People want to do the same thing and experience different outcomes. Wouldn’t it be great if we could lose weight despite a diet of chocolate malts, beer-battered French fries, and triple-decker club sandwiches and an strict exercise regimen that only includes walks to and from the car? Or how about befriending jaw-droppingly beautiful men and women who sparkle with good humor and charm without ever leaving the house? Perhaps you can get that pay raise through the sheer power of wistfulness and hope, rather than suggesting to your boss, “I’d like a pay raise.”
Herein lies the difficulties of behavior change. (And, just to be clear, insight alone does not result in behavior change. Just because you recognize something needs to change doesn’t mean that something will change. Take the current war in Iraq, for example.)
Sometimes I’m surprised that people don’t storm out of the room in frustration. With my burgeoning skills, I advocate for functional change. With their well-practiced habits, people respond, “Yes, but….” It’s annoying to hear someone suggest that you try something different, whether that “something” is a thought or behavior. And even if something does change, progress can seem glacial—particularly to the patient, even if it is evident to everyone else.
Change can really suck. And when things aren’t going well already, the stress of change—or even just thinking about change—can result in people getting angry at the people who are helping them change. It’s grand.
What makes a “real” psychiatrist? I don’t know where I got the idea that “real” psychiatrists practice psychodynamic therapy (think psychoanalysis: free associations, dreams, “tell me about your mother”). I didn’t know any psychiatrists in my youth. The medical school I attended was not inundated with psychoanalysts, with or without tweed suits with the elbow pads, horn-rimmed glasses, and neatly-trimmed beards (though there were a few psychiatrists who routinely wore bow ties). I did not enter psychiatry because of the allure of psychoanalysis.
Therapy training seems to be polarized: there are the cognitive and behavioral people on one side and the psychoanalysts on the other. Most people gravitate towards one side or the other and, at best, limit commentary about the other camp to half smiles and monosyllabic utterances. (At worst, they verbosely disparage the asininity of the other side: It doesn’t work! It’s too simple! It’s too complex! It’s not helpful! Blah! Blah! Blah!)
I find myself leaning (significantly) towards the cognitive and behavioral side and yet, cognitive and behavioral interventions clearly aren’t the end all, be all or psychotherapy—if that was the case, then why do people still practice psychodynamic psychotherapy? (I recognize the fallacy in that argument; there are plenty of things we all do that don’t entirely make sense, yet we do them anyway—like knocking on wood. Or refusing to make any comments about the lack of consults/admissions/patients needing care for fear that if the words are spoken, the “spell” will break and patients will soon show up in droves.)
I’ve spoken with a few people who were fully trained in psychoanalysis and are now behaviorists (of varying degrees) and, when pressed, they will concede that they still peripherally use the ideas of transference and countertransference when interacting with patients. However, they also frame these ideas as “learning history”. For example, instead of (not this bluntly) “You are interacting with me as if I was your mother due to unconscious, intrapsychic processes”, it would be “You learned to interact with people of perceived authority this way because of your experiences with your mother”.
I rationalize that my brain just isn’t sophisticated enough to understand psychodynamics. The practicality of cognitive and behavioral therapies simply resonates with my personality and the way my brain processes information. (It’s also nice that the cognitive and behavioral interventions also have empirical data supporting their efficacy….)
And yet I struggle with the idea that I could be a skilled psychiatrist despite the fact that I do not embrace psychodynamic theory. (Maybe the answer does lie in McHugh’s Perspectives.) If When I end up in New York City (the bastion of psychoanalysis), I fear I might be ostracized for my cognitive and behavioral proclivities. Maybe the analysts will offer interpretations about my resistance to psychodynamics and help me overcome my defenses. Or not.
Brilliance is uncommon. What makes someone brilliant? I define brilliance as someone who can integrate varying and disparate ideas into a lucid discussion. Someone who not only knows a lot, but can make sense of the myriad of ideas. Someone who can easily grasp the different perspectives of the big picture and sort through the details without difficulty. Someone who is enthusiastic and passionate about thinking.
I am not brilliant.
Brilliant people, it seems, don’t sleep a lot. They also seem to have a lot of energy. (And, no, I will not digress into psychiatric diagnostic discussions here. That isn’t the point.) They also seem to have excellent memories; how else can they remember that Descartes said that, chaos theory suggests this, and anthropologists discovered this in some random cave? They have ravenous appetites—and not just for knowledge. (Think former President Clinton.)
I like listening to brilliant people—their brains seem to generate ideas the way weeds sprout throughout a garden.
Is there a way to become brilliant? Is brilliance learned? Or must we rely on our genes?
What is stopping me from writing on a daily basis? Long time readers know that for many years, I wrote every single day. In addition to the usual reasons I give for writing (helps me think better, allows me to exercise creativity, helps me reflect), I’d like to think that writing on a daily basis has helped me to become a better writer. This is debatable, of course. I can’t say that I’m particularly proud of anything I have written recently.
I and every other medical blogger don’t write about 99% of our interactions, and it’s because they’re either not noteworthy, or too noteworthy (not able to anonymize) or we just forget. Frankly, most of what we do isn’t that interesting, or notable, like our patients.
I agree. (I, however, think there are interesting and notable things about most things and people—sometimes these details just aren’t apparent at first blush.)
I’d like to write more about my observations; there are so many amazing, ugly, terrifying, stunning, beautiful, hilarious, ridiculous, amusing, humbling, disgusting, and entertaining events that we all witness everyday. However, just because I find two blackbirds fighting with each other on the sidewalk on a drizzling morning doesn’t mean that it’s worth writing about. Or maybe it is, and I’m selling the idea short.
I still believe in the power of the story. Although interesting conclusions can be drawn from data and other “objective”, measures, stories are ultimately the most effective method of engaging people and the imagination. The power of the story explains the success of Harry Potter and This American Life (this week’s episode, particularly Act Two, is excellent). Many of us organize our lives through narratives (e.g. “What I Did On My Summer Vacation” is usually more interesting than “The Itinerary of My Summer Vacation”).
I’ve had a hard time writing stories lately. I attribute it to my (potentially mistaken) idea that these stories aren’t worth writing about.
This too shall pass. Just not today.
3 Aug 2007 |
Everything you write is a “story” about you, even if it seems like objective thoughts. I don’t know if you are brilliant, but you are certainly engaging. I like to talk more than write, assuming there is someone interesting to talk with. I am not a psychiatrist, but I have engaged in learning and changing, myself and others, for the last 25 years. All processes have some value, I guess. The most effective that I am aware of is using Gestalt “experiential cycle of learning” with contact, modulated resistances, boundary, figure/ground, awareness processes and theories, a la Gestalt Institute of Cleveland.
Comment by Don | 3 Aug 2007 @ 9:10pm
Somehow, I don’t quite know the route, I wound up with a very traditional psychoanalytic psychiatrist. Whom I liked very much, and mostly trusted, though we argued a lot — often about my feelings about psychiatry, Freud, etc. I believe you would say I was resistant to therapy? He did have very good movie suggestions at times, and he was humble enough to acknowlede when he was out of medication ideas and sent me to consult with a big pharmacology muckety muck in the city, which finally led to something that worked.
In retrospect, I might’ve been better off with a CBT kind of person, because I think that’s what I eventually learned to do to myself to keep myself well. If I ever relapse into another major depressive episode, I think I’d steer myself to someone whose training and sympathies lie that way.
But I would go back to the psychoanalyst if I had less life-threatening problems that I wanted to discuss with someone with insight into the way people think — perhaps they are better for such things? Not trivial things, exactly, but things that are not clear-cut DSM pathology, either. Why do I keep doing x, where x isn’t dangerous or terrible but isn’t working so well for me, either? Is it a bad idea to go into career y, given my history of z?
Maria says: The consensus is that all “good” therapists all do the same thing—whatever that means (the list includes things like expressing empathy, working collaboratively with the patient, etc.). Herein lies the struggle: We learn all these modalities and yet, they’re only pieces of the puzzle. I wish I could devise a coherent picture of “good” therapy now.
Comment by LadyGrey | 4 Aug 2007 @ 4:53am
In the past when on vacation, I had felt compelled to have my digital camera ever-present to record all the important things that we saw and did. Then I realized that, rather than enjoying what I was doing, I became like a tag-along reporter, always thinking about camera shots, angles, framing a picture, trying to balance the subject matter, and afterward felt like I didn’t experience the vacation so much on a personal level, but maybe like a spectator for my own vacation.
I think blogging has the same risk of having your thoughts during the day preoccupied by thinking about your daily blog entry so much that it degrades the experience of just living your life.
Maria says: I agree. I neither blog to live nor live to blog—but I do enjoy writing.
Comment by Greg P | 4 Aug 2007 @ 6:45am
I can’t be the only person who HAS stormed out of a therapist’s office in frustration…can I? How embarassing! (I still see that therapist though.)
Maria reminds Abby that she is still very early in her career and is confident that people will storm out of the room in the future.
Comment by Abby | 4 Aug 2007 @ 8:35am
“What makes someone brilliant? I define brilliance as someone who can integrate varying and disparate ideas into a lucid discussion. Someone who not only knows a lot, but can make sense of the myriad of ideas. Someone who can easily grasp the different perspectives of the big picture and sort through the details without difficulty. Someone who is enthusiastic and passionate about thinking.
Well-said. I’m going to print this out and put it up on my wall.
Greg: That is so true. When I used to write regularly, I’d spend the better part of my day just composing paragraphs in my head, much to the detriment of the actual experience. I think there’s a reason why Pearl Buck suggested that no one write before the age of 30, or was it 40 . . .
Comment by karrvakarela | 4 Aug 2007 @ 3:06pm
Insanity: doing the same thing over and over again and expecting different results. == attributed to Albert Einstein
Of course the stress of change ticks people off. So does having someone tell you that you need to change. Oh, yeah? is my usual response, as I think ‘yeah, I know, I know’.
I sure hope you don’t have a neatly trimmed beard.
Good think brilliance isn’t a prereq for competence, hey? As for a way to become brilliant: read like hell. think about it all the time. do mind-altering drugs. (Really? Well, I think so. Never have, myself, but then again, I’m not brilliant.) Look for the unexplored, and explore it; look for the commonly assumed and assume its not true. And if all else fails, do what Feynman did with the blueprint.
Why don’t you write more? Heck, I don’t know: because you have a life? I’ve got to admit, I have a real problem when docs smile that secretive smile and say Well, I sure wish I could tell you about…but I can’t, patient confidentiality, blah blah blah. You mean, you’d tell another doc, but you won’t tell me. Well, okay, I understand, you don’t know that you can trust me. But it does irritate me. (Here’s your psych cue: I wonder what he meant by that?)
Maria thinks Bill is making fun of her in a dry manner and, even if this interpretation is incorrect, will choose to believe that nonetheless!
Comment by bill | 4 Aug 2007 @ 5:10pm
“cognitive and behavioral interventions clearly aren’t the end all, be all or [sic] psychotherapy”
You seem to disagree with this in what you say following, but I think that statement should end like:
“Cognitive and behavioral interventions clearly aren’t the end all, be all of psychotherapy — if that was the case, why is it that CBT doesn’t work for certain people?”
I say this because I happen to be one of those people for whom CBT does not work. It irritates me endlessly that people who practice CBT just sit there and tell you to change your behavior, and care nothing about what you’re actually feeling, or what problems led UP to the bad behavior in the first place. I mean, if it was as easy as “just shape up”, do you actually think people would HAVE mental illness? Don’t you think people would get better a lot faster?
No… I think there is always something going on behind the scenes when someone has a disruptive or dysfunctional behavior or set of behaviors, and that underlying cause needs to be tackled just as vigorously as the behaviors, otherwise the person will eventually just go back to the behaviors. The fallacy in CBT is that people who practice it never look beyond the things you do, and may also falsely presume that once you stop the behaviors, you’re cured. Hahaha!!!
Comment by Niika | 5 Aug 2007 @ 5:04am
Let’s make a distinction between two kinds of brilliance– being really exceptional at something (a brilliant pianist) or being, as you define it, brilliant at thinking.
The first kind of brilliance is almost definitely a result of practice and study, not innate talent. It often seems innate because of the ease at which some people “pick up” certain skills, but that is more the result of liking the subject.
But the second kind of brilliance is the more interesting– where someone appears to be able to make associations and interpretations better and faster than others. I can say, having made it my business to find these people out (alive or dead) and try to imitate them, that the key is this: you are always most brilliant in someone else’s field. So the economist who analyzes social issues (Levitt); the mathematician who turns to philosophy (Wittgenstein); or the neurologist who studies the psyche– they seem brilliant precisely because they had expertise in their field, and applied it elsewhere.
In other words, I think brilliance isn’t about being smarter, but about being different. I’d say this is how paradigm shifts occur as well.
And extending from this, it becomes easy to see how drugs, certain mental illnesses, lack of sleep, etc, might promote “brilliance.”
Comment by TheLastPsychiatrist | 5 Aug 2007 @ 2:11pm
“…the key is this: you are always most brilliant in someone else’s field.”
This may be to some extent true, but it perhaps only scratches the surface. What I see as brilliance begins with someone with an ability, some of it innate, but I think this can be practiced and developed too, to see patterns, in particular patterns that cross semantic boundaries. They’re of course striking when you have a mathematician seeing patterns in philosophical thought, or an economist analyzing social issues, but there are many brilliant in their “own” field based on seeing patterns that others do not see. Perhaps this brilliance comes from not sensing boundaries from one discipline to another.
Comment by Greg P | 5 Aug 2007 @ 2:33pm
I have a question and an offering.
The question(s): Science proceeds on the strength of rigorous observation of phenomena. Behaviorism started on the outside, examining what could be observed as action both in humans and simpler cousins. Cognitive science moved a little closer to the center, observing and analyzing thoughts, beliefs and motivations. Is there another layer deeper, that of feeling (not emotion - see Damasio’s many articles over the past 10 years for the distinction), and is there a way to develop a system of rigorous observation of feeling upon which to build a science? Psychoanalysis seems to attempt this digging deeper, but without the rigorous observational foundation. It seems (to me, based on some basic texts) to rely on semantic interpretation of psychological experience based on a comprehensive but essentially unscientific theory. Is there anyone developing such a science of feeling, and a methodology based on it? Is there a third path that provides the power to change without the difficulty and seemingly “glacial” progress of CBT, and without the obscurity (to both practitioner and patient) of psychodynamic theory?
The offering: I would enjoy a conversation by phone, email, or over coffee with anyone (especially you, Maria) interested in this question and the work I have been doing to develop this third way. Come see my website for contact info, (and for info on my book-in-progress, The Tangible Mind).
Comment by Joseph Shirley | 5 Aug 2007 @ 8:46pm
[…] Maria at Intueri recently wrote I still believe in the power of the story. Although interesting conclusions can be drawn from data and other “objective”, measures, stories are ultimately the most effective method of engaging people and the imagination. The power of the story explains the success of Harry Potter and This American Life… Many of us organize our lives through narratives (e.g. “What I Did On My Summer Vacation” is usually more interesting than “The Itinerary of My Summer Vacation”). […]
Pingback by The Power of the Story « dr. david | 20 Aug 2007 @ 6:23am