It's all about remembering and being remembered.
That's how renowned psychoanalyst and educator Glen Gabbard, M.D., summarized the motivations behind a teaching career that has made him beloved of students and mentees and one of the most sought-after lecturers in psychiatry.
He presented the lecture "Why I Teach" at APA's 2010 annual meeting in May in New Orleans, where he received the APA/NIMH Vestermark Award. He is the Brown Foundation Professor of Psychoanalysis and director of the Baylor Psychiatry Clinic at Baylor College of Medicine.
With characteristic facility, Gabbard wove personal reflections, neuroscientific findings, psychoanalytic insights, and a sprinkling of humor into a narrative describing the teaching profession as an interpersonal transaction in which the teacher is internalized by the student and the teacher, in turn, learns from and internalizes the learner.
He emphasized as well that the human interaction that is at the heart of teaching is also inherent in psychotherapy and needs to be preserved as a part of the psychiatric identity. And so the preservation of psychotherapy forms an urgent motive for passing those skills along to tomorrow's psychiatrists.
"We are trying to preserve a dying art," Gabbard said of the teachers of psychiatric psychotherapy. "I sometimes encounter residents who say, ‘We don't really need to learn psychotherapy as psychiatrists anymore because psychologists and social workers do psychotherapy.’ Or they'll say, ‘I'm really more interested in genetics, neuroscience, or psychopharmacology.’ And even though the [Residency Review Committee] mandates psychotherapy training, it doesn't mean that people will read the texts, go to class, or make appointments with supervisors."
An analysis of data from the National Ambulatory Medical Care Survey, presented at last year's annual meeting, showed that the percentage of visits to a psychiatrist involving psychotherapy declined from 44.4 percent in 1996-1997 to 28.9 percent in 2004-2005.
But Gabbard said that even the so-called 15-minute "med check" draws on the alliance-building skills of psychotherapeutic learning. "When residents tell me they don't really need psychotherapy training to be a psychiatrist, I tell them, ‘Lot's of luck.’ The way I see it, there is no area of psychiatry that can be divorced from the use of psychotherapeutic skills."
He cited the landmark NIMH Collaborative Depression Research Study showing that in a comparison of two forms of psychotherapy, imipramine with clinical management, and placebo, the therapeutic alliance accounted for more of the variance in outcome than any of the treatments themselves.
"The therapeutic alliance is at the heart of what we do as psychiatrists," Gabbard said.
Beneath the economic or practical reasons residents may give for turning away from psychotherapy is likely to be a fear of the kind of mutual internalization that is at the heart of therapy (and of teaching).
"I think a lot of trainees are terrified to look inward and see what's there," he said. "They would rather think of themselves as a healthy doctor treating a sick person. But we have a common humanity that allows us to see ourselves in even the most disturbed patient. By turning inward, we know the patient in a way that other people don't. We discover truths that aren't available in a brain scan.... You can't see the self in a brain scan; you have to see the self by sounding it out with your own human instrument.... I teach to preserve the idea that we don't just treat disorders—we treat a person."
From long experience in the practice of psychoanalysis, Gabbard said he has learned that one of patients' greatest fears is the fear of not being remembered. It is a fear to which anyone should be able to relate.
"It is not only our patients who wish to be remembered. They are simply reminding us of a universal—we all want to be remembered. Life is brief and mysterious, and we do not want to think of ourselves as merely a flash of light between two periods of darkness. I think this is one of the reasons I teach."
He recounted the kinds of experiences that are familiar to any passionate educator and that confirm the adage that the teacher lives on in the student: Residents, mentees, and supervisees have acknowledged over the years, in word and deed, the impact he has made on their training and their lives and on the lives of the patients they treat.
"When you teach, you throw a pebble into the water that ripples and will create an endless array of concentric circles in such a way that you never know where your influence ends," Gabbard said. "My passion for teaching is very much linked to the immortality motive—maybe I can pass something on to those I teach that will make a difference in their lives."
As it happens, the enduring value of interpersonal connections—of the influence of teachers on students and of psychotherapists on patients—is borne out in what neuroscience has demonstrated about how neural networks are formed and sustained, Gabbard said.
"Neural network theory has greatly increased our understanding of internalization," Gabbard said. "Neural networks begin with the firing of neurons in repetitive patterns, and experience creates certain connections between neurons. We take people inside of us as we pass through life … and a set of representations are laid down in the synapses.
"We internalize the way people in our lives have related to us. As we take in the memories of our interactions with others, we wire our cortex with these memories. Those who are significant leaders in our lives become part of us.
"We learn through our mentors, supervisors, and teachers. They inhabit us; they help us get through the day. They may be dead in some cases, but they are not gone."
So, too, altruism appears to be "hard wired." Gabbard cited the discovery of "mirror neurons" that appear to be activated both when an animal acts and when the animal observes the same action in another—hence allowing one animal to understand the mind and motivations of another.
"Mirror neurons help us empathize with our fellow creatures on the planet," he said. "The mirror system allows for the direct and immediate understanding of the inner world of another person, and it is the manifestation of one of the most noble features of homo sapiens."
Gabbard drew attention to a 2006 study by researchers at Duke University that used functional magnetic resonance imaging to analyze brain function while subjects performed either altruistic or selfish acts. "Altruism appears to generate brain activity in areas associated with selfish pleasures such as eating and sex," Gabbard said. "Helping others has a self-interest that is undeniable."
And so it would seem there is more than pretty sentiment to the idea that to give is to receive.
"Each time we enter a classroom, begin a supervision, or mentor a protégé, we are witness to something transcendent," Gabbard said. "We internalize and we are internalized; we teach and we learn. We give to others while enriching our own lives. We remember and are remembered. We become a part of our students and they become a part of us. We are wired together forever, and in the ebb and flow of conversation about ourselves, our patients, and our field, we make a small contribution to the world, and we both part the wiser for it. For everything we take, we leave something behind.
"And we never forget."