‘Been There?’ Sometimes That Isn’t the Point

From Sally Satel in yesterday's NYT:

For other patients, though, the “Have you ever ...” question is less a therapeutic riddle to be solved — as it was in the case of Mr. B — than an expression of genuine skepticism that they can indeed be helped.

It is the kind of question asked by a person who believes his very soul has been warped by calamity. “Sometimes a patient expresses frustration that I can’t possibly help him because I never experienced the trauma that he did,” said Dr. Walter Reich, a professor of psychiatry at George Washington University and a former director of the United States Holocaust Memorial Museum, whose patients have included Holocaust survivors.

“Please tell me what happened, how you reacted to it then and how it lives in you now,” he will ask. He gently prods his patient to step out of his private world, “a chamber often filled with circular and self-devouring ruminations.” In the act of making his experience clear and complete to the therapist, the patient has to make it clear and complete to himself, Dr. Reich explains, adding that “in the process, he accepts into his being something that was once consuming it.”

Addiction, too, can be an intense and defining experience. “I have heard patients say that if you haven’t been there you can’t help me,” said Keith Humphreys, a Stanford psychologist. “So I tell them, ‘I can help you live a sober life because it’s all I have ever lived.’ ”

It’s true that having “been there” can endow a drug-abuse clinician with valuable authority and authenticity. There is just so much bluster a patient can get past a counselor who is a streetwise former junkie (which is why I, the forever-abstinent psychiatrist at a methadone clinic, often seek a second opinion from our counselors). Moreover, that recovered counselor inspires hope that addiction can be conquered.

But most of the time, therapist and patient do not share a history. And even if they do, there is no guarantee it will help. A mutual bond can paradoxically reinforce the patient’s sense of isolation from others. Also, commonality can lead the therapist to identify too closely with the patient, thus compromising objectivity.

In truth, the most relevant knowledge a clinician can possess is the experience of having known and treated many patients already. This is how he learns to become a skilled interpreter of the protean query “Have you ever...?”