Wednesday, August 16, 2006

Couch Time

Reading Dinah's post about Talk Therapy inspired me to think about my view of what it means to be a psychotherapist. The people who have been reading this blog for a while will now exclaim, "Wait a minute. You don't do psychotherapy." Well, that's kind of the point. Let me begin with an illustration. Over the weekend I went to a party where I got involved in a conversation with a friend's wife. As these things happen, the topic turned to what I do for a living. The conversation went something like this:

"So, you talk to criminals to find out why they did their crimes?"

"No, I'm a psychiatrist. I treat brain diseases."

"Oh, so all you do is give them medicine."

(Yeah, like all an anesthesiologist does is put a tube down the patient's throat so he can breath.) "Well, that's pretty important."

"Don't you ever get to talk to them?"

"I don't do psychotherapy. I treat brain diseases."

"Oh, so they don't get counselling. Isn't that sad?"

I've had this conversation with people so many times that I no longer have the impulse to run screaming from the room. I can resist the temptation to say, "No, all I do is give them medicine so they don't rip their clothes off and stand masturbating all day or curse and attack the officers or break the windows out of their cells. That's all I do." They are civillians. They have no clue. They can't help it.

We had a therapeutic prison fad back in the 1950's and '60's. When Thorazine was first invented and we suddenly had the ability to treat psychosis it seemed like anything was curable. Criminality became a disease. And so they were given therapy in Therapeutic Prison. Sentencing laws were modified to allow for indeterminate sentences---no fixed endpoint---so that release was dependent upon the treatment team. Ah, the unintended consequence of how to determine when psychotherapy ends! Inmates discovered that the sentence, like the psychotherapy, became endless. So they did the logical thing that all inmates do in these situations---they sued. They sued for the right to end psychotherapy and leave Therapeutic Prison. The court agreed that indefinite involuntary confinement was unconstitutional even when it was for well-intended therapeutic purposes. And so we are back to our starting point.

Today inmates still want to search for the Answer to "why I do the things I do." And they insist, coincidentally, that this can only be done in Therapeutic Prison. They don't want to hear that the Answer to why they repeatedly use drugs and drink is because they're addicted to it. It must be because of trauma X or dual diagnosis Y, or some other Answer that is the key to never coming back to prison. Honestly, I'm a bit skeptical about the utility of psychotherapy in these situations. I'm of the opinion that if a trip through a 200 year old prison isn't enough to convince someone that breaking into houses and robbing people is a Bad Thing, then all the couch time in the world isn't going to do it.

Fortunately, it is possible to be therapeutic without doing psychotherapy. A good therapeutic relationship---of any kind---can keep an inmate alive. People with personality disorders have a lot of trouble staying alive. They die from medical diseases because they don't take care of themselves. They use bad judgement and take risks that get themselves killed. They are annoying to other personality-disordered people and end up getting murdered. And then there's the suicide issue. A therapeutic relationship involves being available to answer questions and explain how the system works. It involves treating the inmate humanely and with respect. It involves explaining to the inmate what their disease is and how to care for it. It involves giving the inmate a safe place to sob away from the other prisoners when needed. Sometimes it means I walk down the street and hear a voice calling from a distance: "Doc! Hey doc! Remember me? How ya doin'?" and then the former inmate tells me about something I did years before during a brief med check that "really helped".

And yes, I also give medicine.