Resistance: "I have nothing to talk about today"

There comes a time, fairly early in many psychotherapies, when there is nothing left to talk about.  The identified problems have been named and discussed, there is no more need to bring the therapist up to speed on one's history.  In essence, the patient's conscious agenda for coming to therapy has been exhausted.  I tell trainees this often happens around session #7 — truly it's more variable than that — when the patient has voiced all his or her prepared topics, said everything already known or consciously felt about the issues, and offered all the background he or she believes is relevant.  The patient may then appeal to the therapist for guidance, not in any profound sense, but simply to suggest something to talk about, so they don't sit there in awkward silence. A dynamic therapist typically turns this back on the hapless patient:  "Say anything that comes to mind."  This challenge can bring therapy to a grinding halt — or trigger the start of genuine exploration.  For it is only when the patient speaks unrehearsed and without self-censorship, in the moment, that the two can observe the here-and-now workings of the patient's mind.  It has been mere preamble up to this point, groundwork at best and chit-chat at worst, not the real work of dynamic psychotherapy.  Speaking "without a script" allows topics to arise that are impolite, uncomfortable, and awkward, ideas the patient previously thought but chose not to say, feelings that had been brushed aside up to that point.  Some patients unfortunately cannot speak without a script; it is too scary and they are too defensive.  Dynamic therapy ends at that point, although emotional support and cognitive techniques may still prove very helpful.  But for those with the courage to look at themselves, their own defenses, resistance, and unconscious motivation, it's time to dive in and explore the unknown.

In a similar vein, patients at any stage of treatment sometimes arrive to a session with nothing to discuss that day.  They exude an uncharacteristic blandness or boredom, as if to signal: "Nothing to see here, just move along."  With a mildly apologetic tone they claim to have no burning issues, nothing especially vexing or troubling.  In fact, maybe it's time to talk about wrapping up treatment...

If this presentation stands in contrast to the patient's usual enthusiasm, I take it as a very good sign.  Something emotionally important is going on, and the patient's Unconscious is trying desperately to throw us off the trail.  In the language of dynamic therapy, this is resistance: unconscious effort to avoid painful or troubling material in therapy.  Some patients employ this sort of resistance constantly, and for this reason are either very challenging to treat, or they "vote with their feet" and leave treatment early in the process.  But when a new resistance stands in clear contrast to the patient's typical openness, it is easier for the therapist to recognize it, easier to point it out to the patient (who is more open to hearing about it), and easier to identify dynamics that may underlie it.

In my experience, these unusually boring or bland openings lead, more often than not, to the best sessions.  Because the patient is not consciously avoiding a troubling issue, and because I rarely know at first what motivates the patient's avoidance that day, it becomes a shared exploration where new discoveries and insights come to light.  For reasons I can't quite explain, the factors motivating such resistance are not deeply buried or inaccessible.  They usually become apparent to both of us well within the 50-minute hour.  "Making the unconscious conscious" (in Freud's famous words) leads the patient to new and unexpected insights — usually a delightful experience for us both — and also to clearing of the leaden resistance, which is no longer needed to keep the material out of consciousness.  Rather than heralding the end of the treatment, awkward silence at the start of an hour, like the awkwardness near the start of many a dynamic psychotherapy, points the way to important thoughts and feelings.  It turns out there is a lot to talk about.

Narcissists, psychopaths, and other bad guys

A patient of mine recently observed that the increasing use of the the term "psychopath" in popular media is really a disguised way of criticizing selfishness.  Dressing up selfishness as an odd and frightening clinical disorder — slapping a diagnostic label on it — makes for catchy news copy, and grants pundits emotional distance between themselves and those monsters who look just like us, but who lack the empathy and remorse that make us human. I immediately thought of how narcissism had its heyday in popular culture very recently as well, and to similar ends.  Narcissists and psychopaths care only about themselves, and have no qualms about hurting and sacrificing others when it suits their purposes.  These are dangerous people lurking among us; all the more reason to publish lightweight magazine and newspaper pieces on how to spot them in the wild.

Both labels sound like psychiatric diagnoses, but actually they're not.  According to Heinz Kohut and other theorists, narcissism is a quality everyone has to a greater or lesser degree.  It normally develops in infancy: the sense all babies have that the world revolves around them.  However, we gradually learn that we are not the center of the world, and that other people, including our primary caregivers, have their own goals and perspectives separate from our own.  Infantile narcissism is thus tempered by the reality of healthy relationships, although its vestiges are present in our self-pride, and perhaps in our proven tendency to overestimate our own efficacy and performance.  Pathological narcissism in this view is infantile normality carried abnormally into adulthood.  It only becomes a psychiatric diagnosis when the condition fulfills certain observable criteria and impairs social and/or occupational functioning.  Likewise, psychopathy is a personality trait, not a diagnosis.  Renowned psychopathy researcher Robert Hare notes that "psychopathy is dimensional (i.e., more or less), not categorical (i.e., either or)."  DSM-IV doesn't include a diagnosis called "psychopathy" or "sociopathy."  Instead, there is antisocial personality disorder, which overlaps with psychopathy but is not the same thing.

These terms, psychopath and narcissist, are loosely applied personality labels when popularized in the media.  What do they add over simply calling someone callous or selfish?  First, they offer an explanation — a pseudo-explanation really — of frightening and/or mystifying behavior.  Our feeling of powerlessness is eased by the label, as though now that the threat is identified, we may be able to do something about it.  Second, such labels imply that misbehavior is a function of one's character, a categorical determination.  Yet categorical psychiatric diagnosis, especially of personality, is controversial in general.  Moreover, we often overestimate personality factors and underestimate situational ones (the "fundamental attribution error") in explaining the behavior of others.  Using a label like psychopath or narcissist to describe another person (whom we've only heard about in the news, and haven't formally evaluated) reaches for a premature conclusion about the cause of that person's behavior.  In a way, we are falsely reassured.

Third, the label adds power to our verbal disapproval.    We have a long history of abusing psychiatric labels in the service of putting others down.  Consider "idiot," "moron," and "imbecile," all originally coined as official categories describing low IQ.  Or "cretin," which originally referred to physical and mental disability due to congenital thyroid deficiency.  Or the casual use of "crazy" and its synonyms.  Some patient advocates argue further that any diagnostic label used as a noun is demeaning, i.e., calling someone a schizophrenic, a neurotic, a borderline, etc.  Instead, it is more respectful to refer to a person (or patient) who has schizophrenia, or a narcissistic personality.  But that's exactly the point of the popular use of terms like psychopath and narcissist: To show disrespect and disdain, to disapprove.  And to underscore the difference between ourselves and the person with the label.

Our earliest social categories are "good guys" and "bad guys," defining one against the other.  From "cops and robbers," to team sports, to bipartisan politics, to our allies and foes on the world stage, we divide self and other at every level, calling the former good and the latter bad.  Callousness and selfishness are in all of us to some degree, and it hurts to admit it; it damages our self-image.  Instead, we psychologically defend against this realization in ourselves by projecting these traits onto others using a broad brush and pejorative terms.  While some people truly are unusually callous or selfish, the popular use of scientific-sounding labels serves our own psychological needs by identifying "bad guys" and making us feel better about ourselves.

Our response to regretted suicide attempts — Sloppy thinking in psychiatry 5

A person is drunk or angry or momentarily distraught.  Or all three.  He or she takes an overdose or cuts a wrist, then reconsiders — or never intended to die in the first place — and either calls 911 or tells someone else who calls 911.  The police come and transport the person to a psychiatric emergency service where a three-day legal hold is placed.  Despite expressing regret for the suicide attempt, the person is admitted for observation and safekeeping. I sometimes question the clinical utility of short-term psychiatric hospitalization for regretted suicide attempts.  Not that it's always wrong, of course, but sometimes it seems to result from sloppy thinking.  The usual rationale is that it's better to be on the safe side.  I.e., if the person's recent words or actions cast doubt on his or her wish to be alive, it's better not to take chances.  This has merit in cases where there's some honest doubt:  Since our statistical success in predicting dangerousness to others and to oneself is quite limited, "false positives" are the price we pay (well, they pay) to keep the "true positives" safe.

But another reason seems even more pervasive though less often stated:  Hospitalization is a predictable and presumably undesired consequence of expressing suicidal feelings.  At one level, legal holds and involuntary hospitalization "train" patients not to express suicidal feelings, lest they spend three or more days in an expensive inpatient unit with its attendant shame, stigma, and many inconvenient rules and expectations.  It may also serve a related function of taking the patient seriously.  Big consequences follow big actions, real or contemplated, and in this way discourage the patient from "upping the ante" with a more serious suicide attempt.

The other side of the coin is that legal holds and hospitalization make us feel better.  We're taking action, not just sitting there.  Clinical management is clear-cut for a change.  We have an interesting little story with heroic overtones to tell our colleagues.  The treatment plan is easy to justify to third-party payors, unlike more subtle interpersonal interventions.  (A few days ago I was on the phone with a managed care reviewer who demanded a "5-axis diagnosis" and behavioral treatment plan for my dynamic psychotherapy patient.  A more pointless exercise I cannot imagine, except that my patient won't receive insurance reimbursement without it.  This level of skeptical scrutiny rarely arises in hospitalizing the suicidal, even though the cost to the payor is far greater and the benefits sometimes less apparent.)  We're hardly ever faulted for choosing to hospitalize.

Of course, this propensity to "hospitalize first and ask questions later" can backfire.  I recall several times in my residency when homeless veterans came to the VA emergency room with bags packed, seeking psychiatric admission.  Their claims of suicidal feelings — or even command hallucinations to commit suicide — were hard to argue with, even though it seemed obvious that the real goal was room and board, not psychiatric care.  Their complaints quickly disappeared once admission was assured.  At the time I noted that civil commitment laws exist to protect the unwilling and undeserving from being hospitalized; none address those who strive to be hospitalized without a valid reason.

A great many suicide attempts and gestures are communicative in nature.  Far from being unambivalent decisions to die, they are cries for help, expressions of rage, tests of whether anyone really cares.  Our responses as mental health professionals are communicative too.  Hospitalization can say, "I'm not playing your game of manipulative suicide threats — I'm calling your bluff."  It can say, "I hear you, and I take your suicide threat very seriously.  It's my job to keep you safe."  It can say, "I blindly follow the rules.  You say suicide, I call 911."  Conversely, choosing not to hospitalize can say, "I'm not playing into your drama of getting me to overreact," or "I'm not taking you seriously, not hearing your pain," or "I defy the conventions of my profession, you cannot count on me to hospitalize you."

It's important to pay attention to the message in one's clinical actions, and also to realize that one's message can be communicated in different ways.  Hospitalization is not the only way to convey serious concern, even if at times it may be the only way to assure physical safety.  If calling the police is an angry reaction to the patient's misbehavior, it should be re-thought.  Nor should it be an unthinking, reflexive response.  The converse is true as well: If inaction is an expression of angry avoidance, denial of the severity of the patient's risk, or a reflexive expression of the practitioner's bold, iconoclastic nature, that too should be re-thought.

Failure to consider the risks and benefits (pros and cons) of hospitalization on a case-by-case basis would be evidence of sloppy thinking in psychiatric practice.  While it may be less common than other forms of sloppy thinking I've posted about, it still happens disappointingly often.  I also wanted to post about it to give readers a place to comment and ask questions about legal holds, as there is ongoing interest and concern on this topic.

Photo courtesy of Petr Kratochvil.

Psychotherapy branding and marketing

I just read a mildly disturbing article in the New York Times called "What Brand Is Your Therapist?"   The author Lori Gottlieb was a full-time journalist who took six years to retrain as a psychotherapist — her website, but not the article, says she has a master's degree in clinical psychology.  Yet she found herself virtually unemployed after several months and in search of marketing consultants to attract clients.  The thrust of the article is that such marketing involves branding, i.e., defining a niche that promises quick, painless, easily grasped results, and then promoting oneself online and elsewhere using that brand. Gottlieb is clearly uncomfortable about the trade-offs inherent in branding and marketing psychotherapy services.  Traditional psychotherapy is often painstaking, uncomfortable, and lengthy, and thus hard to sell.  In contrast, one-time phone consultations and executive coaching are brief, feel-good interventions that lend themselves to snappy, positive catchphrases that sell better.  Such services may be "fast-food therapy — something that feels good but isn’t as good for you; something palatable without a lot of substance."  Moreover, she notes that many sales techniques clash with the tenets of traditional psychodynamic therapy.  Sharing personal details makes one more approachable and "human," at the cost of complicating and possibly precluding transference work.  Active use of social media such as Facebook and Twitter can attract potential clients and publicize one's "brand," but may also blur relationship boundaries essential for effective psychotherapy.  Gottlieb lays out the dilemmas well in her article, but her practice website illustrates the practical conclusion: Lots of "selling" of various services, few of which are recognizable as psychotherapy.

Of course, I am writing this on my psychiatry blog, which is linked to my own practice website.  I too have grappled with similar trade-offs.  I launched my website over five years ago, and started the blog about a year later.  Several months ago I heeded marketing advice I found online:  I re-wrote my website in the first-person and added photographs.  I expanded the sections on my hospital committee work and past research.  I included more practical information about my practice.

Like Gottlieb, I had mixed feelings about doing this.  On the one hand, helping potential patients make more informed choices sounds innocuous enough.  I want suffering people to be able to find me and to know what I can help with.  I want the process of engaging in psychotherapy to be as transparent as possible.  I explain what I do, and even list my fees on my website (most of my peers don't).

On the other hand, I'm concerned that branding and marketing commodifies a personal healing relationship.  It offers to treat psychological issues in little bite-sized pieces, misleadingly suggesting that therapy to resolve one's indecision about marrying, say, can be completely separate and distinct from therapy to deal with career indecision.  It conflates psychotherapy with counseling and coaching, all of which are useful but different things.  Mainly it risks dumbing down psychotherapy.  Psychotherapy is often complex if done carefully, and in my opinion it can't be conducted as well over the phone, by email, while sitting by the pool with Skype running on one's laptop, or in a guaranteed four-session package.

I haven't availed myself of the whole branding arsenal, since I strive to maintain a psychotherapy practice worthy of the name.  If I ever write a book, offer coaching services, or engage in public speaking, those activities will be clearly distinct from my role as a psychotherapy-oriented psychiatrist.  Moreover, patients and would-be patients seem to agree that informational websites are useful, but that too much branding and self-promotion by a psychotherapist is a turn-off.  That makes good sense, and encourages me to take another look at my own website — I may turn it down a little.  What do you think?

Movie review: "Escape Fire: The Fight to Rescue American Healthcare"

The independent documentary Escape Fire: The Fight to Rescue American Healthcare by Matthew Heineman and Susan Froemke is a thoughtful indictment of the status quo.  Instead of focusing on political polarization, the pros and cons of Obamacare for instance, the film mainly documents the absurdity and waste of what we have now.  Instead of a system to promote health, Americans have a "disease management system" that spends almost twice as much as any other country — and nearly as much on prescription medicines as the rest of the world combined — yet we are 50th in life expectancy, and almost 75% of healthcare costs are spent on preventable diseases that are the major causes of disability and death in our society.  Economic incentives maintain this status quo.  High-tech interventions are reimbursed generously, yet reimbursement for face-to-face primary care often does not even cover the cost to deliver it.  As a result, fewer new physicians enter primary care, and doctor visits become shorter and shorter.  Meanwhile, unnecessary medical and surgical procedures are prevalent despite their risks, and cost thousands of lives each year. Escape Fire uses a firefighting metaphor to make its main point.  In forest fires, sometimes a smaller fire is set in order to deprive the main fire of fuel, creating a firebreak.  Such firebreaks can allow firefighters to escape the area — thus an "escape fire."  The filmmakers use this metaphor to say that the status quo in health care isn't working, and that we may need counter-intuitive and non-traditional solutions to save the system.  I confess that I find this metaphor somewhat ill-chosen: The remedies suggested in the film do not "fight fire with fire."  And there is no escaping our need to address health care.

The film spends much time on the military, in part as a microcosm of the problems facing our larger society.  Soldiers' use of prescription drugs has tripled in the past five years.  A large section of Escape Fire, including fascinating footage inside a C-17 Medevac plane as it crosses the Atlantic, follows Sergeant Robert Yates returning from Afghanistan.  Severely injured in a battle that killed most of his platoon, he suffers chronic pain and PTSD.  Sgt. Yates was given a shopping bag full of pills, but later replaces them with stress- and pain-management techniques he learns as part of an innovative Army program.

Although the film never mentions psychiatry as a medical specialty, mental health issues loom large in both military and civilian health care.  Again and again, patients are depicted in primary care offices reviewing their antidepressant medications, or breaking down in tears.  The current system, devoted to disease management, offers poor care to such patients.  They need time, not reimbursed procedures.  As medical journalist Shannon Brownlee notes on camera: "Health care should have a lot more care in it."

The film proposes several escape fires, i.e., solutions, to rescue American health care.  In 2005 Safeway began to provide financial incentives for employees who engage in healthier behavior, and thereby lowered its health care costs by more than 40%.  (That's how the film puts it.  Actually, from 2005 to 2009 Safeway's health care costs remained flat for the 30,000 employees enrolled in the program, while most companies' costs rose by 40% over the same period.)  This was the one example of a monied interest realigning financial incentives to promote health.  The film would have been stronger with more such examples — I hope there are some.

The military provides a solution of a different type.  Often innovation gains a foothold there before achieving acceptance in civilian society.  Just as America's armed forces were on the vanguard of racial integration and later gender equality, perhaps they can lead the way on health care too.  The Army Surgeon General established a Pain Management Task Force to look at alternatives to narcotics, and now the Army is using acupuncture and meditation to decrease narcotic use in the wounded.  Sgt. Yates, the self-proclaimed "redneck hillbilly" who didn't believe in Eastern Medicine, "decided to give it a shot," and it worked.

I found the profile of Dr. Erin Martin the least hopeful in the near term.  Initially shown as a primary care doctor in a low-fee clinic, Dr. Martin had high ideals, but was demoralized by too many patients and too little time.  She was dissatisfied and frustrated by a system that made her job nearly impossible.  Her escape fire was literally to escape: She quit the clinic, became a fellow in Dr. Andrew Weil’s Integrative Medicine program, and found a practice that supported her patient, humane approach.  The film endorses this as the escape fire for primary care — but of course those clinic patients still need a doctor.

Dr. Martin's path is similar to the one I took myself.  Early in my career I worked for two years in a public mental health clinic.  The patients were in great need, but the system was frustrating and the work demoralizing.  Providing comprehensive, humane mental health care in such a system is an uphill battle at best, and in some respects nearly impossible.  I have much admiration for those who work in such settings.  However, like Dr. Martin, I chose to leave and practice in a way that makes more sense to me.  While the makers of Escape Fire would likely endorse my choice, public mental health clinics still need doctors too.  Moreover, it will be a long time before the American health care system rewards Dr. Martin and others who aim to avoid commodity care.  Indeed, the system is accelerating in the opposite direction.  Those of us who build this particular escape fire in essence work outside the larger system.

As I wrote at the outset, Escape Fire is a thoughtful indictment of the status quo.  The film has been reviewed positively, and it strikes a nice balance between worrisome facts and emotional interest, ending on a hopeful note.  We should have no illusions about easy solutions though.  Healthier lifestyle choices are hard to pursue when fast food is cheap and tasty; a shift to preventative care from disease management would represent a fundamental sea change and a realignment of billions of health care dollars.  For a start, at least, we can agree that American health care is burning, and that new solutions are desperately needed.