Reflections on a Puzzle From a Writer-Patient

I have just finished this book on my therapeutic journey. Writing it has been very emotional and difficult. I have never wanted to give up writing, but at times I wanted to run away from it, fleeing from the repeated confrontation with the more wrenching moments of my life, the more monstrous facets of myself, and the disdainful way I have written about others because I could not do otherwise at the time, the unprocessed desires from my past, the circumstances by which I felt victimized. I often felt hopeless, jaded, and exhausted. But I persevered, and I am proud of that. Writing has been purifying.

While writing, I’ve often wondered if I would revisit the various therapies I’ve attended and also whether I would take part in them in the same order. Would I visit an addiction clinic first, then seek further outpatient counseling, then participate in an intensive psychoanalytic program, and finally enter and remain in individual psychoanalysis? And if I were to follow that same sequence, why would I do so? I could have answered those questions using what the profession itself puts forward as characteristics of quality care: Did caretakers pay attention to the somatic and neurobiological part of me during the four phases of my treatment? Did I receive proper psychiatric counseling and the right medication in the right amounts? Was my safety guaranteed at all times? Were no deprivation measures taken when there were no valid reasons for doing so? Was the care always efficient and effective?

Despite the fact that the last few years have been very difficult, and that I have been critical of certain aspects of certain programs, my answer to both questions posed above is still broadly positive: I would follow the programs again, and I would attend them in the same order. Had I not been able to control my addiction first, there would have been no room for thorough personality oriented and psychoanalytic work. Had there not been the psychoanalytic group therapy first, I would not have been able to benefit from my individual psychoanalysis in the same way.

Still, I cannot conclude here with a final overall positive answer. In my opinion, I received good care, at all stages, but not the best possible care. I do not want to talk here about material details or personal idiosyncrasies of individual caregivers. Every bird is known by its own song, and all caretakers did their utmost for me. I do want to talk about the over-focus of sub-disciplines in psychiatry that I had to deal with. According to the Collins Dictionary of English, “to overfocus” is “to focus too much.” “Too much” does not immediately indicate something healthy, rather something that is done too excessively, in too large a degree. Less would be better, because when you’re too focused on one thing or look at something or someone too much from one point of view, that’s when you lose the overview, the ability to take a different perspective, the ability also to multi perspectivity. Applied to psychiatry, “to overfocus” could mean to give exclusive preference to a neurobiological, hermeneutic, or socio-critical perspective and thus to chemical, psychological, or social interventions.

In itself, there is nothing wrong with preferences and beliefs, especially when they keep people alert, fuel debate and thus lead to new insights. It becomes problematic when one’s own vision leads to everything that does not fit within that vision being reduced to noise, being dismissed as irrelevant. This would be the case in psychiatry, for example, when one would expect all salvation and only salvation from psychopharmaceuticals, and thus cease to believe in the contribution that psychotherapy could make to the recovery of psychiatric patients.

The programs I encountered will not call themselves singleminded. Both can call themselves biopsychosocial. They both recognize that the human being has many aspects, that a person cannot be known holistically if one does not also take into account the social context in which he is embedded, in addition to taking into account somatic, neurobiological, and psychological facets in diagnosis and treatment. The final reports testify to this abundantly. So, on the face of it and even in the facts, the programs I have followed are not reductionist. But why does it still feel that way? Why do I still feel like I haven’t been known enough, and haven’t received the right care at every moment? Why do I still seem to feel that the programs have reduced me to only a few aspects of myself and have not seen me holistically?

I think it feels that way because although a broad diagnosis was formulated and a broad explanatory framework was used, therapy did not tie to that diagnosis the broad recovery path that I feel would have been appropriate at any point in my journey. In other words, I would have hoped for a recovery vision that was and remained as broad as the diagnostic and explanatory framework. Specifically, this would have implied that my counselors in the addiction clinic would have given a broader place in their recovery vision to therapeutic interventions that could have supported me in my quest to better structure and restructure my personality. Conversely, given my therapeutic needs, the psychoanalytic program could have made a broader commitment to behavioral correction and emotional regulation, not on the margins of the program, but as a co-constituent of it, not by referring me to a clinician outside the program for a particular part of my problems, but by providing opportunities within the program itself that were aimed at supporting me in my recovery for that part of my problems.

Without a doubt, I myself am partly responsible for how my trajectory went. One could even say that I am the prime responsible. Shouldn’t I have formulated my requests for help more clearly? I may say, as a patient, that it certainly would have been better had I been able to express myself more clearly. However, the question is also whether the profession should be allowed to say the same? Can it morally and ethically place the initiative in this with the patient? As a patient, should I not expect that one would not question the limits of one’s own frame of reference every time one faces a new patient, and also repeatedly during that patient’s recovery process? Shouldn’t one expect every healthcare provider to continue to look at each patient empathetically and carefully? Wouldn’t it be good if there were people on each counseling team representing different frameworks so that patients could be looked at and listened to in different ways?

By now clinical practice seems to have provided staggering evidence for the usefulness of that proposition. Patients may not care much about academic discussions about which view or model of treatment would be best, or for attempts to prove the superiority of one theoretical school over another. Many physicians realize that there is no best mode of treatment, that all modes of treatment have something good, something that makes sense for some patients at some points in their journey, but not for other patients or at other stages in their recovery.

I would wish every patient to find caregivers who want to be not only senders of messages, but also receivers, who want to be influenced by what patients offer, not just once, until the puzzle has been put together a first time, but many times after that. The pieces of the puzzle my change. They change size, color and shape. They sometimes want to be on the edge of the puzzle, sometimes in the middle, and then in the upper right corner. They want to fit together at times and then they don’t. My wish for every caregiver is that many times in their lives they will have that blissful feeling of having completed a puzzle, that feeling of satisfaction when all the pieces fit and are in place and one can rest for a moment, contemplate and know that it is good for now. Until the next puzzle already presents itself.