The Psychiatrist and Psychotherapy
“What do you think will help your depression?,” I asked my patient. “Confronting my daughter and letting her know she has to respect our wishes,” she replied.
My patient’s problem defied solution by medication. Her timidity was an issue and required confidence building that comes from a strong relationship between doctor and patient. So often we stress the intellectual aspects of treatment, including what psychotherapy technique to use and how many sessions are required, but we need to pay more attention to the rapport we establish with our patients. It is composed of goodwill and understanding, aspects of caring deeply for each patient. Many years ago I came across the results of a survey of psychiatric patients, and I wasn’t surprised to read that patients who considered themselves helped believed that their psychiatrist had understood them.
My residency in the 1970s offered training in the pseudo-Freudian model that was so popular then. I was a blank screen. “What do you mean by that?” was a frequent question we asked our patients. I hesitated to wish my patients even “Have a good weekend.” Psychotherapy was boring and empty. With experience and the guidance of mentors, I evolved. My patients and I talk to each other. I ask about their opinions, likes, and dislikes. My sessions are meaningful and interesting. Psychotherapy is gratifying. I am better at helping patients.
Neuroscience is leaping ahead with discoveries about the brain. A recent book review in the Wall Street Journal of Life on the Edge by Johnjoe McFadden and Jim Al-Kalili makes a startling remark. Physicists reveal the idea that “quantum procedures help explain consciousness and the mechanics of thought. … The scheme is certainly speculative, but it does at least provide a plausible link between the quantum and classical realms in the brain.” Another researcher, Lisa Feldman Barrett, director of the Interdisciplinary Affective Science Laboratory at Northeastern University, reviewed brain imaging studies from 1990 to 2011. She concluded that “no brain region was dedicated to any single emotion. … Emotions like fear and anger, my lab has found, are constructed by multipurpose brain networks that work together.”
In his book, Looking at the Sun, the psychiatrist, Ivin Yalom writes, "The idea that the texture of the relationship is crucial to therapeutic change is nothing new. For a century, psychotherapy clinicians and teachers have realized that it is not primarily theory or ideas but the relationship that heals.” Patients now typically have a psychiatrist to medicate them and a therapist to conduct psychotherapy. Can psychiatry dismiss the study of psychodynamics? There is still much to be learned. Aside from healing the patient, psychotherapy helps to comprehend the brain. Do we even possess the full array of tools to understand psychodynamics and psychobiology? The future of psychiatry should include practicing psychotherapy. If we are to be neuroscientists, we need to appreciate the biochemical, physical, and dynamic aspects of the brain. If we are to remain doctors, we need to understand our patients and try to meet their needs. ■
