Psychotherapy as generic conversation — Sloppy thinking in psychiatry 4

This fourth installment in my "sloppy thinking" series turns to psychotherapy, or what passes for it in some psychiatric practices.  A very brief history: Sigmund Freud, a neurologist, invented psychoanalysis and its offshoot, psychodynamic psychotherapy, about 120 years ago.  It was, first and foremost, a treatment that involved talking — not merely a conversation that happened to make the patient feel better.  Years later, the object-relations school of psychoanalysis and the humanistic psychology movement of the 1960s partly shifted the focus of dynamic psychotherapy away from technique and toward a healing relationship, a shift prefigured by pastoral counseling and by the ministrations of the nursing profession.  Nonetheless, dynamic psychotherapy remained a treatment: a professional service with clear goals and a coherent rationale, aimed to remedy defined psychological conflicts or deficits.  Meanwhile, over the same century or so, academic psychologists developed the theories and practices of behaviorism via experiments with animals, and later applied behavior modification and various behavioral and cognitive therapies to human suffering.  While such treatments could be offered in a humane and caring manner, the relationship itself was not considered curative. Psychoanalysis and psychodynamic therapy originated in a medical context, and psychiatrists historically have been trained in its theory and practice.  (In contrast, psychologists historically tended to practice the empirically based behavioral and cognitive therapies developed in academia, although this distinction between the disciplines has faded.)  Prior to the advent of psychoanalysis, psychiatry was a medical specialty focused on the management of severe mental illnesses that rendered sufferers incapable of living in mainstream society.  But by the mid-20th century, the field had adopted the new "talking cures" to treat higher functioning patients.  For a few decades, roughly 1950 to 1980, the popular image of the psychiatrist was a psychoanalyst with the trademark couch in the office.

The emphasis in psychiatric training and practice shifted dramatically away from psychotherapy and toward medication treatments in the 1980s as a result of several factors.  Promising classes of medications such as SSRI antidepressants and atypical neuroleptics were developed; federal research funding shifted toward biological psychiatry; psychiatry's new diagnostic manual (DSM-III) encouraged medical-model thinking; managed care tightened the screws on reimbursement; and competition from non-physician mental health professionals heated up.  Psychopharmacology became a defensible niche for psychiatry, unlike psychotherapy which saw increasing competition from psychologists, social workers, marital and family therapists, and others.

Currently, many American psychiatry residencies offer minimal training in psychodynamics, or psychotherapy in general (interesting debate here).  I consider this very unfortunate.  Psychodynamically informed treatment is far richer and more sensitive — ultimately, I have to believe, more effective — even if psychodynamic psychotherapy itself is not offered.  For example, unconscious dynamics can help explain medication non-compliance, and can shed light on difficult psychiatric consultations on medical or surgical inpatients.  It's hard to deny that a mental health professional with a deeper appreciation of human emotions, conflicts, and psychological defenses has an advantage over the same professional without this appreciation.

Where's the sloppy thinking?  It results from the inescapable fact that most psychiatric patients harbor thoughts and/or feelings they want to talk about.  A psychiatrist who avoids all such conversation feels like an "ape with a bone," a medication technician who does his own little piece of work well, but misses the big picture.  So the psychiatrist talks with the patient for 30, 45, or 50 minutes, which makes both the psychiatrist and patient feel better in the moment.  It is billed as psychotherapy, but is it?

That depends on what happens in those 30, 45, or 50 minutes.  Is it well-conducted cognitive-behavioral therapy?  Hardly ever.  Nor is it psychodynamic psychotherapy if it's no more than a conversation that temporarily makes the patient feel better.  Dynamic psychotherapy is a structured treatment that includes a dynamic case formulation, a coherent rationale, strategic interventions, and treatment goals — features uniformly absent in this typical scenario.  Some call these unstructured conversations "supportive psychotherapy," but even that has a technical definition and clear goals.  Supportive psychotherapy is more than letting the patient "vent," or chat as though it were a social visit.  Perhaps all this mislabeling is an unfortunate mistake by well-meaning practitioners who were never trained to perform or recognize actual psychotherapy.  Or maybe it's intellectual laziness.  Or insurance fraud.

An honest profession would call such encounters what they are: Humane medication visits.  Stripped of the pretense of psychotherapy, we might admit that it often takes more than ten or 15 minutes to find out how a patient is doing, and that conversely it doesn't require aimless (yet remunerated) chatting for the better part of an hour either.  By clearly differentiating psychotherapy from generic doctor-patient conversation, we'd regain respect from other mental health professionals who have come to believe that psychiatrists don't take psychotherapy seriously, or that we pompously claim we know what we're doing when we don't.  These criticisms really boil down to irritation at psychiatry's sloppy thinking about psychotherapy, a tragic irony considering the field's long history with this treatment modality.

You guessed it: photo courtesy of Petr Kratochvil.

Talk doesn't pay: Comments on the NY Times article

I'd like to take this opportunity to comment on the article that appeared in today's New York Times: "Talk doesn't Pay, So Psychiatry Turns to Drug Therapy."  Gardiner Harris writes about psychiatry's shift from talk therapy to drugs, and profiles psychiatrist Donald Levin of Doylestown, PA (a suburb of Philadelphia), who felt financially unable to maintain a psychotherapy practice, and therefore shifted to a high-volume, medication-only practice.  It is clear that both the doctor and the journalist consider this a sad state of affairs.  Dr. Levin is quoted as saying: "I’m good at it, but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.” That comparison is apt to rile my colleagues who are serious and careful psychopharmacologists.  But Dr. Levin is right:  Most medication management in psychiatry is tediously straightforward.  Which is why it is mostly done by primary care doctors, not psychiatrists.  In the U.S. most antidepressant and antianxiety prescriptions are written by non-psychiatrists.  (And even antipsychotics lately, but this is a different and far more worrisome issue.)  It seems to me that any self-respecting psychiatrist who limits his or her practice to psychopharmacology, i.e., medication management only, should add some value over a visit to a family doctor, internist, or pediatrician.  Either the cases seen should be harder, e.g., "treatment resistant," or the doctor should offer something more nuanced and sophisticated, or more comprehensive.  If so, such a psychiatrist will not be "the ape with the bone."  Unfortunately, my experience suggests this is the exception, and that the shift to medication management has been borne of expediency and financial pressure in many cases, not an earnest scholarly focus on advanced psychiatric medication strategies.  And for this reason, the critique that our field is increasingly populated by dumbed-down medication technicians is not the throwaway line it would otherwise be.

In saying this, I invite a rebuttal.  If psychiatrists who give meds should add something over other med providers, what do psychiatrists who conduct therapy add over other therapists?  The answer is a more comprehensive viewpoint, one that takes into account medical and bodily issues, drug interactions, and similar matters.  And the option to prescribe medications when these are needed in addition.  If we cannot add this value, we should not charge more than other therapists.

Since I have a mostly-psychotherapy practice myself, I took note of several points made in the article.  Most glaring is a starkly misleading statistic.  Harris cites a 2005 government survey showing that just 11 percent of psychiatrists "provided talk therapy to all patients."  I'm not sure why that surprises anyone.  I'm a huge advocate of psychotherapy, yet I don't recommend, much less provide, it for everyone.  It's a treatment — it's expensive, it takes a lot of time, it's often uncomfortable.  I only provide psychotherapy when I predict it will help, and when my patient agrees to it.  While I believe it would be helpful for many patients I see, I nonetheless still treat a minority of patients with medication only.  In my view, one of the best things about being a psychiatrist is that we have a variety of tools.  While I find dynamic psychotherapy more intellectually interesting and humanly engaging than writing prescriptions, I'm glad I can do both.  The 11 percent statistic is meaningless.

Another potential confusion in the article are the widely disparate fees cited, with little explanation.  At one point Harris writes: "A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session."  At least here in San Francisco, this is considerably less than either service is typically worth, even accounting for payment caps by health insurers.  Not to mention that psychotherapy is traditionally 50 minutes, not 45.  But then Harris writes about "a select group of [New York] psychiatrists [who] charge $600 or more per hour to treat investment bankers," and later notes that a nearby colleague of Dr. Levin charges "$200 for most [therapy] appointments."  The truth in my experience is that no psychiatrist starves by being a psychotherapist, even though there is more competition from other disciplines and the overall income may be less.  Talk does pay, just not quite as much.  When psychiatrists complain about comparatively low psychotherapy income, it makes me wonder why they didn't become surgeons.  Seriously, from what I gather surgery is very engaging, very satisfying, and very lucrative.  It sounds much better than doing half-hearted, half-assed psychiatry just for the income boost.

As I wrote last year, dynamic psychotherapy is more than merely a treatment technique to place on a shelf alongside medications.  It is a perspective that informs our understanding of patients even when we do not offer this specific therapy as treatment.  Thinking about our patients dynamically can help us be better medication providers, better CBT (non-dynamic) therapists, better referrers to other professionals.  Psychiatrists don't have to be psychotherapists all the time, but we do need to think psychotherapeutically all the time.  The real tragedy highlighted by the NY Times article is not one man's devolution to an "ape with a bone," nor even a profession's.  It is the loss of intellectual curiosity — of knowing there is a better way, yet choosing not to pursue it.

Should therapists accept holiday gifts?

December brings the annual pleasures and challenges of holiday gifts and how to deal with them in dynamic psychotherapy. Although it is relatively easy to follow a simple rule about this, ideally a good deal of thought goes into a therapist's decision about whether to accept a patient's holiday gift. Below I will give a couple of examples of this from my own practice, and how psychodynamic theory guided my response. All beginning dynamic therapists are taught not to accept gifts from patients. This rule follows from the principle that the therapist should decline all gratifications from the patient aside from the fee paid. A therapist who is swayed by the patient's generosity, physical attractiveness, political connections, or other factors invites a conflict of interest in himself, and thus risks distorting the therapy in pursuit of his own needs and desires. Accepting a gift would be an example of this. Afterwards, the therapist may feel disinclined to challenge the patient, to induce anxiety or point out a contradiction. Conversely, the patient may feel the therapist should reciprocate the generosity, leading to disappointment and possibly anger when the therapist fails to do so.

Naturally, patients often do not know this rule, thus some arrive to a year-end session with a gift in hand. These gifts vary. Some are expensive, some less so.  Some are "for the office," others intended more personally for the therapist.  Some are homemade, or reflect something personal that had been discussed earlier in the treatment, while others are more generic.  Likewise, the nature of the treatment varies from patient to patient, from relatively supportive and concrete, to very "uncovering" transference-based therapy. Given these variables, there is room for some discretion in the no-gifts rule.

A number of years ago I treated a woman who painfully described feeling unvalued by others. Men only appreciated her because she gave them sex; her employer did not value her as a person, but only for her productivity. Our therapy was fairly psychoanalytic in nature. Arriving to a session around the holidays, she handed me a large, beautifully wrapped gift box. It looked store-bought and expensive.  I imagined she had taken significant time and trouble to purchase and bring it to me. With some apprehension I told her that we needed to discuss the gift before I could accept it. She was initially hurt by this. However, it soon became clear to both of us that her gift reflected her belief that I, like others in her life, did not value or appreciate her as a person — she hoped I would value the gift and therefore her. On that basis I thanked her but did not accept her gift, a decision she ultimately understood and agreed with.

It turned out very differently with another patient, an older Russian woman who saw me for supportive therapy. Around the holidays she presented me with a bottle of Kahlua, unwrapped if I recall. We had not been working with transference; I did not see how such a gift could damage our work. Also, it is customary in Russia to offer such gifts to one's doctors. I accepted the bottle with thanks, and pleased my patient. No harm done, and perhaps a bit of good in strengthening our working relationship.

Most dynamic therapies lie between these two extremes, somewhere in the midrange of the analytic-supportive continuum (more about that here). I have accepted inexpensive gifts in such cases, except when I sense that the offer is an unhealthy enactment, or that the patient is sidestepping a useful exploration. As is often the case in conducting dynamic psychotherapy, there is a balance between fostering a warm working relationship, versus encouraging reflection and insight.  In my view, a blanket rule of refusing all gifts is unnecessarily cold and inhuman for many patients, while accepting all gifts may appear "normal" but does not encourage reflection, and may introduce conflicts of interest.  The matter takes case-by-case consideration, neither unthinking acceptance nor unyielding refusal.  It should go without saying that I never expect to receive a gift; it's also helpful to note that most patients do not offer them.

Occasionally the opposite issue proves useful to explore: Whether the patient expects (or wants) me to give him or her a holiday gift.  As we all know at this time of year, both gift-giving and gift-receiving tap deep emotional aspects of our personalities, and sometimes highlight conflicts around themes of self-interest, self-sacrifice, guilt, generosity, reciprocity, and one's value in the eyes of others.  I do not offer my patients holiday gifts, but I do wish them, and you, Happy Holidays.

Carlat on mindless psychiatrists

My fellow psychiatrist and blogger Dr. Daniel Carlat has an article in this weekend's New York Times Magazine.  "Mind Over Meds" is a memoir of Dr. Carlat's growing realization that psychiatry can't be done well in 15-20 minute medication visits, that talking to patients as people is important too. I'm generally a fan of Dr. Carlat.  His blog is one of the few listed on my blogroll (the short list of links over there on the right of this page).  He writes well, and I share his skeptical attitude toward overzealous promotion of psychiatric drugs to our profession and the public.  "Mind Over Meds" is a good article: Carlat reviews the swing from the "brainless" psychiatry of early 20th-century psychoanalysts, to the "mindless" psychiatry of today, where symptoms are treated with medications and the patient may be lost in the process.

This is all on target, and I appreciate how Dr. Carlat is willing repeatedly to make it personal and write about revisions in his own thinking — as he did in this prior NY Times Magazine article, also well worth reading.  The gist is that psychiatry has painted itself into a corner by limiting itself largely to psychopharmacology, i.e., medications, and ceding psychotherapy — understanding the patient as a person — to other mental health professionals.

Unfortunately, "Mind Over Meds" goes off the rails in two ways.  The less important is a passage that I have to believe is just badly worded, as it seems to denigrate psychologists and other non-psychiatric therapists:

Like the majority of psychiatrists in the United States, I prescribe the medications, and I refer to a professional lower in the mental-health hierarchy, like a social worker or a psychologist, to do the therapy. The unspoken implication is that therapy is menial work — tedious and poorly paid.

A couple of early commenters have already chided Dr. Carlat for this "mental health hierarchy" language.  Discussing whether mental health professionals constitute a hierarchy is beyond my scope here, but I believe Dr. Carlat is well aware that the expertise of many psychologists (for example) to do psychotherapy surpasses his own.  In fact, he has recently taken a contrarian position in favor of granting psychologists prescribing privileges.  I doubt he meant this talk of hierarchy as a putdown, but he should have been more clear.

The bigger gaffe is that the article ultimately calls for psychiatrists to do "some sort of psychotherapy... when our patients need more from us than just medication."  Dr. Carlat seems to be satisfied with a little support here, a few extra minutes of listening there.  However, that isn't psychotherapy except in the most meaningless, hand-waving sense.  That is just listening to one's patients, something every doctor should do, from dermatologists to orthopedic surgeons.  I hate to say it, but it's no wonder health plans won't pay for that.  It used to be part of the job, not something extra.

Psychiatrists have a lot more going on than mere doctor-patient rapport — or at least we used to.  Even psychiatrists who choose not to conduct psychodynamic therapy still learned, or should have learned, about psychodynamics, an intellectual and historical cornerstone of our field.  A psychiatrist's work needs to be psychodynamically informed even if he or she only prescribes medication.  As the most obvious example, a dynamic understanding may shed light on a patient's medication non-compliance and help to address it.  Even better, a dynamic understanding of the patient may obviate the need for medications at all.  (To those who argue that psychodynamics has been supplanted by cognitive-behavioral therapies, I note that Dr. Aaron Beck, the founder of cognitive therapy, was a psychoanalyst first.  Even cognitive therapy works better if it is conducted by a psychodynamically informed therapist.)

Dr. Carlat should have gone farther.  Psychiatry needs to retake the position that we strive to understand and heal the mind from the molecule on up  (a position taken by Freud, among many others).  It is true that this encompasses a dauntingly wide spectrum, from psychopharmacology to psychological treatment, and beyond that to social and cultural influences.  As physicians we are the only mental health discipline with the training to appreciate the whole span; other professions, like clinical psychology, may have more in-depth knowledge and treatment skills regarding a particular part of this spectrum.  Of course, any given psychiatrist may choose not to practice at all of these levels — probably cannot, given the sweeping range.  But it is the essence of psychiatry to know about the full spectrum, and either offer whatever treatment is needed at any level, or refer the patient to a professional who can provide it.

It is necessary but not sufficient to see a patient behind the symptoms, to listen.  It is also incumbent on psychiatrists to conduct real psychotherapy, dynamic or otherwise, when sitting with a patient for 50 minutes and charging for it.  Ceding "real" therapy to others has diminished our field and has turned most psychiatrists into technicians.  "Mind Over Meds" is the right title for a much deeper topic.

Sailing between support and insight in therapy

Cross-posted from "Sacramento Street Psychiatry" For more than a decade I've taught a seminar in dynamic psychotherapy to psychiatry residents. One tricky issue that arises every year is the apparent choice between conducting a "supportive" psychotherapy, versus an "analytic" or "insight-oriented" one. I developed a sailing analogy to clarify this issue, and to teach an important point about it.

Most patients appreciate emotionally comforting support. Many seek a therapist who will provide a listening ear, who won't judge them negatively, who will encourage them and praise their successes, and who will offer solace and kind words in the face of setbacks. However, many critics charge that such support requires no special training — other than learning to listen, no small feat perhaps — and can be offered by teachers, relatives, clergy, counselors, and many others. Supportive therapy is sometimes derided as "buying a friend."  Indeed, friends often offer support of this type.

Dynamic psychotherapy, originally derived from Freudian psychoanalysis, strives for something else. Freudian analysts are stereotyped as cold, painstakingly "neutral," and anything but supportive. While this caricature exaggerates reality, it nicely illustrates the contrast between "support" and "insight." In this type of therapy the patient is left to grapple with his or her own thoughts and feelings. These are brought into the light of consciousness by the therapist, but not softened or eased by emotional support. The aim of such therapy is not to help the patient feel better in the moment, but to lead to deep self-knowledge and the ability to accept one's own feelings as they are. Critics sometimes claim that such therapy doesn't really help or that it's unnecessarily harsh, but no one calls it "buying a friend." It isn't all that friendly.

Psychiatry trainees learning about psychotherapy are usually told to aim for as much "insight-oriented therapy" as the patient can tolerate, and as much "supportive therapy" as the patient needs. In other words, insight is really the goal, but if a patient can't tolerate the process to get there, add support as needed. Even presented this way, trainees often cubbyhole patients into "support cases" and "insight cases," as though these are permanent categories, like blood type.

My sailing analogy aims to break down this sharp (and artificial) categorization. The aims of insight and support are fluid, and change moment by moment within a given therapy.

If you've ever been sailing — or windsurfing, which was my original version of this comparison — you appreciate the trade-off between stability and forward motion. Let the sail billow loosely and the boat floats quietly in the water. It is very stable but it doesn't go anywhere. Tighten the sail to catch the wind, and the boat starts to move. However, in doing so it also leans over. It feels less stable, and in extreme cases threatens to capsize. Although I'm not much of a sailor, and even less of a windsurfer, I was struck by the kinesthetic reality of this moment-to-moment trade-off. At every moment, one chooses how tightly to trim the sail, and thus how much stability to trade away for forward progress.

In dynamic therapy, the therapist chooses how much anxiety to allow (or invoke). Minimize anxiety by avoiding painful topics and providing ample emotional support, and the boat of therapy sits stable but motionless in the water. The therapy is comfortable but does not go anywhere. Introduce some anxiety by gently confronting the patient, or simply by not offering as much support, and the boat of therapy starts to move. However, it also becomes less stable, and in extreme cases may threaten to capsize. The job of the therapist, the sailor in this scenario, is to adjust the sail at every moment, such that anxiety and stability are in balance: Enough stability that the patient can trust the process, enough anxiety to propel the therapy forward.

The sailing analogy can be extended by noting that some boats are inherently more stable.  They can withstand more sail pressure and go faster, while others are more easily capsized and need to be sailed more carefully. Likewise, some patients are more resilient, some more fragile. Also, external stressors in a patient's life are like a strong gusty wind blowing over the water. In such conditions a boat will move ahead even if the sail is loose. Tightening the sail in such conditions is more apt to upset the boat.  This parallels therapy in the face of severe external stressors or trauma, when a lighter, more supportive touch is needed.  Conversely, in calm conditions a boat can be sailed more aggressively. Likewise, a person not dealing with severe current stressors can bear more anxiety imposed by the therapy itself, which may allow more fundamental change to occur.

The main point is that patients don't come stamped with "support" or "insight" on their foreheads. Everyone is on a continuum between the two and benefits by both. Moreover, everyone moves along this continuum on a moment-by-moment basis, the result of a complex interplay of defenses, the topics being discussed, and the relationship between the two parties. A sensitive therapist recognizes this and tailors the therapy accordingly.