“No, I cannot forget where it is that I come from
I cannot forget the people who love me
Yeah, I can be myself here in this small town …”
– John Mellencamp
When I began my psychiatric training in earnest thirty-three years ago after a challenging rotating internship, the indoctrination that began was regimented, sanctioned, scripted and complete. I knew from a very young age, training-wise, that my job was to ask a few very open-ended questions, listen, formulate my thoughts about my patient and his reason for coming to see me, and then discuss this with my supervisors to come up with a treatment plan. A plan that sometimes was, oddly enough, kept a secret from the very person it was supposed to help. The name of the game in those days was to figure the patient out before he did it himself, and then to guide him with judicious rigor and well-timed and brilliant interpretations toward increased insight and mental health.
Yes, I was trained in a predominantly psychoanalytic program that was only beginning to bring in the psychopharmacologists, who would later dominate the agenda.
I was taught to be the proverbial blank screen. I was to show little emotion, offer little to no spontaneous conversation or banter, and to never divulge anything of note or merit about myself except under the most dire circumstances. I embraced the psychiatrist persona that was the norm for that time. This therapeutic stance was just that, but it was not real or fun to me to practice that way. I will never forget how shocked, and yes, maybe a little hurt, I was when one of my long-term psychotherapy patients (a lady who had a panic disorder that would be quickly and fairly easily treated today) blurted out: ”I might as well be talking to that doorknob over there as to be talking to you. You never say anything!”
When I took this to my supervisor, a prominent psychiatrist who had literally written the book on these kinds of interactions, he praised me for maintaining my therapeutic distance and stance through this obvious transference-based outburst by my patient. He gave me pointers on how to proceed from there, mapping out a strategy for the next several months. I dutifully went back to work. The patient came to see me one more time and never came back. She was not getting what she needed to get better, and she quit.
Today, I am working in a small South Carolina town. One of my duties this morning was to go over to the probate court at the courthouse building, five minutes away from my office by car, and testify about an evaluation I did a week ago. On arriving at the probate court office, I encountered the judge sitting at her secretary’s desk, taking a phone call.
“Aren’t you in the wrong place?” I teased her. “Your office is in there.”
“I know! One of my staff had a death in the family, and the other one had already planned a vacation, so I’m doing it all today.”
Soon afterward, we entered the hearing room, which is just that, a room with one long wooden conference table, a dozen mismatched chairs, a wall full of musty bound county record ledgers, and us. The judge was joined by me, a clinician, the patient, her appointed attorney and an unsmiling bailiff.
The format, unlike the proceedings one county up in another courthouse, was informal. Information was shared, the usual legal wrangling was dispensed with, and we all made it clear to the patient and each other that we cared about her, wanted her to get treatment and supported her in doing this. Even in her pre-psychotic state, she seemed to grasp the feeling in the room, the common sense of purpose, and the unification of all involved. We even joked and laughed together a few times, which felt wonderfully good and real to me. I realized, mid-hearing, that I was doing something in this sunny small-town courthouse that was going to make a real difference in someone’s life.
I will always be grateful for my training, my supervisors, my colleagues and the experiences and baseline knowledge and skill set they imparted to me. I use those skills every single day.
However, that can never hide the fact that “I can be myself in this small town,” and it feels good when I am. I’m proud of what I can do to help people here, and that’s exactly the way it should be.
Greg Smith is a psychiatrist who blogs at gregsmithmd.
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