Wednesday, June 17, 2009

Are Psychiatrists Professionals, Friends, or Healers?

Another question from a visitor:

Are psychiatrists professionals, friends, or healers? I personally believe that healing occurs in a time and place beyond professional rules and regulations. Even friendships can be healing. I wonder if professionalization of medicine is antithetical to a healing process that is dependent on...deep human connection.
This is a good question, one I've often thought about.

The standard of practice in psychiatry, and in other areas of medicine, is for the therapeutic relationship to be "well-boundaried." Mind you, this seems like an obvious truth; furthermore, any healthy friendship also needs to be "well-boundaried." Many unhealthy friendships or family dynamics are problematic due to unhealthy or absent boundaries. But in psychiatry, there are formal legal and professionally-mandated restrictions around the type of relationships permitted between therapist and patient, or between therapists and former patients. In general, I would say the rule is that any interaction between psychiatrist and patient (or between psychiatrist and former patient) needs to be considered a "therapeutic action," or at least an attempt to be a "therapeutic action," and if this interaction cannot be justified as such, it would be considered outside a healthy boundary. These rules protect patients from unethical practioners.

But I do consider any type of healthy human interaction to be a manifestation of a type of friendship. And I consider it a healthy way to live, to consider that all of one's interactions in the world are "friendship-building" activities. To experience the very personal relationship of psychotherapy as strictly bereft of "friendship" seems wrong to me.

Different individuals will have different needs or wishes in this regard. For many people, they prefer to interact with a psychiatrist or other professional in a polite but formal and distant way. Many people would not want to have a friendship with their psychiatrist or physician.

For many others, closeness and trust in a therapy relationship is extremely important to nurture.

One thing I strongly feel to be true is that the therapy relationship needs to be a setting in which growth of healthy relationships outside of the therapy relationship can be encouraged.

I am reminded of some of the psychiatric theory from the previous century about "object relations." This theory generally considers that relationships become "internalized" as abstract mental models, during the course of development. Relationships with parents during early childhood become the first internalized models. Recent evidence establishes that early peer relationships are extremely important in psychological development, perhaps having an equal or larger effect than parental relationships in many cases. Included in these internalized relationships are a sense of "other," a sense of "self," and a sense of expected dynamics between "self" and "other." Future relationships then develop which tend to be in synchrony, or in a type of resonance, with the internalized models. If these internalized models are disturbed by unhealthy relationships, absent or neglectful caregivers, abuse, environmental adversity, or inherent neuropsychiatric symptoms (such as innate tendencies to be anxious, irritable, depressed, etc.), then future relationships are likely also to be disturbed. This leads to a vicious cycle of unhealthy relationships and escalating symptoms.

In a therapeutic relationship, I think this "object relations" idea is important. The therapeutic relationship should aim to be one in which previous vicious cycles are not allowed to repeat. Over time, if the therapeutic relationship is healthy, it could perhaps become "internalized" as well, hopefully as a model of comfort, stability, nurturance, respect, trust, and healthy boundaries. In this way, I think the role of therapist is a bit more like the role of a parent, in that there is an element of friendship, a strong expectation of nurturance, a benevolent "paternalism" to some degree (some desire this element more or less than others), but also the observation that the "parent" becomes less and less necessary for meeting personal needs as the relationship develops over time.

There can sometimes be experiences of very great personal need. The experience of therapy can partially meet this need. The boundaries of the therapy can feel tremendously frustrating for a patient if this need is only partially met. Yet I feel that part of the growth experience in therapy can be to come to terms with this frustration, i.e. that the therapist is a positive, caring figure, but also that the therapist is limited and unable to meet any need completely or perfectly. If the therapy is to be truly effective or "healing," then the more complete or "perfect" satisfaction of needs eventually could occur outside of the therapy, during daily life.

Here's a light-hearted poem about this theme. It's by Hal Sirowitz, from the collection My Therapist Said.
You shouldn't tell everyone that you're
in therapy, my therapist said. Some people
might think you're crazy. If
someone asks why you go to the city
at the same time each week, you should
just tell him that you have an appointment
with a friend, which is not really a lie,
because I'm your friend. But I'm also
so much more. You can insult me, & I'll
never get mad. I'll just say that you're
transferring again. I'll never leave you,
but you can leave me. One day you'll
tell me that you don't need to see me anymore,
& instead of being mad, I'll be happy,
because that'll mean you're cured. But
I wouldn't advise you to do that
in the near future. You still have problems.

* I like this poem but it's okay with me if you tell people you're in therapy!
**Thank you to the reader who found the author's name & info for me.


mysadalterego said...

1. I really liked that piece too. But maybe it hints at why I shouldn't be a psychiatrist.

2. Thanks for clearing up the idea of object relations. I've never read a clear coherent explanation of it and always thought it was some kind of voodoo.

3. I really disliked the paternalism that my last shrink took toward me. I kept yelling at him to quit trying to save me and just *help* me. It never got through. He got mad at me for not "accepting" his paternalism. I really am against it in any doctor-patient relations. But I do know that some kinds of patients want it. I usually try to refer them to someone else.

Anonymous said...

I need a type of nonjudgemental, guiding, somewhat protecting paternalism from my psychiatrist.

My mom met my pdoc one day and expressed her concern about how dependent I was on my psychiatrist. She thought I needed to become more independent and self-relient. I wondered about the same thing too.

My pdoc replied that he encouraged a type of "maternal dependence" the type that allows a person to feel safe and take chances, and grow, in a safe environment.

I like that. I like that there is always at least one safe place for me to just "be" no matter how I am feeling. I appreciate that there is always at least one person who will continue to benevolently guide me and support my growth.

I believe this has been, and continues to be one of the most important factors in my struggle towards being mentally well. It is so therapeutic for me and continues to be what helps me both heal, and keep trying even if nothing else seems to consistently help me.

Just one more thing for me: If I did not believe my psychiatrist actually liked/enjoyed my company...I could not open up as much as I do. I feel safe to trust and express myself because there is an element of "friendship in our relationship. I recognize this friendship has a few more boundaries than other friendships...but I need someone to really care for me in order for me to let them in.