I’m A Dinosaur
I was looking at the screen hoping that the senior residents would provide me some case material so that I can supervise them in Psychodynamic Psychotherapy. This process has always been my favorite aspect of teaching. Residents would present tape recorded sessions with their patients and we would carefully dissect not only the content but the process. This week no one has anything to present. I ask them to tell me about the patients they have been following and I receive a superficial overview of the cases. I do not get a sense that they have thought of these cases in any meaningful way. The patient is a series of complaints, and the treatment is responding to these symptoms and reducing them. They do use some of the lexicon of CBT and DBT, but do not seem to have thought deeply. The idea that there is an unconscious seems to be lost. There is no connection between the present and the past. We remain in the present and remain attached to symptoms and behaviors.
To be fair, most patients do not think about what therapy actually is. The most common reason that people seek therapy is so that they can “talk to someone”, as if the act of expressing distress will somehow remove the symptoms that create the discomfort. When people recommend therapy they tell the person “maybe you should talk to someone” and for the most part they lack an understanding that psychotherapy is a complex and broad field.
But the worst part of the feeling on this day was the idea that perhaps I was wasting my time. Not because of the residents I was trying to teach, but more so because of the changes in the field itself. It would be rare for any of these individuals to practice psychodynamic psychotherapy. Their future practices will consist primarily of medication management and referral to a therapist, most of whom are using more manualized and evidenced based treatments such as CBT and DBT. Rarely will the psychiatrist act as the therapist, and in these cases it will focus around supportive therapy provided during a medication visit. This is where the field has been going and most of the recent graduates have adjusted to it.
When I began my training, one of my fellow residents observed that psychiatrists and surgeons were similar. We both actually performed the procedure personally, unlike internists who rounded and for the most part had nursing staff administer the actual procedure itself. Now, I feel that we are more like Physical Medicine & Rehabilitation specialists who prescribe the treatment that is provided by a series of individuals in both the inpatient and outpatient setting. Either way, the days where the psychiatrist performs the majority of the procedure is long past.
Psychotherapy was our procedure. We had to sit with the patient for 50 minutes and provide the service. Although ECT existed, it was considered a procedure of last resort rather than our primary procedure. The use of medication was limited by the severe side effects of the older medications. Psychosurgery has fallen into disrepute.
Psychiatrists are embracing their identity as medical doctors. They now study the brain. They understand physiology and pharmacology. They are more adept in the field of genetics and neuroimaging. They understand a broad array of medications that have effects on multiple receptors in the brain. They provide medication management, ECT, TMS and Ketamine. They provide medication to combat addiction . They talk about side effect profiles, and metabolism of these medications. They are so much more knowledgeable of the other medical specialties and the role of psychiatry within them. They speak of primary medical illnesses that mimic psychiatric disorders. They are clearly much better doctors than I ever was. I listen and try to understand where my procedure fits in. In the end, I realize that it might not.
The idea that I am a dinosaur became evident to me after the death of my friend who was a supervisor of dynamic therapy for my residency program. He was one of the few people that I could speak to about therapy. We read the same books. We had many of the same approaches. We were both trained in the classic tradition and we would often discuss how our approach was dying. With his death I had no one in my circle to talk to about therapy, and my frustrations in teaching it. Meanwhile, my department was adding faculty but almost all were non-MD’s( social workers, psychologists, mental health counselors) and they provided mostly manualized treatments that are highly structured. The Psychiatrist’s we hired had minimal if any training or interest in Psychodynamic Psychotherapy, and were not interested in increasing their knowledge.
My patients approach care differently as well. They are looking to feel better and do not want to spend years looking at repressed memories from a time that they barely remember. They do not want to look into the deeper meanings of the symbols that come forward in their dreams. They want to solve a problem. Since they have access to information on the internet and they are much more knowledgeable. They know that there are certain therapies that work and that take a limited amount of time. They wish to get back to their lives without their symptoms. A part of me understands this. If I feel uncomfortable but ultimate search is for a modality that will bring me comfort.
I look at my bookshelves, and notice that few of my books pertain to the practice of medicine. Those that do are over 20 years old. Meanwhile the shelves are overflowing with books on psychology, sociology, philosophy etc. I know my shelves look different than those of the physicians I am training. In fact, I am not sure if we even have “bookshelves” anymore, since almost all of our trainees use their tablets to read.
In the 1990’s there was a push towards viewing psychiatry as a specialty that deals with the brain rather than the mind. The so-called “Decade of the Brain” led to a major explosion in our knowledge concerning genetics, neurophysiology and pharmacology. There was talk about each new medication “curing” mental illness. We no longer needed analysts in Psychiatry. The Chairs of Psychiatry in major medical schools became more involved in the neuroscience world and less involved in the psychological world. Residents were now looking towards the brain and the various interventions that we could use to improve the brain’s functioning. I saw my practice suffer. Patients would call my office looking for a medication, and would be upset if I did not give them a prescription. They would arrive to the office with completed questionnaires, a diagnosis and the literature around a medication that would be useful.
Despite this explosion in knowledge, outcomes did not improve for many of the more severe illnesses. But the grave for psychodynamic psychotherapy was being dug. As evidence began to mount concerning a variety of time limited and evidenced based therapies, we were beginning to shovel dirt over the coffin. Yet, there was always a group that tried to keep it alive. Many adapted it to fit the modern time limited and evidenced based model. Transference Focused Psychotherapy, Panic Focused Psychodynamic Psychotherapy. Interpersonal Psychotherapy are models of care based on dynamic theory but with a time limited and manualized approach.
The question is whether or not the form of Psychodynamic Psychotherapy that I was taught can survive in the present time. Much like the Dinosaurs some forms are doomed to become extinct. Psychiatrists will continue their well deserved entry in the field of medicine and will continue to provide sound treatment for the millions who suffer from mental illness. Manualized and time limited Psychodynamic Psychotherapy will continue to find their niche, much like the Avian-dinosaurs did during the mass extinction. Many of the large land dwelling dinosaurs may not be so lucky as far as becoming essential in the treatment of individuals with illness. However, we will continue to be the best approach to those who seek more than symptom relief. It will become the tool of choice in the search for meaning and individuation.
I am a Dinosaur, but feel that I am also an important link to understanding the person and helping them grow. I am an important link to a time where doctors were aware of the patient’s life. I am an important link to helping the individual find their purpose and meaning.
