Interview de Michael Garfinkle, psychanalyste new-yorkais

INTERVIEW DE MICHAEL GARFINKLE, PSYCHANALYSTE (NYC)

Co-réalisée avec Gabrielle Bouvard.

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Why did you choose psychology?

When I was in high school, I did research in cardiology until throughout university with the thought I would pursue medicine. I grew up in Toronto, Canada. As you know, kind of like in France although a little bit different, Canada as social medicine. And it was a time when all doctors in Canada, after they earned a certain amount of money, couldn’t earn more. Let’s say you were working in September and you had made that amount of money, you still had to work until December, but you wouldn’t get paid anymore. So, I would see every year the doctors becoming very depressed.

More to the point, I started realizing that although I wanted to do something that would help people, there was a new way to have a philosophy of life that could interact with the work I was doing. In other words, if as a cardiologist you live from one day to the next and think that people have to live a different way and it has no bearing on your practice, this bothered me, I think this wouldn’t be right. 
So, I did a double major psychology-art history degree in Toronto and I started speaking to my adviser at the time. At the end of first year I started taking classes in psychoanalysis and Freud. I found that really appealing and I found an adviser to work with. I decided I would commit my undergraduate education to the history and theory of psychology, specifically to psychoanalysis. I wrote a thesis for my bachelor degree on the difficulty of translating Freud into English.

Then I wanted to take the theoretical interests I was developing into something that had a practice. I had two choices: one was to pursue medical school, and the other one was to pursue graduate school in psychology. I had no interest in being a psychiatrist at all, just none, I thought it was a terrible idea.

Why was that?

Because I don’t think the biological explanations of psychiatry were sufficient. I didn’t think they were wrong, but I thought they were insufficient. And I didn’t want to be in a practice where I’d be forced by everyone who I met to consider the biological primary.

So, I found one of the few psychology programs in the country that was basically all psychoanalysis, and decided that was what I wanted to do. I became a psychologist because I wanted to be a psychoanalyst and I learnt a lot of interesting things about psychology along the way. I did five years of Ph.D and I went to a program that was very intensive with evaluation, so I learnt a lot about psychological testing, we did a lot of internships, etc. I already knew that I wanted to be in a private practice, and that’s what I did immediately when I graduated.

Psychoanalysis can be controversial. Some people in France might say that Freud was addicted to cocaine, or that he falsified his results. How is it perceived in the US?

Outside the biggest cities of the US, the status of psychoanalysis is not that high, but in the cities, especially in New York, or Boston, Chicago, Los Angeles, Seattle, there isn’t a bad feeling about psychoanalysis. There is no feeling among the people that I know, including me, of belonging to some king of strange sect.

1519564_770208169703288_1893499673854011849_oSaying that Freud was a cocaine addict is like saying that someone was a homosexual. Okay, so what? He was addicted to cocaine because at the time they thought that cocaine could cure many things. At that time people didn’t even think they could get addicted to it. He wrote some interesting papers about cocaine. There is a whole book of them, called the « Cocaine papers ». It’s a very interesting insight about that.

Freud was a neurologist first, all of his early work was about the neurology of marine life and this idea of psychoanalysis came through cases of hysteria. He would encounter these people who had all these physical symptoms that had no cause. The treatment at the time was hypnosis and it produced a temporary relief but never a lasting one, so the question was: what is the meaning of the symptom?

« To me, the question of the meaning of the symptom is a good one. I could spend the rest of my life wondering about meanings of symptoms. »

What I found clinically, and I’m not the first one, is that when someone understands the meaning of their symptom, they experience relief.

I have no hatred of cognitive behavioral therapy, but I couldn’t imagine spending my life having people come in and say « When I think a certain way I feel depressed » and basically helping them not to think that way anymore. That said, I work with people young and old so there is a place for some behavioral intervention. When some patients are very depressed, I might say to them: « While we’re working, it might be a good idea to exercise a bit more ». I don’t feel religious about psychoanalysis, so I don’t have the impression of betraying anything by inclining some aspects of cognitive behavioral therapy in my practice.

If what psychoanalysis does is correct, which is take things that our mind doesn’t want to think about and put them into the forefront of our mind, why would a field like that ever be popular? It would be a little crazy in a way. You don’t want to spend time with a friend who every time you’re with him, tells you about your problems, about things you don’t want to think about. With psychoanalysis, you have to accept that kind of position that is outside the center, to actually work effectively. So there are critics, but the work can be demonstrated, without a doubt. Some people will ask where the scientific evidence is. Well, the truth is, there is some. There are various studies that are published in big journals, but if I’d tell you that this coffee is hot, you wouldn’t need scientific evidence to believe me. Science has its place, but science is not everything. People can become religious about science too. Psychoanalysis tries to find a better balance.

In France, to become a psychoanalyst, you must have engaged in an analysis beforehand, an intensive and often several years long one. Is it the same in the US ?

Here the expectation is that you’re in an analysis to become an analyst, but it depends on where you go. Some of the schools of psychoanalysis in France and one or two in the UK, lesser here, they demand that you completed an analysis. What you’re describing is true of the people who follow Lacan, who say that if you enter an analysis to become an analyst, then it isn’t a real analysis. This is because for him there would be the question of desire : what is your desire for the analysis if it is just for professional reasons? So in Lacanian schools they absolutely demand that you completed an analysis, and then you can start training.

psychoanalysis

In America, the culture is a little bit different about that: here people have to be in analysis while they’re training. So as long as you’re in an analysis for the first day of class, you’re fine. However, there are rules about your analysis: you have to go four times a week minimum, the session lasts 45 minutes usually. It is a commitment, but the purpose of it is so that when you’re listening to someone, you have a little bit more of a sense of your subjective bias. And if you feel something listening to someone, you have some greater ability to say: « This is a feeling that I never had before and that is someway induced by the person I’m speaking to » versus « That is a feeling that comes up for me all the time ». Imagine the person who every time he has a patient, the patient falls in love with him. It may not have anything to do with the patient. The analysis helps to clarify that. It takes a while. It goes slowly and takes this long because it takes a while to get to that level of discourse. It is very hard. People come in for treatment and they say: « I’m having a problem with something », whatever it is, and the next thing that is going to happen is something that is going to make treating them more difficult. Immediately, right at the beginning, you start to see resistance. With psychoanalysis, you learn what to do with resistance. It is the only school of psychology or psychotherapy that has a theory like this. It is very important that in your own treatment you feel that as a patient.

What internships did you do during your studies ?

I started off at a psychoanalytic institute, I did one internship there. Then, I went in a public hospital. It was an old hospital that was designed for tuberculosis back in 1910. It turned into a very low status public hospital. It was just basically filled with people who had nowhere else to go. It was the kind of places where patients had prostitution rings among them and there was a drug trade for crack and all sorts of things like that in the hospital. So, I spent six months there, working with typically very medically ill and psychotic people. That was very intense. Then, I spent a year between Colombia University Medical Center and the New York State Psychiatric Hospital doing inpatient psychotherapy with schizophrenia, group psychotherapy, testing and some regular outpatient therapy. It was a very good experience.

Were your patients diagnosed with schizophrenia delirious at the time ? How do you work with that as a psychoanalyst?

Yes, some of them could be, but most of them had hallucinations. Psychoanalysis works very well with psychosis actually because it works with the idea of everything, language, body symptoms, in someway being a metaphor where there is the expression of something. So even with the hallucinations, you treat them as meaningful.

maxresdefaultAs an example, there is a guy I worked with, who was brilliant. He went to Oxford and could speak five languages. When I met him, he had tried to kill himself several times. During the day he was usually very nice and at night he would take his clothes off and masturbate on the floor and hand out little pieces of paper that said: « Men should not sleep with men, it is an abomination before God », these sorts of things. So one day I came into the unit and 15 people were holding him down on the bed, injecting him with tranquilizers because he was kind of insane and they tied him down with restraints. I came to the room and yelled at everyone to leave and closed the door.

I invited him to tell me what was going on. « They’re everywhere », he said. And I asked: « Who’s everywhere? », and he said: « They’re singing, it’s so beautiful ». I realized he was thinking about sirens, from the Odyssey. I said: « It is not a problem, you are tied down ». And we sat for two hours, we didn’t say anything to each other, but at the end, he had calmed down on his own. He got up, he put his arms around me and said: « I need to take a nap ». And that was it.

There is a way of getting into a deeper core and inside, in the middle of the treatment center, where you have treatment rooms, and rooms for the patients with a piano and all sorts of things, you work with them in all these places and you get to be a part of their environment. It is very demanding and you also become a little crazy yourself in this situation. Like at the end of the day, I would be exhausted, I’d be sitting in my chair, writing notes, and realized that I should have left an hour ago but I just couldn’t stop writing. But in psychosis, the idea, the symbols start to break down. People can say they have an attachment to a spoon but when they talk about spoon, they mean something different. And sometimes spoon could mean love, or spoon could mean men, or women. The benefice of working so closely is that you can help them redevelop their capacity to symbolize. And that’s really what psychoanalysis can help them with.

I did an internship in a psychiatric hospital and it seemed to me that the treatment was based on medication rather than psychotherapy. Have you ever felt that way ?

The statistics for most medication, especially for anti-psychotics, show that for a third of the people, it cures them, for another third it helps them a little, and for another third it23097618-sick-girl-bombarded-with-medication-vector-illustration-stock-vector does nothing. That is pretty much the experience people have. For that final third, they’re in hospital. Where I was, they didn’t take psychotherapy seriously. When I told the psychiatrists I wanted to do psychotherapy with the patients, they said: « Go ahead, we don’t really care, as long as it doesn’t get in our way ». I had supervision as I needed. It worked out really nicely but yes, for them it was just medication and you see what the medication does. It is just tranquilizers, that’s all. And if you want to kill yourself or kill everyone or tear your hair out, sleep is maybe better, but not for a lifetime. It’s not a life, really.

Do you supervise other psychoanalysts ?

Yes, and it works like an apprenticeship. I’ve been supervised myself, and I also teach. I never took a course to learn how to supervise someone, I learnt that from my experience as a teacher and a supervisee, also as a psychoanalyst. There’s a lot in common between psychoanalysis and supervision. You are not treating your supervisee, but you are helping them dealing with the things that come through from working with their patients. I can help them with conceptualization, that is a lot of the work actually. If they need help on the way to say something, sometimes I might help them a little bit, but most of the time I ask them: « What is it about this patient that makes speaking so difficult? » And sometimes what you find is that some patients make the analyst feel like everything has to be exactly right. Narcissistic patients can often have that effect. You feel like if you say the wrong thing, they will be very mad at you. And to some point, supervision helps to confront that rather than being afraid of it.

Sometimes, personal things come up during supervision. I try to be respectful of people’s privacy, but on the other hand if I see someone who is struggling with a particular issue, I might ask. I have a supervisee who is going through a divorce, so if he is presenting clinical material of someone who’s having an affair, then I am a little bit more careful.

Usually, I see my supervisees once a week.

And are you still supervised ?

Not now, I have been. Every now and then, some colleagues of mine will suggest forming a group to discuss something or to read something together, but nothing formal and regular at this point.

How many patients do you have currently?

I usually work in my office from 35 to 50 hours a week, which means somewhere about 25 patients.

Isn’t that too much?

Probably. Most days I work from 9 am to 7 pm. I don’t take breaks between patients, I prefer not to. I take a little bit of time for lunch in the middle of the day. Some days I block some mornings off to test children. But I like it, I’m not old so I have the energy. It is even a little bit hard to sit all day so sometimes I take long walks or bike rides.

How do you manage to combine all of your different activities ? (Psychoanalysis, psychological testing, teaching, etc.)

lacan41-2I agree with what Lacan said even if I don’t see myself in his camp (although for some reason most of my friends are – but you know, it’s because they’re more fun at parties haha). However, what he said is that whatever the psychoanalyst does, it is psychoanalysis because we see things through the filter of psychoanalysis. The psychotherapy work, even if it is not a psychoanalysis, works with the same principles, like free association for example, interpretation, etc.

In an evaluation of a child (IQ testing, achievement test, different neuropsychological tests, Rorschach, TAT), I will meet with the child’s parents, I will go in his classroom, I will meet with him in my office and after the testing I have to write a very long report. What I do is that the report is very integrative : I don’t talk about intelligence without thinking of the Rorschach for example. Everything is connected to everything else. When I read reports from some of my colleagues, things are more divided than in mines. The personality is separated from the rest. They have learning disabilities and they’re not happy in school. Why aren’t they happy in school? They don’t go that far.

However, I am glad to have different activities. Actually it is nice to have some variability because if you do the same thing all the time, it gets a little bit demanding.

Have you ever wanted to work in a prison or somewhere different from where you currently work ?

Well, I spent four years helping an organization trying to look after seafarers, people who work in the merchant marine and were captured by pirates. So, I helped develop a treatment protocol to help them figure out what to do with these people once they were released from these camps where they were being held.

That was different, I found myself on cargo ships and I was lecturing in Africa, down the coast, in Australia, in Hong Kong and I was talking about this, which in a way has nothing to do with psychoanalysis except that my explanations followed my understandings that way.

If someone asked me to do something like that again I’d say yes, but I never wanted to work in a prison and have a full-time work there, or work in a hospital and have a full-time job there. I value my freedom and my independence too much. To be in the bureaucracy, that’s not for me. It is too much to be where there are too many layers.

And what about psychological expertise? 

I do forensic evaluations as well. I work in an ethics committee in one of the churches of this country, and one of the Jewish organization as well. I evaluate the clergy when they’ve done something wrong. Before they let someone repent, they want to make sure they have the capacity to do so. I do all sorts of assessments.

I also work with people going through divorce. I can talk to the lawyer and advocate for the child well-being. Sometimes I’m working with the parents but usually from the child’s perspective. In Family Court, at least in New York State, the judge has a lot of power. Because of that, people who are advising the court, like me, have more influence. We can really help the judge understand that something is not in the psychological interest of the child.

What part of your work do you like the most ?

I like all of it, I like how it has worked out. I wish I had a little more time to write, but I’ll found that. Without sounding silly, the idea that I get to sit in my office and that people come in and tell me things that they would never tell to anyone else, with the idea that I’m going to help them, and then to see that in fact I can, feels like a very fascinating and fantastic thing to do. So, I like that a lot. It’s a huge responsibility.

The people that I meet are mostly people in crisis. Even if I get to see them get better, which I do, they’re still in some sort of crisis. So if you see on a regular basis 25 people in crisis, you have to make sure that it’s balanced by something else, otherwise…  You have to take care of yourself.

What is the most difficult thing you have to face ?

Patients have crisis all the time, real crisis. Sometimes at 11 pm I’m on my cellphone talking to someone for an hour. Suicide doesn’t come up often in my practice, maybe because I help them enough so it doesn’t come up all the time. But sometimes, especially with teenagers, this comes up as a possibility. Basically there are these moments when someone is in danger, or when you see someone who usually does very well, all of a sudden starts to fall apart.

You know, I have a patient who every now and then would take something from my office and throw it. It doesn’t scare me, she’s not violent toward me, it’s not that. She is a very smart, very talented person. You see these things and it’s hard to see someone, an adult who otherwise does okay in the world, just fall to pieces. But then you balance that by knowing that you can do something about it.

There are many attacks on your ability to think. A lot of what happens when you get to know someone very well who is having difficulties, is that you get to know their mind and often in their own mind, they’re having trouble thinking about their personal problems. To be with people who can’t think can stop your own ability to think sometimes. Sometimes someone leaves and it is even hard for me to remember what just happened. Or in the middle of the session I realize it’s about 15 minutes I haven’t paid attention. And then the question I ask myself is: « Why did that happen? What’s going on? » And I go back to my patients in a way that will be helpful to them. But then again this is why I like analytic work: if you’re a cognitive behavioral therapist and you stop listening, you’re doing a bad job and that’s it. You’re supposed to listen. As an analyst, if you fall asleep, you have to ask yourself why.

« If you’re sitting with someone and you start having a fantasy about something, interrogate the fantasy, don’t think of it as a distraction. »

What is the problematic you encounter the most ?

I would say depression. In a way it’s a little bit hard to say but for adults who come in, it is depression or anxiety, mild to severe.

You said sometimes your patients call you at night for example. What kind of distance do you put between you and your patients ?

With almost no exception, no one has ever taken advantage of that. Especially with younger patients, the teenagers that I see, sometimes they send me a text saying « I had a very hard day, I asked a girl out and she said no. I’m heart broken. » All that person may want me to say is « I am really sorry to hear that and I’ll see you next week ». So that kind of access doesn’t inconvenience me very much, it doesn’t feel exploitative.

In my answering machine, I give my personal phone in case of crisis, so if someone calls me during vacation or weekends, I’m going to take that seriously.

And how about talking about your personal life, or touching ?

I don’t do any of that. I don’t talk about my personal life. But patients ask all sorts of personal questions and it’s interesting to know why that matters to them. I think small talks with therapists are most of the time defensive. And it’s fine.

« The goal of a good therapist is not to take a hammer to every defense to get rid of them. »

About touching, if I’m meeting patients, especially if they’re not American patients, they might want to handshake. I don’t mind shaking someone’s hand, but eventually after a while I’ll say something. You know, not to make the person feel embarrassed, I don’t want to humiliate anyone, so you have to be very careful, especially with that sort of thing. I have a few French patients and they want to shake hands at the end of every meeting. The question is: Is that the kind of moment at the end when a person is having some kind of anxious experience about leaving, where the handshake comes as a strategy to manage the anxiety (like « We’re leaving as friends ») ? Eventually, there has to be a way to work out these sorts of things. But to be very strict about doesn’t go very well.

How do you see your professional future ? 

Here they say that therapists die in their chair. Hopefully rather later than sooner. If I wanted, things could stay exactly the same. We’ll see. I like my life here, my office is three blocks away from my home, I never take the subway, I can bicycle around. It is a very expensive city, but you also earn a lot here. For right now, I like it as it is.

How much is a therapy session ? 

It is about $150 an hour. It’s really expensive here in the United States, more than the UK, more than France. But about 3/4 of my patients have some kind of private insurance policy that reimburses them 60 or 70% of what they pay. So if I charge $300, they’re only paying $70, so out of their pockets it’s actually not very much.

Do you have any advice for psychology students ?

keep-calm-and-study-psychology-305

For people who want to go on to be in some kind of clinical psychology practice, I would say first that it’s a hard life but a good life. When I was in graduate school, one of my professor said: « You’re about to enter the loneliest job in the world so make sure you have friends and family. » I think that’s very good advice. It is very demanding work, but it’s a different kind of demanding. You won’t break your back or be yelled out by a boss, but it’s personally very difficult. But I don’t know many professions that allow as many possibilities as being a therapist does. You can teach, and supervise, and write, and work in your practice, etc. In that way, it is very unique.

« Anyway, to see a therapist or to be supervised makes it easier to find a balance, because you spend all this time helping people at a very intimate level and in a way you’re depriving yourself of the same thing on a regular basis. »

And how about those who’d like to work in the United States ?

The biggest obstacle for people who didn’t train in this country is that you need a Ph.D. Once you have the Ph.D. you can come. It is easier if you know people, but it is a very good place to be. The longer you stay in a place, the harder it is to leave, so if you finish your training and you start working in the same city, you probably won’t want to leave.

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