One of my favorite aspects of addiction medicine is the relationship that I am allowed to build with my patients. The relationships are different than in other areas of psychiatry, where the doctor is always working to maintain a certain distance from patients. Too far and the psychiatrist won’t build the trust needed to truly engage the patient. Too close and the psychiatrist becomes a friend, or even a fantasized romantic partner. With addiction medicine those concerns are more straightforward, especially as a doc who has been in my patients’ shoes, at the edge of losing everything and finding the way back. I often feel more like a measured friend (a friend who charges for visits and can’t do anything beyond the bounds of medical practice!).
Supportive vs. Expressive Psychotherapy
Psychiatrists who are psychotherapists often choose between supportive therapy vs. expressive therapy (one cool thing about residency at the Medical College of Wisconsin is that they are a rare program that still teaches psychotherapy). To explain the difference let’s use the case of a person who feels ‘unheard’ by his/her partner, children, and friends. The situation is common because some people don’t like hearing other people complain. Patients sometimes see a psychiatrist or therapist for that reason alone. The situation often worsens as the unheard person tries harder and harder to be heard, pushing potential hearers even further away.
Simply listening to a person in that position can be helpful. Supportive psychotherapy is all about listening, clarifying, and validating feelings. I have noticed now more than ever that most doctors are lousy listeners, and one of my goals, as I reset my life, is to do a better job of listening. So often this summer I’ve listened to doctors’ agendas while trying to get my own opinion across. And I’m a doctor, dammit!!
I don’t want to give the wrong impression, that my responses to a patient’s problems are ‘taught’ or ‘canned.’ Another great part of addiction medicine is knowing people who have done well for years, knowing the challenges they have faced and the recoveries they have made. I truly tear up when I hear about the loss of a dog. Divorces don’t push me to tears, but dogs do. The loss or a child or grandchild is as bad as it gets, No supportive therapy classes necessary for those horrible situations.
As useful as supportive therapy can be, I can’t always be supportive. Supportive psychotherapy is a huge part of any therapist’s practice, but it doesn’t work well, in my opinion, for treating addictive disorders. And yes, I have been faulted for being too analytical, sometimes by people who never returned to my practice. I might say “that’s enough about what you CAN’T do; let’s talk about what you CAN do.” That goes over well with some people and poorly with some people. I wouldn’t say something like that, of course, at a first appointment, and not until I notice that the person is stuck in a pattern of thinking that is not working out very well. But after a second near-fatal relapse in a parent’s basement, I believe that the appropriate comment is “what the hell were you thinking?! In the case I described above It is important (eventually) to help the person understand how life works, so he/she doesn’t repeat the behavior with other people who enter his/her life. Maybe expectations are off, or the person is over-sharing, or maybe the person is choosing to share problems with people who, for whatever reason, are not choosing to listen.
That reminds me – have you ever talked with someone who hogged the conversation, or maybe came to your house for a brunch but stayed until evening, after everyone else left? I tend to say something like “I think it is time for you to go – we have things we need to do.” Nancy is mortified when I say something like that, but my reasoning is that the person likely does the same things with other people, who then probably, eventually, say the same things. To that person, what I’m saying is just something he/she has heard a hundred times before, and not likely to offend. Nancy still becomes mortified.
I prefer psychodynamic psychotherapy, which to me is more interesting and more challenging. Expressive or psychodynamic psychotherapy is sometimes called ‘anxiety–provoking therapy’. To use our unheard patient, a psychodynamic therapist would try to understand WHY the patient often ends up with partners or friends who don’t listen. Or why the patient wants to be heard so badly – so badly that he/she ignores all of the signals others are sending, saying “I’m not interested; please stop.”
None of us are perfect, and there is nothing wrong with being an ‘over-sharer’. I do it myself, including in this blog! And yes, I am aware that I have a captive audience that can’t always simply walk away. Polite people don’t do that. One interesting thing about working in the prisons for several years was hearing patients say “shut the F up, you’re talking too much” or “why you so damn fidgety?!” Yes, I realize I am fidgety. But heck, I was hypoxic!! Aways something to work on…
The challenge with psychodynamic therapy reminds me of that movie ‘Inception.’ The writer of that movie probably got the idea from psychodynamics: the goal is to get the patient to think of the idea in an acceptable form, ideally by having the person figure it out him/herself. If I say “you are too sensitive”, the person will reject me and the horse I rode in on. A better, but not great line would be “I wonder why that happens?” Even better would be to present things in a way that leads the patient to ask and try to answer that question, because then there is a greater chance that the person will change his/her behavior, which is the goal.
A good and smart psychotherapist moves back and forth between supportive and expressive stances, becoming more supportive when the patient is struggling and more expressive when the patient is doing well. Doing that well is truly an art, and one that isn’t as appreciated as it once was now that they have EMDR and a thousand other cool-sounding things. If you want to have good psychodynamic therapy, find an ‘analyst’. A local chapter of a psychoanalyst society would be a good place to start. Analysis is the ultimate form of expressive psychotherapy, where a patient sees the analyst two or three times per week and (yes) lies on a couch, with the analyst behind the patient’s head and out of view. People often think that the more a person sees a therapist, the worse-of they are. But in the expressive psychotherapy field, it is the opposite. Seeing an analyst several times per week can sometimes create stress that makes things worse for a patient.
Where does addiction treatment fit in? I see value to both approaches. But addictionologists can also connect more closely, at least with patients who are doing well. I share my email with all of my patients (and everyone else) and enjoy it when they write. I received so much support during my recent crisis, that helped me through the toughest days. I even share my cell phone number in many cases. That access is rarely abused, and it is easy to pass on an inappropriate request by text or phone. Any negative aspects, in my opinion, are more than balanced by knowing how people are doing between appointments, by being able to answer interesting questions that come up, and by receiving heartfelt messages when my own health is challenged.
Not exactly the norm in modern healthcare, but I have heard the same from other addiction docs-especially those who have ‘been there.’ Doctors: Are you truly listening? How much work does it take for a patient to ask you a question, in or out of the office? Not your ‘assistant’ but you, yourself. Medicine is changing, and not necessarily in a good way. My grandma talked for years about the doctor who stopped by the house to say hi to my grandpa, when he was dying at home from colon cancer. I’ll bet that doc loved his job. Do you love yours?