January 19th, 2012
 As posted below, I joined HealthTap a month ago, impressed with its vision of bringing real medical expertise to the public in a Yahoo Answers type format. Since then I’ve participated actively. As of today, I’ve answered 40 questions, and I’ve been thanked by 30 members — it’s tempting to call them patients, but they’re not. Other physicians have agreed with my answers 60 times; I’ve agreed with some of theirs as well. HealthTap claims I’ve helped over 4000 people; I have no idea how they calculate that. I’ve earned 3600 points and 13 rather trivial “awards” by virtue of my activities, granting me “Level 7″ status as a “Leading Medical Expert.” I haven’t yet used the mobile app or social networking links (i.e., to Facebook, LinkedIn, or Twitter), nor have I written “tips” or “health guides,” collections of answers and tips under a defined theme. I also haven’t done much with the networking feature: I “follow” one other psychiatrist, and eight physicians follow me, which basically means they find out immediately if I post something (and their dedicated readers see it as well, like a Facebook “wall”). Today, HealthTap reposted my piece on support and insight in therapy to their blog.
All in all, it’s been fun. The awards, points, and “levels” are a bit silly, but they add some zing. Answering questions in 400 characters isn’t as hard as I expected, and part of the fun is deciding what to say in so few words. It’s also interesting to read what other MDs write, especially in fields other than mine. And it does feel nice to volunteer simple answers to real questions people have.
HealthTap democritizes medical knowledge, and brings the public closer to instant “ask your doctor” convenience than other health sites I’ve seen. But looming over the enterprise is the reality that we are not “your” doctor. The terms of service and legal disclaimers underscore that no doctor-patient relationship exists via the site, and that medical answers are intended to be generic, not for an individual. But patients, I mean members, mostly ask first-person questions that address their personal medical concerns. That’s the whole idea. And very often we doctors reply that there are many possible diagnoses or etiologies to consider, but that only an in-person medical evaluation can sort them out.
While HealthTap is an inspired effort, in my opinion it is hampered by the wrong model. It tries to be a social networking site, when in reality it’s a knowledgebase. Social networks derive value from interconnected communications among members; think Twitter and Facebook. But people don’t chat about health issues on HealthTap, nor do they befriend others. They seek answers to questions. HealthTap’s social network model encourages asking the same questions over and over, since quick access to doctors is emphasized, not the fact that thousands of questions have already been answered. For example, in my one month on the site several members have asked how to treat anxiety. It’s a good generic question, but it’s already been answered a number of times — at least as well as one can answer such a broad question in 400 characters.
HealthTap encourages doctors to create a Virtual Practice to “enhance your reputation, get new patients, and improve practice efficiency.” I don’t quite see the utility, but perhaps this works better for other specialties. I can imagine a family physician pointing real patients to his or her HealthTap page for tips or guidelines about common complaints.
I think HealthTap would serve its members better by embracing the knowledgebase model. Make prior questions and associated answers more easily searchable, and give searching priority over asking anew. If a user’s specific question is not found, it could be submitted to HealthTap staff for vetting. Duplicate or incoherent questions could be rejected, grammar and spelling cleaned up, and meaningful tags added to facilitate retrieval later. To encourage participation, doctors could still be recognized for answering quickly or often, or with answers colleagues agree with. Thanks could still be offered by members for helpful answers, and everyone could still log into personalized pages as they do now.
HealthTap is reportedly popular and growing rapidly. HealthTap Express, the mobile app, is the #1 Staff Pick on Android Market. As long as people seek health information online, and as long as doctors volunteer to provide it, HealthTap’s future seems bright. But it could be so much more if its architecture better matched its primary purpose. Social networks are great for social networking. Knowledgebases are great for organizing, storing, and retrieving knowledge. The doctor-patient relationship, a small social network, cannot exist on HealthTap, but a great deal of medical knowledge already does. Its organization and accessibility could be greatly enhanced without sacrificing the responsiveness and personalization that brings smiles to the HealthTap team and its members.
December 19th, 2011
Last week I was invited to join an online service called healthTap. I signed up this weekend, and have been enjoying it so far. It’s a free membership site where users ask brief medical/health related questions. The questions are then answered, also briefly, by one or more physicians in the “Medical Expert Network.” Each doctor has a personalized page listing all questions he or she has answered so far, some additional related material, as well as practice and contact information. There is no compensation for the doctors other than this publicity, including easy, built-in ways to spread one’s thoughts using social media such as Facebook, LinkedIn, and Twitter. There’s also a free mobile app to access the site.
My early impression is that healthTap started with a Yahoo Answers model, then greatly improved it by vetting professional respondents. Answers are a maximum of 400 characters (a short paragraph), so the information comes in small, bite-sized chunks, not long monographs. The quality of the answers varies of course, but it’s generally pretty good given the space limitations.
I just added a healthTap widget to the right-hand column of this page. It shows some of the questions I’ve answered. You can read each answer within the widget by clicking, and it also aims to sign you up on healthTap. I see no harm in doing so. You’ll have access to a well-meaning group of 6000 US-licensed physicians in all specialties, who volunteer to answer your health questions. Note that there is no doctor-patient relationship formed this way: Having questions answered online is no substitute for a real in-person consultation.
December 3rd, 2011
 Tonight I was invited to an advance screening of “A Dangerous Method,” a film about the early days of psychoanalysis. It stars Keira Knightley, Michael Fassbender, and Viggo Mortensen, and will be in wide release by Sony Pictures Classics this month. The invitation was extended to Psychology Today bloggers, among others, in the hope we’ll publicize the release. Since I was gifted with a free viewing, I invite readers to consider this review with my potential conflict of interest in mind.
Overall, I was pleasantly surprised by the film, which has received mixed but mostly positive reviews so far. It humanizes both Freud and Jung, and introduces us to Sabina Spielrein, a real-life patient of Jung who later became a renowned psychoanalyst herself. Jung’s reputed sexual affair with Spielrein is treated as fact in the movie, and serves as the main dramatic focus. Some reviewers feel Knightley overacted the part of Spielrein. I thought it was pitched about right: a troubled young woman having illicit sex with her therapist would naturally be agitated and volatile. I did find Spielrein’s willingness, from the first session, to participate in newfangled psychoanalysis to be a bit optimistic. Also, her suggestion at one point that “there is man in every woman, and woman in every man” too-neatly implies that she gave Jung his idea of the anima and animus. Nonetheless, Spielrein is very well played.
In contrast, I found Fassbender’s portrayal of Jung more vague and wooden. The film suggests he was a psychic who could foretell the future in dreams and premonitions. His feelings toward Spielrein seem confused, not merely ambivalent or conflicted. And he refers to countertransference years before Freud published the term, although it could be argued the two historical figures may have discussed it between themselves earlier.
The decline and fall of Freud and Jung’s collaboration is the secondary theme, and here I was particularly impressed with the believable way Freud was portrayed. A pioneer, pragmatist, and controlling intellectual, he knew his treatment approach was controversial and sought to rein in Jung’s more expansive and spiritual predilections, which the elder Freud saw as giving ammunition to his enemies. Instead of the usual stereotype as a gruff, unyielding father figure preoccupied with sex, Mortensen plays Freud as somewhat authoritarian, but fundamentally smart, affable, and very concerned about the future of his psychoanalytic movement. Their famous 1909 falling-out on the deck of a ship sailing to America is played with a soft touch: Freud refuses to let Jung analyze his dream for fear of losing his authority (something Jung later recounted as due to Freud’s secrecy over his affair with his sister-in-law Minna Bernays). In the film, Jung is hurt by this non-reciprocity, and goes on afterward to develop his own theories of the psyche.
The film is beautifully photographed, and has a number of nice touches. The opening and closing credits are shown over a close-up of handwritten correspondence, the main way Freud and Jung communicated with each other. In one scene Jung conducts a word-association test using physiologic data collection — an accurate depiction of some of his research at Burghölzli, the psychiatric clinic of Zurich University, where he worked from 1900–1908. I even liked how the film showed the evolution from horse drawn carriages to automobiles, which of course happened in the same time period.
The American physician-psychologist William James was Freud’s contemporary and wrote: “I can make nothing in my own case of his dream theories, and obviously ‘symbolism’ is a most dangerous method.” The film “A Dangerous Method” is not nearly so dismissive of psychoanalysis. Yet, in its depiction of the dueling dream interpretations of Freud and Jung, and the complex relationship between Jung and Spielrein, it deftly highlights how symbolism is indeed a dangerous method of transacting human relationships.
November 6th, 2011
 The following post is an adaptation of an argument I presented on Sacramento Street Psychiatry, my blog on the Psychology Today website. As usual, I welcome your comments.
Western medicine’s great strides are largely due to understanding etiology (the biological basis of disease), defining a nosology (a system of categorizing diseases), and testing treatments aimed at these nosological entities, not at individual patients. Take 100 healthy volunteers, swab their throats with Streptococcus, and perhaps 88 will soon develop strep throat. Both our knowledge of bacterial infections (etiology) as well as repeated empirical observation of similar cases leads us to conclude that Streptococcus causes a recognizable condition called strep throat (nosology). Once patients are diagnosed with strep throat — once their conditions become exemplars of this disease category — experiments can be done to show which treatments relieve the condition. Western medicine is the accretion of such knowledge.
Hypotheses about disease categories, and about treatments aimed at these categories, can be tested using randomized controlled trials (RCTs), our most powerful statistical method to assess the effect of independent variables. As in the rest of medicine, evidence supporting the efficacy of psychopharmacology, as well as manualized psychotherapies such as CBT, depends on sorting patients into nosological categories such as “major depression,” applying different treatments to comparison groups, and finding statistically significant group mean differences. In psychology such a research approach is called nomothetic; the goal is to identify general laws of behavior.
However, another kind of knowledge is important too. Why didn’t the other 12 subjects get strep throat? Is it the same reason for all 12, or is the answer different for each of them? Looking at what makes people unique, as opposed to members of a category, is called idiographic research in psychology. This is the nature of psychodynamic theory and treatment, and why it resists the usual RCT approach to research. Patients who present for such treatment rarely fit neatly into a category such as “depressed.” They vaguely say their lives aren’t working well for them, or that their relationships are unsatisfying in a particular way. They lack meaning and purpose in life. They get a “funny feeling” when dealing with competition. Their boss triggers authority issues. They can’t trust their spouse’s fidelity. And on and on. Such complaints are not exemplars of a nosological category. We may not know what causes schizophrenia or bipolar disorder — we have no etiological understanding of any psychiatric disorder, one reason they are called “disorders” and not “diseases” — but at least these labels reflect a coherent nosology. Not so with the presenting complaints of most psychotherapy patients.
Psychodynamic therapists and psychoanalysts find little of value in the nomothetic approach. DSM-IV and similar nosology sheds no light on the particular patient in the office, with his unique history, dreams, fears, hopes, etc. The psychoanalytic/dynamic perspective is to understand the uniqueness of that specific patient, and to promote unique helpful changes that may have no relevance to any other patient seen in the practice.
This is not to discount the importance of the nomothetic approach where it applies. If a patient’s condition is exemplary of a nosological category, it should be treated that way. Doing so allows us to use powerful research tools to separate bias and wishful thinking from real treatment effects. If a patient presents with major depression, bipolar disorder, or schizophrenia, nomothetic research can and should guide treatment. In such cases, psychodynamic therapy must stand or fall on the same RCT basis as other treatments. The evidence base for manualized psychotherapies such as CBT, IPT, and a few others is stronger than for dynamic psychotherapy. If someone is seeking relief of major depression, pure and simple, I am happy to refer them to a CBT therapist, and have done so on a number of occasions. It would be nice to be able to claim strong evidence for the efficacy of prescription antidepressants as well, but unfortunately this is less clear.
CBT and other manualized therapies for specific conditions are much easier to study than dynamic therapy for ill-defined complaints. So it’s really no surprise there are more such studies. Idiographic research methods, e.g., pre and post measures in single-case designs, have been used to study dynamic psychotherapy, both whether it works and how. But nomothetic researchers consider this “weak science”: There are no control groups — no groups at all, actually.
The bottom line is that dynamic psychotherapy has different goals than CBT or medication. It doesn’t aim to treat a nosological category such as major depression. Since it isn’t based on a nomothetic treatment model, RCTs are the wrong assessment tools to use. Idiographic research methods may be statistically weaker than their nomothetic counterparts, but they are the best that this domain of inquiry allows. (Seligman argues that naturalistic surveys have their place too.) Dynamic psychotherapy is based on a rich theoretical foundation that has been scrutinized and refined for the past century. But ultimately it comes down to the individual and the unique mix of discomforting feelings and troubling thoughts that led him or her to reach out for help.
September 25th, 2011
 People sometimes wonder whether I “analyze” everyone I meet. This is usually asked with some fear that as a psychiatrist I can “see right through them” and instantly know things about their innermost thoughts they’d prefer to keep hidden. Although this is true (just kidding), I try to reassure them with the following analogy.
Imagine an architect whose business and personal life includes walking into and out of buildings all day. Does the architect “analyze” every building — home, coffee shop, office, gym — all day long? I doubt it. Perhaps if a particular construction is especially creative, or unusual, or singularly beautiful or ugly. But most of the time an architect relates to buildings the same way everyone else does: for the personal reasons he or she visited there. (If there are any architects out there, please confirm!)
In my experience the same is true of psychiatrists and other mental health practitioners. We deal with people all day, both professionally and personally. When working, our attention is directed in a certain way, toward understanding the person in front of us. After all, this person paid good money for us to focus our attention exactly this way. Other than this, though, we deal with loved ones as loved ones, colleagues as colleagues, store clerks as store clerks, and so forth. It is only when someone’s personality or behavior is noteworthy and unusual that we may find ourselves viewing them momentarily through our “psychiatrist glasses.”
I’ve heard it works similarly for doctors and medical diseases. Occasionally a case of acromegaly, cerebral palsy, rheumatoid arthritis, or psoriasis can be diagnosed in a stranger on the street, or in a crowded elevator. Most of the time, though, people are just people.
The question about analyzing everyone often seems to harbor some anxiety. It feels threatening to have possessors of mystical and limitless insight lurking among us, wantonly tearing holes through the public persona and self-image of each innocent bystander.
Fortunately, this is a fantasy. Being a psychiatrist doesn’t make me a mind-reader. It usually takes an hour of formal intake interviewing before I begin to have a sense of a person’s personality. Often it takes more than one session. While it’s true that people, not just psychiatrists, can pick up clues to personality early in a conversation, psychiatrists aim more for accuracy than speed. Instant on-the-fly psychiatric diagnosis or case formulation is fraught with uncertainty and error because it is based on insufficient data. As professionals, we are trained not to shoot from the hip, and for good reason: because our opinion should mean something. If the considered views of psychiatrists are to matter more than the hunches of untrained persons, we must refrain from offering half-baked, “cocktail party” assessments. I cringe when I hear a colleague spouting off about a politician or celebrity known only through the media. A detailed study of someone not personally interviewed, e.g., a psychohistory, may be defensible; an off the cuff opinion cloaked in psychological jargon is not.
“Analyzing everyone we meet” is literally impossible, and as in the case of the architect, would be a huge distraction from everyday life. Moreover, even attempting it is unprofessional. We should reserve any such analysis for the clinical office, where the setting is conducive, and the data sufficient, to make a meaningful assessment.
September 18th, 2011
 Tara Parker-Pope of the New York Times blog Well featured my prior post, on the feelings some patients have as they imagine whether their psychotherapists have been in therapy themselves. My post was about patients’ fantasies, not the reality of therapy for therapists. Nonetheless, many of the comments argued for the great value of such therapy, and one or two expressed amazement that such therapy is not universally required. I agree that psychotherapists have much to gain from personal therapy, and in this follow-up post I’ll offer some reasons why.
Is therapy required in order to become a therapist? In the U.S., generally not. According to Geller, Norcross, and Orlinsky [1]: “In most European countries, a requisite number of hours of personal therapy is obligatory in order to become accredited or licensed as a psychotherapist. In the United States, by contrast, only analytic training institutes and a few graduate programs require a course of personal therapy.”
A “training analysis” is required to become a psychoanalyst. I.e., one must be analyzed oneself. However, in the U.S. personal therapy is not required to practice other schools of psychotherapy, nor to obtain licensure in mental health disciplines such as psychiatry, clinical psychology, etc. Specific training programs within a discipline may require it, and certainly a large number of programs recommend personal psychotherapy for their trainees. Indeed, many strongly encourage it by offering referrals to therapists, low-fee therapy, time off from training to attend therapy, and so forth. In a 1994 survey of psychologists by Kenneth Pope and Barbara Tabachnick, 84% reported having had psychotherapy themselves, although only 13% had attended a graduate program requiring personal therapy for therapists-in-training [2]. Whether by mandate, urging, or independent choice, many practicing psychotherapists can claim experience in “the other chair.”
At the most commonsense level, a therapist who knows what it is like to be a patient may be more empathic, and may anticipate unstated feelings more readily than a therapist without this first-hand knowledge. For example, vacation breaks can feel extraordinarily disruptive to patients, a fact that can be taught in lectures or textbooks (or blogs), but may not be fully appreciated until it is experienced oneself. Transference in general is better understood experientially than learned academically. Even non-analytic therapists can benefit by recognizing transference and other common “real-time” emotional reactions, conscious and unconscious, in their patients or clients; these can affect rapport, treatment adherence, and so forth. Psychodynamically informed practice is a hallmark of psychiatry, even when psychodynamic treatment is not offered. The same, I would argue, is true of other mental health disciplines. Psychologists conducting CBT and clinical social workers leading support groups should know about psychodynamics too. And the best way to learn dynamics is experientially, in one’s own psychotherapy.
The argument is even stronger for therapists who practice traditional psychodynamic therapy, where transference and countertransference are essential treatment tools. As I wrote last year, it takes self-knowledge to use countertransference therapeutically. Without this self-knowledge it would be impossible to sort out the patient’s issues from one’s own. In seminars for psychiatry residents, I point out that our field has no blood test or brain scan to directly measure thoughts and feelings in the interpersonal space. Our own feelings, countertransference broadly defined, is the sensitive instrument we bring into the consultation room. The therapist’s own psychotherapy “calibrates the instrument” so he or she can better trust its readings when applied to patients.
To me, this is the main reason to recommend therapy for therapists. In addition, others have argued that it normalizes and destigmatizes being in therapy (assuming the therapist discloses his or her personal therapy to the patient); that it improves one’s performance as a therapist non-specifically, by relieving stress and tension; and that it may give the therapist “a valuable perspective on what works and what doesn’t.” Several commenters on the NY Times blog believe the therapist’s own therapy encourages humility, and may decrease errors based on hubris and unexamined countertransference:
We are to be one of the self monitoring professions, responsible in a unique way as the stewards of our treatment with our clients…. Having our own issues worked with … goes a long way toward ensuring a unique quality of care.
I would be very wary of a therapist who had never sought therapy for him or herself. To me it would smack of an “I don’t need it — it’s for messed up folks like you” attitude.
I am also frequently shocked by the stories my patients will tell me about being in therapy with someone who clearly hasn’t worked on their issues. It can be very damaging to a patient…
A personal psychotherapy does not guarantee that a therapist will be caring, non-abusive, technically proficient, or effective. But there is little in psychotherapy, or in life, that is guaranteed. Psychotherapeutic work, particularly the psychoanalytic and psychodynamic varieties, seems closely tied to the therapist’s self-knowledge and willingness to self-reflect. If we are to use our own perceptions and reactions as sensitive instruments in the consultation room, we are well-advised to take good care of the equipment.
[1] Geller JD, Norcross JC, and Orlinsky DE, The Psychotherapist’s Own Psychotherapy: Patient and Clinician Perspectives, Oxford University Press, 2005.
[2] Pope KS and Tabachnick BG, “Therapists as Patients: A National Survey of Psychologists’ Experiences, Problems, and Beliefs” Professional Psychology: Research and Practice, 25(3), pp 247-258.
September 11th, 2011
 Recently a patient asked whether I’d ever been in therapy myself. Without answering his question directly (see my post on psychotherapist disclosure and privacy), I replied that many of us have, and asked what it meant to him. It would be a bad sign: “How can you help if you need help too?” We went on to discuss his feeling that being in psychotherapy marked him as defective or deficient. He would naturally prefer a therapist who did not share similar defects and deficiencies.
Many patients take the opposite view. They believe a doctor who knows what it’s like to be a patient can better empathize with them. So this patient’s concern stood out in my mind — he truly feels his psychotherapy is a mark against him, a kind of declaration or admission that he is damaged. I later reminded myself that professionals — and others, everyone really — regularly use services offered by others in the same field. Lawyers have their own lawyers, doctors see their own doctors. Chefs eat meals made by other chefs, barbers get haircuts from other barbers. The only problematic examples that come to mind are when the condition being treated is shameful or morally repugnant, or when the condition could directly affect the service being offered. Examples of the former: police officers who require the “services” of other police officers after committing crimes, and clergy who need spiritual or moral counseling for their own transgressions. Examples of the latter: a neurologist with brain damage, and a business consultant who cannot maintain his or her own business and needs outside help. How does this apply to psychotherapists, and what light does it shed on patients’ feelings about seeing therapists themselves?
The need for psychotherapy feels to many people like a sign of defect/deficiency/damage. In speaking with patients I often highlight the “need” in that sentence, and contrast it with “want” or “could benefit by.” Some patients make themselves feel worse by telling themselves they “need” therapy, when it would be just as accurate to say they are apt to benefit by it, or even that they desire it. I don’t believe it devalues psychotherapy, or psychiatric medications for that matter, to note that they’re frequently optional. Most depression improves on its own eventually, and people may choose to muddle along in life dissatisfied, angry, or in a series of bad relationships. Remembering that psychotherapy is a choice may take some of the shame out of it.
That’s only part of it, though. No one worries or cares if one’s proctologist also needed to see a proctologist at some point, even though proctological conditions feel shameful to many people. In addition to shame, there is moral repugnance associated with mental illness, even, or perhaps especially, the apparently milder problems that lead people into psychotherapy. Often unstated is the notion that one chooses to be emotionally weak, distraught, hotheaded, or whatever, and that this choice is selfish, unfair to others, or otherwise immoral. Moreover, that seeking professional help to “snap out of it” or pull oneself together is self-indulgent and akin to laziness. While the idea isn’t totally groundless — there is some choice in how to act, and even how to feel sometimes — it assumes far too much conscious choice. Most troubled patients would give anything to be happier, at least consciously. In returning to my patient’s question, perhaps he would not trust a doctor who willingly made himself dependent on others to help steer his life back on course. It may feel as morally suspect as the corrupt police officer or clergyman: a character flaw in the traditional sense.
Alternatively, there may be concern that a psychotherapist who needed therapy (“needed” in scare-quotes as noted above) cannot perform well as a therapist. This would be analogous to the brain-damaged neurologist or the business consultant whose own business is failing. The logic may be pragmatic: A psychotherapist should have his or her own life in order before claiming to be able to help others. Or it may be fear that residual pathology lurking in the therapist may be harmful to the patient. Or it may be a transferential need for an idealized, faultless therapist. Each of these can be addressed as it arises. We each have our blind spots, and can help others without necessarily being able to help ourselves. It is better to have sought treatment for potentially hurtful pathology, than to have ignored or denied it. No therapist is perfect.
Any or all of these concerns about the therapist may also apply to the patient himself. Being in therapy may make a patient feel ashamed, or morally bad or wrong. It may highlight a fear of incompetence or harmfulness. It may clash with a need to be perfect. Asking the therapist “Have you seen a therapist yourself?” may be an easier way for the patient to broach sensitive feelings about his or her own participation in therapy. This seemingly simple question can carry a lot of meaning, and if explored in detail, can help a patient understand himself better.
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