Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Friday, December 6, 2013

Use the Couch, Luke

First off, I want to state that my post, The Couch, First Session, got more hits on its first couple days than any post I've ever written, and I don't know why.  Is it that in questioning the validity of the DSM-5, and the efficacy and safety of psychotropic meds, people want something deeper? Is it the freak show effect-who are these weirdos? Is it a general interest in something you've heard of but didn't know much about? I'd very much like to know, so if you have any thoughts about it, please share them.

This is meant to be a follow-up post, where I write about what it's like for me to be an analyst. In later posts, I'll go into more detail about what it's like to work as an analyst. Appropriately, I'm going to free-associate.

One admittedly small way my training has helped me-and this is mainly from my own analysis-is in finding things. You know when you misplace something, and you look all over for it, and you can't find it? That doesn't happen so much anymore. Instead of trying to figure out where it could or should be, or methodically rooting through drawers and cupboards for hours, I free associate. I just relax and wait for the first thought to pop into my head, and then I go wherever that thought seems to indicate, and most of the time, I find what I'm looking for. If that were all analytic training had done for me, I'd eat my hat, but it is a perk.

Another change I've noticed in myself is what I call "The Vampire Effect".  As a medical student and resident, I found myself looking at people's veins. Not just patients, mind you. Friends, family, the new acquaintance who was wearing short sleeves when he shook my hand. My eyes would wander, surreptitiously, I hope, to the antecubital fossa, and I'd think, "Hm, that's a pretty nice vein. I could get blood out of that." No doubt this habit was related to the fact that the better I was at drawing blood, the more sleep I could potentially get on call. And I'm grateful that it seems to have faded.

But something similar happened with my analytic training. Something related to a skill I needed to develop to become an analyst. Something that is experienced by other analysts and analytic candidates, but less so or not at all by most others. ( I really hope the random Joe walking down the street doesn't spend time thinking about getting blood from people's veins). It's a way of thinking analytically, which sounds pretty obvious. But you get in the habit of listening for latent content, and for recognizing that there are underlying unconscious processes going on all the time, and that manifest content is not always what it seems, and that unacceptable thoughts and feelings often appear in other guises.

All well and good, but try telling the friend who believes he's never had an irrational thought in his life that he chose his profession not because he "just happened to like it", but because he feels competitive with his (father, mother, spouse, sibling, cat, take your choice). Or telling the friend who "forgot" he had a meeting with his boss that he has conflicts about his aggression towards authority figures.

The responses you get, if you're foolish enough to say things out loud, are along the lines of, "Oh, please, don't give me that psychobabble, I just forgot." And you respond with, "Okay."

But meanwhile you're thinking, "A repressed memory is a forgotten one from the subjective point of view of the individual in whom repression has taken place. Indeed, we may remark parenthetically that we don't know for sure whether there is any type of forgetting other than repression." (Brenner, Charles; An Elementary Textbook of Psychoanalysis; New York: Doubleday, 1974, p.81).

I hope I'm not arrogant enough to think I always know what's really going on with everyone. In fact, if I did think that, I'd be pretty crappy at my job, because I wouldn't be able to listen for anything I didn't expect. But in the same way that medical training allows you to recognize certain constellations of symptoms and signs as a particular disease entity, one that someone untrained might miss, analytic training allows you to recognize certain basic ideas about conflict and the unconscious.

The point is, it can make you a little nuts if you see stuff that other people don't, especially family members, and I think it makes you gravitate more towards being around other analysts, or people who are trained to think analytically.

The first class I took as a candidate was, not surprisingly, Introduction to Psychoanalysis. One of the readings for that class (I can't seem to find it), described qualities necessary to practice psychoanalysis. There were things like, patience, selflessness, comfort with silence, openness, lack of judgement. It made Psychoanalysis sound like a monastic order. I think that's pretty close to how it feels. There's a definite religious quality-the institute I'm affiliated with is like a shrine to Freud:

But I've come to think that it's more like being a Jedi. You're involved in this archaic practice that requires years of training and apprenticeship. Most people think it's useless or non-existent, but you and your fellow Jedis recognize that there's a powerful, universal force, the unconscious, that affects everything and everyone. As I understand it, George Lucas underwent a Jungian analysis, so the analogy may not be that far off the mark. And sometimes, a lightsaber is just a lightsaber.


  1. Just a guess, but maybe the spike in hits for your post "The Couch" was due to its being featured on Shrink Rap.

    Some laypeople are anxious that therapists, especially analysts, "analyze everyone they meet." I suppose dynamically trained therapists vary in the degree to which we do. In the post below, I aim to reassure people that I go through life pretty much as every else does. Of course, the potential is always there...


    1. Nice post. While I was reading it, I realized that my post might make it sound as though I walk down the street diagnosing people. As you say, only if it's some really aberrant behavior, like a particularly ugly building for architects.

      I find myself caught in analyzing mode with people I know, usually know well, who are behaving in problematic ways and clueless as to why. It's hard not to think like a shrink under those circumstances, especially with family members (teenage children).

      Reasonable thought about Shrink Rap linking to the post, but they've linked to other posts of mine, so I'm not really sure.

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  3. I think that psychoanalysis and psychodynamic training should be having a Renaissance of sorts. I base that on a number of things I have encountered in my training and reading. The initial proof positive for me was attending Otto Kernberg seminars and reading his work on borderline personality disorder. Back in the day, there were no other approaches to treat people with severe problems with chronic suicidality and parasuicidality. I was fortunate enough to train with Jerome Kroll who taught me more about the disorder and psychotherapeutic techniques. Jon Gunderson's work with borderline personality disorder with borderline personality disorder is notable and his dynamically based GPM has been shown to be as effective as dialectical behavior therapy. I am currently half way through Eric Kandel's latest book "The Age of Insight" and he writes very convincingly about Freud's best thinking (as well as critiquing what was not his best) in looking at the relationship between art and science. Rather than rejecting Freudian psychology out of hand - Kandel uses Vienna in the interaction between art, literature, and psychoanalysis to demonstrate an initial focus on unconscious emotion on the part of the artists and the person viewing the art and how that was subsequently developed. Kandel seems like a champion for the unconscious to me and at the level of neuroscience it makes perfect sense.

    I think it is also notable that there seems to be a conscious effort to avoid the significant areas of the unconscious that Freud was focused on. There is hardly anyone who can talk with authority about the sexual consciousness of men or women. I used to depend on the work of the late Ethel Person. In a discipline that was focused for so long on unconscious sexual dynamics - what has happened? We are left with a little manual of pathological sexual behaviors, some notions of a new "sexual addiction" supposedly with the same neurobiological substrate as other addictions, and no insights into the sexual consciousness of 21st century people beyond what you read in the latest embarrassing magazine polls.

    Psychoanalysis like psychiatry has survived because when all of the rhetoric clears it is one of the few areas you can turn to a get unique answers. During the decades of viewing the brain as a powerful computer, the idea that each computer is unique in its experiential computations seems to have been lost. Psychoanalysis gets us back there.