Couch is a series about psychotherapy.
For some people, the psychiatrist’s couch is a metal examining table.
On such a table, in a hospital 20 years ago, a young woman waited for me. She weighed 65 pounds and was covered with fine hair. Her face was little more than a frame of bones. I was a new psychiatry resident, and I had been told by a nurse that the patient had refused to drink her nutritional supplement. “You’ll need to put in a tube to feed her,” the nurse said.
Just a few weeks before, I had gone to see a screening of Frederick Wiseman’s documentary “Titicut Follies” (1967), which was shot at a Massachusetts state mental institution. The brutal treatment of patients at that hospital was so shocking that after its release, Massachusetts successfully banned the film for many years — ostensibly to protect patient privacy but more likely to hide the state’s deplorable care of the “criminally insane.” In one of the most grueling scenes, a patient who has refused food is held down by guards, and a fat nasogastric tube is shoved into his nose. A white slurry of nutrients is poured into a plastic funnel at the other end of the tube. A doctor flicks his cigarette ashes into the funnel as the food goes down.
I called the psychiatrist who ran the eating disorders unit to express my reluctance to force feed. She was kind but firm about the unit’s policy. She explained that it was a voluntary unit and that patients who agreed to be treated there had consented in advance to tube feeds if they would not eat. She also explained that a starving person had lost capacity to reason. At such a low weight, the patient could not make rational decisions, and thus could not be allowed to refuse lifesaving treatment — in this case, food.
I asked how a nasogastric tube should be placed in a patient who refused it. The answer seemed to come straight out of “Titicut Follies.” Five security guards would come to the unit. One would hold the patient’s head, and each of the four others would hold a limb. I would slip the tube into the patient’s nose while she was restrained. I pictured myself as one of the subjects in Stanley Milgram’s famous psychology experiment, a normal person who proves willing to torture others when ordered to do so by an authority figure. That wasn’t me. I didn’t flick ashes. I did psychotherapy. I told the attending psychiatrist I found it abhorrent. She asked me, respectfully, to do the best I could.
Back at the exam table, I asked the patient why she didn’t want to drink her nutritional supplement. She said she felt full and would drink it tomorrow. She said everything she thought I wanted to hear. She’d drink it; of course she saw the need. But not now.
It was time for me to do the talking. I told her that to prepare for my residency, I had done a yearlong medical internship, during which time I had struggled to place nasogastric tubes. In fact, I explained, I had never done it properly. I would lose my nerve when a patient recoiled, and the tube would not make it into the stomach, but emerge through the mouth. I asked this patient to imagine what it would be like to have five men holding her down while a tube was smashed through her nostrils. I used what I had seen in “Titicut Follies” to describe a scene in which the patient would be violated and helpless.
After several minutes of this, the patient drank the supplement in my presence.
At the time, I was in my own psychoanalysis. Only my analyst knew the real reason I had never placed a nasogastric tube: I had a terrible phobia of vomiting. If I thought a patient was about to vomit, I found an excuse to leave the room. I would never do anything that might make a patient gag, not even use a tongue depressor.
Unfortunately, psychoanalysis is not an effective treatment for phobias. But exposure therapy is, and there is nothing like a medical internship to expose a person to vomiting. To some extent, I had been desensitized. Before my internship, I couldn’t have sat through that scene in “Titicut Follies,” and I certainly couldn’t have spent 10 minutes discussing nasogastric tube insertion with a patient in such detail. But the phobia was still there.
I had imagined that once I was a psychiatrist, the problem would be moot. I was mistaken. To my surprise, hospitalized psychiatric patients gagged, too. The medications they took could make them choke on their food, and when they overdosed on pills, they were fed a nauseous black slime of activated charcoal that bound the pills so they could not be digested. I still felt impaired by my phobia.
After the incident with the anorexic woman, I wondered if I had had to bully her because I couldn’t handle the alternative. A different psychiatrist might not have needed to threaten the patient with force. This other, less troubled psychiatrist might have defused the situation through rational discourse, not intimidation.
Something else bothered me. My patient wasn’t the only one who had been made to conform to someone else’s expectations. So had I. I didn’t like having a policy that struck me as brutal shoved down my throat.
Psychoanalysis tends to move about in time, with the focus shifting between formative experiences and the patient’s daily life. I spoke with my analyst about my past, of course, but the goal was to get better at managing the present. I felt that childhood problems that should no longer have relevance — my phobia, my dislike of being told what to do — had undermined me as a competent adult.
As we unpacked the incident, I began to see that what had seemed like my weaknesses had actually been beneficial to the patient. My phobic avoidance of nasogastric tube placement had become a means of standing up for my own and my patient’s autonomy. “Titicut Follies,” my phobia, my aversion to authority and the needs of my patient had converged that night on the eating disorders unit. I told the patient the truth about myself and about her own powerlessness at that moment. The patient and I had an honest conversation, and no force was necessary.
In psychotherapy, doctor and patient create a narrative together, brought to life by each individual’s personality and life experience. The narrative exerts pressure, hopefully in the direction of health. In my own treatment, a consulting room full of books and journals, the classic divan and the thoughtful presence of the analyst were all part of the push toward self-confidence and professionalism. For my anorexic patient, the doctor wore scrubs; there was no couch or any of the soothing accouterments of the psychotherapist’s office. We had to use our imaginations.
Anne Skomorowsky is a psychiatrist at Columbia University Medical Center and an assistant professor of psychiatry at Columbia University College of Physicians and Surgeons.