Silence

The idea for this post came from a reader who prefers to remain anonymous, but I did want to give due credit, so, you know who you are, and thanks.

Silence is very important to me, both professionally, and personally. I'm pretty sure I picked the right profession for myself, because I don't much like talking (I do like listening), and I'm comfortable sitting silently with patients.

As an aside, one of the attendings from my residency did his residency, way back, at Menninger, when the Menninger brothers were there. So he was surrounded by a lot of analysts for 4 years, and he told me, "For people who spend their days listening, when you get them in a room together, they sure do like to talk."

I have found this to be true, but maybe not to the extent I formerly believed. In one of my first analytic classes, we read a paper about choosing patients who are appropriate for analysis. When I walked into the classroom, before class started, the guy teaching the class asked me what I thought of the paper. So I summarized. "You can't be too sick, you can't be too well, and you never know 'til you try." At the time, I thought that was pretty much everything there was to say about the paper, even though we went on to discuss it for 1 1/2 hours.

Now I'm not so sure. Maybe it has something to do with the value analysis places on language-it is, after all, a "talking cure" (Note that the phrase was coined by Bertha Pappenheim, AKA Anna O, while she was being treated by Joseph Breuer for hysteria. Hers is the first case recorded in Studies On Hysteria, by Breuer and Freud). Or maybe it has to do with the fact that the more time you spend listening to a person, the more you discover how much more there is to know about that person. And the same is true for most, if not all subjects. The more you know about a subject, the more complex you realize it is. So if I thought there wasn't much to say about that paper, it was probably a reflection of my ignorance.

What about silence? It's not the therapeutically exclusive provenance of psychoanalysis. It happens often in face-to-face therapy, and it may even be more difficult to tolerate in that setting than in analysis, where both the analyst and analysand are protected by the lack of eye contact.

Silence can take on many meanings in a therapeutic setting. For the patient, it can be withholding and aggressive, as in, "You can't make me talk!" It can be a form of hiding, as in, "I'm ashamed of my thoughts and feelings, so I'm not going to humiliate myself by sharing them." It can be an attempt to level the playing field, "You don't tell me anything about yourself, so I won't tell you anything, and that way I won't feel helpless and inferior."

It can also be an expression of trust, "I'm comfortable enough with you that I don't feel obligated to entertain you or be socially appropriate by babbling or trying to make conversation." And it can represent an attempt to share an experience or idea that is difficult to verbalize.

Patients have feelings and thoughts about the therapist's silence. It may be seen as punitive, humiliating, rejecting, abandoning, empty, containing, comforting, and many other things.

Therapists also have views about their patients' silences. Are they being hostile, or controlling? Are they confused? Are they attempting to sort through some experience that has not existed for them in the verbal sphere? Are they frightened? Am I doing something wrong? Am I doing something helpful? Do they need me to say something? Am I distracted and therefore have nothing to say?

These questions obviously reflect therapists' feelings about their own silences.

One important question is, why is silence often experienced as uncomfortable? The straightforward answer is, because that's not what people do in normal social interactions. But why is that? What's wrong with not talking? It's true, we're social beings, but speech is not the only form of communication.
At parties, people who don't talk much are considered uninteresting. In many educational settings, children who prefer to take in a discussion and not comment frequently are often thought to not be paying attention. And in medical school, when I was in new, complicated settings like the OR, or the ICU, and was asked by residents or attendings if I had any questions, I usually didn't because there was so much new information to absorb, I hadn't yet reached the point of being able to formulate a question. This was sometimes viewed as evidence of lack of interest on my part.

So we can agree, I think, that both silence and speech are complicated. One thing I wonder is, what happens when clinicians not only don't have time to talk with their patients, but don't have time to sit in silence with them, either?


These are some interesting quotes about silence, that I found on PEP-Web:

From the APSaA Winter Meeting, 1948:

CHAIRMAN: President William C. Menninger, M.D.
2:00 P.M. Robert Fliess, M.D. (New York): Silence and Verbalization: On the Theory of the Analytic Rule.
Discussants: Therese Benedek, M.D. (Chicago); Robert C. Bak, M.D. (New York)
Author's Abstract: Verbalization releases regressive affect, collateral to repressed ideation, thus interfering with the maintenance of repression. The speech-apparatus is substituted for different erotogenic zones, whereby speaking becomes excretory instinctual discharge, words excretory product, and silence equivalent to sphincter closure. Technical and theoretical consequences deriving from these “pleasure-physiological” considerations are discussed.


Greenson, R.R. (1961). On the Silence and Sounds of the Analytic Hour. J. Amer. Psychoanal. Assn., 9:79-84

The most frequent silence met with in psychoanalytic practice is the silence of resistance. This silence means that the patient is either consciously or unconsciously unwilling to verbalize. Since the patients in our psychoanalytic practice are attempting to communicate to us in accordance with the basic rule, i.e., attempting to put all their thoughts into words, if they become silent, it means that they are opposing the procedure of psychoanalysis. It is then our task to overcome this obstacle by attempting to find the motives for this resistance. Here, we are often aided in our task by the fact that the patient communicates despite his resistance...
Silence, however, may not only indicate a resistance to a certain content but may itself be the content which the patient is trying to convey. For example, patients may fall silent during an analytic hour when they are unconsciously repeating some historical event in which silence was an important element. Primal scenes and primal auditions often make their first appearance in the analytic hour as a restless, agitated, wide-eyed silence. The patient is repeating in the presence of the analyst the silent excitement and anxiety of the primal experiences.
Silence may indicate an identification with a silent object. This happens frequently in the analysis of candidates, who in this way identify with their silent analyst. This should be kept in mind when the silent patient seems to be not only comfortably silent, but confidently and poisedly silent. Furthermore, silence can represent an identification with an inanimate object, a sleeping object, or a dead object. This reaction, however, I have only seen in extremely disturbed and repressed patients.


Zeligs, M.A. (1961). The Psychology of Silence—Its Role in Transference, Countertransference and the Psychoanalytic Process. J. Amer. Psychoanal. Assn., 9:7-43

Let us first conjecture as to what a state of silence between any two (or more) human beings might signify. Obviously it could reflect many different psychic states and qualities of feeling.2 It might evidence agreement, disagreement, pleasure, displeasure, fear, anger, or tranquility. The silence could be a sign of contentment, mutual understanding, and compassion. Or it might indicate emptiness and complete lack of affect. Human silence can radiate warmth or cast a chill. At one moment it may be laudatory and accepting; in the next it can be cutting and contemptuous. Silence may express poise, smugness, snobbishness, taciturnity, or humility. Silence may mean yes or no. It may be giving or receiving, object-directed or narcissistic. Silence may be the sign of defeat or the mark of mastery. When life-and-death situations are
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2 Because of its ubiquity, silence has been thought about in many frames of reference. Poets, dramatists, and philosophers have loosely used the concept "silence" metaphorically and allegorically to symbolize death, eternity, truth, wisdom, strength, etc. Literary references to silence are frequent in the classics from all periods of history...
3 It is interesting that the aphorism, "Silence is golden, " represents what is left of the complete saying, "Speech is silvern, but silence is golden, " the part about speech having since dropped out of popular usage, historically attesting to the transitoriness of speech as compared to the permanence of silence. This derives from an ancient proverb written in Aramaic which first appeared in the Talmud Megillah and Midrash Rabba Esther (Chapter 6) in relation to prayer, as follows: "If a word is worth one selah, silence is worth two. (Silence invokes Thy praise.)"... The later Hebrew equivalent then became, "If a word be worth one shekel, silence is worth two, " pointing to the material advantage of keeping one's own counsel...
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being sweated through there is little occasion for words.3 Silence may be discreet or indiscreet. A tactful silence serves to prevent the expression of inappropriate thoughts and feelings. The art of being tactful combines the skilled use of silence in verbalized as well as nonverbalized action. Thus there is a hidden component of silence in every verbalization. When complete silence is inappropriate or impossible, a gesture, grimace, or mimetic expression serves as a compromise between verbal and nonverbal communication.

I'd love to hear about people's experiences with silence, so please comment.

The Rest of the Meeting

As much as I enjoy the annual APSaA meeting at the Waldorf, I find it exhausting. So I only have three more groups to write about, because that's all I could manage to get myself to.
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D. W. Winnicott

1. A Winnicottian Approach to the Treatment of Children and Adults with Asperger’s Syndrome: The Psychic Impact of Neurological Difference

This was another case-based group, so I'll have to stick to theory. A member of the British "middle school" (that's halfway between the Kleinians and the Freudians), Winnicott was a quintessentially British pediatrician. He had a drawing game he would play, particularly with children, where he would begin a drawing, and the child would add something, and they'd take turns, until he got a sense of what was happening emotionally for the child. His intuition with patients was astonishing. In The Piggle, he writes about his treatment of a young girl who went by the nickname, "Piggle". Her family lived far from him, so there were long stretches when they weren't meeting regularly. After one of those periods, she came to his office, and as soon as he opened the door and looked at her, he knew, without being told, that she needed to be called by her real name from then on.
Winnicott's writing is a little strange. His style is clear, but his concepts are often paradoxical. He was the originator of the term and concept, "transitional object", which he describes as an object that exists somewhere between fantasy and reality:

...the third part of the life of a human being, a part that we cannot ignore, is an 
intermediate area of experiencing, to which inner reality and external life both contribute.

If you've never read the paper, link to it, above. It's worth the time and effort.

He also originated the concepts of the "good enough mother", and the "holding environment". It's this last that is relevant for the treatment of Aspergers, or Autism Spectrum ( a term I seriously dislike, for reasons I can't get into).

Basically, the mother (or whoever is in that role) creates a safe, controlled environment for the baby, using her affection, often physical, and empathy for containment. "Spectrum" babies have great difficulty tolerating that kind of interaction, which they experience as intrusive. So from the get-go, things are different for those babies.

The presentation was about coming at the treatment from this perspective, and a lot of the focus was on helping the patient deal with the anxiety that goes with interacting with the world, for those with Aspergers, including pharmacological.

Nuff said.

2. Facing the Facts: Self-Disclosure and the Analytic Relationship

This group dovetailed nicely with the one about  the Analyst's Experience of Loss and Death, but it had a very different feel to it. There was something going on with the group, or the presentation maybe, that created a different environment in the room, so that people were not particularly forthcoming with their own experiences surrounding self disclosure.
There's always the tension between how much one tells ones patients about oneself, and how much one withholds. And either side can constitute a technical error. One thing that's difficult for people to talk about is the degree of sadism that exists in withholding information from patients. It's hard to remain cognizant of that, and at the same time, remember that there are good technical reasons not to tell the patient much about oneself. And I think that discomfort played out in the group discussion.

3. Research in Psychoanalysis: Concepts and Methodology of Single Case Research: the On-Line Archive

I was really excited about this group, and unlike the psychotherapy training group, I was not disappointed.

I've been thinking about this for a while. The typical analytic paper involves an initial section about the general topic, say, perversion,  with some relevant literature referenced, followed by a case presentation, including process, and finally a discussion. So what you're talking about here is an "n of 1".
The thing is, there are a boatload of "n's of 1" out there, so why not combine them into something analogous to a meta-analysis.

Well, this is happening. And it's called a "Meta-Synthesis"(qualitative, rather than quantitative). A group from the University of Ghent, in Belgium, is doing this work. They've compiled a whole bunch of single cases, and are starting to mine the data these cases generate.

They have a website, in English, called the Single Case Archive, where you can sign up for free, and search for different parameters within papers that have already been published. It's still pretty primitive, but it's expanding.

At the meeting, the Ghent people started out talking about why they decided to do this work. They were concerned about the overestimation of the quality of measures. In particular, with convergent validity. They modeled this, and it turned out that, if there are three different outcome measures used for the same data, the convergent validity is extremely poor (correlation coefficient 0.0-0.45).

They also modeled the impact of the measurement error, and it turns out to be abysmal.
Say you have a perfect measure, and you use it to measure 2 variables, x and y, and it turns out that x and y have a 0.60 correlation. If you then re-measure using a measure with a 0.45 correlation with the first, perfect measure, you will find that there is only a 0.12 correlation between x and y. So the true correlation between x and y is 0.60, but with a crappy measure, it looks like it's 0.12.
They figured this out with something called "Spearman's Disattenuation Formula".

One of the speakers showed a graph of a treatment, where interpersonal factors were being measured. There was an unequivocal improvement in the patient's ratings over the course of the treatment. However, this happened to be the speaker's patient, and he knew that the treatment was a disaster, and that the reason her interpersonal measures improved was that she was completely isolating herself.

So context is key, and you don't get that kind of data from a checklist. You get it from a detailed description. I can't wait to see where this research goes.


Well, that's my take on this year's meeting. Signing off.

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.

Tales from the Waldorf

This week is the annual winter meeting of the American Psychoanalytic Association (APSaA), which always takes place at The Waldorf in NYC. I'll be attending a number of the sessions, and I'll report back on what I learn.

The first time I attended the meeting, I was a PGY-3, because my supervisor, a truly hard-core analyst, encouraged me to go. I was a bit skeptical, so instead of putting in for conference time, which I probably wouldn't have gotten anyway, I scheduled my call so I would be post-call on the first full day of the meeting (I could leave the hospital by 11, and I was off the rest of the day). Of course, I hadn't slept at all, and by the time I got there, I was psychotically tired. I'd never been to The Waldorf before, and I had no idea where I was going, but I spotted a man wearing a tweed jacket and a cashmere vest, and I figured he must be an analyst, so I followed him.
Worked like a charm.
In retrospect, I'd have to say that attending the meeting that first time was a nodal point in my decision to pursue analytic training. It was a bit intimidating-try sitting in a room with 50 analysts talking about masturbatory fantasies (not their own)- but people were warm and encouraging. They had a very reduced fee for residents, something like $25-, and they had special sessions intended just for residents and students.
The important part, though, was the experience of listening to case presentations. I was a PGY-3 then, so I'd written and listened to my share of intakes and H&P's. I had never heard a case presented in this way. I had never walked away from a case conference in residency or medical school with such a full, deep understanding of who the patient was-what his early life was like, how it influenced his way of being in the world, how he relatedness  to others, what his wishes and fears were, his sense of values, his conflicts, fantasies, imagination, sexuality, anxieties.
Amazing.
And even better were the questions people asked. The first group I attended was about Psychoanalysis and Technology. I went in thinking (granted, I hadn't slept) it would be about what technologies were useful, what new and cool gadgets were on the horizon. No. It was more like, How does one handle silence in a phone session? Has the patient put the phone down? Did the call get cut off? Is there more tension because there's nothing to look at? In a long distance analysis, where does one position the video camera? Should it be pointed at the analyst, or the ceiling above the couch? Where does the patient place her camera? What is the meaning of the camera to the patient? Does it become an object that represents attachment to the analyst, the way medication can? Does it contribute to voyeuristic fantasies?
Again, different from and so much more than I was accustomed to.

There are hundreds of discussion groups, workshops, symposia, etc. There are sometimes fun talks on Saturday afternoons. One year they had Lorraine Bracco talking about her role as the psychiatrist on The Sopranos. They had Andrew Jarecki showing extra clips from Capturing the Friedmans. They had Daniel Menaker speaking about his book, The Treatment, a novel about a man in analysis, and at the same talk, Oren Radovsky, who directed the movie based on the book.

Here's a smattering of some of the groups:

*The Analysis of Masturbatory Fantasies: Theory and Technique (I believe that's technique of analysis)
*The Integration of Psychoanalysis and Couples Therapy
*Schizoid Modes in Narcissistic and Borderline States
*Freud as a Letter Writer
*Pharmacotherapy and Psychoanalysis
*Conversations for Analysts: the Embodied Experience of Analytic Listening
*The Analyst's Pregnancy
*Effects of the Holocaust on Survivors and Family Members
*Emerging Perspectives on Gender and Sexuality: Online Relations
*Psychoanalysis of Twins
*Edward Albee's "Who's Afraid of Virginia Woolf?" Are You?
*Love, Sex, and the American Psyche: Political Sexual Scandal
*Psychoanalytic Aspects of Assisted Reproductive Technology
*Trauma and Mastery Through Art: The Life and Work of Frida Kahlo
*Research on the Relation of Psychoanalysis and Neuroscience
*"Facing Death" Psychoanalysis and Psychoanalytic Psychotherapy of Patients with Cancer
*Privacy: A Quaint and Anachronistic Concept? (for residents, trainees, and students)
*Happy Endings in Real Life and in the Cinema

I'll get to the details of the groups I've attended in the next post. So far, four, on supervision, psychotherapy training, psychosis, and loss/death.

Til Then...

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.

The Couch, First Session

I've been thinking about writing this post for a long time, and I'm still not sure what I want to express with it, but it feels important.

I read this post on 1BoringOldMan. It's about how psychoanalysis wasn't focused enough on signs and symptoms, and DSM, starting with III, is focused too much on them, resulting in the loss of ability to really understand ones patients.

This struck me because as much as this blog is about the practice of psychiatry, and as much as I post about coding and insurance and medications and policy, I mostly leave out what I mostly do, which is psychotherapy, and specifically, psychoanalysis.

I think I'm cagey about it because analysis has so fallen from grace that it's a little embarrassing to acknowledge that this is what I trained to do. If I were 85 years old, I could say I trained back in the days when all psychiatrists did analytic training. But I'm not 85. And I graduated from my training institute about a year and a half ago.

I feel like it's discrediting to "admit" I'm an analyst, that I won't be taken seriously as a psychiatrist, or as a physician. And I have this sneaking suspicion that many of the folks who speak derisively about analysis don't know much about it. And that many of the people who disparage Freud haven't read him.

So what I'm gonna do here is write about what's involved in analytic training and practice, and then describe some of my thoughts and feelings about what I do, and why I chose to do it, and why I think it's worthwhile, in several posts.

To become an analyst, you need to apply to and be accepted by a psychoanalytic training program or institute. I filled out an application which asked for my demographic information, my education and work history, publications, memberships in professional organizations-basic CV stuff. It also asked for 2 references, where else I was considering applying or had applied, and names and dates of any psychotherapy or psychoanalysis I've had. That last was the most personal piece of information on the form, which might seem surprising. They could've asked about my toilet training or primal scene exposure. Or at least about why I want to be an analyst. But there were no short essays or personal statements.

They don't need that kind of personal information on the application. Instead, they have interviews. These are very different from the kinds of interviews I had for college, where it was mostly informational, or medical school or residency, where interviews function as supplements to an application. These were the grueling crux of the application process.

I interviewed with 2 different analysts, 2 times each. I don't remember for sure, but I think each of the 4 interviews lasted at least an hour, maybe 90 minutes. Or it might have just felt that long. The first interview with each analyst was a get-to-know-me session. The second involved more getting to know me, following up on things I spoke about the first time around. And I also had to present a case, which seems like it would be the hardest part, but it wasn't. It was the easiest.

I bought two suits. I wore one to the first interview with Dr. G, and the other to the first interview with Dr. E. Then I had them dry-cleaned, and I switched off for the second interviews. I also prepared two different therapy cases, each of which reflected certain challenges, and the ways in which I work with patients, and my ability to think analytically.

I had a lot of internal debate about how I wanted to come across. Specifically, just how neurotic did I want to appear. Too much, and they'd think I was unstable. Too little, and they'd know I was lying. I had an intuitive sense that I was about the right amount of neurotic for this kind of training-you don't train to be an analyst if you're not at least a little screwed up-but I wanted to make sure to seem like it.

I discovered pretty quickly that how I wanted to seem was irrelevant. And that discovery made me want to do psychoanalytic training all the more. Because the people I interviewed with did not shy away from asking difficult questions about my family, my motivations, my conflicts. And they did not settle for pat answers. And they pursued important topics. And they did so with kindness and without judgement. And I realized that I wanted to be able to do what they were doing.

My residency did a pretty good job with psychodynamic psychotherapy training. It was emphasized strongly. And I'm grateful for that. But my feeling now is, "If that were all the training I'd ever had in insight-oriented therapy, I wouldn't be able to do therapy in a way that I consider meaningful."

It shocks me when I think about the things I missed with patients early on, often transference issues, that are now so obvious. Ten years from now I'll probably be thinking the same thing about my 2013 work. But that's good. Because it means I'm constantly trying to improve.


They talk about the "tripartite" model of training, at my institute, at any rate, and others like it.

Part 1-Classes
Part 2-Supervised Analytic Cases
Part 3-Personal Analysis

Part 1-Classes
Mondays and Wednesdays, 7-10pm, 4 years. The readings are extensive. There are papers and case descriptions to be written. There are nerve-racking case presentations, reading ones process notes to an analytic deity and waiting to hear what people think about the work you're doing. Examples of classes:

Freud, Early Theories
Freud, Infantile Sexuality
Psychoanalytic Listening
Technique
Child Development
Adult Development
Character and Neurosis
Case Development
Cognitive Neuroscience
Psychic Trauma
Theory of Narcissism
Ethics
Borderline Conditions and Paranoia
Empirical Approaches to Psychoanalytic Thinking
Relational Psychoanalysis and Intersubjectivity
Dreams
Affects and Affect Pathology
Gender and Sexuality
Universal Phantasies
Termination
...and more

Part 2-Supervised Analytic Cases

Around the end of the first year of classes, you're expected to pick up an analytic patient, usually from the low-fee treatment center. Analyses last quite a long time, so you can expect to accept a low fee for quite a long time. And most analytic candidates have finished their residencies, or PhD's, or Psy-D's, or Social Work Degrees, and are seeing private patients. In other words, this is a loss of income.

You see the patient, on the couch, 4-5 times per week, and you have supervision once a week. Over the course of training, you pick up at least 2, but often 3 or 4 additional analytic cases, often low-fee, 4-5 times per week, and supervision once a week for each. And you have to treat both genders.

Yes, I did write, "On the couch." And yes, it feels like you're in a Woody Allen movie. Patients lie on the couch, and you sit behind them. As archaic as it sounds, it's quite useful.

There are initial writeups of your "control cases", 6 month summaries, and a final summary, either before you graduate, or when the patient terminates treatment, whichever comes first.

Part 3-Personal Analysis

In some ways this is the easiest of the three parts. You show up, 4-5 times per week, you lie on the couch, you free associate, or try to, and you leave. And you pay your monthly bill. The fee is set between you and your TA, or training analyst, so if you can't afford it, the TA will cut you some slack on her regular fee.

The truth is, this is the hardest part of the process. One well-published senior analyst likes to say that an analysis is like getting a PhD in yourself. It forces you to look at all the things about yourself you've been trying to hide from since childhood-shame, guilt, anger, aggression, sadness, longing, sexuality, tenderness, competition, cruelty, to name a few. It forces you to question your assumptions about yourself, the people in your life, and the world around you. It asks you to give up your accustomed ways of interacting with the world, defenses that have protected you most of your life, and move on to other ways to be that don't cause as much pain. And it asks you to establish an intimate bond with someone you can never truly get to know.

You can say that all good therapies, of whatever stripe, try to achieve the same goal-a better adjusted self. But it's not the same. And I'm not knocking other therapies-I practice them.

Before I began my training, I was in face to face psychodynamic psychotherapy twice a week, for several years. And my therapist was an analyst. It doesn't even come close to what analysis is like. The frequency, the supine position, the wacky isolation from not seeing the analyst with the simultaneous vulnerability of being totally exposed to this stranger, these induce an intensity that I can't imagine being replicated in other types of therapy.

The personal analysis has evolved over the years. It used to be a "reporting analysis". This meant that your analyst, in whom you confide your deepest, darkest thoughts and feelings, and into whom you pour all your transferential feelings towards primary figures in your life, would report on your progress to the progression committee, which included people you regularly work with. Nice.
What often happened was that candidates would stay in their training analyses until they graduated, and then they would quit the training analysis, and change to a private analyst, with whom they could be honest.

At some point, someone figured out that this wasn't a good setup, and reporting analyses were done away with.

TA's are a bit of a controversial issue these days. After you graduate from a training program, you can go on to get certification, which involves being immersed in the treatment of several unsupervised analytic cases, over several years. and an extensive writeup of these cases, which will be presented to a national certifying body. Once you've done that, you can then go on to be even further certified as a training analyst. I don't even know what's involved. I think you may have to sacrifice sheep. Or emotional support ducks.

The idea is that training analysts have so much more, uh, training than everyone else, that they're the only ones who are qualified to treat analytic candidates, who represent a special subgroup of analysands, because they're also students, and eventually colleagues, and you WILL bump into your analyst outside of his office, at conferences, or the annual institute dinner, or in the tiny elevator that takes you to your classes. The only reason that never actually happened was that I walked away and took the stairs. For real. The nice thing about analysis is that it's okay to be rude to your analyst. It's all grist for the mill.

I'll continue in a later post. For now, we do have to interrupt.

(For the next post in this series, Use the Couch, Luke, Click HERE).

Try This! It's Fun!

A friend sent me a link to Google Books Ngram Viewer. You can look up words, in various languages, and see how frequently those words showed up in books, during a specific time frame.

For example, I looked up Psychiatry, Psychoanalysis, Freud, CBT, ambivalence, Ego, and Id, and it came out like this:

I looked these up in English, but there are language variations you can use, such as British English and American English, and other languages. There's even an English Fiction category.

I thought it was a bit strange that there were spikes in both "Ego" and "Id" in the early 1800's, while Freud was born in 1856.

I checked Oxford Dictionaries Online, and Ego's origin was listed as early 19th century, from Latin, literally, "I". Freud used the German word, "Ich", which also means "I".

Id's origin was listed as:
1920s: from Latin, literally 'that', translating German es. The term was first used in this sense by Freud, following use in a similar sense by his contemporary, Georg Groddeck.

So I don't know where the early 1800's spike came from. I'll have to check my trusty OED, if I can find the magnifying glass that came with it.

I threw "ambivalence" into the mix because I was pretty sure it was coined by, or at least used very early on, by Freud. Since it first appears around 1910, that may be correct. Looks like another job for the OED.

Artwork for the Office

Enough already with the E&M coding. It's time for some pretty pictures.

What artwork do psychiatrists have in their offices?

I always wonder what the impact of the artwork is, which has made me very particular about what I choose to put on my walls.

In my first office, which was in the hospital I was working for, I had a painting that I bought from a man in the park across from the hospital. His name is Alan Streets, and here's a link to his site.

This is a painting he did of the Brooklyn Bridge, in the same style:

The one I have is this awesome painting of the buildings on the park across from the hospital, except that everything is just a little crooked, like the one above, and I watched him paint it.

But when I moved to my own office, it seemed a bit too personal (and a little too creepy), to put on my wall. I wanted something brighter, and maybe thought provoking. But not too thought provoking.

Well, I couldn't find anything like that, so then I just bought some nice paper that I happened to like and framed it.

It seemed fairly innocuous, and I still think it looks like balanced stones. My patients commented on it occasionally.

In my current office, I really wanted something special, that I liked looking at. But it couldn't be too personal or showcase my tastes too much. It could be thought provoking for my patients, but not too controversial or "out there". I wanted it to be colorful. I wanted it to be a real "work", but not too valuable, especially since I can't afford anything like that. And I wanted it to not scare anyone.

I had purchased another painting on the street about a year before the Alan Streets one. It was by a man named Ivan Jenson. It's very similar to this one:

I really like it, and I had intended it for my office, but on looking at it, there's something disturbing. Maybe that's what I like about it. But I couldn't see subjecting paranoid patients to it, or even regressed analytic patients on the couch.

I also bought a poster from him, that looks a lot like this, except with bolder strokes and more brown than blue:

This one's called "Bearded Man", and I suspect mine is, too, and that they're not intended to be anyone in particular. A little Van Gogh, a little Stalin when he still had hair. But it was a little too "Freud" for me to be comfortable putting it in my office with my analytic couch. I already feel like something out of a Woody Allen movie.


I thought about going the standard New Yorker route. You know:

Or:

They were just too predictable. And I didn't want anything silly.

I liked the idea of having something New Yorky, though. Ikea has this one:

But it's a bit too Ikea.


I did buy a little 10x8 painting from a young man who was selling his work on Union Square. The poor guy was trying to make rent, and I didn't have much cash on me, so he sold it to me for whatever I had, I think $30. I offered to bring him more money the next day-he was just a kid-but I never saw him again. It's a great painting of the Bushwick Subway Station, slightly impressionistic, in muted blues and purples, like it was raining the day he painted it. But it's tiny, and it sits on my desk. I doubt most of my patients can even see it well.  I don't remember his name or I'd list it, because the kid has talent.

Then what?

I love Charlie Harper

but I thought that would be too specialized.

I think Banksy is great

But he's a little sarcastic.

I'm a huge animation fan

But in my office?

For quite a while, I just left the walls completely blank, other than my diplomas and license registration. Admittedly, there was something soothing about the plain white walls.

Then one day, I was in a store that sells used house stuff, and I saw this up on the wall:

The walls were very high, so I couldn't see it well, and I almost walked away. But I couldn't stop looking at it, and I finally asked the guy to take it down. He wanted $10 for it, and it was already framed, so I figured the frame alone was worth 10 bucks.

I took it home, dusted it off, and looked it up online. It's a poster Frank Stella did for the, obviously, Lincoln Center Festival '67. I don't know if mine's one of the originals, but they sell for $400-$800 online.

This is the one I put on my wall. It's colorful and interesting. It has an intricate graphic pattern and cool lettering (you can't see it in this image, but the background is graph paper). It's cheerful but not silly, and certainly not scary. It's New Yorky, but not in an in-your-face way. And I like it.

Writing this got me thinking about why what decorates the walls of ones office matters. And to whom.

Am I concerned about influencing my patients too much with my tastes? With my self? Am I worried about criticism or ridicule of the things that are important to me? By hiding my aesthetic preferences, do I want to limit my patients' intrusion into my world? Am I trying to get my patients to comment? Or not to comment?

I was thinking that if I really wanted to be non-comital about it, I'd put up a Rothko poster, which doesn't tell you much about what I like. But which one?

And wouldn't my patients just wonder why I picked the pink one rather than the purple?

So what do other shrinks have on their walls? And why? I'd love to hear about it.

I Was Inspired

In my last post, I simplified the leap from 99212 to 99213:

99213 = 6 exam elements and 1 ROS

So I started to wonder if I could have an equally simple mantra for 99214.

Well...not really.

But let me see what I can do.

The problem is that for a 99214 exam, you need 12 elements from 2 or more organ systems. Not gonna happen. So the Exam is not going to help here, which leaves History and MDM.

History:

You need a Detailed History, which includes 4 elements of HPI, 2 ROS systems, and 1 PFSH.

Can I make that easy for myself?

Hx x 4, Psych + 1, and Allergies.

Not so easy.

The good news is that MDM is not that hard. Either 1 worsening condition or 2 stable conditions counts.

So for MDM: 1 worse or 2 same.

And here's the 99214 Montra:

99214 = Hx x 4, Psych + 1, Allergies, 1 worse or 2 same

Not really jingle-worthy, but could be worse. Could be raining.

A Simplified 99213

Okay. I've plowed through figuring out how to E/M code three different notes. And in case you were wondering, I can't remember what to do from one note to the next. I have to keep referring back to my own posts. I imagine after I've done it 100 or so times, I will remember. But the whole process is so meaningless, so devoid of context and content, that I can't retain it.

(I've decided there should be a new way of swearing at people: "Oh yeh!? Well E/M code you!")

I can't do this for every single note I write. I NEED a shortcut.

So here it is:

With few exceptions, all my notes will be either a 99212 or a 99213. On the rare occasion when I think I've spent a lot of time on complicated issues, especially psychopharm, I'll code formally and see if it's worth a 99214.


How to differentiate 99212 from 99213?

Well, since you only need two out of the three key components to meet any level, I'm going to ignore the most convoluted one, MDM, and just focus on History and Exam.

And I absolutely refuse to include another E/M@!3#&%#  Table.

Exam is the easiest. You need at least 6 elements for a 99213.  So my note template should look like this:

General Appearance:
Speech:
Thought Process:
Thought Content:
Associations:
Judgment:
Insight:
Mood/Affect:
Other:

Even in the most Freudian session, I should be able to come up with 6 of these.

Exam? Check!

Now History. You may recall, or not, that a 99212 History is Problem Focussed, and a 99213 History is Extended Problem Focussed.

So what's the difference between a Problem Focussed History and an Extended Problem Focussed History?

1 ROS!

That's it!

Both require a brief HPI, including 1-3 elements,  and no PFSH. So just 1 ROS.

Now I'm really disgusted.


And now that I've uber-simplified things, these are some questions I have:

1. Does insight count as its own exam element?
2. Does writing, "ROS negative for anxiety or depressed mood," constitute a valid ROS?
3. What am I missing?
4. Can I list defenses as "Other" on the exam?
5. Do dreams count as one element of the history?


And once again, to summarize:

99213=6 exam elements and 1 ROS.

Now I need a template I can use. Maybe next post.

E/M Psychoanalysis Note-Tuesday

Here's the second note of the week:


Name: Socrates     DOB: 469 BCE      Date of Service: 11.27.12

Start time: 2:30pm  Stop Time: 3:15pm.  Total Face Time: 45 minutes

CPT: 90836, E/M ?????

CC: F/U for "Self Knowledge"

Interval History: Patient's checking behavior has not worsened. He met with one of his students yesterday, about whom he has had some homosexual fantasies, and had a dream last night in which he was trapped in a cave where he could only see shadows. 

ROS: none

PFSH: The patient works closely with his students.

PME: 

• Speech-Greek
• Thought processes-logical
• Thought Content: Focussed on dream
• Affect: Mildly Anxious
• General Appearance: Wearing toga
• Other: Uses intellectualization and reaction formation as defenses

Dx: Anxiety NOS, consider OCD

Current Meds: none

Labs: Ordered-none; reviewed-none

Allergies: Hemlock

Psychotherapy Note: Interpreted dream in the context of the patient's concerns regarding his homoerotic fantasies.

Plan:

Continue psychoanalysis 4x/week


And here we go again with the coding:

The interval history has, maybe 1 or 2 elements, say associated symptoms (checking), and timing (an implicit "overnight"). In any case, it certainly doesn't have 4 elements, so it's a brief history.

There is no ROS.

And there is one element in PFSH.

So for the level of history,

Level of Hx	HPI	ROS	PFSH
Problem Focussed	Brief	None	None
Extended Problem Focussed	Brief	1 System	None
Detailed	Extended	2 Systems	1

we end up with "problem focussed".

Once again, the Exam has 6 elements.

And for the MDM:

You get 1 problem point for checking, an established, stable problem. 

There are 0 data points.

And the risk is low, for one stable, chronic illness.

Making the MDM straightforward.


In summary, then:

Level of Care	Hx	Exam	MDM
99212	Problem Focussed	1-5	Straightforward
99213	Extended Problem Focussed	>6	Low Complexity
99214	Detailed	12 from 2 or more organ systems	Moderate Complexity
99215	Comprehensive	2 from each of 9 organ systems	High Complexity

This gives us a 99212 E&M code.  

Now, this was interesting as an exercise, but I don't really want to do this kind of careful review for every note I write. It would be easier to keep the note to a minimum and bill as a 99212, which most notes will probably turn out to be, anyway. But then, sometimes, it's possible to eke out a 99213, or even a 99214, and this makes a very real financial difference. 

So is it worth it to comb through every note? I don't know. Thoughts?

E/M Psychoanalysis Note-Monday

In my last post, I included an example of what I think would be a reasonable 99213 note.

But that example is most suitable for psychopharm or psychotherapy of low frequency. I've been trying to figure out what to do for my psychoanalysis patients, who I see 4 times per week.

This is my attempt at 2 such notes for the same patient. I'll include the Monday note in this post, and the Tuesday note in my next post:


Name: Socrates     DOB: 469 BCE      Date of Service: 11.26.12

Start time: 2:30pm  Stop Time: 3:15pm.  Total Face Time: 45 minutes

CPT: 90836, E/M ?????

CC: F/U for "Self Knowledge"

Interval History: The patient expressed conflict over homosexual impulses.  He also c/o increasing obsessional thoughts over the weekend, in which he worries about being poisoned, and checks his food and drink 4-5 times before partaking of them. He is increasingly argumentative, particularly with authority figures.

ROS: Patient reports increased checking behavior, as well as insomnia.

PFSH: Patient has difficult relationship with his wife.

PME: 

• Speech-Greek
• Thought processes-logical
• Thought Content: Obsessional thinking and compulsive checking
• Affect: Anxious
• General Appearance: Wearing toga
• Other: Uses intellectualization and reaction formation as defenses

Dx: Anxiety NOS, consider OCD

Current Meds: none

Labs: Ordered-none; reviewed-none

Allergies: Hemlock

Psychotherapy Note: Interpreted patient's defenses, encouraged less intellectualization, and further exploration of his emotional life.

Plan:

Continue psychoanalysis 4x/week



Now to determie the E/M code: 

The Interval History includes 4 elements:

• Severity- "Increasing" and checking 4-5 times
• Timing-"Over the weekend"
• Context-"With authority figures"
• Associated Syptoms-Checking

So this is an extended Interval History.

The ROS includes 1 system-Psychiatric.

And the PFSH includes 1 element of Social History.

Looking at Table 2, History, from my last post:

Level of Hx	HPI	ROS	PFSH
Problem Focussed	Brief	None	None
Extended Problem Focussed	Brief	1 System	None
Detailed	Extended	2 Systems	1

Since 3 out of 3 elements are needed for History, this note would have an 
Extended Problem Focussed History.

Next is the Psychiatric Exam, which includes 6 elements.

And finally, the MDM.

Since obsessional thoughts are an established problem that is worsening, this would earn 2 problem points.
In addition, since the patient is increasingly argumentative, that is another established problem that is worsening, worth another 2 points. So there are a total of 4 problem points.

There are 0 data points, since I didn't review labs or call anyone etc.

And the Level of Risk is moderate, since there are one or more established conditions that are worsening. I don't think I can call this a "severe exacerbation", but if I could, then the level of risk would be high.

Looking at the Table for MDM, we have:

Overall MDM	Problem Points	Data Points	Risk
Straightforward	1	1	Minimal
Low Complexity	2	2	Low
Moderate Complexity	3	3	Moderate
High Complexity	4	4	High

Since only 2 out of 3 elements are needed for MDM, this would qualify as Moderate Complexity.

Finally, summing it all up :

Level Of Care Requirements (2 out of 3 needed)

Level of Care	Hx	Exam	MDM
99212	Problem Focussed	1-5	Straightforward
99213	Extended Problem Focussed	>6	Low Complexity
99214	Detailed	12 from 2 or more organ systems	Moderate Complexity
99215	Comprehensive	2 from each of 9 organ systems	High Complexity

Ladies and Gentlemen, this is a 99213 note. Ta Da!