Teaching Supportive Psychotherapy to Psychiatric Residents

Abstract

"Mr. A" is a 45-year-old married teacher pursuing a doctorate in education at a local university. Although he completed the course work without difficulty, he feels "stuck" and unable to move ahead with his dissertation. In this setting, his chronic, low-grade depression has worsened and now includes profound feelings of humiliation, despair, and hopelessness, near-panic-like anxiety, insomnia, and trouble functioning at his teaching job. His wife urges him to get help after he begins to talk about an impulse to jump from their balcony. Mr. A went through a period of depression, heavy drinking, and narcotics addiction in his early 20s, after a sports-related injury forced him to drop out of college. He was referred to a psychiatrist but felt the psychotherapy had been "too openended" and "a waste of time and money." With his wife's support, he managed to stop drinking and using narcotics and has remained sober ever since. He went on to become a valued high school teacher and coach, receiving several medals for excellence in teaching. Later he was awarded a full scholarship to an Ivy League university, where he earned a master's degree in education. Asked about any other events in his life that may have contributed to his current depression, Mr. A mentions that his father was a heavy drinker who used to chase him around the house with a loaded gun when drunk. The father was diagnosed with cancer shortly after Mr. A started the doctoral program and died after a brief illness, during which Mr. A lived with and helped care for him. The second-year resident to whom Mr. A has been assigned admits to her supervisor that she is already having a "sinking feeling" about Mr. A. He says he is too depressed to talk about his future, much less make any important decisions about his life. He is also reporting debilitating side effects from the antidepressant she has prescribed and has warned her that he is "sensitive" to most drugs. The resident describes him as "not just stuck, but sticky-I feel like I'm wading in molasses." She finds herself wanting to end sessions early but tends to run late because of his last-minute reports of alarming physical symptoms or fleeting thoughts about "blowing his brains out." The resident has noticed that although Mr. A is relentless in his protestations of worthlessness, he likes to wear a sweatshirt from the Ivy League school he attended, and he enjoys acting as an auxiliary therapist in groups-"a pretty good one, too." The resident adds ruefully, "I guess he just needs support, but we haven't had that course yet. What do you suggest?".