I was at a course the other day and someone piped up from the back:

‘In an ideal world everyone needs a counsellor, that they can talk to every week about their problems’.

I expect that quite a lot of people would agree with this statement, but not me.

Different psychotherapies (’talking therapies’) are easily confused and I’m not talking about directed therapies such as cognitive behavioural therapy, family therapy or behavioural therapy.  These therapies are aimed at specific psychiatric conditions, are goal directed and administered by trained practitioners.  

Counselling on the other hand is difficult to define, and tends to be performed by those with limited training and aimed at people without strictly classifiable mental health problems.  As such it seriously encroaches on normal experience and the implication of the statement above is that people going about their everyday life need professional help to deal with common problems of everyday living.   

There is little evidence that counselling helps, and some evidence that it actually makes people worse.  There is a danger that attending a counsellor for a problem will introduce the expectation of experiencing distress and in some way validate it.  Some people regard simply attending counselling as a mentally healthy thing, but is airing your problems suitable for everyone, and could it be that people attend counselling as a proxy for real action?  Counselling is popular and this is given as justification for it continuing to be available, but what people want and what’s in their best interests is not always the same thing. 

An argument could be made that the counsellor is taking the place of the parish priest in these godless times.  With many of my patients I feel that what they really need is some good friends, who can offer support, sympathy and real world feedback.  Friends are also a lot cheaper.

Often, when I meet someone I don’t know and I tell them that I’m a psychiatrist, they say something like ‘Oh, so are you psychoanalysing me?’ I don’t exactly known what they mean, but I have a feeling it’s something like ‘are you looking into the deep recesses of my soul, and seeing things about myself that I don’t even know?’

Which would be a neat trick. 

I used to think that this was a relatively silly question, which shows a lack of understanding of both psychotherapy and psychiatrists.  For a start it assumes that all psychiatrists are psychotherapists, which is not the case; this misunderstanding is fairly universal within the media, so is understandable.  It also treats all psychotherapy as if it were one single approach (this being Freudian) and there are many many different psychotherapeutic methods. 

What people are actually saying is, if you are a psychiatrist you must be a psychoanalyst and if you are an analyst you must be a Freudian psychoanalyst.  It does, however, give an idea of the strange and mysterious powers that people might consider a psychiatrist to possess.  

Here’s a definition of psychoanalysis:

Psychoanalysis n. a school of psychology and a method of treating mental disorders based upon the teachings of Sigmund Freud (1856-1939).  Psychoanalysis employs the technique of free association in the course of intensive psychotherapy in order to being repressed fears and conflicts to the conscious mind where they can be dealt with. (Oxford Concise Medical Dictionary)

So, if we’re being picky, psychoanalysis involves a element of treatment and just dissecting someone’s personality apart when you meet them is not psychoanalysis, it’s being nosey.  

Lastly an important part of psychodynamic psychotherapy is in the therapeutic alliance formed between analyst and patient - this is unlikely to be formed during a ten minute conversation at a party.  Even the briefest of analyst-patient contacts involve sessions over multiple weeks. 

Recently, I have in a way begun to see what people mean.  We have a case discussion group at the hospital in which I work where one of our number presents the case of a patient, who for whatever reason sticks in their mind.  When I presented a history it became evident that there was a question that I hadn’t asked.  My position on this was that I had simply forgotten; the psychoanalytical view was that my forgetting had significance (perhaps I was subconsciously afraid to ask the patient?), as would my reaction to being challenged on my oversight.  The point is, that something relatively innocuous had provided information about me which others could now see but of which I previously had no knowledge. 

I now sometimes find myself being careful what I say lest it be interpreted in some way.  For example I hesitate to make a joke in case it betrays a discomfort with subject matter.  Is this what people mean?  As psychiatrists, and doctors in general, we’re observers of behaviour.  A neurologist is trained to spot a posture consistent with a neurological disease, an orthopaedic surgeon, a limp.  With psychiatrists it’s a little less concrete, but we’re all trying to spot signs that tell us that someone might need our help.  If that’s psychoanalysis, then yes, I suppose I am.