Our guest writer is Dr. Charlie Gardner. He co-authored the piece on gender and psychiatry posted recently Click Here to Read this Article. But, there are several personal connections with this piece on practicing psychiatry and psychoanalysis in a small town: first a connection with his grandfather and father; second a connection we have from the 1980’s. Charlie Gardner’s grandfather was an old-time country doc who did home visits; drove a flivver. Charlie’s dad taught at the Yale Psychiatric Institute (and taught one of my dream courses). Charlie was a resident at Cornell Westchester when I was on faculty.
Charlie writes of the vicissitudes of small-town analytic practice. In a sense, he has been training for this for a couple generations. Let’s listen to what he has learned over the past few decades. I hope that we will hear more from him … and from our readers.
Nathan M. Szajnberg, MD, Managing Editor
Analysts as “outsiders,” and outside the Big City by Charles Gardner, MD.
Non-urban analytic work: since the waning of the Menninger Clinic and the Lodge is there such a practice? I have several colleagues and friends who do analytic work outside cities, mainly in suburbs. (Access to analytically-oriented treatments outside of cities or major prosperous suburbs is scarce to non-existent, as everybody knows).
Here are just three of the interesting complications to doing classic analytic work outside urban settings: 1. physician anonymity; 2. patient privacy; 3. competition(s) in a small town.
1. The physician has little or no anonymity. Your patients see you at the diner with your family, at cocktail parties, benefits, at church, at clubs, at music performances, at medical staff meetings or fund-raising events, at weddings and funerals, Junior League and garden club events, and, for those of us with home offices (like Freud), patients know where and how we live and how well-weeded our front gardens are. They see our spouses and kids coming and going. I have had many experiences of patients driving my own kids home after various school events, and even finding out that my kids had sleep-overs at patients’ houses. Their kids are sometimes pals with your kids.
Grist for the analytic mill? Somewhat similar – but not identical – experiences are also routine in academic analytic environments (such as at the Columbia Center, where I trained).
But, all grist is not necessarily worth the time and effort of the milling.
One of my city colleagues asked me why I do analytic work with patients who might be part of my world. I replied that, if I eliminated everybody who might have some contact with me, my busy wife, or my three active kids, I would have no patients at all. We are not hermits. I have found myself playing a tennis match opposite a patient from another team! There is a whole story in that, yet to be told.
Even better, and also yet untold, was finding that my former analytic patient had been assigned as my anesthesiologist for my hernia repair! He and I have had a few laughs about that, since then.
2. Your patient has less anonymity. Analysts focus on psychic reality, sometimes to a fault. However, with either prominent patients or with local patients (or both), you learn more about their external reality. I have seen supposedly abstinent patients pounding back Martinis at my favorite restaurant, and looking up at me sheepishly. When patients give me their address for billing, I usually know which house they live in. Often, their kids have been to my house and have seen me dirty and sweaty from the garden or from the tennis court, or their parents have driven up to pick up their kids to find me with a cigar and a beer and a shovel, working out front. I run into patients at Home Depot, at the supermarket, or at the wine shop. Occasionally, a patient will inform me at some point along the way “You do know that Janice (who is my first and only wife) and I are great pals at the Garden Club (or on the tennis team, or some committee, or whatever).” They often assume that I discuss such things with my wife, which I absolutely do not.
Thus reality raises interesting boundary issues, along with all sorts of intrusions into the development of analyzable transferences. I believe I have found graceful, effective, and gracious ways of dealing with it all, a topic I will address in later pieces.
I am known in my town as a participant in my large evangelical church, various charitable committees, and as a sportsman and sports competitor of all sorts, from shooting sports to tennis. My kids are very well-known, too. My spouse has been, perhaps, better known than all of us for her participation in Conservative politics and in Bible study groups. It is difficult to be anonymous in smaller towns if you lead an active, engaged life.
Psychoanalysis and other variants of Psychoanalytic work have been an urban phenomenon, with little patient contact outside the office (other than training analyses). Furthermore, Psychiatry and especially Psychoanalysis has been mainly (I do not know the stats) thought of as a practice of Jews – both traditionally urban but also cultural if not ethnic minorities who, in the past (but no longer today) were not fully integrated into the arena of WASPy society. It seems that this is less so today in Psychiatry and Psychoanalysis, but, again, I do not have any data – nor should it matter.
I have discussed this issue many times with Christian analyst colleagues, both Catholic and Protestant. We wonder whether neurotic patients want a priestly figure of some sort, a wise wizard, somebody outside their world in whom to comfortably confide and yet idealize. Years ago, I was consulted by a devout reborn Christian patient who (rightly) wanted analysis; she was disappointed to discover that I was not Jewish. We explored that. It turned out that she was concerned that I was not an “outsider”; that she would be more comfortable confiding in somebody who might be outside her socio-cultural world, and that she might run into me at a golf outing and flirt with me. A successful 5-year analysis ensued from that awkward but very promisingly-open beginning.
3. In a discipline-crowded small town, new therapy types appear.
On the other hand, my town and my general area has seen the birth of a large number of “Christian counseling centers” in recent years, marketed heavily through the churches and parishes. These centers, with trained “Christian Counselors,” have absorbed large numbers of patients who would have consulted Psychiatrists in the past. In some cases, pastors who know me are now competing with me for patients.
Further, some of our local Internists have variously-trained therapists on their office staff to whom to refer emotional problems while they supply the Lexapro or whatever. It is a profit center for them.
An issue raised by outcroppings of Christian counselors, or Internists’ hirees, is whether one can do the most effective analytic work without being an “other” in some way, an outsider of some sort. But this issue may be moot in these times when everybody is a “therapist.” Today, the Psychiatric monopoly on help for emotional distress is long gone: the market, as it were, is wide open, and analytically-oriented Psychiatrists and, for certain, Psychoanalysts, find less demand because of that.
Back to my small town. A week ago, I met a patient at a neighboring club who presented me, on a hot evening after a grueling tennis match, with a chilled glass of Chardonnay. “Thanks so much, ” I said. “I needed that.”
That sort of thing is an unavoidable part of analytic work, in the ‘burbs.
Charles S. Gardner, MD, is a Psychiatrist and Psychoanalyst in Greenwich, CT, faculty at the Columbia Center for Psychoanalytic Training and Research, past Associate Clinical Professor of Psychiatry at Cornell Medical College, and past Chairman of the Department of Psychiatry at Greenwich Hospital-Yale New Haven Health.