Compartmentalization In Psychotherapy

 

I had this thought after my post about supportive psychotherapy in psychiatry.  In the experience of most psychiatrists, it plays a major role.  The related questions are – why isn’t that role acknowledged and why are psychiatrists even reluctant to use the term.  I had the thought that it is due to compartmentalization and before I research that concept to see if anything has been written about it - I thought I would write down my observations.  

The first thing that comes to mind is the idea that psychotherapy needs to be provided according to a specific formal or informal protocol and a prescribed number of sessions. Psychoanalysis is the obvious prototype of a specific method that can include the number of sessions and approximate duration of therapy.  Over the years the method has been adapted to shorter courses including crisis intervention and both transference- based and non-transference-based psychotherapies.  Psychodynamic therapy has been manualized (Klerman, Strupp, Luborsky) and adapted to both crisis intervention (Viederman) and short-term settings (Sifenos, Gustafson).  Hybrid versions such as psychodynamic and cognitive behavioral therapy (Garret) and existential-psychodynamic therapies (Yalom) have been developed. Complex developments like this probably have many people questioning where to draw the lines.

The second issue is how all these developments fit into psychiatric practice.  You can be a psychoanalyst and maintain well defined courses of therapy and a consistent technique. Some psychoanalysts practice part time and have a separate psychiatric practice.

A third issue is how supportive psychotherapy gets implemented in more common types of practice.  The most common expectation of employed psychiatrists these days is seeing 3 or 4 new patients a day and another 8-10 follow up patients.  Most of the practice includes patients with severe psychiatric disorders that require medical treatment and ongoing assessment and treatment of both medical and psychiatric disorders.

An exciting idea is the ability to provide supportive psychotherapy to all people seen in those settings.  A common stereotype promoted in the press is the idea that people are seen for medications only.  The usual reasons given is that this is the best way for psychiatrists to make money and/or it is a sign that pharmaceutical companies have manipulated psychiatrists into providing care this way.  I have illustrated many times on this blog that all those ideas are incorrect.  Today I want to approach the issue form the perspective of psychotherapy.

It is very difficult to maintain any kind of useful relationship with a patient solely discussing medications. That is true for any physician but most importantly psychiatrists. What else happens in those appointments? Non medication related situations are discussed.  Life is inevitable and people who are stabilized on medications still encounter stressors and crises just like everyone else.  The main difference is that most of the people seeing psychiatrists have major psychiatric disorders that can be destabilized by stress.  They also have first-hand experience with medications that have been useful in the course of their illness.  In those situations, there needs to be a detailed discussion of whether the crisis represents an exacerbation of the primary disorder or something else. That appointment will typically require more than an answer to that question. The patient wants to feel understood by a person who knows them well, wants to leave the appointment feeling better then when they arrived, and wants some ideas about what can be done to alleviate their suffering. A prescription may be added or changed but it is not the primary intervention in that scenario – supportive psychotherapy is. 

Even in scenarios where consultations are done in high acuity settings – there needs to be enough flexibility to recognize the true nature of the problem and intervene psychotherapeutically.  The following vignette illustrates that point:

The patient is a 70-yr old woman who was acutely admitted to the CCU with chest pain to rule out a myocardial infarction. On day 2, the Cardiologist caring for her sends a psychiatry consult because he is concerned that she is depressed and a possible suicide risk.  The psychiatric consultant sees her and observes a depressed appearing women who seems healthy and vigorous.  The consultant notes she recently retired as the CEO of a large company and is having some difficulty adapting to that transition.  She had anticipated travelling in retirement but her husband has a chronic illness and she is the primary caregiver.  The discussion focused on the role transition and existential issues associated with retirement.  She agreed to follow up discussions in the outpatient clinic.  Following the consultation – the consultant met with the Cardiologist and explained the formulation, that antidepressants did not seem to be indicated, and that a suicide risk assessment had been done and that the risk was low and that inpatient treatment was not indicated. 

In the example above this was a typical extensive consultation done on medical-surgical patients.  Psychiatric consultation is critical in these situations because it affects the discharge process of beds with rapid turnover and keeping a patient there longer than necessary can be a major problem. Despite the intensity of that information gathering the consultant can do a supportive psychotherapeutic intervention that the patient was interested in pursuing. It requires a consultant who can quickly identify the relevant theme for psychotherapeutic intervention. I would see this as a problem in pattern recognition that does not seem to be discussed very much in the psychotherapeutic literature.  Most of the discussion of patterns is focused on object relations and the recurrent themes in relationships, although Klerman, et al discuss role transitions as a potential cause of depression. The existentialist may say that meaningfulness may be a better conceptualization.

This is one of many examples of how psychotherapy does not need to be compartmentalized as a separate intervention and can be added into the assessment or any scheduled appointment.  Instead of thinking of psychotherapy as a 40-50 minute block of time once a week – can it be 10-20 minutes weekly in addition to everything else occurring in that appointment? 

People tend to think of psychiatric appointments these days as “med checks”.  This was modified slightly a few years ago when psychiatrists were allowed to use standard E&M (Evaluation and Management) billing codes like all medical and surgical specialists.  There is a complexity dimension and even a psychotherapy dimension.  The main problem with all these billing codes is that they are not reality. They need to be completed to get reimbursement and they need to be completed in a rigid stereotyped way – but they cannot be counted on to reflect the reality of the session. They are constructed for business purposes and not clinical purposes and that is evident if you read a handful of the notes.  You are likely to see a template of required bullet points that are generally headings of evaluations or symptom lists.  They contain limited useful information and nothing about the real exchange between the patient and the psychiatrist.  They say nothing about the shared experience in the room or the quality of that relationship. 

That also suggests a lesser-known form of supportive psychotherapy and that is existential therapy.  In psychiatry, existential psychotherapy leads to association to work by Victor Frankl, Ludwig Binswanger, Leston Havens, and Irwin Yalom.  Although there are some academic psychology departments that specialize in it, most of the psychiatrists and psychologists I know who were self-identified were trained as psychodynamic therapists or psychoanalysts first. Yalom had stated that is probably the best training for existential therapy and most available. For this post, an interesting adaptation of existential therapy is the application to brief visits suggested by Ghaemi and co-authors.      

As you study existential psychotherapy – arriving at a coherent current approach and strategy may seem like an impossible task. Some of the early work by Minkowski and that work reviewed by Havens includes some techniques that I have encountered in other therapies – like paradoxical intention. Binswanger’s description of approaching a patient with mania is probably the most accessible.  The best distillation of the process is probably Ghaemi’s 2018 description of existential psychopharmacotherapy.  He suggests an open-ended interview style – even in patients being seen for brief medication-based visits. The goal is to encourage spontaneity and expression.  Allow the patient to provide the narrative that they think is the most important.  Questions relevant to the medication can be asked later in the interview – but the more open format allows the patient to describe their current problems, symptoms, and adverse effects in their own terms rather than the rigid descriptors of the DSM or associated checklists. Most importantly the interview is focused on phenomenology or the personal internal state of that patient rather than group averaging that may not apply. In the context of empathic understanding by the psychiatrist – the patient feels understood and the therapeutic alliance is enhanced. The alliance is necessary for discussions of the treatment plan, its modification, and informed consent. This is a common form of psychiatric practice, although most practitioners would be hard pressed to discuss it as an existential approach. Many do describe it as supportive or humanistic. Consistent with the compartmentalization theme of this post – most psychiatrists do not think of it as therapy even though it is a critical aspect of psychiatric practice.

Psychodynamic therapies also have several short-term approaches and like existential psychopharmacology.  Some of those authors have described approaches that can be used in crisis intervention with or without medication and during brief visits with a medication focus.  Gustafson discusses specific implementations as common dynamics in psychiatry.  He discusses a trial intervention that can be done in less than 10 minutes.  It is primarily a clarification that makes sense of the current anxiety or depressive state as a natural consequence of what they may be trying to avoid and provides a theory for the mood state.  I have seen similar interventions used in cognitive behavioral therapy.

I hope that I have been clear about the issue of compartmentalization in psychotherapy.  It can occur at the macro level with the silos of major therapies (some 200 by one estimate). Thise silos are often reinforced by practitioners engaged in debates about the design of trials, efficacy, and who is the most “evidence-based”.  Even after those technical and political issues are brushed aside, practitioners are faced with rigid ideas about how psychotherapy needs to be provided. The reality is that every encounter with a psychiatrist should be conducted as though it is psychotherapeutic and there are plenty of options to consider.  The good news is that I am sure a lot of it is occurring already – but because of the classification problem – it is not being counted.  

 

George Dawson, MD, DFAPA

Supplementary 1:  I omitted one of the main factors responsible for compartmentalized psychotherapy to improve the readability of the post and that is managed care constraints.  Managed care is an insidious force that affects all aspects of psychiatric and mental health care.  In psychotherapy when I worked in a CMHC - our therapists had to complete pages of documentation just to provide indicated psychotherapy to people with chronic mental illnesses.  Later when I worked for a managed care company - they had reviewers that approved psychotherapy on a session by session basis.  In some cases they would decide that 3 sessions of psychotherapy were enough and stop payments at that point.  I have also been told that they do not cover psychotherapy provided by a psychiatrist and that I needed to refer to the patient to a counselor.  Even in the ideal world where a course of brief therapy is recommended for a duration of 8-12 session (from the research) it was rare to see a patient receive that many sessions.  Billing, coding, and utilization review are all impediments to psychotherapy. 

References:

Frankl VE. Logotherapy and existential analysis—a review. American Journal of Psychotherapy. 1966 Apr;20(2):252-60.

Binswanger L.  On the manic mode of being-in-the-world.  In:  Strauss E. Phenomenology Pure and Applied.  Pittsburgh.  Duquesne University Press; 1964.

Yalom ID.  Existential Psychotherapy. New York: Basic Books; 1980.

Längle A. From Viktor Frankl’s logotherapy to existential analytic psychotherapy. European psychotherapy. 2015 Feb 18;12:67-83.

Havens LL. The existential use of the self. Am J Psychiatry. 1974 Jan;131(1):1-10. doi: 10.1176/ajp.131.1.1. PMID: 4808428.

Havens LL. The development of existential psychiatry (Karl Jaspers, E. Minkowski, and Otto Binswanger). J Nerv Ment Dis. 1972 May;154(5):309-31. doi: 10.1097/00005053-197205000-00001. PMID: 4554757.

Ghaemi SN. Rediscovering existential psychotherapy: the contribution of Ludwig Binswanger. Am J Psychother. 2001;55(1):51-64. doi: 10.1176/appi.psychotherapy.2001.55.1.51. PMID: 11291191.

Ghaemi SN. Feeling and time: the phenomenology of mood disorders, depressive realism, and existential psychotherapy. Schizophr Bull. 2007 Jan;33(1):122-30. doi: 10.1093/schbul/sbl061. Epub 2006 Nov 22. PMID: 17122410; PMCID: PMC2632297.

Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check". J Clin Psychiatry. 2018 Apr 24;79(4):18ac12177. doi: 10.4088/JCP.18ac12177. PMID: 29701934.

Gustafson JP.  Reading the ability of the patient to change his or her life.  Psychiatric Times.  February 2007, Vol. XXIV, No. 2    https://www.psychiatrictimes.com/view/reading-ability-patient-change-his-or-her-life

Photo Credit:

Many thanks to Eduardo Colon, MD for allowing me to use his photos.