilling life. What would the patient be like if he did not live out the guilt of his parents, for example. Lewis, sixty-six comes to mind. He is the son of holocaust survivors. Parents who instilled in him a sense that the world is a frightening place and he must be suspicious at all times. Lewis has embraced this philosophy unwittingly, living his life in constant fear, but not exactly understanding what he is afraid of. Imagining Lewis without anxiety is what some theoreticians call an “analytic stance”. If Lewis could come to understand that he “inherited” this fear from the trauma his parents experienced, then he could begin to separate out his reality from theirs. In so doing, Lewis could come to experience life in a more relaxed and engaging manner. Moreover, his physical symptoms of irritable bowel and intermittent headaches might improve substantially. A patient without anxiety uncovers the goodness of his soul, as anxiety can obscure that. Keeping the vision provides hope for patients. All of this is not spoken, and yet, magically transmitted between therapist and patient. How to teach these concepts is challenging and yet also very fulfilling. As with sculpture, each student has to find his method. The art of psychotherapy lies in its creativity and in its uniqueness with each therapist/patient dyad. There, I have said it again.

 

https://en.wikipedia.org/wiki/Hans_Loewald

Why Is It Hard To Stay Curious?

 

The therapist, as Hans Loewald says, holds in mind an image of the patient without neurotic distortions. In other words, the therapist can see how the patient mis-perceives his universe, and in so doing, causes himself to suffer, and so it stands to reason that if perceptions could be more accurate, or less historical, then the patient would suffer a lot less. In other words, we, as humans, unconsciously feel that current situations are triggering past situations, and so we react as we did in the past, without the benefit of a more mature mind. The therapist, mindful of this distortion, envisions the patient with a more mature mind, and thereby imagines a patient with a more fulfilling life. This imagination creates therapeutic zeal, which in the right amount, can carry the therapist and the patient through hard therapeutic times, but if the therapeutic zeal tilts to a more self-centered approach by the therapist than that zeal can kill the treatment. This brings me to my class tomorrow. We will discuss how to imagine patients without symptoms, without being overbearing or inserting one’s own agenda. The sweet spot of curiosity without a specific agenda is the gift we give to our patients. Yet, it is hard to stay curious. Maybe we didn’t sleep well. Maybe we are burnt out. Maybe the patient is boring. Maybe we have too many acute issues on our plate and there is not enough bandwidth to think about someone else’s problems. Maybe we are  hungry. My class is designed to talk about ways in which we mess ourselves up, and by we I mean we therapists. That perhaps building a psychoanalytic practice, or a psychotherapy practice is not what we want to be doing. Can we express that out loud? Maybe we have serious ambivalence. Here, we as therapists, believe that talking about ambivalence is the key to bringing authenticity and depth to one’s inner life, and yet, at the same time, we feel shame in talking about our own ambivalence towards the profession. This ambivalence changes every moment, with every patient, and with the maturing practice and yet, how do we talk about that without feeling shame and without worrying about getting referrals. Do we pretend to always be curious, when, in fact, there are times when we lose our curiosity, when we just want to go home or we just do not want to get out of bed? If authenticity is our holy grail, then we need to be authentic with ourselves, and our trusted colleagues. We have to hold in mind ourselves, with the humanity to know that we do not always show up for patients in the way that we might hope we do. Despite many hours of training, and despite many hours of reading theory, and despite our own treatment, we fail patients, or we are less than optimum, at times. Psychoanalytic work helps us with the concept of repair. We try to repair, knowing that we are flawed. That repair can be a healing process does not justify the fact that we let people down, in subtle ways, in every hour, and with every patient. This is a field of humility. I like to say. We know we do not know what we are doing, and yet, we are motivated to keep trying to do things better and better. We are motivated to stay curious, and then to be curious as to why we lose curiosity. That’s what we do, and for that, patients are helped through the human suffering that brought them to our offices. Or, I should say, we hope for that.

Staying Curious

 

Stay curious. This is my message for my current class, “Building A Psychoanalytic Practice”. To stay curious, I say, is to wonder how what you, the therapist says, impacts the patient, and how what the patient says impacts  you. “Find your voice of curiosity” I say, encouraging them to see psychotherapy/psychoanalysis as an art, in which each moment is unique, and each reaction to each moment is also unique. This moment by moment analysis of the session is the complexity of psychotherapeutic work. The therapist is challenged to think on multiple levels at the same time, and in so doing, there are many options about what to say and when to say it. Finding your voice means making informed choices about what to say, when to say it, and how to say it. With professional growth comes a shared interest, between the therapist and the patient about being curious, and how that curiosity can lead to compassion and understanding of deep suffering. With that curiosity comes a passion and with that passion, a practice is built, most often slowly, and with that slowness, nerves of steel help tremendously. There is both anxiety and shame in building a practice which makes staying curious quite challenging. No one wants to admit that they are skill-building, while at the same time, taking on the responsibility of a patient’s mental health. And yet, that is how we grow. We build skills the hard way, by watching people suffer, and at times, inadvertently adding to their suffering, and then we try to walk it back, and grow again. Again, it helps to be curious both about how we help people and also about how we don’t. Being curious means not having answers, but generating more questions? Why did that patient not come back to psychotherapy? What do you think happened? Those are the questions we need to ask, along with the opposite question of why did the patient come back and why do they keep coming back? Being curious makes it fun, but at the same time, allowing one’s mind to open to multiple answers, can be unpleasant and painful. That is why both therapist and patient often resist curiosity and that is why my class presents to me a welcome challenge.

Building A Practice: Let’s Talk About It

 

Wednesday begins my fall teaching activity which is entitled “Building A Psychoanalytic Practice”. In this class/seminar we talk about what goes into a private practice. In medicine, private practice is all but extinct. The vast majority of physicians work for big employers such as UCLA, Kaiser, Cedars-Sinai and USC. Electronic medical records has made it such that payment is based on clicks, and so the emphasis is on checking off boxes, meaning there is little room for a narrative, at least with a physician. The narrative, if it happens at all, is delegated to what they call “lower-level licensed professionals” such as nurse practitioners and physician assistants. The distinction between those two “lower-level” professionals is not clear to me, but I digress. What is clear to me is that the story the patient wants to tell, putting symptoms in context, is falling to people with less training and that deeply concerns me. I digress further. In my lonely world of being a private practice physician/psychiatrist/psychoanalyst, there are few comrades, particularly few younger comrades. So I teach to foster a community of professionals who want to struggle with that narrative, who want to hear patient’s stories and understand symptoms in context. Without context there is an over-prescribing of medications, resulting in the patient having a deep sense of pathology with regards to their behavior, as opposed to understanding that self-destructive, or avoidant behaviors may have a historical context. Understanding can lead to compassion and empathy  and in so doing psychopharmacology can be less relevant. To be clear, I do not advocate an either/or, psychotherapy or psychopharmacology, as both can be used in harmony, but I do think that psychopharmacology without psychotherapy takes away from the attempt to understand the human suffering, and in so doing, denies the complexity of the mind. My class will focus on deep listening, and how deep listening requires time, both time to learn how to listen, and time spent actually listening. In other words, the training required to build a practice is intensive, and in parallel, the work we are asking from our patients is also intense. The upshot of the class is the more time you have with patients, the deeper your work can be, and so when we market our practice, we market our time. We do not advertise quick fixes, or a limited number of sessions. In contrast to insurance-based work, where a limited number of sessions are given, we promote the opposite idea, that the work is open-ended, and it is done when it makes sense to be done, not when an external entity says it should be done. This is a very unpopular notion. It is why I began this post with my loneliness. Patients and insurance companies want to hear that there is an end in sight. I say we can’t promise that, and that honesty is what we are selling. Such controversial ideas, when stated out loud, in the past, has created a polarized class. Some students feel relief to have these ideas verbalized, while others feel despair, that they will not build a practice if they can’t propose a time-frame. I am a provocative teacher, or so I have discovered. Wish me luck.

Teaching, Teaching and More Teaching

 

So, where, whom and why do I teach? The where is easy: UCLA, New Center for Psychoanalysis and LMU (sometimes). The whom, is also easy. I teach psychiatry residents, child psychiatry fellows and psychotherapists. The why is the challenging question. It keeps me stimulated mentally and it keeps me feeling young and in touch with the next generation. That is the short answer. The longer answer is more complicated. Do I like the admiration that sometimes results from a teacher/student relationship? Yes, and no, is my answer. Yes, it sometimes feels good, but no, with that admiration comes the flip side of “falling down” at times, as the student matures professionally. The teacher/student relationship, like the parent/child relationship is fraught with both idealization and devaluation. Like raising a child, in the beginning, there is a feeling of deep love, on both sides, but as the relationship develops over time, the dynamics get more nuanced, more layered with good and bad feelings. To teach is to grow, I would like to say, and I believe that to be true. Yet, with all growth, comes pain, and struggle, and so the challenges are large. I see myself as a life-long student, and as such, I have signed up for the life-long struggle of learning, growing, and expanding, which can feel exciting, but it can also feel  remarkably humbling. No one said growing is easy, and so it is not.

Is Psychiatry As Bad Off As I Say It Is?

Check out Kelly Brogan MD…http://kellybroganmd.com/, a psychiatrist, similar to my thinking, advocates for mental health without medication. Now, I do not completely agree that medications are hurting patients, although sometimes that is true, but I do agree that we as psychiatrists have gotten trigger happy, which means we are too eager to prescribe, and too reluctant to listen and put symptoms in context. I have recently taught second-year psychiatry residents (UCLA-15 total), psychodynamic psychotherapy students (New Center for Psychoanalysis-9 total) and I am about to teach primary care doctors .https://www.cme.ucla.edu/courses/event-description?registration_id=146702 about the diagnosis and treatment of anxiety disorders.  In each of these very different audiences I lament the loss of history taking in psychiatry, associated with the rush to prescribe and the consequences being unrealistic expectations and poor understanding of one’s personal dynamics. Associated with this are tremendous health care disparities in psychiatry where those without means are given care which is significantly lower quality than care given to those with discretionary income. Further associated with this are training programs where students learn to read checklists as opposed to asking and listening to open-ended questions. The patient’s narrative is lost and with that comes the loss of the excitement and joy of self-discovery; this loss being for both patient and provider. Burn-out seems like an inevitable consequence of our new model of care, but it will take many years to document this and so we must wait for evidence to validate our suspicions. Meanwhile patient care is suffering, and those with means can seek out care that makes sense, while those dependent on public funds are left to focus on symptom relief and not bigger picture understanding of what is killing their vitality. “I make students depressed” I say frequently, always to laughter, which goes with the grain of truth this gloomy picture represents. Exposing the problem remains the first step. Hence, I will repeat myself until this broken system starts to mend.

Did I Mention I Was Teaching Transference Tonight?

http://myshrink.com/

Freud initially thought that transference was an impediment to treatment, but as the years went by, he began to “discover” that understanding transference was the holy grail of treatment, meaning it is the part of psychotherapy which creates personality change. In other words, how we feel about ourselves, based on early relationships is often recreated in our meaningful relationships and if we form relationships which are harmful to our self-esteem, then we need to reformulate our opinion of ourselves, based on a new relationship. This new relationship, in the form of psychotherapy, allows the patient to examine how he projects on to others ideas from his past, and in so doing re-affirms his previous notion that the world is mean/cruel/withholding towards him. If the patient can see his own projections then he can open himself to new possibilities which includes relationships in which he feels valued/loved/cherished. This is a simple notion, which in practice, requires many hours, in fact, at times, many years of treatment to see how deeply held beliefs can be faulty and damaging.

Joe, thirty-two comes to mind. “I am going to disappoint you,” he tells me with great certainty. “Why do you say that?” I ask, thinking about his declaration. “I disappoint everyone in my life. I just do.” He says with little elaboration. “You mean you disappointed your mom,” I say, thinking that he is referring back to his earliest relationship in which he felt terrible sorrow for not making his mother happy, and in fact, disappointing her by not becoming a doctor or lawyer. “It must be terrible to feel that you disappoint people,” I say, thinking about what it is like to think that you will cause a significant other deep pain. Joe starts to cry. His tears speak volumes to his sense of inevitability that he disappoints; that is just what he does. “Maybe you disappointed your mom, but that does not mean you disappoint everyone,” I say, stating the obvious, but also knowing that it needs to be stated. “The issue is that you feel like a disappointment, and that is a terrible burden to bear,” I say, trying to help Joe understand that he carries around this painful feeling that he cannot shed, since he is so attached and identified with his mother. “I wasn’t abused,” Joe says protecting his mother. “Not in the traditional sense, “I say, “but you weren’t cherished for who you are, and that is a different kind of trauma,” I say, trying to help him understand the childhood feelings he carries forward into adulthood. “I don’t get it,” he responds impatiently. “Yes, we have more work to do,” I say, knowing that this is a painstaking process.

Teaching Transference

Trans·fer·ence

transˈfərəns,ˈtransfərəns/

noun

1. the action of transferring something or the process of being transferred.

   “education involves the transference of knowledge”

   • PSYCHOANALYSIS

     the redirection to a substitute, usually a therapist, of emotions that were originally felt in childhood (in a phase of analysis called transference neurosis ).

   How do you teach this concept? I wonder. We repeat behaviors from the past and impose them in the present, and in so doing, our behavior is out of proportion to the present situation but our behavior makes sense in a historical context. In other words, all actions are reactions to past experiences as well as reactions to current experiences. So, if Barb feels that I am being mean to her in session, I may in fact be mean to her, and/or she may get triggered by something I said which reminds her when her mom was mean to her, and in that situation, I am the trigger, but she does not see that immediately, so she feels very hurt and disappointed by me. With time in psychotherapy, Barb and I can come to see how she felt my behavior was “mean” and she can also talk about how it reminded her of how her mother treated her when she had a boyfriend that her mom did not find suitable for her. As we unpack her feelings of hurt and disappointment, Barb comes to see how in other parts of her life, particularly in her close relationships, she often feels hurt and disappointed, and this may, in fact, be her carrying forward painful experiences she had with her mother. “Maybe I am too hard on my boyfriend,” Barb says with the suggestion that her insight into her behavior is slowly expanding. Helping Barb understand how she feels that everyone will treat her as her mom did, opens her eyes to the understanding that maybe she carries with her painful assumptions, which, when tested out, turn out not to be true, but without opening her mind to the fact that she is making assumptions, she then constantly feels hurt and disappointed. Through talking about the transference, Barb has the opportunity to grow emotionally, such that she can begin to understand how she can take a benign comment, such as “I wonder what you find attractive about your boyfriend,” and given her history with her mother, she hears “what on earth could you like about that man?” In her mind, she is prepared for a judgmental, critical attitude towards her boyfriend, such that she cannot entertain the possibility that my question is one of curiosity and not criticism. Clearly, tone is critical in this discussion, but even with a neutral tone, there is the sense that Barb is so convinced that the discussion is going to be antagonistic, and as such she must go on the defensive when talking about her boyfriend. This is a simple notion of transference, but one which I hope will illustrate the point. The point being that by reacting to our past and not our present, we, who have been hurt in childhood,  continue to feel the pain and we do not open ourselves to feelings of acceptance and love. In essence, understanding transference can  be transforming, creating a life-changing  and maybe even a life-saving experience.

    

See also…https://shirahvollmermd.wordpress.com/2014/02/03/teaching-transference-2/

Psychic Retreats

Tomorrow, in my Psychoanalytic Technique class, the topic is silence, and what to do about it. The meaning of silence, the challenge of silence, and the patience with silence will all be ripe for discussion. We will springboard from John Steiner’s work about psychic retreat, where he teaches us that patients often withdraw into silence as that is a safe space; safe from anxious and depressive feelings. More to the point, many people, particularly males, who withdraw in social circumstances, due to fear of having feelings, are often labeled as “on the spectrum” when in fact, they are using a defensive psychological organization to cope with psychic trauma. The misunderstanding between trauma symptoms and “spectrum” symptoms is particularly upsetting to me, because it is one thing to understand a patient as trying to cope via withdrawal as opposed to understanding a patient as incapable of nuanced feelings and social skills. This distinction is critical and it takes time with patients to really understand this difference. A severely traumatized individual will have no friends because he/she is frightened of the feelings generated by friendship, and this can seem identical to the “spectrum” individual who has no friends because he/she is not able to have the reciprocity required in relationships. Two fictional examples come to mind. One, a young male, isolated, lonely, and despairing, has never had friends because he is antagonistic and arrogant, by his report. In the intensive treatment he is often silent, requiring what I have called “hide and seek” such that he hides and I need to seek out his psychological state of being. Without my seeking, he remains hidden. The meaning of my seeking is that it serves to reassure him that I am indeed interested in his mental state. The issue of how long to remain silent as opposed to “seeking” him is the art of my work. The second fictional example is a fifty year old woman who often says, ten minutes into the session “that’s it. I have nothing more to say.” This seemingly abrupt ending to her thought process has puzzled me for many years. It is clearly defensive in that she protect herself from deeper intimacy with me, but at the same time, she is frustrated by her inability to deepen her treatment. Her psychic retreat would not be confused with “spectrum” issues and yet, she isolates herself in our sessions such that there is no reciprocity. She does not play “hide and seek” since she simply hides from me, in that “she is done”. She does not leave however, as she waits, perhaps with unconscious hope, that there is more to be said. Our work is focused on understanding these retreats and how historically speaking, these withdrawals saved her from feeling unloved in her family. Both these fictional examples illustrate how silence is as important as verbal output, as they both convey how the patient organizes his mental interior and as a result how the patient can share, or not share, those very private experiences. John Steiner has helped us a great deal with talking about the quiet, the dark space, if you will, within the psycho-therapeutic hour.