The Burden Of Being Responsible

Two posts in two days, talk about writer's block being unblocked.  Processing my personal struggle through words yesterday, has had an important affect on my state of mind.  Who says words don't matter and talking doesn't help?  Which takes me to my next confession.  I have come to the conclusion that I am a relational therapist.  My year long course in psychoanalysis is almost over and I have traversed many concepts such as traditional psychoanalysis, contemporary psychoanalysis, conflict theory, object relations, self psychology and interpersonal therapy, to name a few, given that all of it is mostly just skimming the surface.  But the more I have read, the more I am finding myself changing on how I do therapy.  

Over the past year, I have gradually and almost without any conscious planning, moved towards intersubjectivity, relationships in therapy and my own presence in the room.  No, I don't mean that I wasn't present prior to this transition, but merely that I was trying pretty hard to be invisible, irrelevant.  But I don't anymore.  The downside being, I am very aware when I am tuning out during a session (downside because it still annoys me) and instead of turning it on to the patient (in my head), I now really question my own interference in the moment.  I have caught myself being lost in my own dilemmas and have now dared to bring myself back in he session and disclose to my patient, that I had tuned out.  And low and behold, the patient has already noticed.  They were just too nice to call me out.  Now I take responsibility!  

However, I will add a foot note, just so there is no confusion.  I don't discuss what is going on with me, nor do I disclose my personal dilemmas because even as my style has changed, the therapy is FOR the patient and I am not the guest of honor.  I have been faced with questions about why I had tuned out? and then follow up about what may be on my mind, when I confessed that I was preoccupied.  But even in the relational therapy and all the intersubjectivity, boundaries and the delicate art of disclosure, remains of utmost importance.  Hence the focus remains on the guest of honor, and not on me.  The upside, the sessions are more intimate, more fluid and I don't feel the pressure to fix everything.  I am more comfortable saying, "You tell me."or "What do you make of it?" or "I need to think about this."  That being said, I have also seen that what is going on with me, changes my sessions and today was a perfect example.  I was calmer and felt better about processing my own thoughts and was more comfortable pushing my patients to look at the reenactments and patterns (today happened to be a day of such sessions, or may be I was more tuned in).  

To make the long story short, may be today I understand why I wrote, what I wrote last night.  It was the responsible therapist in me, that felt trapped and paralyzed by my own doubts, inadequacies, battles about my roles and the stigma of children with learning needs, special needs.  I had carried that burden with me for months and certainly for last 3 weeks to this Thursday.  

Today I felt at peace.  Not only did I face my fragile ego that was bruised but I also rebelled against my super ego that kept telling me, to not talk about this so openly.  At the end of the day, I decided that I will not stigmatize my precious child, by keeping my feelings hushed about his struggle and my own struggle as his mother.  I am his advocate and I can help many more like him by talking about him out loud.  

Whether you are the therapist, who is mature enough to admit to the patient that he/she was wrong, or didn't know what was going on but can definitely work with the patient to find out, or a mother like me who finally decides to throw caution to wind and hold her head high to cheer her son on, welcome to the club.  It is intense, personal and never easy because the burden of being responsible, lies in being vulnerable and being vulnerable is the only way to expand your horizons.  

As Dr. Brene Brown Said:
"Vulnerability is the birthplace of innovation, creativity and change."

The Couch Reversed

After a long absence I am back.  I have a few thoughts about what made it possible for me to come back today.  Last few months have been a whirlwind for me to concentrate on this blog and muse much.  I don't think there are enough hours in the day to contain what goes in my life on any given day.  I am nearing the end of my 3rd year and it is only 3 months away.  Hard to believe I started here midway through second year.  I have bad days and I have good days.

I worry about my impending cord severing in 17 months to be on my own and it scares me to think I will be on my own.  One would think moonlighting is a good practice to run solo but I still have options to consult, mainly because I am probably quite lucky to have that option.  I am losing one of the best times of my life at the end of these 17 months and I feel like I want to grieve at times.  I am sure, I am starting to.

One of the best things I have done for myself over the last 2 months is exactly what the title of this post says.

Have you figured it out yet?

And if you thought of therapy; you are the winner.  You are pretty awesome at this guessing game.  

So after 8 months of monkeying around this idea of getting in therapy for myself, I finally gave in.  The proverbial couch is literally reversed.  It is quite a transformation and one that I never knew would make me think so much.  

For many psychiatry residents, esp. if they are like me and see or want to see a lot more therapy patients, it is something that just has to be done.  I hope all programs provide supervisors for therapy cases, as they should but I also hope that many psychiatry residents do not end up ignoring the need for their own work to be done.  If you have a supervisor that is open to working simultaneously with you and on you, that is great.  My supervisor on other hand never had a choice and mainly because of me.  I am used to taking charge and in my mind, I had this one hr a week for case consultation, so I would walk in and use every minute of that hour for my patients.  He got to get glimpses in my personality but by the time I brought up the question of my own work with him, I already had a mindset that this is an hour paid by my program and I shouldn't use it for myself.  Not to mention I had 8 cases for therapy and at times 10-15, so I needed this hour more than ever.  

I started noticing my anxiety as a therapist get louder, the more intense therapy with my patients got.  The emotions and reactions in me were what forced me to be very honest with myself about what did I want myself to be able to do when I take on people for therapy.  

I started reading more this year.  Yalom, Bowlby, Beck, Wachtel, Gabbard, Robert Karen and numerous articles here and there.  None of these people that I admire so much and learn so much from, got so good at what they do without having their own work done.  

I want to be half as good as any of them.  That is what I want.  So I can't ignore the need to be the patient in order to be an effective therapist.  

I finally gave in and asked my supervisor to be my therapist.  That in itself was an intense experience from having to process my need to have the safe path to therapy with a known person than to open to a totally new therapist, finding a new supervisor and then realizing I lost my supervisor relationship with my now therapist.  It was something that came so unexpected yet proved to be a great stepping stone into the new relationship.  

Now 5 weeks into it, I have started to understand why my patients, who come sit across from me in my office; keep coming every week.  I understand that they are the ones doing the work and when they ask me questions about what to do, they are not meaning to put me on spot, neither are they looking for a magic formula; but rather exactly the opposite.  They already know what they are asking me, I just help crack the code.  Sitting across from my therapist when I share things that make me question my own abilities, limitations and that frustration that I feel with myself many times; I hear myself say things I only think about but am too scared to admit to myself.  It's like I believe, as if I am superhuman or should be superhuman.  I have started to understand my worries and anxieties in ways I probably already knew.  It is so odd how actually saying them out loud is akin to giving life to something many of us like to keep buried.  Reversing the role makes me see how without this step, I was never going to be able to fully understand the person who sits across from me every week without doubting the process every step of the way; because I never had the experience from the other side.  

Dealing with my own life and facing my own limitations, I have to do it; to do what I want to do.  The proof is in this post.  Took me 2 months from my pledge to write here to actually write this.  The only thing that has changed is that now once a week I get to be the patient.  I get to be able to let it go and face myself without reservations.  Something so hard to do but has a profoundly liberating effect.  Most probably one of the reasons I am back here writing again.  

So if you are a therapist, psychiatry residents or aspiring to be either one of those, keep your work on yourself in your mind; not as an option but as a necessity.  Not because it is cliche; but because it is anything but.  

As Irvin Yalom says, 

"Self exploration should continue throughout life, including entering therapy at various stages of life."

    

Choices Choices

I will be a 3rd year in just two more weeks.  Ack! Time has flown and this means I have two more years left to finish training.  This also means I have to pick a track for the next two years of my training.  Third year of training spans over 12 months of outpatient clinic for all Psychiatry residency training programs.  Outpatient is a different breed.  This is where residents learn to work with patients who are functioning and are able to participate in treatment.  These patients in so many ways help put the inpatient work in a new perspective by shifting the dismal and seemingly hopeless inpatient work to a more stable and predictable one.  Inpatient training teaches residents the art of managing acutely unstable patients from admission to hospital stay and culminating at discharge.  At the same time like any other medical model it seems to have a slew of repeat patients, many admitting multiple times in short periods of time.  That is what sometimes makes many physicians jaded.  I think 3rd year is the perfect time to switch to outpatient so residents can break the cycle for themselves and re-energize before making career decisions moving into 4th year and beyond.  

Like many programs this past year we started assigning PGY-2 residents at least two patients for long term therapy.  I have found therapy to be challenging, at times scary and very rewarding.  What makes it somewhat easier when it seems so hard, is having a supervisor who helps you explore your own emotions and guide you along.  I have to pick a track for 3rd year and I have decided to pick Psychotherapy as my main track, which means I will have at least 9 therapy patients, along with my regular clinic through out the year in addition to the group therapy.  It is daunting and I am not sure if I will be able to handle this but the only way to move forward is to dive in deep and see what happens.

No matter what happens, the bottom line is that I am excited about moving up the ladder, changing work environment and taking up what I love most about psychiatry - healing through words.

Happy PGY-3 to me!!