Is this psychotherapy?

April 5, 2017|Psychiatry

“Create a safe zone where anything can gain expression.”

– Carl Rogers, PhD

The patient

“I have no purpose,” Audrey said. She sat immobile, a woman of 45 who looked 10 years older. Audrey hated New York, the crowds, the weather. Her husband, a successful sales executive, supported her; a month earlier, they had moved from California to New York. Her depression and panic attacks dated back to childhood. She also suffered from arthritis, asthma, and lupus. Audrey told me that her parents, long dead, were dreadful. “My mother was the most abusive person. She put out cigarettes on my arm; beat the s*** out of me, my brother, and sister.” She said that in New York, she stayed in her apartment on her couch or shopped for clothes that, ultimately, remained in the closet.

According to Audrey, nothing helped. She was on psychoactive medications prescribed by her Beverly Hills psychiatrist – Cymbalta and Wellbutrin for depression, Klonopin for anxiety, Abilify for agitation. She also took Neurontin for nerve pain and opioids for arthritis, prescribed by a pain specialist.

The process

She was suffering from the trauma of losing a father when she was 3, and living with a mother who tortured her and interfered in her psychiatric treatment throughout adolescence. Audrey’s mother would insist on joining the session or breaking off therapy before it could be effective. Audrey was articulate and intelligent, a patient who could benefit from insight-oriented psychotherapy. We discussed additional options, including cognitive-behavioral therapy, meditation, and dynamic group therapy. Audrey wanted monthly sessions with me, mostly to discuss medication and how to tweak it. She discredited psychotherapy, so we settled for what I considered to be less than optimal care.

In residency and beyond, psychiatrists learn to develop a treatment plan based on the patient’s history and symptoms. Some individuals want to understand the origin of their suffering with a thrust toward recovery and independence. Others lack that capacity and need to shore up their defenses through supportive intervention. The direction of how to proceed is often a compromise between what the doctor sees as ideal and what the patient desires.

Outcome

All seemed stagnant for 2 years. Then, Audrey’s demeanor changed dramatically. She enjoyed walking her dog in Central Park; she reflected on her devoted husband, who encouraged her. Audrey’s transformation progressed.

Three months later, her husband took a position in Montreal. On a visit to New York, she told me that she no longer disliked the city, even the noise and the cold weather. I questioned what made the difference. “You saved my life,” Audrey said. I asked what she meant. “You were always there for me,” she said. “You made an effort to try to help me get better. ... You can be funny, witty.” She ventured that she had been through “a change of life, maybe a midlife crisis.” She made new friends in Montreal. “I’m getting rid of the negative people.” Audrey planned to continue psychiatric care in Montreal. In part, Audrey credited improvement to our sessions, and I told her I was grateful to be of help.

Another case

Arthur was a seriously ill, 88-year-old retired pulmonologist, so weak that he was being spoon-fed when I entered his room. He had a “fear of dying or living with disability” from diffuse lymphoma, complicated by tumor lysis syndrome after chemotherapy. “I don’t want to give up, for myself and my family,” he said.

Arthur told me about his struggles to achieve despite poverty in childhood. He needed a scholarship to attend a local college. There were trials at a medical school that failed out less capable students. He commuted and studied at the kitchen table until 3 a.m. Arthur’s mother-in-law had disapproved of him and wanted her daughter to marry a wealthy businessman. During their courtship, Arthur gave his girlfriend a gold bracelet, which he said she should keep it regardless of whether they broke up.

Arthur had a modest evaluation of his capabilities despite a good practice. Meanwhile, his home life progressed: Two of his three children became doctors; the third succeeded as an accountant. His marriage thrived.

At the end of our session, I expressed surprise that his mother-in-law had taken such a dim view of a suitor with determination, impressive credentials, and a future that would be a source of pride. I also assured him that he had chosen fine doctors for his care.

The next time I visited Arthur, he heaped praise on me for turning his life around. I had restored his hope. His daughter, who was visiting later, told me that, no matter how much the family and medical staff encouraged Arthur, “nothing happened until he met you.” I, of course, thanked Arthur for his gratitude and experienced amazement at the success of the talking cure.