Technorati.com, the popular blog portal, recently invited bloggers to contribute to their newly revamped site. I signed up and submitted an article there, on ADHD medication. I'm happy to say it appeared on their site this morning, as the leading post in their "lifestyle" section. (I'm sure it will rotate out of the leading position soon.) We contributors agreed to submit content appearing first on Technorati. I'll re-post the piece here once I learn how long they'd like me to wait. For now, head over to their site and take a look, and feel free to comment there, here, or both.
Ending therapy
Two events prompt me to write about therapy endings. In the more abrupt and traumatic of the two, a local psychiatrist died last month in a tragic accident, leaving many patients suddenly without their doctor. The other event, far more commonplace, was the decision of one of my own patients to stop therapy. These events illustrate opposite ends of a continuum, as I hope to describe below. I discussed typical features of open-ended dynamic psychotherapy in my last post. Timelessness, wide focus, relative freedom from protocol and direction, and promotion of transference all come into play when such a therapy eventually comes to an end. Since this type of therapy has no "built-in" ending, each ending is unique.
In the real world psychotherapy often does not feel timeless. External events like a job change, a move, or a change in insurance coverage may end therapy prematurely. Therapists retire or move their practices far away. These endings are not chosen by the patient. Any unchosen ending can feel like a loss, or even an abandonment. These events do come with advance warning, however, and can be discussed ahead of time. The emotional repercussions can be contained, reviewed, and comforted in what is termed the "termination phase" of treatment: the sessions between acknowledging that therapy is ending, and the actual last session.
However, sometimes there is no warning, for example when a psychiatrist or other therapist suddenly dies. Such events are emotionally traumatic. Patients feel the acute loss of a relationship they came to rely upon, and often there is a rocky transition to another doctor, facilitated by the colleagues, professional partners, or secretarial staff (if any) of the deceased therapist. This mini-community steps in, without advance preparation nor much knowledge of the patients affected, to make the best of a very difficult situation. I consider this one extreme of the continuum of therapy endings, the pole where it is not the patient's idea or wish at all.
In my view, the ideal way to end psychotherapy is not the other pole of the continuum either, where the decision is entirely the patient's. This was the case with my patient who recently decided to end treatment after making much progress over the past couple of years. Yet, in my opinion she had a long way to go. Obviously, it is the patient's choice to spend time and money on therapy; I can't keep anyone in therapy if they choose otherwise. And sometimes a patient's unilateral choice to stop reflects progress: a newfound ability to assert oneself, or to make definitive life decisions. Nonetheless, it isn't an ideal outcome because it isn't collaborative.
Psychodynamic therapy relies, first and foremost, on a "working alliance" between patient and therapist. If the patient feels he or she must make a unilateral decision to end therapy, this alliance has been damaged somehow, or was never strong in the first place. In a therapy with relatively little protocol or explicit direction, and where transference is promoted as a therapeutic tool, the one bedrock that both parties can rely upon is their mutual aim to help the patient. Ideally, then, a time comes when the patient feels ready to stop, and the therapist feels likewise. This is the midpoint on the continuum of therapy endings, where it is neither the therapist's abandonment of the patient, nor the patient's defiant separation from the therapist. It is a shared understanding that the work is ending, the culmination of a shared exploration in therapy.
Yes, this does happen in real life, although not as often as anyone would hope. Yet even when it's the patient who chooses to end therapy, and the two parties "agree to disagree," it is still very beneficial to plan ahead and allow for a termination phase — the length being roughly proportional to the length of the therapy, from a couple of sessions to several weeks — to discuss the ending. Unexpected feelings can arise when time is short. By exploring these feelings, therapy can be therapeutic until the very end.
"I don't want to be in therapy forever!"
In this age of managed care it may seem surprising, perhaps even suspicious, that traditional psychodynamic therapy is designed to be open-ended, with no fixed number of sessions or duration. This can be anxiety-provoking both to third-party payers, e.g., insurance companies, who prefer to know from the start how much a treatment will cost, and to the patient, who also invests money, time, and emotional commitment into treatment. In addition, many patients find themselves uncomfortable with a growing sense of reliance or dependence upon the therapist, a feeling intensified by the lack of a defined stopping point. Part-way through the process many patients muster the courage to ask: "How will I know when to stop? I don't want to be in therapy forever!"
In contrast to traditional open-ended, exploratory psychotherapy, shorter-term manualized therapies have gained prominence in recent decades. Based on psychodynamic, cognitive-behavioral, or other schools of thought, these treatments, often 12 to 16 sessions in length and with a defined beginning, middle, and end, appeal both to third-party payers and to many patients. Solid research evidence supports these shorter-term therapies as effective treatment for depression, anxiety, and other common symptoms. They are particularly suited for addressing well-defined fears (flying, spiders, public speaking, etc.), shyness in dating or other social situations, depression after a recent loss, and the confusing squirl of chaotic feelings after a relationship ends. The advantages of time-limited treatment are fairly self-evident; one sensibly wonders why anyone would choose the older open-ended alternative.
In contrast to time-limited therapies, traditional exploratory treatment invites wide-ranging discussion of thoughts and feelings; it is not limited to a specific topic or concern. It also has a timeless quality: if a topic doesn't arise today, it may arise next week or next month. A person avoids talking about troubling issues for only so long; eventually even the most shameful or ineffable topics are broached, detoxified, and worked through. Thus, open-ended therapy excels when problems are ill-defined or hard to talk about; when one is vaguely yet pervasively dissatisfied or frustrated with career, relationships, self-identity, or other central aspects of life.
Open-ended treatment tends to be less directive — steered less by the therapist — and thus more conducive to promoting and observing transference. And since transference interpretation is one of the best ways to bring unconscious thoughts and feelings into consciousness, open-ended therapy is well-suited for problems that originate outside the patient's conscious awareness.
Open-ended therapy can be more anxiety provoking than time-limited varieties. There is no set agenda, no obvious protocol or series of treatment steps. It is hard to know how "far along" one is, and sometimes it isn't clear whether any real change is taking place. The "active ingredient" that makes therapy work is less a matter of technique and more a result of a certain type of human relationship.
In the midst of all this murkiness, patients note subtle progress over time. Relationships gradually feel less frustrating, career decisions less intractable. But when does this process stop? The answer is simple and complex at the same time. On the one hand, therapy naturally ends when a patient "got what they came for." Feeling fundamentally satisfied with life is a good indication. Since this is subjective, no one can say except the patient him or herself, who often takes further investment of time and money into account as well. On the other hand, dynamic therapists consider a therapy complete when all major areas and conflicts of life have been discussed, explored, and resolved in some manner. As many of these conflicts are unconscious, this assessment is made by the therapist, not patient, and can be quite complex.
Neither the patient nor the therapist wants therapy to last forever. Ultimately our job as therapists is to make ourselves obsolete. Nonetheless, the nature of open-ended dynamic treatment provokes concerns about dependency and "getting too comfortable" with therapy, and often elicits a reactive fear that therapy might last forever if the patient isn't careful. These feelings are themselves well worth discussing in therapy; their resolution brings the patient a big step closer to an ending both parties can endorse. For more on this topic, see here and here.
It is also true that sometimes patients and therapists disagree over whether it is time to end. In my next post, I'll discuss various ways and reasons therapies end, and some of the dynamics that result.
Healthcare reform & psychiatry
The recent debates over U.S. healthcare reform are long overdue, yet still sadly inadequate. (The discussion is about health insurance, actually, not the care itself. But I titled this post "healthcare reform" since that is what everyone is calling it.) There is no need to rehash the plentiful evidence that the current system is broken: millions of uninsured, job lock to maintain health coverage, unwarranted claim delays and denials, whole industries devoted to medical paperwork and reimbursement, and the near impossibility, given a pre-existing condition, of purchasing non-employment based insurance at any price. Hardly anyone across the political spectrum argues for the status quo. The national debate centers on how to provide universal, or universally available, coverage to all Americans. Some argue that with proper incentives, private insurers could cover everyone. Similar to health coverage in the Netherlands, this proposal aims to preserve the private insurance industry and competition in the marketplace. Others argue that health care does not follow classic supply-demand principles, and that competition among private insurers has not controlled costs. A publicly funded, government-sponsored option is preferred to remove the profit motive and gain efficiency through standardization.
Universal health coverage is the norm in virtually all developed countries. I believe Turkey and the U.S. are the only remaining exceptions. Some nations, Britain for example, have nationalized health care — doctors are government employees. Others, like Canada, use public funds to pay doctors in private practice, much as Medicare currently operates in the U.S. These systems are not perfect. In particular, there are longer waiting times for elective procedures, sometimes on the order of months. But surveys repeatedly show that citizens (and doctors) of these countries are happier with their health services than Americans are with ours. And studies also show their health outcomes are the same or better than ours, for far less money.
There are many places to read about health insurance reform that do a better job than I can (e.g., here). From my reading, I believe a single-payer plan such as those in Australia, Canada, and Taiwan would greatly improve health care in the U.S., while preserving patients' ability to choose their own doctors, and also doctors' ability to work in the private sector. It's a pity this option, so popular across the globe, is a political third-rail here. In my view, publicly funded health insurance (think Medicare) is no more "socialist" than the public funding of highways, police departments, and firefighters.
In a nutshell, that's my view of publicly funded health insurance in general medicine and surgery. But what about psychiatry in particular?
Universal coverage would be a boon for the seriously mentally ill. Schizophrenia and severe chronic mood disorders render many sufferers unemployable and ineligible for private insurance. Some eventually qualify for Medicare and/or Medicaid, the limited forms of public health insurance that already exist. The additional stigma attached to using public programs due to severe disability would abate if public health insurance became a mainstream reality. Others with debilitating but less severe forms of mental illness do not qualify for Medicare or Medicaid, but cannot maintain private insurance due to frequent job loss, chaotic lives, depression, and so forth. The affordability of care and treatment is a constant stress atop an already stressful existence.
Universal health coverage would change all that (see this report from the California Endowment). Canadians talk about their comfort in knowing their friends, acquaintances, coworkers — fellow citizens — have access to health care regardless of circumstance. Healthy Americans might feel this way, too, when the chronically mentally ill among us are assured access to care.
At the other end of the psychiatric spectrum are relatively healthy individuals who seek psychotherapy for help in living a life that is basically stable, but is unfulfilling, frustrating, anxiety-laden, or sad. In the U.S., most health insurance, private or public, limits coverage for this type of treatment. Many private plans cap the number of treatment sessions to 20 or fewer per year; Kaiser Permanente additionally requires that a mental health professional "believes the condition will significantly improve with relatively short-term therapy." Medicare does not cap the number of visits, but covers only half its "allowed fee" — the patient or supplemental insurance pays the other half.
It should be noted that traditional dynamic psychotherapy, the kind I do, considers it beneficial when the patient pays for therapy himself. Directly paying for therapy focuses the dynamics between patient and therapist by excluding distracting intermediaries. It matters more (to both parties) that the patient gets what he or she is paying for. Sometimes patients express unstated feelings toward their therapist in how they pay their bill; this can be interpreted as transference, moving the treatment forward. Moreover, dynamic psychotherapy is an intensely private undertaking: Many patients choose to forgo insurance coverage even if they have it, to avoid a public record of the treatment, or the need to document it with third parties.
All that said, many more people can benefit by psychotherapy than can afford to pay for it directly. A universal health plan that covered therapy in a substantial way (say, as Medicare does now) would make this service available to many who could not receive it before. Third-party payment issues are handled all the time in dynamic therapy even now. And not all therapy is psychodynamic; I know of no concerns regarding CBT (cognitive behavioral therapy), for example, being paid by third parties.
In short, U.S. healthcare — more accurately, health insurance — reform that universally covered mental health treatment would revolutionize care of the mentally ill in this country. Benefits could be as visible as fewer homeless on the streets and in the jails, as subtle and pervasive as a comforting sense that Americans care about each other both in body and spirit. I hope we have the will and the wisdom to make it happen.
Borderline personality disorder: parasuicide
In my last post, I highlighted diagnostic challenges related to borderline personality disorder (BPD): Sometimes dramatic, self-destructive behavior leads to reflexive, inaccurate use of this label, while other times eagerness to diagnose a medication-responsive illness such as bipolar disorder can lead to overlooking BPD. Naturally, this barely scratches the surface. Thousands of books have been written about BPD. This editorial from the May 2009 issue of the American Journal of Psychiatry provides a concise summary of controversies surrounding the diagnosis. Even the Wikipedia entry on BPD has extensive useful information. Today I'll focus on another central feature of BPD that has proven challenging to residents I've supervised (and me): parasuicide. Parasuicide refers to self-harming behavior identified by the patient as suicidal but unlikely to actually result in death. Sometimes termed a "suicide gesture," typical examples include taking a handful of pills, and cutting one's wrists to draw blood, but not deeply enough to damage veins or arteries. Often the patient realizes later that suicide was not "really" the aim of the behavior. (Aim and intent become complex philosophical issues once the idea of a dynamic unconscious comes into play. Can one intend something without knowing it? Can intent be discerned by a therapist over the patient's heartfelt disagreement?) Many patients in therapy eventually describe a very unpleasant, difficult-to-name emotional state that is relieved by these activities — especially painful, self-mutilating actions such as cutting or burning oneself.There is a sense of tension release. A communicative aspect is also often apparent, as in showing one's anger or rage to important others, and eliciting an emotional reaction from them in return.
Parasuicide puts families and therapists, especially beginning therapists, in an uncomfortable position. These actions must be taken seriously, as failure to do so can make the person feel (further) abandoned and even angrier, leading to a spiral of increasingly self-destructive behavior. "Upping the ante" in this way can even lead to accidental death. For example, it is not widely appreciated that even modest overdoses of acetaminophen (Tylenol) can cause lethal liver failure. A seemingly minor overdose can unwittingly prove fatal. On the other hand, parasuicide looks manipulative. It is loudly claimed to be suicidal but isn't "serious." Families and therapists become angry themselves, potentially resulting in isolation, retaliation, and further harm to the patient. Patients brought to the emergency room after parasuicidal behavior challenge the on-call psychiatrist, often a resident, to walk a tightrope between dismissing the risk too casually, versus overreacting on the principle of "better safe than sorry." Patients are sometimes hospitalized unnecessarily. A fascinating theoretical paper on psychiatric risk assessment can be found here.
To its credit, dialectical behavior therapy (DBT) tackles parasuicide head-on, as its top priority. This is wise not only from the perspective of patient safety, but also as a means to contain the anxiety of treatment providers. It is very difficult to work collaboratively with a patient who both scares and angers the therapist. While DBT addresses the problematic behavior itself, the manner in which a patient induces such negative feelings in the therapist is a direct focus of psychodynamic therapies. Transference-focused psychotherapy (TFT), another empirically validated treatment for BPD, was developed by Dr. Otto Kernberg and colleagues at Cornell, and pays particular attention to the communicative aspect of parasuicidal acts.
Parasuicide may look and feel manipulative to observers, but to the person with BPD it is a desperate attempt to secure relief from painful overwhelming feelings. It is both highly characteristic of the disorder, and one of its most challenging clinical features.