Sunday, November 23, 2014

Overcoming Psychoanalysis

You may call this a success story if you like, but it shows the psychiatrist learning from the patient and not vice versa.

It is probably not an uncommon story. Anyone who has trained in psychoanalysis or a reasonable facsimile has been faced with the fact that Freudian and post-Freudian treatments do not work. Most often we learn it while working with a patient.

Clinically speaking, Dr. Robin Weiss’s patient, Julia, seems to have made some real progress against her depression. Weiss is happy with the outcome of the ongoing treatment. And she makes clear that Julia has helped her to become a better physician:

Many years have now passed. What’s become of Julia? She inhabits a life unrecognizable from this vignette, a life changed in many ways for the better. Alas, she still has a chronic relapsing illness — severe depression — for which there is yet no magic cure. But she has succeeded in training me to become a better doctor for her, and she continues to come to me for treatment. Though modern psychiatry can’t always cure every disease, I can at least help Julia do some of the heavy lifting.

Weiss is sufficiently self-aware to see that her patient was right to want to help her to get over the influence of psychoanalysis. 

We know that there is no magic cure for depression, but we also know that most psychiatrists today would prescribe medication and would direct the patient toward cognitive therapy.

Of course, Weiss prescribed medication. Without knowing more about the precise nature of Julia’s depression we cannot really say how much it helped.

And yet, Weiss’s approach to therapy does not seem to include the latest from cognitive treatment. At first, she took the opposite tack. Where Aaron Beck and the other practitioners of cognitive treatment ignored the supposed “root cause” of depression, Weiss, influenced by psychoanalysis, wanted to seek it out.

She writes:

Julia agreed to take antidepressant medication, which reduced her most immobilizing symptoms. Yet sitting in my office, wrapped in an afghan I had there for warmth, she looked like a sad and lonely waif. What was the origin of her melancholy? Unless we could better understand it, it would probably continue to predispose her to severe depressive episodes. So we embarked on more intensive psychotherapy.

Weiss wants to discover a root cause. Julia wants to make a human connection with Weiss.

This conflict, between Weiss’s clinging to a modified psychoanalytic framework and Julia’s fight for what she needed, defined the treatment.

Depressed patients fell detached, disconnected, and isolated. Therapy ought to allow a depressed patient to develop a rapport with his or her therapist. It is not rocket science. It is not difficult or complicated.

From the onset Julia knew it. Dr. Weiss learned it.

A human connection requires reciprocity between patient and therapist. If a therapist refuses to share any information about him or herself or if the therapist, at the limit, refuses any communication beyond empty interpretations, the patient will feel even more isolated, even more worthless.

Julia fought her psychiatrist because she knew that she needed to make a human connection and she saw that Dr. Weiss had to overcome her own training in order to let one happen.

Weiss recounts Julia’s opening gambit:

From the start of therapy, and despite her weariness, Julia mustered the determination to protest what she called the “rules of therapy” — especially the notion that I would not disclose personal information about myself during her treatment. She’d manage a faint, defiant smile and rattle off interrogations: “Don’t you get bored listening to us mental patients?” “You’re holding your head in your hand — do you have a headache?” “Do you have children? How many?”

She hadn’t learned this rule from me. She came to treatment under the assumption I would adhere to it. This was understandable; the caricature of the infuriating Freudian analyst, stroking his beard and deflecting the patient’s question with another question (“And how do you feel about that?”), pervades popular culture.

And in fact, the rule originated with Freud. In a 1912 paper, he advised doctors practicing psychoanalysis that the physician “should be opaque to his patients, and, like a mirror, show them nothing but what is shown to him.”

I will not explain why this is a terrible idea. I have done so elsewhere. This case report has value because it shows how Julia helped her psychiatrist to overcome her aberrant training. She had to help her doctor before her doctor could help her.

Of course, Weiss is not, strictly speaking, a psychoanalyst. And yet, she might as well have been. She has suffered its influence. She refuses to make a connection with her patient… thus driving her further into her mind and further away from human connection.

Weiss describes it:

Here, Julia’s instincts about my willingness to talk about myself were partially correct. I’m not doctrinaire, but neither am I one to divulge much about my private life.

Even if you’re not a classical Freudian analyst, there are good reasons for a therapist to adopt a posture of neutrality. For one thing, patients need to be free to take the discussion anywhere, including uncomfortable or taboo territories. If therapy were reciprocal, therapists might close off avenues of conversation that they themselves might want to avoid.

So I tended to be my usual “therapist self” with Julia: attentive, open and, I hoped, warm — yet neutral and withholding when it came to my own life. But the more I withheld from her, the harder she pressed me to open up. It was impossible not to wonder what lay behind her insistence.

Unhappily for Julia, Dr. Weiss uses her knowledge of post-Freudian psychoanalytic theory to misunderstand the case:

Julia presented me with a therapy challenge. She had honed the art of shifting the valence of a conversation toward the other person, hiding herself. She desperately wanted to attach to me, and this was her tried and true method of establishing intimacy — or her approximation of it. But by persistently asking me personal questions, she also threatened to repeat the dynamic that left her feeling isolated and alone in the outside world.

If Julia was severely depressed, she was not establishing intimacy or any other kind of connection in the real world. By asking personal questions Julia was highlighting her therapist’s failure—perfectly rationalized—to make her feel less alone in the world.

Undeterred Weiss offered an interpretation, to the effect that Julia was merely trying to repeat in therapy her relationships in the outside world, the pattern for which derive from childhood:

When I pointed this out to her, she withdrew. No matter how gently I offered this observation, she experienced it as a rebuke, a hurtful break in our growing closeness. However, if I failed to point out these moments, I feared she wouldn’t see that she was unconsciously trying to mold our relationship into yet another of those unsatisfying one-way relationships in her life. I was in a quandary.

A quandary of her own making, one must add. Obviously, Weiss was trying to make the relationship unsatisfying. Julia was trying desperately to forge something else.

Taking a page from D. W. Winnicott, Weiss calls him a psychiatrist. In truth, Winnicott was an influential psychoanalyst who initially trained as a pediatrician.

Fortunately, Weiss learns the futility of offering even post-Freudian interpretations:

As therapy continued with her, I heard how flat and tinny I sounded whenever I attempted to analyze what was going on between us. When I lapsed into too clinical a mode, our connection would wobble, and her alienation became palpable.

So, Weiss began to change:

In contrast, as I began, in the face of her challenges, to let down my guard, our alliance grew stronger, and she became open to treatment. We would laugh together about her bringing me just the right greeting card or a flower from her garden — exhibiting her need to challenge “the rules” and exposing my need to interpret her actions….

I may have been a slow student, but eventually I understood: I was the one who had to change. From then on, when she saw that look in my eyes, I said yes, I did have a migraine. We followed episodes of the TV show “ER” together, and I told her where I was going when I left for vacation.

The point is well taken and important.

Just about everyone who has ever trained in anything resembling psychoanalysis has, advertently or inadvertently suffered Freud’s influence. Most of us who did so have had a patient who showed the futility and the uselessness of following even a modified version of Freudian technique.

I had similar experiences myself, so I recognize it well. I applaud Robin Weiss’s honesty in sharing her experience.


Larry Sheldon said...

I have evidence that some of this kind of activity does irreparable damage.

Larry Sheldon said...

I wish I could talk about it.

BabbaZee said...

Many people continue to assume that serious problems such as hallucinations and delusional beliefs are quintessentially biological in origin, but we now have considerable evidence that traumatic childhood experiences (poverty, abuse, etc.) are associated with later psychotic experiences. There is an almost knee-jerk assumption that suicide, for instance, is a consequence of an underlying illness, explicable only in biological terms.

But this contrasts with the observation that the recent economic recession has had a direct impact on suicide rates, a rather dramatic (and sad) example of how social factors impact on our mental health. Neural activity and chemical processes in the brain lie behind all human experiences, and it’s undoubtedly helpful to understand more about how the human brain works. However, this is very different from assuming that some of those experiences (psychosis, low mood, anxiety, etc) should be classified as illnesses.

The human brain is not only a complex biological structure; it is also a fantastically elegant learning engine. We learn as a result of the events that happen to us, and there is increasing evidence that even severe mental health problems are not merely the result simply of faulty genes or brain chemicals. They are also a result of experience — a natural and normal response to the terrible things that can happen to us and that shape our view of the world.