Dave offers his reflections about what it’s like to be a psychiatrist disguised as a family therapist. Hint: The language is different, and no medications required
Dave: I was talking with a younger psychiatrist about my clinical work. He said, “I don’t know…what you do isn’t really therapy is it? I’d say you are more of a Family Psychiatrist.” I am not sure what he meant. So I have been thinking about it.
I don’t usually introduce myself as a Family Therapist. I usually say something like “I’m a psychiatrist, but I work with families. I don’t use medication very much.” If I say I’m a family therapist and leave out the fact of being a psychiatrist, I am leaving something out. My experience as a psychiatrist working with families is meaningful to me. Maybe I like it because it activates uncertainty and gives patients something to be curious about.
I have always thought of myself as a therapist realizing there are a lot of ways to be a therapist. But “therapist” is an inclusive designation, like describing someone as a musician. Both are broad generic categories. The noun ‘musician’ covers a lot of ground, many different instruments, styles and variations in skill.
I remembered what Milan Kundera said about writing novels, “Novels are not psychological, they are clinical.” I like that idea. That’s why I remembered it. Over my years of trying to understand how therapy works I found it helpful to learn how literature works to convey meaning and experience. Novelists are outstanding clinicians, inspired observers of human behavior. Language in psychotherapy works like language in novels.
I could change what the psychiatrist said. He might say you think differently from therapists I have known. And how would he know how I think? He would know it from how I use language. I do not take language from a theoretical system and apply it to them. I practice figuring out how to use languge to get them to think abut their experience. Practice leads to skill in doing that.
I am a psychiatrist I am not a psychological theorist, I am a clinician. When I am ‘working’ doing therapy I am not thinking of psychological theory, I am thinking clinically. What does that mean?
‘Clinical’ comes from medical language relating to the observation and treating of actual patients rather than developing and applying theoretical formulations. “Clinic” thus “clinical” is derived from a Greek word for ‘bed’, ‘clinical’ suggests being “at the bedside”. I am a clinical observer, focused on context and on relationships and attempting to characterize them with language.
When I come to a clinical situation I bring a large fund of knowledge and a large fund of experience. I keep those funds in the background for use as needed. I enter the clinical situation attempting to figure out what is needed, what is possible. In order to do that I listen to their story realizing it is an edited and distorted story, I see the whole family because in that way I get a sense of variation in the experience of shared experience.
The MD part of my professional self is important to me. That MD knows about being insufficient. The MD both the pre-psychiatry and trained psychiatrist knows what it means to have his back to the wall, to be perplexed, to fail, to have patients die, to have patients recover miraculously.
The family comes in together and we begin a conversation in which the primary reality is metaphorical. When I take the history I am listening at a metaphorical level. Empirical realities, the facts, are included but are not of primary importance. In the therapeutic interaction the organizing principle is poetic not consensual empirical reality. My perceptions are based on my conscientious experience not on someone else’s research.
So I do something I call Symbolic Experiential Family Therapy (SEFT). It is an anti-school school of psychotherapy. There is a dynamic framework constantly being reinvented in each clinical encounter. There is no manual. The framework is grounded in large Funds of Knowledge and Experience. It is a therapeutic method beyond interpretation. That is I don’t make interpretations. I comment. I observe, but I don’t make interpretations. What looks like interpretation are suggestions, possibilities.
The therapeutic language I use resides in the endlessly inventive ambiguity of poetic reality. What do I mean by that? I am always in relation to them in relation to language. In poetic reality, I find relations between language and experience in the moment. I pay attention to myself, but not myself in isolation, I pay attention to myself in relation to them. I think of myself as being something like a song writer. I am paying attention to life as I encounter it and making comments that are always quasi-metaphorical. I give off opinions, usually limited to 1-2 sentences. The remarks create experiences. My remarks are always aimed at change.
I follow a rule system impeccably. The rule system is not in a book or hung on the wall, it is integrated into my whole self. It has developed over time, a habit of intellect that helps me to do what is best for the work. It is guided by two major influences; the moral requirements of the community and by a sense of beauty. I mean a sense of aesthetic wholeness, the sense of aesthetic wholeness is different from understanding.
My blogging partner, Amy Begel is an artist of therapeutic language. Her clinical postings (for example, The Mystery of the Vomiting Woman or When Sad Becomes Mad) give you a sense of what I’m talking about. She is clinically experienced in dealing with the unending ambiguities of body and mind, without giving into the abstracted standardizing medicalized language that always leads back to where doctors and their patients become stuck.
Attention to the problems that perplex doctors and patients requires a combination of artful and graceful interaction. The good therapist in the territory of mind and body is not defined by the possession of superior knowledge. The good therapist is someone who has abundant experience in dealing with clinical complexity. Amy Begel embodies that range of experience. With subtlety she helps patients and doctors discover possibility in relationships.
I will have to go and find that psychiatrist and tell him his effort at setting up a distinction didn’t work very well. I am a therapist, I am a psychiatrist and I work with families. All of that can be lumped together to make me a Therapeutic Family Psychiatrist. So the distinction he constructed didn’t hold up, but it did activate some conversation with myself. I hope you have been able to join in with my wondering.