Excerpts from Must Read Books & Articles on
Mental Health Topics
Books, Part XXIV
Of Two Minds: An Anthropologist Looks at American
Chapter Two: What's Wrong With the Patient? (pp. 56-83)
"Beginning to get decent at psychotherapy is like discovering
an extra limb and finding it incredibly useful. Once you discover
it, it's a little difficult to go back to doing things with two hands.
When I'm in a social interaction, I get a little embarrassed with
myself. You see people who have boundary problems, and they're seductive
and alluring and you can get sucked in. It would be hard, now, to
let myself go with the slow with someone like that. Part of me would
be noticing what was going on, what was happening. I can't turn it
Earle is a tall, slim New Yorker, quite
elegant, rather sardonic. He had, as most psychiatrists used to, a
background in the humanities. He was thought to he one of the better
psychotherapists in his residency program. He was considering analytic
training. ''The way I think now," he said, "is very different
from the way I thought in medicine. There is so much less that is
explained by rules that apply to more than one person. When I first
started, I wanted there to be some unifying theory. Rules and so on.
Actually, what's Important is knowing the particular person. All people
have their own system, their own way of how things work, with particular
fears, particular wishes. Getting to know that instance is much more
important than the rule it may test or not. One thing I've noticed
Is that I'm much less judgmental of my patients than they imagine
me to be. I really am. It's not interesting to me anymore to make
a judgment: it's interesting to understand. The more I know my patients,
the less I diagnose them. The closer you get, the less helpful it
is to classify and the more you doubt the classifications. I think
my process has been that of coming at the patients with some vague
and cherished theories and hoping that they won't disprove them. And
they did. They always do."
Psychodynamic thinking is a curious
and highly distinctive manner of thought: between those who think
psychodynamically and those who do not, there is a gulf as wide and
alienating as between those who think logically and those who do not.
It is notoriously difficult to characterize. Psychotherapists produce
an array of metaphors to describe the therapeutic encounter--it is
a dance, a duel, a drama, an attempt to listen with a different car,
to listen for what is under the surface or behind the words: it is
peeling the onion, unraveling the psyche, piercing the armor of the
character: it is an attempt to see the translation of motive into
action in which every action serves the self.
If achieving basic competence in diagnosis
and psychopharmacology is like becoming a master bird-watcher, learning
the skill of psychotherapy is more like learning to he a storyteller.
One might describe Freud's central contribution to psychotherapy by
saying that he "discovered" the unconscious, or at least
that more than any of its other discoverers he demonstrated that we
are all motivated in ways we do not grasp for reasons we cannot give.
But his more fundamental legacy was to suggest that we can decode
our behavior and our history to discover the grammar of a particular
person's emotions, the implicit rules that explain why a remark offends
one person but makes another laugh, why one person enjoys aggression
and another finds it terrifying. Analysts listen for the stories that
emerge from the way people talk about other people, the way they experience
those people, the way they experience the therapist, and the way they
experience themselves, although what the analyst hears is not just
what the patient says. As diagnosticians listen for clues to a diagnosis,
therapists too listen for clues to a model. They listen, however,
in a very different way.
At some point in their first year, young
psychiatrists are assigned their first psychotherapy outpatient. In
their second year, which is their outpatient year, residents can take
on more cases, hut only an ambitious resident--ambitious, that is,
as a psychotherapist will take on as many as ten. (That year, their
other patients are outpatient psychopharmacology patients. A resident
may carry a monthly caseload of more than one hundred psychopharmacology,
patients, whom he sees for fifteen or twenty patients, minutes apiece,
and three psychotherapy patients.) In the past. residents were encouraged
to see their psychotherapy patients twice or even three times weekly,
but these days many factors militate against doing so. Usually a resident
meets with each patient once a week for forty-five or fifty minutes,
although occasionally a patient will arrange to come in less frequently
(usually for financial reasons) or more frequently (maybe twice a
week). For each patient, or for every two patients, the resident has
a supervisor, usually an analyst who volunteers his time in exchange
for an affiliation with the medical school. The resident meets in
private with the supervisor once a week to discuss the case. During
the outpatient year, this resident also runs a therapy group for patients,
usually with two residents per group, and as a class, residents participate
in a once-a-week session that is described as their own group therapy.
At least one hour of lecture time each week (usually out of two to
four hours) is devoted to psychotherapy throughout the residency,
in all residency programs I have seen. Most residents also enter psychotherapy,
some even psychoanalysis, at some point during residency, in part
for their own training and in part because they feel they need it.
A great deal of time, then, is designated for learning psychotherapy,
or at least was when I was doing fieldwork. This training, however,
is more optional than the training in diagnosis and psychopharmacology.
As a psychiatric resident, you must admit patients and diagnose them.
That is your job. Psychotherapy training involves more choice, more
willingness to go along with what is offered or seek out what is not.
The specific kind of therapy taught
to psychiatric residents is called "psychodynamic psychotherapy,"
and its theories and practice derive from psychoanalysis. Psychiatrists
use the term to refer to therapy that is guided by psychoanalytic
thinking but in which a patient may come anywhere from five times
a week to once a month and may use a couch but usually sits in a chair
and talks with the therapist face-to-face. The term "psychoanalysis"
is reserved for a specific kind of practice: the patient has very
frequent sessions, the patient lies on a couch and cannot see the
analyst, the therapist is in or has completed training at a psychoanalytic
institute. The term "psychodynamic" is used more broadly
to include not only psychoanalysis per se but a way of thinking and
practicing that is psychoanalytic in feel and style. Psychoanalysts
serve as the primary psychotherapy teachers for young psychiatrists,
and psychoanalytic writings serve as the primary texts. Residents
are supposed to learn the theory and practice of other kinds of psychotherapy
as well cognitive-behavioral therapy, couples therapy, family therapy
but in general these approaches have low visibility and low prestige
in psychiatric training programs. When I refer to psychotherapy, then,
my prototype is psychodynamic psychotherapy.
The learning process itself is more
practical than this description suggests. In American culture, psychoanalysis
is often associated with intellectuals. People who read Freud are
often fairly highbrow. What is taught to young psychiatrists about
psychodynamic psychotherapy is not intellectual at all. The expertise
they acquire has to do with Freud only obliquely. It develops beneath
the surface of texts and lectures.
In the first place, the lectures on
psychotherapy, for the most part, do not present general theories
of human experience. They do not discuss the extensive scientific
literature on emotion and human development. They do not explore the
difficult psychoanalytic writings of W. R. D. Fairbairn, D. W Winnicott,
Otto Fenichel, Heinz Kohut, Harry Stack Sullivan, Otto Kernberg, and
others. Discussion of Sigmund Freud and human development is extremely
cursory. No young psychiatrist is seriously expected to read much;
even when reading is assigned, there is no sanction against a resident
who does not read, and it is widely understood that the clinical needs
of the hospital take precedence over a residents lectures. The primary
method of training is apprenticeship. I sat through an eight-week
seminar on child development in which Jean Piaget's stages were presented
but never fully explained, never critiqued--despite an enormous psychological
literature on the topic--and never mentioned by any resident again.
I have listened to hundreds of lectures to psychiatric residents.
Few of them presented as much material as an average professor's lecture
to undergraduates. Very few of them gave evidence of even an hour's
preparation for an hour's lecture. Virtually none was attended by
all of the residency class.
Nor, for that matter, does the institution
treat the lectures as very important. In the first rear the first
psychotherapy patient is often assigned before residents have been
told much, formally, about the actual process of psychotherapy, as
if to imply that the resident can't do much harm, even though the
gist of the teaching is that in fact the resident is a lumbering bear
in the patient's porcelain psyche. One first-year resident was incensed
by this: "Well, there was a lot of anxiety because you don't
know what you're doing, and I was very angry at the department for
thrusting us into that situation before sic had had any lectures at
all. What is psychotherapy? How does it work? What are some basic
principles? I knew a little bit by reading and by three months of
therapy I had had, but that wasn't much, and I just really didn't
know, my role was very ill defined, and I just felt a lot of anger."
The point of the lectures is not to
teach facts or a science but to teach a practical skill. The lectures
talk about what to do in therapy rather than why the therapy works.
(This is also true for the lectures on psychopharmacology and diagnosis.)
In the summer seminar series I attended, the lectures on psychotherapy
were so down-to-earth as to seem brutally naive to the outsider. Where
do you put the clock in your office? If you must meet a patient a
hundred feet from your office, do you talk on the way there? About
what? Do you shake hands? These turn out, as it happens, to be matters
of great concern, but they do have a fugitive air of teaching etiquette
to someone about to host a dinner party with neither food nor drink.
When a seminar does focus on a text,
as did one that I attended with advanced psychiatric residents, the
discussion tends to circle around the ways that the ideas can be borrowed
to understand one's current patients. Even in this class, where the
text--Melanie Klein's Envy and Gratitude--as treated with greater
historical and textual sensitivity than I had ever encountered in
a psychiatric setting, the young psychiatrists took the ideas loosely
to interpret their patients' behavior. When the class looked at a
sentence in which Klein talked about "incorporating the breast,"
for example, one of the psychiatrists exclaimed that this was exactly
what her patient was doing with her now. Klein, of course, was being
somewhat metaphorical about infant thought, but whereas a psychology
graduate student might have struggled to understand the specific meaning
of the metaphor for Klein, the clinically oriented resident ignored
that question and instead stretched the metaphor further.
The primary teaching of psychotherapy
takes place in the one-on-one "supervision" for an hour
a week, often days after the actual therapy has taken place. Unlike
the rest of medicine, the teacher sees the student perform very rarely.
In surgery, there may be a see-one, do-one, teach-one approach to
cutting, but a senior surgeon hovers by a student's elbow. In most
cases, a psychotherapy supervisor never sees a patient in person.
In many cases, the supervisor never sees a video of the session or
listens to a tape recording of it. Instead, the resident and supervisor
meet at a prearranged time, the resident tells the supervisor what
went on in the session, and the supervisor advises the resident on
what to do next. Periodically the supervisor sends an evaluation of
the resident to the director of residency education. The belief that
residents learn anything more than the fine art of deception from
this process springs directly out of the psychodynamic way of looking
at the world.
In psychodynamic psychotherapy, one
person pays a second person a significant sum--$50 to $150, occasionally
more--for the privilege of talking to him for less than an hour. He
may repeat the exercise once or more each week for many years. The
second person, the "expert," comments on what the first
person has said. What makes the relationship strange is that the goal
of the second person is not to understand and say what is true about
the first person's remarks or even what he thinks. The psychotherapist
is explicitly taught not to give advice, not to counsel, not to act
as a kindly friend. The psychotherapy relationship is deliberately
not modeled on teaching, though there is often more coaching in it
than is acknowledged.
Psychodynamic psychotherapy has developed
out of the belief that our deepest motivations are occult, for the
expert as well as for the seeker of help. Thus, therapy cannot provide
a one-way window into the patient's soul. The patient cannot see the
real source of his unhappiness--we cannot see our sunglasses when
we are wearing them, but everything we see is darkened by them--and
the therapist knows that he too is limited by his own personality,
though because of his training less so than the patient. Instead,
therapy is conceived of as a relationship between two people from
which the nature of the patient's hidden psyche must be inferred.
Freud's metaphor was that the psychoanalyst and the patient were like
passengers on a train. The patient sits by the window, describing
the scenery as it passes by, but she does not know what is important.
The psychoanalyst knows what is important, but he sits beside her
blindfolded. He must infer from the way she talks to him what the
landscape really looks like. The therapist's job is also to interpret
the relationship between therapist and patient as a means of understanding
the patient, despite the full awareness that neither party has full
access to the thoughts and feelings of either.
Psychodynamic supervisors assume that
because we are all shrouded from ourselves, young residents cannot
but reveal their implicit assumptions about their relationships with
a patient. Particularly in residency--that is, at the earliest stage
of training in psychotherapy--supervisors tend to treat supervision
as being focused on residents' insecurities and blind spots, for our
inability to understand other people owes much to the hard shell of
our emotional defenses. In other words, supervision is really about
the resident. That's why handwritten notes--process notes," scribbled
dialogue written on scrap paper at the end of the session--are understood
(in this culture) to be as helpful as video recordings.
A supervisor listens primarily to the
way in which a resident thinks and responds. He is trying to understand
the way a resident presents herself and what she presumes in a conversation
that might he interpreted by someone else in a way the resident might
not expect. One supervisor told me that he treated the supervision
as couples' counseling with half the couple present. I here is also
more than this. A supervisor tries to interpret, through a resident's
account, what a patient is actually like. But the focus tends to be
upon the resident even when the discussion centers on the patient.
In 1992, I sat through a summer's worth of one resident's supervisions
with two different supervisors. Paula spent hours writing up the notes
from each session (she was very conscientious), and at each supervision
she would arrive with the sheaf of paper and read it through, with
the supervisor commenting on what was said and whether it should have
been said another way.
The transcript of one such supervision
ran in part as follows. In the therapy hour, the patient and therapist
(the resident) were discussing the patients anger at seeing the therapist
in the supermarket, because the patient claimed that the therapist
had seen her and turned away, while the therapist said she had not
seen her. The resident read these notes to her supervisor:
PT: You've misunderstood me.
TH: No, you've been saying a lot of hurtful things.
TH: It's hard to see that you can be hurtful. When you hurt, perhaps
it helps to put people down.
PT: No, I never put anyone down.
[The supervisor remarks to her, "You are young, and you have
everything you want." Paula continues to read without comment:]
TH: In a relationship, you feel that no one should get hurt.
PT: Yes, that's right.
TH: 'That's why you're so isolated. It'll be a long wait for a relationship
that doesn't hurt.
PT: I'm isolated?
PT: You have something there but the issue here is chemistry.
[Paula says in an aside to the supervisor, "Every time it gets
heated, it goes into chemistry."]
PT: Like Sam.
TH: Were there specific things that bothered you about Sam?
PT: Yes [she lists them].
TH: And with me?
PT: No, it's just chemistry.
TH: Baloney. I think you call it chemistry because you're uncomfortable.
PT: It just reminds me, when I come here, that I see someone younger,
who has done something with her life. I haven't.
[Supervisor doesn't say anything here, even though it confirms his
PT: I don't mean to change the subject, but I was thinking about
how you think I've tried to hurt you. People always misunderstand
me. They used to call me a snob. I'm shy.
SUPERVISOR: The subtext here is that she was shy in the supermarket,
that's why she didn't come over. She's not a snob, not aggressive--just
avoidant. If you were feeling less embattled and more warmly, you
could have interpreted that to her and said, "I wish I had
seen you, so that you "wouldn't have had to feel as rejected
as you did. I hope that if I had seen you, I would have had the
wherewithal to introduce you to my husband."
PAULA: She never says things directly, never owns things. I had
to do this for me.
SUPERVISOR: She said pretty directly that you bothered her, and
that you've succeeded at things she's failed at. She hints at this,
as if you could be two girls chatting together.
PAULA: She asked me if we could do therapy outside.
SUPERVISOR: Talking about it is more important than doing it. PAULA:
With her, in therapy, doing is key.
SUPERVISOR: The issue is doing it with you. You embody so much she's
not. She's on a slippery slope, got a late start, blew it with the
first attempt. You come along, dressed in pink, even, she's seen
you smile--think of her fantasy life. You're lucky and you don't
deserve it. How can she justify this? She's been unfairly treated,
and it will come so easy for you and you don't even make attempts
to be nice the way she does.
PAULA: How would you make her feel more comfortable?
SUPERVISOR: Well, you could apologize for what happened in the supermarket.
PAULA: But I've done that. I truly think she needs me to go to lunch
with her or walk around the campus. All I was trying to get her
to do was to own her own aggressiveness.
SUPERVISOR: Good, but you would have done it differently if you'd
realized that this issue was jealousy not the comparison with her
previous therapist. You are acting here as if you don't think enough
of yourself to believe that someone could be jealous of you.
What the supervisor said quite clearly
is that this resident could not hear the patient envy her. To become
a better therapist, she would have to learn to listen to all the ways
a patient might perceive her. But now she cannot hear the patient
clearly because her own personality muffles her ears. For the supervisor
to see this, it didn't really matter that the session had been written
down from memory. As Freud remarked about dreams, recollection is
as useful as exact recall because what was unconscious then will not
be consciously removed in the retelling. We reveal ourselves as vividly
when we lie as when we are truing to he honest.
Supervisors tend to be supportive. This
supervisor was consistently so. Supervision can nevertheless he exquisitely
painful. Paula was just shy of thirty during these sessions, and at
the time she was lonely and depressed. (There was something going
on at home.) I am struck, looking hack over my notebooks several years
later, that I knew she felt bad about herself when we met. I wrote
about her bad feeling in my notebooks. Yet somehow, as we spoke over
the course of the summer, as I talked to her about psychotherapy and
what it was like to do it, as I went from supervision to supervision
with her, I could no longer see her as someone who might he stiff
and awkward with patients because she was depressed. I think that
it was so painful to see her expose herself week after week despite
her determination to present herself as a good therapist that I could
not hear to see her as clearly as her supervisor did, although I sat
there recording the supervision in my notes; I think that nay be a
clue to the level of shame residents can experience in the kindest
supervision. Certainly Paula experienced the supervisions like a switch
on sunburnt skin. Shortly after this exchange, the patient left therapy.
If a therapist is not helpful, whatever
that means to a patient, the patient usually goes away. The force
of this experience as a training exercise, that the outpatient is
not like some graduate school paper assignment but an independent
person who votes on your skills by choosing to see you or not (which
the inpatient, of course, cannot) did not become clear to me until
my own bout of doing psychotherapy. To get some sense of this skill,
I had signed up as a volunteer at a local outpatient clinic. I had
eight patients, one once a week and three twice a week for more than
a year. I was supervised by the same people who supervised the residents.
My second patient was a rude, miserable
man who didn't think much of women to start with his girlfriend had
just thrown him out and when he called up the outpatient clinic for
an appointment, he protested at the standard price and asked for someone
cheaper. He was passed on to me, the anthropologist in training who
because she was not training for a degree could accept reduced fees
($10 per session; it went to the clinic). Although he no doubt felt
that he had been offered cut-rate goods, he decided to see me. During
our first hour, he remarked aloud that I probably wasn't smart enough
to have gone to medical school, suggested that I was too young to
be of any use to him, told me that when I grew up I'd have some business
cards, and then, after railing about my inability to get his girlfriend
hack, left after several sessions and did not return for months. He
was not, as they say, an ideal candidate for psychotherapy. Yet I
felt terrible when lie dropped out of therapy and tremendously reassured
when, eight months later, he decided to reconnect. (I referred him
elsewhere because of my teaching schedule.)
Very few of the patients whom residents
see for psychotherapy are ideal candidates for psychotherapy, and
so the feeling of being abandoned by a patient is quite common. Student
therapists enter the clinic hoping to do long-term therapy with people
like themselves and instead find themselves speaking in rounds about
the self-esteem issues of drug addicts and felons. (At clinics where
trainees are allowed to take patients for very low fees, there are
more noncriminal, job-holding, well-put-together patients who are
willing to see a student therapist if it costs them virtually nothing.)
Even so, what students learn is that keeping patients is more important
than understanding theory. In private practice, a psychiatrist has
an income only if he keeps his patients. That is why there are two
Freuds, the Freud who is read by scholars and intellectuals, who take
the abstract portrait of the psyche seriously and who debate the epistemological
issues he raises, and the Freud of the clinicians, sometimes unread
but inspiring, who helps clinicians think in a way that is helpful
One way to characterize the Freud of
the clinicians is by saying that training in psychodynamic psychotherapy
teaches student therapists to be more conscious of the way they empathize.
Empathy is a natural human process. You see someone caving; you feel
sad. You see someone smile; your day brightens. It is also true that
when you become more self-conscious about empathy, you see how constrained
it is by who you are--the way you perceive someone, the way you feel
about that person as a certain sort of person, the form of your own
past and of your own anxieties, hopes, fears, ambivalences. The psychoanalyst
Roy Schafer places a dissection of the therapist's empathy at the
center of his book The Analytic Attitude, a taut exegesis of
the way analysts do their work. Schafer does not pretend that analysts
have an uncluttered, transparent view of patients, nor that analytic
theory-the intellectual's Freud-always provides accurate and reliable
insight. He sees that a patient tries to describe himself to an analyst
and that the analyst experiences empathy for the patient. That is,
the analyst genuinely tries to understand what the patient is feeling
and thinking, and in that process vicariously experiences some of
what the patient thinks and feels. Schafer points out that what the
analyst feels empathically is not exactly what the patient feels.
For a start, an analyst may build many models in his mind of who the
patient is, all of which might be consistent with the "data,"
with what the patient has said. The analyst has his own sense of who
he is in the analytic setting; so too does the patient. Each has a
kind of "second self": the patient presents himself as more
miserable than most of his colleagues think he is; the analyst presents
himself as more competent than most of his colleagues think he is.
In fact, Schafer says, the relationship between analyst and analysand--between
their second selves--is "fictive." The two create it together.
It is their own narrative, and it is a story about who they are to
each other. That, Schafer says, is what makes analysis work as therapy.
The analyst does not feel exactly what the patient is feeling, because
his perceptions of the patient, drawing as they do from his prior
analytic experience and his idiosyncratic understandings, are always
subtly different from the patient's own, particularly because the
patient is slightly different in the consulting room and in his life
outside the analytic encounter. When a patient looks into the mirror
of his analysis, then, he sees not a direct reflection of who he thinks
he is but something different. " This gives him possibility,
Schafer argues. It makes him feel free.
That awareness of the difference between
what a patient thinks and feels, what a therapist thinks and feels,
and how each thinks and feels about the other, is one of the first
major lessons of the resident's psychotherapy training. Suzanne, for
instance, started out shocked that psychiatric patients were not always
grateful for her help but would actually see her as the enemy. She
was the classic "nice girl," always friendly, always helpful,
a June Cleaver in a brash late-twentieth-century world. By the end
of her first year, she had decided that "sensitivity" was
her main problem. She called it "overinvolvement": "Working
with these disturbed patients, they can pick up things and they can
read things that normal patients cannot, and they zero in on your
insecurities. I had one patient whom we committed to the hospital.
Every day she would say to me, 'I hate you. I hate you because you
keep me here.' For me it was a devastating thing to be told. I care
about people a lot, more than they care about themselves sometimes,
more than I should."
By the end of her second year, Suzanne
felt far more competent as a therapist. She ridiculed herself for
thinking that she had known what she was doing before: "This
year has been an incredible year for personal growth. I laugh sometimes
because at the end of last year, my first year, we had what we called
'therapy patients.' What a joke! I had no idea of what I ryas doing
at all. I remember this one young woman, a young married woman who
had a new baby and was having sexual problems. I would sit there week
after week not knowing what to say, just feeling totally overwhelmed.
[Suzanne, never married, had at that point just broken up with her
boyfriend.] She came back week after week: it was just beyond me.
Hearing all these intimate things and not knowing what to say or do,
what my role was, I felt that I wasn't prepared for this, the lecture
course we had just wasn't enough to prepare me to sit in a room with
another person who was suffering and feel like I can work with them
in some way to help them gain insight and make changes.
"I started to understand more and
more. I could see why the patients were coming back, that if a patient
feels understood he's going to come back, he is getting something.
I learned to lower my expectations, to meet people where they are
and they will feel understood. Sometimes they feel like maybe you're
the only person on earth that they can come and sit in a room with."
"Sometimes I feel like I'm engaged
in a dance with the patient--they're doing some steps around me and
I'm trying to follow them on the dance floor in a sort of figurative
way. Sometimes we're moving in the same direction, and other times
we're just falling over each other. One week a patient all of a sudden
turned on me. It felt like a bucket of anger just thrown over me.
At first I was shocked. Then I said to myself, wait a minute. This
has got to be transference ["transferred" from another context]
because I know realistically I've done nothing to offend him. Sure
enough, it had to do with feelings from his mom that were projected
in the anger and the hurt. I didn't confront him at the time because
he was too upset to appreciate the interpretation, plus he was mad.
Weeks later we did. But I'll tell you, even more critical to me was
the fact that during the session, I had stepped back. I had recognized
this. It feels like I now have a view of the world that is very special
and is kind of neat."
Recognizing the patient's distortion
of the therapist is the psychotherapeutic equivalent of getting a
driver's license. The story implies that the young therapist is beginning
to do real therapy because she is able to distinguish what the patient
is experiencing from what she has experienced. All of us know that
sometimes someone is angry at us because he's really furious at the
boss, but most of us still get angry in response. Therapists try to
live in a double-entry bookkeeping state at all times. They try to
he deeply emotionally engaged with the patient and yet not to respond
out of their own needs, not to hit back after being hit, not to express
pain after being hurt. They try not to respond in kind. That is the
"special, neat" way of perceiving the world in psychodynamics:
that we each create the world we live in: that we always see through
molded glass, and that much of the time, when people are angry at
us, we are not the cause of their anger but merely the vehicle for
their self-generated, self-inflicted, wounding rage.
After the end of residency, Suzanne
explained that what she had learned in residency was to understand
the patient without interrupting with her own needs (getting angry
at an insult), yet still to he able to use her own sense of self in
the service of understanding someone else: "What psychiatry did
for me was to take away my insulation. I found myself face-to-face
with a lot of ugliness, and I had to learn to tolerate it, to let
it be real. There was no way to close my own pain out, and if you're
careful it becomes really useful. For example, I don't think I ever
really learned how to deal with anger or process anger myself, and
I see that in a lot of my female patients.
It's real useful for me because I know
where they're coming from. I know what the problem is. At first you
think, what do I bring to them, I haven't solved this one. But I'm
not in the same boat. I don't walk in their shoes. I may have gone
through similar things but not the same thing, and I can keep the
distance. You can say, 'When he said that to you, I bet you were furious,'
and the look of relief on their face! How did you know? I could have
stabbed him.' So you use your experiences, and you help the patient."
Young psychiatrists say repeatedly that
what they learn to do in psychotherapy is to interpret someone else
by factoring out their own participation, by overriding their need
to see a good, just world, their need to maintain their honor, or
their need to have other people see them as kind. That is, they become
increasingly capable of understanding a relationship as the outcome
of two complex interacting individuals and to interpret the behaviors
of the other person more intricately through the contours of their
own selves, as if they were predicting the speed and height of waves
by the features of the shore on which they break. They say that they
learn to bring their experience to bear on understanding someone else
and yet to act on none of their own reactions, which are merely tools
for further understanding.
In order to do this, young psychiatrists
(or student therapists) need to construct self-conscious models of
patients and themselves: "I know realistically I've done nothing
to offend him.... [The anger] had to do with feelings from his mom."
The way they develop those models is by talking endlessly about people
and what makes them tick: their secret fears, their wants, their dreams,
their embarrassments, their confusions. They learn to talk about an
event by explaining it from the perspective of all the different actors,
and their tales get funnier because they develop a sharper sense of
the parallel universes people sometimes seem to inhabit. This is not
like the process of learning to diagnose. The person diagnosing learns
to distill a diagnosis out of a patient's narrative and to see that
many different lives can share a common label. In psychodynamics,
the models are rarely taught and memorized abstractly (although some
models are, such as the Oedipus complex, in which a male child separates
from his mother and identifies with his father). For the most part,
the models remain specific, as something some patient did at some
time that is kind of like what she did some months later. Mostly,
the models are about motivation, and because of the cleaner attention
to motivation, the young psychiatrist becomes an increasingly better
spinner of tales.
Tom, for example, entered residency
later than most of his peers, first working for years in internal
medicine. He is a bluff man, pragmatic and to the point. He spends
Saturday playing ball with his kids, rarely reads novels, and thinks
he ought to follow the research in his field but doesn't. In the first
months of his residency, he felt demoralized about doing psychotherapy:
"I'm frankly terrible still at any kind of real psychotherapy.
I mean, basically I'm comfortable with trying to make a diagnosis
and prescribe the right medicines for these guys. If it's just me
sitting there trying to help someone in psychotherapy, I just don't
know enough. Actually, I don't know anything." He was reassured
to discover that he liked the patients. He had bad dreams, before
residency, about being locked up with craze people. But the real surprise
here has been that I've really enjoyed the patients. No matter how
crazy some of these guys are, I can really empathize with them. It's
made me feel real good to feel that kind of a bond with the patients."
At the end of that year, Tom said that
one of his greatest problems was empathizing too well. Understanding
his patient's misery made him miserable: "It's terribly difficult,
People come to you day after day, just pour out all this misery and
open up to you. It's gut-wrenching. When someone's not psychotic but
they live with so much pain, you really feel it. Psychiatry just pulls
down all these horrors. You feel so drained." At the same time,
he was clear that he felt that he had become better at understanding
his therapy patients: "It's hard to say how you arrive at some
kind of idea of what kind of person you're talking to. It's not any
one question or one physical or emotional characteristic of that person.
It's the combination of a lot of little things. I think I've become
a much more feeling and sensitive person this sear." In his last
year, Tom said he didn't believe in classical technique. He thought
that a good therapist is more helpful when he does not try to help.
He said that psychotherapy worked because he had seen it work for
him: but he said that it worked in spite of and not because of grand
theory. He said that what was important about the process was that
a patient was willing to give up the "big secret" that he
had been holding inside, namely that things had not been working right.
he said that he didn't think it mattered so much what you did at that
point as a therapist as long as you were "there to help guide
them in this exploration of themselves."
And as his sense of what he was doing seemed to become more simple
and concrete, his account of motivation grew more acute: "I had
this one patient, this huge woman who came in last year. She's a really
good person, funny, witty, would never miss an appointment. We have
a great time. Her whole story is kind of indicative of how loose my
psychotherapy can he, Once her depression had cleared [this is a very
medical phrase], I was trying to explore her childhood [first the
medical necessities, then the psychotherapy]. She picked up that I
felt uneasy about what I was doing.
"Well, I moved offices after we'd started meeting, and when she
saw how desolate this room is, she brought in a plant. It was pretty
much a sick plant. I said, 'You're not supposed to bring gifts, and
I can't take care of plants. These things die. I don't even water
them. I'm incapable of watering plants.' She said, 'No problem.' She
just left it there. Unconsciously, I guess I wanted to torture her
by letting this plant die in front of her. Every week we would joke
because I never watered it. I honestly completely forgot about it
consciously when she wasn't there, and she would accuse me of being
"Now, I have this other patient
who is young and attractive. I didn't think she was that seductive,
but I had her on videotape, and my supervisor certainly thought she
was. He said that there was all this transference. In fact what he
said was 'Oh, boy.' Well, she starts to comment on the plant, week
after week. I never told her somebody gave it to me, I just said,
'I never water it. I don't take care of it.' She said, 'Well, I'll
take it home. I'll bring it to life.' l said, 'No, you can't do that.'
At the end of one session she just picked it up and left with it.
So one of these weeks she's going to come in with the plant she brought
back to life for her psychotherapist, whom she loves, which is okay
except that now I have to explain this to the other patient who thinks
I'm a sadist. I never should have taken the thing to begin with."
"We're really storytellers,"
one resident remarked. One of the more remarkable qualities of psychotherapeutically
oriented psychiatrists is how capable they are of remembering the
story. This becomes obvious in a case presentation or a seminar with
psychodynamic clinicians. Like any academic presentations, a presentation
has a great deal of data and some theoretical framing. In an academic
setting, however, the audience tends to focus on the theory. The listeners
remember the theoretical claim being advanced, and they tend to pursue
it with questions, often quite forgetful about the actual data mentioned
by the speaker. In the psychodynamic setting, the listening clinicians
tend not to pursue the theoretical argument (the speaker disagreed
with So-and-so's reformulation of such-and-such an argument). Instead,
they talk about patients, and they remember what seems to an outsider
to be a stunning amount of detail: where a forty-year-old patient
attended school, how her mother behaved at graduation, what her father
said about it. A first-year resident said, "I used to find it
very difficult to remember what was going on with a patient. Then
the guy who ran the psychiatric emergency room said, 'Remember the
story. Everyone's got a story.' And then I began to remember."
What they remember has a certain form.
Master chess players can be distinguished from nonplayers because
they hold thousands upon thousands of chessboard positions in their
memory. When master chess players are shown, in an experimental setting,
a chessboard pattern that could be arrived at by play, they can remember
it far more accurately than nonchess-playing subjects and probably
associate with it moves that would take advantage of the position
or even specific games. But they are no better than non-chess players
at remembering random images or randomly rearranged chessboards that
could not be arrived at by normal play." Academic psychologists
have argued that expertise depends in large part on the amount and
organization of knowledge around the area of expertise--what they
call the "domain": chess, ballet, Aztecs, psychiatry, whatever
the expert is an expert in. Many argue that the highest level of expertise
is indeed (as therapists argue) reached after ten years in the domain.
Experts' memories seem to depend on their capacity for perceiving
meaningful patterns (cognitive scientists would call them "schemas"),
and the immense storage in their domain of expertise seems to enable
them to plan strategically in that domain and anticipate potential
sequences of moves in the future.
What a psychotherapist remembers is
a lexicon of narrative patterns that she uses to understand what is
going on with a patient, moment to moment, in a particular session
and over a long analysis. The complexity of this memory is not unlike
the complexity of a chess player's memory. Like the psychodynamic
understanding of a life, a chess game consists of a series of patterns
each of which has some causal relationship to the past but is not
entirely determined by it. Like a life, each chess game is unique,
hut, also like a life, the chess game moves from pattern to pattern
(board position to board position, event to event) that appear in
many other games and many other lives. And like the skilled therapist's,
the skilled chess player's expertise lies in part in being able to
remember and recognize these patterns far more readily than the untrained
person and to anticipate strategy on the basis of those patterns.
These patterns are best described as
"emotion-motivation-behavior bundles." By that I mean an
emotion (such as anger) that interacts with a motivation (she is a
nice person and does not see herself as hating her patient) that causes
some piece of behavior (she was furious at her patient but didn't
allow herself to recognize the anger, and during the session for some
reason she was unable to hear her patient). Young psychiatrists tell
stories by chunking details around such patterns, which can then he
combined in many different ways, or which may emerge in new form in
new patients. (The word "chunk" is used by cognitive scientists
to evoke the way people remember details by pulling them into a central
concept, like iron filings to a magnet.) Identifying these bundles
is complicated by the inherent oddity of separating out an expert's
own emotional responses from the relationship the expert is trying
to interpret. That is why it takes so long to become a psychotherapist
and why it is easier to be a competent diagnostician (but not a psychopharmacological
connoisseur). In psychotherapy, there are many more patterns related
to one another in more complicated ways. In some important sense,
you are not a competent psychotherapist until you arc a connoisseur-level
expert. There is no public and clear-cut threshold of adequacy, no
basic competence, as there are in diagnosis and psychopharmacology.
When psychotherapists tell stories,
they are learning to figure out the emotion-motivation-behavior bundles
that (as they would see it) explain the way people in the story relate.
Telling the story well (convincingly) demonstrates their mastery.
For example, for many months I met with a psychotherapeutically oriented
resident every Friday and chatted with her While the tape recorder
was running. When I met her, she was the chief resident of the outpatient
clinic. The strain of this responsibility on someone naturally shy
and prone to identify even with people she didn't like made her so
nervous that she lost ten pounds in the course of the year and began
to smoke. Over that year we talked about psychotherapy, how she had
learned to do it, what it was like to go into analysis-she had just
started analysis at the time of our conversations-and how she understood
what she was doing. These excerpts from our conversations give a flavor
of the way she told stories about how people were with people, why
they acted, and what they felt.
She's a very troubled lady.
She was incredibly depressed, chronically suicidal. She would come
to my office and-"sob" is not the word for it, the building
would empty. Everyone in the annex knew my Friday 3:00 patient was
there. Through all this she kept telling me in a semiconvincing way
how she loved me, in a maternal way. She suddenly partially got it
together, decided to get a job, went from no Prozac to three pills
a day, and started doing wonderfully. We went from doing crisis management
to talking about how- she felt about things and how she reacted to
people and what hurt her. How she felt about being in therapy as opposed
to how suicidal she was this week. Then I went on vacation. I came
back and tried to talk to her about what she felt like. She says,
yes, she missed me, but you know she understands I have to goon vacation.
By the way, she says, I flushed my Prozac down the toilet and there's
nothing to talk about because I can't help her and life is hopeless.
Then she canceled her appointment the next week. I tried to bring
it up, but she was absolutely not angry at me. I was important to
her, all this positive stuff. What happened to me is that I sat there
and I started to get furious at her. At some point I realized how
angry I was, I realized it was probably coming across to her, and
I felt I had to make some acknowledgment of that. But then she canceled
the next appointment. What my anger was telling me was how incredibly
angry and hurt she was but she's not able to express that to me. So
what she did was not conscious, obviously, but basically she made
me feel it and one of us was conscious of it and could do something
with it. The initial reaction is, no, I'm not really feeling this
because it wouldn't be right to feel that, how, can I get angry at
my wonderful poor sick kind patient who obviously needs help and is
in such distress, I couldn't be having thoughts of strangling her
right now, could I? So first you try to pretend it's going to go away
or it's not really there. When denial doesn't work, you hopefully
start to become aware of it, and if you're comfortable enough with
yourself and your emotions, you can pick it up and look at it.
I think [a second-year resident] has
learned to be out there, to really let his emotions out with the patient,
to really react however you react and be able to feed that back. Because
he doesn't feel threatened anymore. I think I'm more engaged now than
I was a year or two ago because I know I can shut it off. I know that
I have control over myself and my life, and I'm not going to lose
it in a session with a patient if I let myself get angry, if I let
myself feel close to them. I used to have a lot of reluctance to doing
that. Supervisors would say, what are you afraid of? The more I let
myself be comfortable looking at that, then I could use the information.
I could drift into a fantasy about this patient and wonder, what's
the character of the fantasy? That tells me where the patient is.
But the threat is that your emotions are out. It's safer to say, no
matter what this patient says or does it will not affect my life.
I'm not going to get upset or angry.
I got this intake, there was this couple
that had come in basically because the wife was having so much trouble
with her workaholic husband and she really felt like he was putting
in too many hours and working too hard, he wasn't home for her, he
wasn't emotionally available, he wasn't this, that, and the other
thing, and I sat through the interview going, this is my life, I don't
know how to help myself, I don't know how to help them, and I presented
in team. I went with the facts, but basically my presentation to the
team leader was, I can't take this case, first of all, I relate too
much, and second, I haven't figured out how to deal with it and maybe
someone older and wiser could figure out how to deal with it. I haven't
been able to figure out how to do it in my own life. And the team
leader just thought it was charming and wonderful and he said, "Well
that's great I think that's exactly why you have to take the case.
Because you have so much common experience, you can really use that
to help them." I said, "I've been struggling with this at
home for a year and a half and all we do is scream at each other."
He said, "Trust me." They had five sessions of couples therapy
and sent me a postcard six months later saving that their marriage
had never been better. I have no idea what 1 did.
Analysis-I'm now in the second week--truly
is regressive. I've gotten hack in touch with feelings that I had
as a child, which I never had access to. In face-to-face therapy,
I was making some effort to dredge up all this stuff, and it wasn't
working. Now, it seems like all this stuff is accessible that wasn't
accessible before. The whole experience has been rather like being
in the dark and haying the lights turned on. They're not all turned
on at once. But you can now start to make out shapes where all you
could see before was black. You have a little more access to yourself.
But also, as you find the light switch for yourself, you go back to
our office and show someone else where it is so they can turn their
I think as I get more experienced, I
have a better cognitive understanding of what I'm doing. I feel more
like, you know, when someone asks you how to get to the restaurant
and you can't really draw the map. I want to say, I know how to get
there, I know that when I see this house I turn, but I can't say,
well it's on this street. That's kind of how I feel.
Here feelings are causes. 'They become
entangled with a motivation, with someone's complicated set of hopes,
fears, and dreams, and through that entanglement they cause a particular
behavior. Mostly, the feelings the therapist talks about are negative.
That makes sense because the negative ones are those that trouble
people most. ("I didn't realize that I was upset with her, but
I put the oatmeal on the burner for breakfast, and you know, I just
forgot about it and her pot was destroyed.") What the therapist
often does in a story is to follow a feeling through a range of emotion-motivation-behavior
bundles. For instance, in the discussion of the "very troubled
lady," the resident talks about the good-girl patient who is
so miserable (and, one later infers, angry) that she lets the entire
building know but also loves the therapist, wants to please the therapist,
and so pulls her life together. The therapist goes on to say that
the patient is furious at the therapist when she takes a vacation
but does not want to acknowledge the anger, and the conflict leads
her to flush away the medication that she was taking to please her
therapist. Then the therapist segues into an account of how the patient's
unacknowledged anger made her, the therapist, angry, and how she sort
of recognized it and tried to "catch" it but didn't entirely
succeed, and the patient felt hurt and mad and canceled the next session.
This then led into a discussion of communicating anger without being
able to express it and ultimately into the therapist's anxiety about
her difficulty in acknowledging her own anger. A major theme of "powerful
feelings that you are afraid to acknowledge" dominates the account,
but there are multiple smaller patterns that the therapist infers
and patches together into a coherent narrative of a portion of someone's
life. In listening to this story, it becomes clear that the therapist
has met many people who have difficulty recognizing their own anger.
They are all different from this woman-each person is unique-yet,
listening to this therapist talk was like watching a chess player
recognize hoard positions and know instinctively what is going on
and what to do next.
There are several other features of
this therapist's discourse that are not uncommon. First, while good
psychodynamic residents use a language marked as a specialist's language,
with words such as "regressive," "transference,"
"internalized," and so forth, the language rarely--at least
in my experience--dominates the discourse, which tends to be couched
in commonplace words. Second, they use abundant metaphors to indicate
the thinking and feeling process. This woman uses spatial metaphors
to indicate emotionally powerful events--"shaping" events--and
she uses contact metaphors to indicate her capacity to understand
her own emotions: she "is in touch with" or "has access
to" herself. All people do this, but this discourse is so much
more feeling-focused than average that the metaphorical quality seems
very marked. The metaphors are particularly striking when this resident
talks about what she does as a therapist. Again and again, this therapist
resorts to spatial and contact metaphors to point to what she does,
and she feels inadequate to put the details of her practice into words.
This feeling of inadequacy is quite common among even the most skilled
and senior therapists. They have, in general, a remarkably difficult
time verbalizing what it is that they do. Third, many therapists tell
stories against themselves and use patients' stories to make sense
of their own experience. This is what this woman does, for instance,
in the supervision anecdote and the couples therapy anecdote: the
resident who cannot listen when he is threatened, the workaholic husband
who frustrates his wife because he is unavailable. The stories are
funny because they suggest that the doctor must remember that the
patient is the one with the illness. Finally, this therapist, like
many others, thinks that what she has learned to do requires courage
and is inherently good.
For young psychiatrists--particularly
psychotherapeutically oriented ones--this language of feeling pervades
their lives. "Two visitors? Oh no, that brings up all my childhood
anxieties." They are encouraged to talk about their feelings
about their patients, their teachers, and one another. They are told
that the most important feature of relationships is talking about
feelings. They are told--and they experience--that psychotherapy is
full of intense feelings. They are told--probably correctly--that
emotion is at the center of psychotherapy, that the therapy will "take"
only if a patient is emotionally involved in it, that a patient can
hear something fifty different times but will understand it only if
he hears it when he is emotionally vulnerable. They are told that
understanding people is understanding emotions. They use a language
that is so feeling-rich that to outsiders it seems a little strange.
Residents become deeply immersed in
one another's lives. Despite the striking and increasing emphasis
on biomedicine, young psychiatrists are enculturated by their institution
into the expectation of intense involvement with one another. My field
notes are full of this intensity, of April's feelings about Bambi,
of Bambi's interpretation of Chris's anxiety about April's feelings
about Bambi, of David's understanding of the role of Dr. Edwards's
supervision of Bambi on April's feelings about Bambi, of a constant
over-interpreted interdependence with peers. With psychiatrists, particularly
young psychiatrists testing the waters of their psychodynamic knowledge,
standard expectations of social distance disappear. If you do not
talk about your feelings and their personal sources in one-on-one
social interaction, you are substandard. This is heightened by an
intensified observational alertness, which means that psychiatrists
notice anxiety or distress more quickly than nonpsychiatrists and
are much more likely to ask about its meaning (this livens up dinner
parties attended by both psychiatrists and nonpsychiatrists).
A resident breaks up with her boyfriend
and says, "But it's really good to go through this with a group
of psychiatrists, they really understand." Chances are that she
will speak about the breakup in detail with many, if not most, members
of her class. Young psychiatrists will talk and talk about their experiences
and one another's with them, with others. They are, with respect to
private matters, the singularly most talkative people I have ever
met. They talk about private matters to the point that they may feel
abused. "We were very, very close," Suzanne said when she
was talking about another resident. "We started out last year
in the same location, even on the same team. He trusted me, I trusted
him. We were both going through a bad time, he's having trouble with
his girlfriend, I'm having trouble with my boyfriend. We're very supportive
of each other. What happened was that I started going to a therapist
so I had someone to unload on, but he didn't, he kept coming to me.
Boy, did he need to go to a therapist, but he didn't, he kept coming
to me. I had to sort of withdraw. I love this person, I care about
him a lot. It felt like his problems were starting to overwhelm me,
and I started to feel used."
The rest of the class talked about whether
she had a crush on him or he on her; why had he talked to her so much;
why had she put up with what had become an asymmetrical exchange;
could she tell, once he went into therapy, that he was changing; what
about her; hat did that say about their therapists? their capacity
One could argue that these young adults
have chosen a career in psychiatry because they enjoy talking about
feelings, and for many of them this might be true. But it is not true
for all, and whatever an individual's motivations may be, the culture
created by psychotherapy training is so powerful that the social demands
are hard to avoid. Residents get to know one another extremely well.
They work with one another, hang out with one another, are enculturated
side by side. They also participate in group therapy together. Most
residencies have what is known as a therapy "T group," or
training group, which is run by a professional expert in group therapy
and meets every week for an hour. In the residencies I visited, participation
was explicitly required only for a year, but most groups continued
to meet throughout the residency period. I was never allowed to attend
these groups, on the grounds that they were too private. But I frequently
heard about what had happened in them. During these sessions, people
who worked together daily were expected to talk about their private
vulnerabilities and fantasies about one another. Sessions not infrequently
ended up in tears or rage. They were promptly followed by working
interactions with the same people.
In the T-group, discourse was actively
psychodynamic. "There is a lot that goes on in the group,"
remarked one resident, "and it's weird because we're aware of
it. I've had kind of transferential feelings towards Fred because
I consider him to he like a father. I project feelings onto him. I've
told him so. I caught myself doing it. I described to him that I felt
that way, and fifteen seconds later I w as doing it again." "I
his discussion must have been particularly memorable in the group-I
heard about it from several people because the two men invoked were
at that time competing, at the end of their second year, for a chief
residency position, an administrative post with a fair amount of prestige.
The resident continued, "For me to drop my guard and admit my
weaknesses to someone that I'm openly competing with is a concern
to me because I'm showing weakness when I'm supposed to be in competition
and looking strong. Also, thoughts come to your head, like you realize
that you just admitted some degree of psychopathology to everyone
you work with. What will people think. Yet to be open is to be competitive,
because it is to assert psychodynamic competence, as if to say, "I
know myself, while you fear yourself, you refuse to acknowledge your
weaknesses." Another resident said irritably about the first
meeting of one T-group that Agnes--the resident who was soon labeled
the most psychodynamically astute in the group--had asked to be the
first person to tell the story of her life (they went around the group
in turn, in the beginning), and, by choosing to be very personal,
she had upped the ante and taken control of the group.
When young psychiatrists gossip, they are learning how to work. They
are at least as nosy and curious as the rest of us. Unlike the rest
of us, what they get from their gossip is professional expertise,
little narrative packets of behaviors, motivations, and emotions.
And the gossip is probably as important to their development as their
supervision is. I found the informal focus on how people are emotionally
put together particularly remarkable in the discussions about residents
who were disliked. Those residents the other residents dissected.
They knew that they should not really pass judgment on these people,
who they thought might be much like themselves, yet they couldn't
stand them. They really tried to figure out what drove them nuts about
these people. The following are excerpts from my conversations.
I don't really know, all I know is that he apparently has
a much harder time. When he was growing up, he didn't have any parents,
or maybe a stepmother or something like that, and Florida was kind
of a drug capital in that period, and I think he probably had a lot
of problems. 1 know he had a lot of therapy, but trying to give him
the benefit of the doubt, I just hope this is an improvement over
the way it used to be. I hope he's going in the right direction. I
think there are a lot of times when he shows that he has a conscience
and he's genuinely sorry for what he does. It doesn't seem like it
prevents him from doing a similar thing again. I will say this, though,
he has definitely added a lot of life, a lot of' spark to our otherwise
kind of boring social life that we had last year. There's a certain
neediness about it.
I've had conflicts with Anne, for example.
I've definitely used my understanding of her dynamics. I've understood
that the only way to resolve problems is to be very frank and honest
rather than harbor resentments. I haven't told her why I feel that
she's done what she's done. Very often, my understanding of her is
that she's rather narcissistic and that she really tends to walk over
people sometimes, and so when she goes to walk over me, I've called
her on it and I've told her that this is where I stand and these are
my concerns and this I why I would appreciate it if she wouldn't do
what she's doing, and she's responded to that. I haven't told her,
well, you're narcissistic and just don't think about other people.
Obviously that wouldn't go over too well.
Diane is what I would call a group
deviant. She's flamboyant, she's hysterical, by that I mean very dramatic,
everything's extreme in her descriptions of things. People looked
at that as peculiar and odd. So she got set on the outside fringe
of the group, not yet labeled the group deviant. Then she engaged
in some behaviors that irritated and angered, alienated her from certain
charismatic members of the group, and these charismatic members spread
the word. So everyone became sympathetic to the charismatic members
and further alienated from the outlier, and that was when she became
the group deviant. To fit in now, she would have to dump the odd behavior,
I mean that's like telling someone to grow two right arms. It's just
not possible for her to change her behavior like that. She would have
to go through five years of analysis to be able to change her defense
patterns and behaviors. When people get together and talk about the
difficulties of residency, it's Diane. All their concerns were legitimate,
but they weren't talking about anything more important, like how hard
it is to take care of people who don't want to become better. How
hard it is to take care of people who will never be functional. That's
hard. So we use Diane as a way of expressing anxieties and frustrations
These accounts display many features
of a young therapist's discourse: the technical language, the spatial
metaphor (although in the absence of personal reflections, there are
no contact metaphors), the identification of feelings, and sequences
of emotion-motivation-behavior patterns. What they add is the sense
of relentless determination in trying to figure out why, despite all
their training and all their rationality, some of their peers behaved
so badly (on the one hand) and the other residents weren't mature
enough to cope (on the other).
Psychologically minded people create
such models (large and specific) all the time. Psychiatric residents
(and others in training) have two additional sources of help in building
these models. The first is psychodynamic theory, which provides a
great abundance of partially abstract models to interpret human behavior.
The residents learn this theory from teachers, from peers, and occasionally
from books. The theoretical model suggests that if someone exhibits
a certain set of behaviors, the behavioral pattern is this and the
motivating emotions are that. For example, in a well-known book entitled
The Drama of the Gifted Child, the analyst Alice Miller describes
highly successful people who do not have the secure self-assurance
you would imagine. Their success seems hollow to them, their failures
monumental; although they are envied and admired by many, they feel
empty, abandoned, and depressed. They strive for more success to quench
these feelings, but to no avail. Miller calls these patients "narcissistic."
She describes a narcissistic person as someone who learned to be and
to do in order to please someone else and to be loved by them in return.
That is why they arc so successful and why their success is so meaningless
to them. Such a model explains what motivates these patients and,
ultimately, how therapy should be focused so as to help them understand
and reshape their motivations. Young psychiatrists read such a book
and make sense of it by using the model to explain people they know
or indeed to explain themselves. Miller remarks that many insightful,
intuitive children who grow up taking care of their parents by being
good, responsible children become psychotherapists as adults. That
is how they make use of their earlier intense interest in what their
parents felt and needed.) The models offered in various texts do not
all complement one another. Sometimes they flatly contradict one another.
(A famous example is penis envy. Some psychoanalytic writers believe
that women are motivated by penis envy; others do not.) In general,
psychiatric residents (or psychiatric clinicians) are not worried
by the contradictions, and in general they do not see their task as
one of arbitrating them. These models are tools they can use to help
them understand their patients. They are like spades and garden shears,
useful or not useful, rather than like equations, true or false.
The second source of models is a privileged
access not only to a greater-than-average range of human experience
(including serious depression and psychosis, which laypeople rarely
see and recognize) but also to feelings and stories usually kept private.
By the time they graduate, psychiatric residents not only have seen
hundreds of severely disturbed patients, they have heard hundreds
of detailed accounts of fantasies, actions, desires, frustrations,
and so forth, the likes of which most people encounter only in novels
and in a handful of living people. These are not abstract models.
They are stories of how one patient spoke about commonplaces for three
months in therapy and suddenly began to cry or another abruptly quit
therapy and called back four months later, or how the son of an entrepreneur
was crippled by his fathers great success, yet had to take care of
him as he sank into senility. These are like chess games a young psychiatrist
plays again and again, seeing lives unfold, looking for the ways different
strategies play out in different settings. They help a psychiatrist
say to herself, "Ah, that is the way you reacted to your brother's
death, but it is not the way all people would react. It is a unique
reaction, and it tells me something about you, because I have seen
similar reactions to different problems and I have seen people react
differently to similar problems."
This learning process probably helps
most young psychiatrists to sense other people's emotions more accurately.
At least the process helps residents to make fine distinctions between
emotions and their roles in different settings. I think it also enables
residents to sense emotions more keenly. My evidence is simple and
observational. I believe, having spent years in this world, that good,
psychodynamically oriented residents become more intuitive over time.
They seem to be able to meet a person for a short time and to summarize
that person's experience in a manner that rings true. Some residents
become identified as "wizards" who are able to interview
a patient and dazzle a crowd with their skill in understanding, who
give people in their office a sense that they have understood them
deeply. Even so, the understanding is undoubtedly shaped in an idiosyncratic
fashion: out of the many possible valid interpretations of one person's
behavior, a therapist settles on one, and, because no person has a
single interpretation of his own life, a patient's sense of being
understood arises in what is essentially a negotiation between his
perspective and that of his therapist. It must also be said that some
psychiatrists never learn. Some residents are clumsy in the psychodynamic
china shop at the beginning of their residency and remain so at the
"It's an anxious profession,"
another resident remarked at the end of his first year. It seemed
to me, in sorting through my transcripts and notes, that there were
different modes of and stages in coming to terms with psychotherapy.
First and most common was rejection and a sense of inadequacy, coupled
with an appreciation that psychopharmacology is easier to master.
All psychiatry residents feel this inadequacy to some degree throughout
most of their residency. How could they not? A second-year resident,
skeptical of psychotherapy but caught by his own expectation that
to be a good psychiatrist was to be a good therapist, reported, "I
felt like an imposter. Someone was actually coming to me weekly for
psychotherapy, and I didn't know what I was doing. My supervisors
would reassure me by explaining that it takes ten years before you
become comfortable doing psychotherapy. And I thought, ten years?
ten tears? I didn't expect to he an analyst after my residency, but
I expected to be confident. I thought, don't give me that crap. But
everyone said ten years. So I felt better, but I am still much more
secure with the psychopharmacology and much less secure with psychotherapy
I feel very put off by it. It's easier to be a competent psychopharmacologist
than it is to he a competent psychotherapist. The patients don't seem
like they're getting better, or a patient leaves and I feel terrible.
And I feel anxious, because even though I know it takes ten years
and all that, still I feel sheepish and stupid with a new supervisor."
Then one must become engaged with the
ideas of psychotherapy before being able to feel much ease in the
practice. This leads to mild paranoia, because a resident who recognizes
that there is a new way of' seeing but feels he hasn't got it thinks
that everyone is pointing at him. Of course, he is right. Senior psychiatrists
have meetings to talk about the residents and how they are doing,
and these discussions are in large part about the residents' personalities
and whether they can make it as psychiatrists. "They have these
meetings," Phil complained in his second year, "and they
talk about us. I'm sure they think I'm too extroverted and outgoing.
It's so unfair. I can't stand it."
Phil turned out to be a reasonably gifted
therapist, but he was not an intellectual, and he was not comfortable
in the training experience. By the beginning of his second year, he
had the guarded look of the hunted. "Before I was a psychiatrist,"
he said, "I was innocent on the unconscious level. Now I'm guilty
on the unconscious level. The year has been really hard. I'm sure
psychiatric training is harder than other fields. For myself, I've
had a lot of self-doubt about professional identity, about my ability
to do this work, the ability to be a psychiatrist, whether I've got
it inside of me. In cardiology, if someone had a specific arrhythmia,
there is just one specific treatment, and if that treatment doesn't
work there's a specific alternative. In psychiatry, first of all,
you don't have anything to diagnose that's as concrete as an arrhythmia.
But then, you can make a good clinical assessment on one level, but
if you neglected something you would he called on and criticized,
and you'd have to ask yourself, why did I do that' The chances are
that the reason I didn't go into a certain detail was so deeply seated
in myself that I'd have to do some serious self-analysis to understand
why 1 missed it.
"There are no excuses in psychiatry.
Everything you do is for a reason. Circumstance just doesn't exist
in the minds of psychiatrists. Senior psychiatrists are always looking
at you and judging you. I was on call the other day, and I slept from
about ii p.m. to 3:30 a.m. I went to sleep again at 6:00 a.m., and
for some reason my watch alarm didn't wake me up. I was late for sign-up,
and my excuse that my watch didn't wake me up was meaningless. I missed
the time for some reason: some unconscious motivation meant that my
watch didn't wake me up. That's understood. Any psychiatrist would
say that it's understood. My unconscious is guilty of not wanting
to go to morning sign-up rounds."
The final step in the learning process
is developing some sense of mastery. That people feel as if they know
who the good therapists are says something very interesting about
this profession, where you never see the professional's work. Residents
and more senior psychiatrists certainly had clear views about who
was as likely to be a good therapist and who was not. Often the judgments
were quite consistent. The capacity to use oneself to understand another
self is not, after all, a mystical quality. It is a part of human
intuition that some people have naturally and that psychotherapists,
who often fall into this category, learn to hone. What becomes surprising
is how the process of honing can make a person feel as if he is becoming
unnatural. It transforms the way he looks at people, thinks about
people, reacts to people. Good psychotherapists sometimes say that
they have always had the skills they have now learned to use, but
that using them skillfully has changed them utterly. Or so at least
In both of these approaches, the biomedical
and the psychodynamic, what one learns to do affects the way one sees.
A psychiatrist in a hospital (or a more biomedically minded psychiatrist)
learns to memorize patterns and starts to use them in a rough-and-ready
way. He learns to think in terms of disease and to see those diseases
as quickly and as convincingly as a birdwatcher identifies different
birds. For him, what is wrong with a patient is that the patient has
a disease, and being a good psychiatrist involves seeing the patient
in terms of the disease. For him there is a clear-cut difference between
illness and health. A psychiatrist in an outpatient clinic (or a psychiatrist
thinking psychodynamically) learns to construct complex accounts of
his patients' lives. He thinks in terms of the way his patients are
with other people and in terms of the emotions and unconscious motivations
that lead his patients to hurt themselves. Here there is no clear-cut
line between health and illness. What is wrong with a patient is that
his interactions with other people go or have gone awry, and being
a good psychiatrist involves understanding how and why. Both take
the complex mess that is human misery and simplify it in order to
do something about it. In the process, each approach constructs a
different person out of one unhappy patient.