Becoming a psychiatrist: Harvard residency notes

Back in 1991-1994, I attended my psychiatry residency at McLean Hospital, the preeminent training program in the Harvard system at the time. I took extensive notes in lectures and have kept and reviewed them over the past few decades. In this column, I plan to gradually transcribe some of those notes, metabolized now after 25 years of practice and experience, and share them with PL readers. Occasionally I'll comment based on my own views now if relevant, but mostly I'll let the notes speak for themselves. For completeness, I'll include the name of those who taught me, some of whom are now deceased, but I do so with the disclaimer that they have not reviewed or examined this material. I believe what is recorded is a faithful transcript of what was said, but if anyone disagrees with any attribution, it will be removed. Nassir Ghaemi

The nature of psychotherapeutic work

A lecture by Leston Havens MD, 12/7/1991

Freud really wasn't a therapist. Psychoanalysis thought it could get the right explanation and give it to the patient. But it's not so simple. We penetrate to possibilities but rarely facts. Trauma was a fantasy, then a fact, now a fantasy again.

We're all worried about each other, and about ourselves.

In our therapeutic impotence, Freud brought us a grandeur. Our task today is much humbler, like being an engineer as opposed to a physicist:

Our goal is just to know how we feel.

Seeking explanations for our feelings sends us in the wrong direction. When you seek what's wrong with a patient, you frighten the patient, and yourself. The smallest finding can be blown up out of proportion. We psychiatrists are the only profession that uses adjectives - neurotic, borderline - to diagnose.

Most people are mostly well. Even a dying patient is mostly healthy.

Our minds are not capable of doing this work. You exhaust yourself if each time you see the patient, you try to figure things out. Relax. Freud's evenly hovering attention was good advice. Take no notes, never formulate the case, allow yourself to be surprised. What can we do when aren't primarily figuring things out?

I recommend the maxims of Marcel Proust: The novelist's first invention, he said, was to stand somewhere, to have a different perspective. What the first novelist invented was fallacy. The 1st problem is to make the reader keep reading. What attaches to the human being is not the human being, but the image we form of him (the transference). You suppress the rest of the person; you don't want to know that. I don't want to know that Marilyn Monroe also did the dishes. You create an image, and you keep the whole person out of it.

It's like falling in love: a case of image collusion. Then you get married, and the whole persons get to like each other, because if you like yourself, your humanness, your recognize and like it in another person.

So, in a novel, somewhere around page 1400, you begin to like the whole person.

In psychotherapy, the initial interest is in the image: the doctor; the borderline; the diagnostic concept relates us to the patient. Then the whole person comes back eventually. When the psychiatrists opens us up, like the surgeon, he finds all the usual suspects. The combinations may differ, but the contents are the same.

The whole person always needs some help; he can't do certain things. We need to make movements to help that person along. That's the work of therapy.

How do you give someone courage?

The bodily movement is encouragement: a giving of courage.

That's why the resident's four tasks in training are:

  1. Help someone mourn a loss.

  2. Leave people alone.

  3. Hang up the phone.

  4. Encourage people.

Five laws for the treatment of pain:

1. If what you’re doing is working, keep doing it.

2. If what you’re doing is not working, stop doing it.

3. If you don’t know what you’re doing, do nothing.

4. Never call a surgeon.

5. ? Never call a psychiatrist.

Ned Cassem, 1/5/1993

Psychotherapy supervision

Freud’s conception of sublimation involved the integration of affect into the self, allowing one to satisfy and utilize one’s drives. The manic person runs away from his affect by organized activity. He is unable to realize the importance of being with affect, of acknowledging despair. The depressed person recognizes depression but is unable to utilize it as an experience of the self: depression becomes an overwhelming conception. The schizophrenic person has a mania of thought -thoughts are all disorder, excessive, separated from each other. The opposite of mania is meditation, the removal of all thought.

Elvin Semrad’s view, which I share, is that there is always a part of the self that can recognize problems, and it can always be addressed, and the task of therapy is to strengthen that part of the self. In Winnicott’s terms, there is a false Self, one’s external characteristics, which is necessary for existence. Beneath it is the true self, You, which cannot be expressed, and which is developed in therapy. But not all of that private You should be expressed; part of it can be expressed at certain times.

(9/27/91, Walker Shields MD)

Risk management

The most important part of documentation is to record the reasoning behind decisions.

You cannot prevent suicide; you can only intervene.

Statistics: 50% of depressed persons have SI. 30% make suicide attempts. 10% of those who make attempts eventually commit suicide. 60% of suicides occur on the first attempt.

The critical element for suicide is not so much the symptom (e.g., depression), but where the person is in their illness.

Differentiate between depression and despair.

On admission and discharge write: The patient was examined for the presence of suicidal ideation, and it was not found.

(9/27/91, Douglas Jacobs MD)

On psychopathology

You should always read a novel and a biography at the same time.

A hallucination is a dream while awake.

St. Dymphna was the patron of mental disease.

(9/27/91, John Maltsberger MD)

On beginning psychotherapy

When you begin psychotherapy with someone, identify roles and goals: Identify your role and the patient's role, and your goals and the patient's goals. And the common goal. There should be clear and explicit agreement on purpose.

The foundation of the therapeutic alliance rests on three things:

1. Mutual liking: an attachment between you and the patient

2. Clear agreement on roles and goals

3. Working together on issues in the patient's life, separate from the therapist-patient relationship

Bring to light the anxieties of the situation and force the patient to speak it aloud.

Reality is never as good or as bad as our wishes or our fears

(9/26/91, John Gunderson MD)


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