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.

Saturday, January 18, 2014

First Day at The Waldorf

I know it's Saturday, but the meeting is quite a whirlwind, so I'm gonna start back on Wednesday and work chronologically. My Wednesday groups were:

1. On Being Supervised: The Science and Art of Teaching in a Supervisory Relationship
2. Workshop on Psychotherapy Training: Who Are We Training and How Do They Best Learn?
3. The Analyst's Experience of Loss and Death
4. Lacanian Approaches to Treatment of Psychoses

Note: I can't reveal any clinical material that was discussed, so I'm going to try to present a gist of what each group was like.

1. On Being Supervised...

This group was chaired by a friend of mine, which is the main reason I signed up for it, but it's good I did because it was excellent. The presenter was C. Edward Watkins, from Texas, who it turns out is not an analyst, but has written a lot about supervision. He talked about establishing a written contract with supervisees, indicating rights and responsibilities. When you consider how intimidating supervision can be, this is a great idea. He talked about the supervisory alliance, which is as essential as the therapeutic alliance. Plus the guy has the most wonderful Southern drawl.
One thing I would have liked to hear more about was parallel process, where the dynamic between the patient and the therapist starts to play out between the therapist and the supervisor. It can be eerie and a little embarrassing when it happens, but it helps to elucidate a lot that's going on in the transference.
What was really interesting though, was the discussion. Some people talked about the difficulty of teaching psychodynamic psychotherapy to pharmacologically minded residents. There's a lot of, "I dare you to convince me that this is useful when I can just prescribe meds or do CBT." Others said we, as supervisors, have to meet residents where they are and let our enthusiasm and knowledge spark their interest. Some complained that even residents who try to be interested often don't have an ability to appreciate or understand the impact of the unconscious. I said there needs to be a balance between encouraging enthusiasm and healthy skepticism. But the discussion shifted in the direction of, "Who pursues a career in psychiatry today, and what do they expect the nature of that career to be?" And, "Is it possible to be a psychiatrist without any sense of the workings of the unconscious?"

2. Psychotherapy Training.

I was really looking forward to this group, because I recently became (got suckered into being) the curriculum director of the psychodynamic psychotherapy training program at my analytic institute. The people presenting at this group have done a lot of work in the area of teaching psychotherapy, especially to residents.
I was disappointed, though. The presenters are co-authors of Psychodynamic Psychotherapy: A clinical manual, and Psychodynamic Formulation, which seem to be pretty popular, but which, in my opinion, advocate a cookbook approach. They talk about "operationalization", and use constructs such as, "Describe/Review/Link" and "Listen/Reflect/Intervene". And then they break these down into subsections. Their argument is that since residents are coming from a medical model that uses algorithms, they need to be given an algorithm. My argument would be that this is precisely why they need to NOT be given an algorithm.
The book I use, Becoming a Psychotherapist, by Rosemary Balsam, is wonderfully written and decidedly not cookbook. I wish I had known about it as a resident. It's a bit dated-there's a discussion of whether or not therapists should have ashtrays in their offices. But she manages to convey a sense of how to think about the patient, and what's going on in a given session, without resorting to lists of defenses and ego functions. The author, incidentally, was the first person to write about the analyst's pregnancy.

3. The Analyst's Experience of Loss and Death

This was the best group I attended. The presenter was a woman who talked about illnesses and deaths in her family, and how they affected her work with a particular patient. She included process material, so we could hear the give and take between her and her patient. The issues discussed included whether and how much information to disclose to a patient, and this can vary between patients. Some you tell more than others-you just have a sense of what's right. There are issues surrounding the analyst's wish to share, wish for connection, and the need to say aloud and make real what is so pressing internally.
There was a discussion about the holding environment that we create for our patients, and wondering what creates the holding environment for us, that allows us to do our work.
One of the main questions was, "Does the patient ever really not know?" given that there are always unconscious communications taking place.
Then there was the discussion of what happens after. How does the analyst work with the patient's fantasies about what's happened? These days, lots of information is available to patients online, and they do learn about us, even about our tragedies. And some patients treasure the idea that they know something about the analyst, that the analyst doesn't know they know, and will not discuss their thoughts and feelings.
The presentation was incredibly moving, so much so, that many of the people in the room felt comfortable enough to talk about their own losses, and how these have affected their work. My feeling is that a presenter who can describe such painful experiences, and create an environment that allows people to open up about their own pain, has done something right.

4. Lacanian Approaches to Treatment of Psychoses

I signed up for this group because I have a psychotic patient with whom I feel I'm hitting a dead end in therapy, and I wanted a new perspective. I trained in a Freudian, ego psychological model, so I know nothing about Lacan, except that he seems to be very popular among some analytic sectors, and that Lacanian work advocates intentional lack of clarity, to open up avenues of interpretation for the patient.

Since this group was highly case-based, I can't write about what was discussed. I thought, instead, that I'd try to write about some of the Lacanian concepts that came up in the discussion.

This is from Wiki:

Jacques Marie Émile Lacan (13 April 1901 – 9 September 1981) was a French psychoanalyst and psychiatrist who has been called "the most controversial psycho-analyst since Freud". Giving yearly seminars in Paris from 1953 to 1981, Lacan influenced many leading French intellectuals in the 1960s and the 1970s, especially those associated with poststructuralism.

Lacan's first official contribution to psychoanalysis was the mirror stage, which...describes the formation of the Ego via the process of objectification, the Ego being the result of a conflict between one's perceived visual appearance and one's emotional experience. This identification is what Lacan called alienation.

The Three Orders

The Imaginary is the field of images and imagination, and deception. 

The Symbolic order structures the visual field of the Imaginary, which means that it involves a linguistic dimension... Language has Symbolic and Imaginary connotations...

The Real, for Lacan, is not synonymous with reality. Not only opposed to the Imaginary, the Real is also exterior to the Symbolic. Unlike the latter, which is constituted in terms of oppositions (i.e. presence/absence), "there is no absence in the Real." Whereas the Symbolic opposition "presence/absence" implies the possibility that something may be missing from the Symbolic, "the Real is always in its place."

The big Other is designated A (for French Autre) and the little other is designated a. 

"1. The little other is the other who is not really other, but a reflection and projection of the Ego. He [autre] is simultaneously the counterpart and the specular image. The little other is thus entirely inscribed in the imaginary order.

2. The big Other designates radical alterity, an other-ness which transcends the illusory otherness of the imaginary because it cannot be assimilated through identification. Lacan equates this radical alterity with language and the law, and hence the big Other is inscribed in the order of the symbolic... The Other is thus both another subject, in his radical alterity and unassimilable uniqueness, and also the symbolic order which mediates the relationship with that other subject."

The Name-of-the-Father (French Nom du père) is a concept that Jacques Lacan developed from his seminar The Psychoses (1955–1956) to cover the role of the father in the Symbolic Order.

I don't understand any of this, but I think the idea, at least with respect to psychoses, is for the patient to get unstuck from the Imaginary order, and make his way at least to the Symbolic order, if not to the Real. Or it's The Emperor's New Clothes. I can't tell.

That's it for today. Next up: Winnicott in Aspergers; Self-Disclosure; and Single Case Report Research.