The Family Doctor: Psychodynamic Psychotherapy in Tightly Knit Communities

Although unusual, psychodynamic psychiatrists engage in the prac- tice of treating multiple members, and constellations of members, of families with psychodynamic psychotherapy as well as other treatment modalities. Such clinicians are considered the "Family Psychiatrist." Psychological charac- teristics of such families who cannot be referred to other clinicians are articu- lated. The literature on psychotherapy in small rural communities is reviewed as having relevance to define the ethical issues that arise in such treatments. These issues include: maintaining therapeutic neutrality; creating functional, flexible, and appropriate boundaries; maintaining confidentiality; promoting patient autonomy and growth; as well as managing conflicts of interest. Rel- evant countertransference issues are examined. This brief contribution is intended to put an unconventional, but not uncommon, practice into the literature. I am aware of several other cli- nicians who, like me, treat many members (and constellations of mem- bers) of large, multigenerational family cohorts. I have seen the mem- bers as individuals, as couples, and as families. I have seen in-laws, and even a beloved employee (who was "just like family"). I have always practiced on the upper west side of Manhattan, an area that is home to a surfeit of competent colleagues. "Why," you might rightly ask, have I chosen to be the "Family Doctor"? It is clear why one would not want to engage in this practice. Psy- chodynamic psychotherapy derives its concepts of the therapeutic "frame" (Langs, 1982) and treatment boundaries from psychoanaly-