Tuesday, August 20, 2013

The Psychotherapy of Psychosis

I was lucky enough to find the Practical Psychosomaticist blog recently.  Jim Amos is the productive author of this excellent content that is both scholarly and creative.  In a recent post and comment to my reply he said that is was good that I let people know that psychiatrists do psychotherapy.  I thought I would expand upon that and more importantly the psychotherapy of severe psychiatric disorders - something I happened to learn how to do out of necessity of realizing that there needed to be a lot more communication with people than a discussion of medications and symptoms.  It flows from the way psychiatrists are taught to do comprehensive assessments but these days it is not obvious.

As previously noted, my training occurred at a time when there was often open warfare between the biological psychiatrists and the psychotherapists.  Even though most of the political power in departments had shifted to biological psychiatry there was still an opportunity and expectation that residents would learn how to do psychotherapy.  For my last three years of training I saw at least three patients a week in hourly psychotherapy and was supervised on a 1:1 basis for each of those hours by a psychiatrist or psychologist who was also a therapist.  Those sessions were frequently recorded and the supervisors listened to the audio or reviewed detailed process notes of the sessions.  I had additional supervision for patients who were seen in a more standard follow up clinic setting or in a community mental health center.  I had additional supervision for couples therapy, family therapy, and therapy with children and adolescents.  There were ongoing seminars on psychotherapy  and direct observation experts conducting psychotherapy.  As a medical student, I also had a very unique experience with infant psychotherapy set up and run by two very innovative psychiatrists at the Medical College of Wisconsin.

Talking to people about their problems and how to solve them always seemed natural to me.  I think that there is always an open question about whether good psychotherapists are born and not made.  It makes sense that patience and empathy required are not evenly distributed across the population.  When a psychiatrist learns that you may have an interest in psychiatry as a medical student, the usual areas for exploration is whether you have had personal experience with mental illness or whether one of your family members has.  Even in grade school, I had extensive contact with people both inside and outside of my family with mental illness.  When you have that experience it leads to an appreciation of the whole spectrum of human  thought, emotion and behavior.  Denying mental illness, addictions and brain disorders doesn't work.  I heard the stories and personally witnessed severely disabled people being cared for at home with minimal resources.

Having that type of lifetime experience can result in a better understanding for the problem, but it does not lead to the type of technical expertise needed to talk with people in a therapeutic manner.  I can recall my initial surprise when I witnessed a psychoanalyst tell a sobbing patient that he had to stop crying and try to tell us the details of his history.  It seemed like the wrong thing to say, but it turned out to be highly effective in terms of changing the tenor of the interview and making it more productive.  Seeing psychiatrists interact with patients and studying the theory was one of the more valuable aspects of psychiatric training and it occurred in hospital wards, clinics, research settings, texts, videos, and seminars.  As the influence of psychodynamics seemed to decrease other models were also studied most notably cognitive behavioral therapy of CBT.   It was similar in many ways to what had been taught as supportive psychotherapy as opposed to insight oriented psychodynamic psychotherapy.   Psychotherapy supervisors practice varied schools of therapy and I mine were psychoanalysts, psychodynamicists, a Rogerian, behavioral therapists, cognitive behavioral therapists and supportive psychodynamic therapists.  I eventually learned how to do an assessment and figure out what psychotherapeutic approach might be the most useful.  It also provided me the skill needed to discuss past psychotherapies with patients I would be seeing in assessments. the efficacy at the time and why it might not be working several years later.

The psychotherapy of severe psychiatric disorders is a relatively new innovation.  As part of my studies in the past I had read about Harry Stack Sullivan's approach and more recently (but still 40 years ago) the work of Grinker.  There was some crossover with Kernberg and Kohut and their work on narcissism and borderline personality disorders.  Some of the early large scale work on the psychotherapy of schizophrenia (1,2) showed that supportive psychotherapy may have an impact and that insight oriented psychodynamic therapy probably did not.

On my first job at a community mental health center, I sent a letter to the founder of Dialectical Behavior Therapy (DBT) and she sent me a copy of her research manual from field trials that were being conducted in the late 1980s.  I used Beck and his associates as resources to learn about Cognitive Behavior Therapy (CBT).  In the process I noted a common reference to what Beck described as the initial case of CBT in an outpatient setting with a patient who had a diagnosis of schizophrenia.  Practically all of the CBT in the 1980s and 1990s was focused on depression, anxiety, and later severe personality disorders.

After three years at the community mental health center, I moved on to an inpatient setting for the next 22 years.  Most of the people I saw there has severe mood and psychotic disorders or problems with severe addiction.  The experience a lot of people have in these settings is not very good.  It seems like a situation that is set up for containment and for many people it is.  They found themselves in a crisis and many cases hospitalized for and excessive amount of emotion that fades rapidly after they leave the original situation.  In other cases the emotion does not fade and they remain in a crisis in the hospital.  Some people recognize that something is happening to them and they need a safe place to recover.   Everyone has a theory about how they came to the hospital and whether or not they may need treatment.  Inpatients on a mental health unit are often there because of legal holds based on dangerousness laws that vary from state to state.

I was able to talk with people in an unlimited manner in this setting, sometimes many times a day.  I was able to engage them in a process that looked at their theories about life and about the problems that led them to the hospital.  We could discuss at length what types of treatments they were interested in.  I was also able to talk with them about delusions, hallucinations, and psychotherapeutic approaches to address those symptoms.  At one point along the line, I noticed there was an interest in supportive psychotherapy with patients experiencing psychotic symptoms and it was summarized in 1989 in a remarkable book by Perris (3).  The research evidence and theory continued to build over the next two decades with excellent courses at the annual American Psychiatric Association meeting.  That included a 2009 course given by several experts in the cognitive behavior therapy of severe psychiatric disorders (4).

Decades of training and practice has undoubtedly made me a better psychotherapist. It taught  me why you "practice" medicine and don't master it.  It has also made me mindful of how much of the interactions between psychiatrists and the people they see, need to be seen from a psychotherapeutic perspective.  That includes the environment a person is seen in and anyone else in that environment that they may encounter.  It also allows for a lot of treatment flexibility that reflects a comprehensive psychiatric assessment.  The best diagnostic assessment may suggest a medication is the best solution for a particular set of problems, but knowing you can also address that problem in a different way if the medication cannot be tolerated, if it fails or if the person changes their mind is a game changer.

Sometimes all it takes is an open and highly detailed conversation.

George Dawson, MD, DFAPA

1: Stanton AH, Gunderson JG, Knapp PH, Frank AF, Vannicelli ML, Schnitzer R, Rosenthal R. Effects of psychotherapy in schizophrenia: I. Design and implementation of a controlled study. Schizophr Bull. 1984;10(4):520-63. PubMed PMID: 6151245.

2: Gunderson JG, Frank AF, Katz HM, Vannicelli ML, Frosch JP, Knapp PH. Effects  of psychotherapy in schizophrenia: II. Comparative outcome of two forms of treatment. Schizophr Bull. 1984;10(4):564-98. PubMed PMID: 6151246

3.  Perris C.  Cognitive therapy with schizophrenic patients.  The Guilford Press. New York, NY, 1989.

4.  Wright JH, Turkington D, Kingdon DG, Basco MR.  Cognitive-Behavior Therapy for Severe Mental Illness.  American PSychiatric Publishing, Inc.  Washington, DC, 2009.

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