What is Psychotherapy and What’s in A Code?

 

After a recent discussion about psychotherapy done in psychiatric treatment – I decided to write this post in order to capture the complexity of some of these sessions. I hope that this post serves multiple purposes including a demonstration about how business management affects psychiatric care and the range of services that people receive in psychiatric follow up appointments. The audience for this post will be people seeking psychiatric services, psychiatrists of all orientations, and anyone interested in quality psychiatric care.

The fundamental unit of psychiatric care comes down to what tasks need to be completed in a set time frame and there are a lot of variables. Rather than list those variables – it is probably easier to describe a limited or rationed task scenario and compare that to an abundant task scenario.  Most peoples experience with psychiatrists in the US will fall somewhere between the extremes.  From a scheduling perspective there are no assurances that what a patient needs on a particular day will be the session they are scheduled for.

In the most limited care, the patient is seen for follow up or “medication management”.  These visits developed as part of a coding scheme that suggested that psychiatrists could see patients for very brief (5’-15’) periods of time with an exclusive focus on the medication a person was taking, whether it was effective, and whether they were experiencing any side effects. To speed up the process, many clinics have templates that are rapid checklists of symptoms and side effects.  In some cases, as the patient speaks the psychiatrist is checking off items on the list so that at the end of the session, a couple of sentences can be typed and the note is complete. Depending on the setting, additional information that might be acquired in the rooming procedure during a standard medical appointment (like pulse and blood pressure) may or may not be collected. Before psychiatrists started using standard billing codes like the rest of medicine, there were codes that assumed this limited care could be completed in anywhere from 5’-15’.  As far as I know - no other medical specialty had codes that were as restrictive.  In some clinics patients would be seen for that period of time every 6 months.  That duration and frequency of medication focused visits might work well for some people, but there is an understandable concern about quality when it is applied on a population wide basis. That concern is amplified where patients have more medical and psychiatric complexity (high risk for medical or psychiatric complications).   

At the other extreme, a psychiatrist may see a patient for 30-60 minutes in follow-up. A psychiatrist who typically sees people for 30 minutes would review the efficacy and side effects of any psychiatric medication.  They also may cover more medical or neurological considerations and following another condition like the patient’s problem with hypertension, diabetes, or neurological conditions.  In the remaining time, there is a detailed discussion with the patient.  In the case of a 50'- 60’ appointment, the psychiatrist is most certainly providing psychotherapy in addition to medical treatment. They may be providing psychotherapy exclusively.  Standard billing codes can be used, there are also psychotherapy add on codes and a separate psychotherapy code. Over the years, a lot has been written about the financial incentive for seeing many more of the briefer visits per hour than longer sessions involving psychotherapy. Practice setting tends to be the overriding factor.  If you are employed in a clinic or hospital, there is some administrator telling you how many people you need to see in a day.  That number is referred to as physician productivity.

There is a lot of confusion about what constitutes psychotherapy. At its core, psychotherapy is a teaching experience where the therapist attempts to assist the patient in solving problems that complicate their psychiatric disorder or affect their ability to adapt to life situations.  That can cover a lot of ground including inflexible thought patterns, stressful relationships and current or past stressors. It can also be a very focal problem that might require some directive education like sleep hygiene, diet, and exercise modifications. The teaching needs to occur in the context of a relationship that is both empathic and collaborative.  That collaboration is often referred to as the therapeutic alliance to indicate that the physician/therapist and the patient are aligned to focus on and resolve a mutually agreed upon set of problems. The common view of psychotherapy is that it needs to be long in duration and that the therapist “analyzes” the patient during that time. That description comes from psychoanalytic therapy that is a very specific therapy done be relatively few psychiatrists and it does not represent most of the brief psychotherapy done in treatment sessions.

There has not been a lot of study of psychotherapy in psychiatry in the real world. The best single study by Mojtabai and Olfson (1) and it is the most often quoted.  The most notorious quote is:

“ …..third-party reimbursement for one 45- to 50-minute outpatient psychotherapy session is 40.9% less than reimbursement for three 15-minute medication management visits.”

That led to the expected provocative articles about psychiatrists abandoning psychotherapy or being too motivated by money.  The reality of what it takes to keep a practice open in the face of paltry reimbursement was never mentioned. Some articles got so extreme they called for the end of psychiatry, replacing the greedy psychiatrists with therapists trained to prescribe. The authors of the article provide a much more balanced perspective including their opinion that many psychiatrists were still providing some kind of therapy and that their measures of what constituted therapy may have undercounted the therapy provided.

Polarized viewpoints of what actually occurs when a psychiatrist sees a patient probably described very little of what happens in real life sessions. From working in various settings with psychiatrists of three generations, there are many styles of practice and how psychotherapy is integrated – even into very brief sessions.  I was fortunate enough to work with a psychiatrist who ran a clozapine clinic and a separate clinic for long-acting injectable medications.  Both clinics were probably the largest in the state. He would typically see people in 20’-30’ appointments based on the complexity of the care they needed on that particular day. He was an expert in psychopharmacology and medicine as it applied to that patient population. But more than that he was empathic and knew the relevant life details of all of his patients. There was obviously a high degree of patient satisfaction and engagement in treatment.  One of the obvious markers of his success was patient interest in this physician after he made a career change.  His former patients would approach me in the hallway and ask me how he was doing or if I had heard from him. They would talk about him in the most positive terms. I don't recall seeing that happen with any other psychiatrist who moved on.

Papers on the minimum time needed to provide a psychotherapeutic encounter have been written for the past 40 years now. With the advent of managed care – many of them emphasize how the rationing aspect has reduced the time for both verbal and medical interventions. The latest guidelines for residency training emphasize the need to learn psychotherapy but beyond advanced interviewing techniques cognitive behavioral therapy or CBT seems to be the predominate paradigm – even though residents are still exposed to a variety of paradigms from their supervisors and mentors. 

The best single paper I have found that describes the psychotherapeutic aspect of medical treatment within the confines of a “medication management” session and its considerable constraints was written in 2018 (2).  The authors argue for the need for a human-to-human connection consistent with the existential orientation in psychiatry in order for treatment with medications to work.  The main features described are empathic listening and alliance building. One of the primary ways they are realized in the sessions is a focus on the patients own description of the problems or progress. 

As I read through this paper, I realized that I had been conducting outpatient visits in this manner over the course of my career but that nobody had previously described it in these terms or suggested why it had been so successful.  But even as I read this brief paper – I realized that the description was incomplete. It did not describe the many active psychotherapeutic interventions that I had used over the years.  I learned most of them as supportive psychotherapy in residency and they include interventions that would now be described as behavior therapy, cognitive behavioral therapy, and brief psychodynamic therapy and they all happened in the constraints of brief sessions that were generally 20-30 minutes long – in addition to whatever I needed to cover about the medications and other medical conditions.

These 20’-30’ sessions are currently No Man’s Land in the field of psychiatry. It is easy to extremely pessimistic about them.  As I previously noted they can be a political football – since any bias can be projected onto them. That is probably why there has been so little research in the area. It is as if the managed care and CMS template for these codes is an inescapable reality. Everything on the template is all that occurs in one of these sessions. I would propose a thought experiment to counter. If you are a psychiatrist seeing patients in these sessions and billing these codes – do you cover more information than what is in the bullet points for these sessions? Is the patient predictable from session to session – is more lengthy clarification needed? Are there any sessions where the entire session has very little to do with medications?  Are there any sessions dedicated to crisis intervention and only verbal interactions about that crisis? Do you see family members during these sessions and discuss their concerns? When you assess whether a person is experiencing suicidal thoughts do you know how to discuss them in a therapeutic manner?  If the answer to any of these questions is yes – it is highly likely that some form of psychotherapy is happening – even if you do not consciously pull up a psychotherapy technique that you learned and used in the past.  That psychotherapy happens whether you decide to record it on a template or not.

I think this area requires a lot more study. The information transfer between two people that can occur in 20’-30’ minutes is vast – even if it is semi-structured. The first step is determining what really happens in these brief sessions.  If anyone does that study, I think we will find out that the treatment that happens is much more than medication management.

 George Dawson, MD, DFAPA

 

References:

1:  Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008 Aug;65(8):962-70. doi: 10.1001/archpsyc.65.8.962.

2:  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.

Graphics Credit:

Photo by Eduardo Colon, MD

 

More On Conscious States and Suicide

“Did you remember all of that noise I was making in the bathroom?  I was trying to kill myself.”

The person I was talking with had been discharged from a hospital about two months ago.  He was admitted there because of an exacerbation of a mood disorder and possible psychosis. The main reason he was admitted from the emergency department was suicidal ideation. That is the most frequent indication for hospital admissions in the United States. Even then who does and does not get admitted is controversial. It is common for persons to be sent to the emergency department by their families or outlying facilities where there are legitimate concerns only have the patient deny the problem and get released from the hospital. There is a lot of drama involved because one of the decision points is whether or not suicidal person needs to be placed on legal hold and treated on an involuntary basis. This frequently leads to speculation about the true nature of what a person says or alternatively accepting "no suicidal thinking" at face value and dismissing them. 

I think it also highlights the significant limitations of interviewing people and adequately    understanding their conscious state. The best example is the rating scale approach which is really somebody’s idea of what the optimal interview questions might be to assess a suicidal person. The commonest depression checklist is the PHQ-9 (1).  Item 9 in the PHQ 9 involves suicidal thinking and the rating is as follows:

Thoughts that you would be better off dead, or of hurting yourself	0 – not at all
	1 - several days
	2 - more than half the days
	3 - nearly every day

Depending on where you practice clinics have different conventions about this item and how it needs to be approached. Any elevation usually leads to a more intensive assessment of suicide potential. That typically involves a clinical interview but also could involve the use of another checklist. It should be apparent that this item is a focused on the approximate frequency of suicidal thinking. It assumes that the patient can actually report this and that it is more significant than other metrics like the intensity of thinking. For example, is one extremely intense thought about suicide more significant and potentially lethal than thinking about it frequently but easily dismissing those thoughts? This is one of the basic limitations of any assessment of the person’s mental status. Clinical interviews and rating scales are very crude approximations of a person’s conscious state. Assessing someone’s potential for suicide is a clear example. There is also the notion of rating scales being “quantitative” measures and they are not. There is an entire field of research suggesting that these “measurements” lead to greater precision and I doubt that is true.

All of that brings me back to the first patient. Here he is somewhat annoyed that nobody seemed to realize on an inpatient psychiatric unit that he was trying to kill himself. At the same time he made every effort to conceal that fact while he was hospitalized. He only disclosed it months later after his mood and associated cognitive processes had stabilized. It reminds me that I also have talked with many people who were intent on killing themselves and presented themselves as being very well so that they could be discharged and attempt suicide. The popular literature is full of stories about people who reassured their families or appeared to be doing well only to carry out a planned suicide attempt. This is clearly a high risk conscious state that can escape detection and lead to very high risk attempt or death.

“The gun just went off.”

I talked to many survivors of gunshot wounds that were self-inflicted. In large trauma hospitals, psychiatrists are consulted by surgery services who have successfully treated the patient. The psychiatrists job is to assess the patient and determine whether or not they need further acute psychiatric care or they can be discharged home. I generally ask for a very detailed description of what happened including the type of firearm used, the time of day, the associated thought process, the overall psychiatric context, and the sequence of events just before the firearm goes off. The common explanation that I have heard is a recollection that someone was pointing a loaded gun at themselves and that at some point it "just went off". There is no recollection of a conscious effort to pull the trigger. Numerous secondary analyses are possible including that it is just a rationalization against self-harm or an attempt to avert psychiatric hospitalization. In keeping with the theme of this post - there is also a possibility that the patient’s conscious state at the time of the suicide attempt was so chaotic that it cannot be recalled or reconstructed. There is precedent for that state and that is delusional depression. If the patient is clearly delusional all of the usual deterrents like fear of dying, intense dislike of pain, not wanting to harm the family, and religious beliefs no longer apply. The standard risk analysis for suicidal thinking no longer applies. There is a delusional process with associated emotions that lead to very high suicide risk.

“I felt real bad about what happened 50 years ago and so I stabbed myself.”

The delusional process can be very subtle. Psychiatrists are typically taught to pay attention to hallucinations and classic forms of delusions. Those types of psychotic thinking are fairly obvious. In the case of depression and some forms of psychosis the delusion can be very subtle. An example might be feeling guilty about a trivial event from a long time ago. Everyone can relate to that kind of guilt or embarrassment but what if it is suddenly linked to the idea that death is preferred to the emotional burden of that trivial event. People in their 50s, 60s, and 70s could focus on events that happened when they were in middle school or high school that might start to disrupt their lives and lead to suicidal thinking. In the example given a severe suicide attempt occurred by self-inflicted stab wound over a trivial incident happening in the eighth grade. The patient was unable to recognize that this was a delusional thought process until the depression and psychosis had been adequately treated.

These examples all highlight how a person can go from being no risk at all for suicidal behavior to being at very high risk. The changes are subtle and they might not be apparent to the person experiencing them. The risk analysis models that are used are all linear and additive and do not capture the conscious states of people who become suicidal. The limited consciousness theories that we currently have would suggest that it is really not possible to experience the conscious state of another person in the transition to high suicide risk is probably a good example.  Even the best possible definition of empathy fails if the person cannot recognize the state that the psychiatrist is trying to reflect back to them. 

Time domain is another perspective on the fluidity of conscious states both in the case of suicidal thinking and substance use disorders. It is common for a person to describe themselves as becoming a person that they never wanted to be associated with both substance use disorders and suicidal thinking.  They are able to see those patterns in retrospect but not at the times they occur.   

It may be apparent that suicidal thinking can be a transition from a questionable belief to certainty. I listed a few of these beliefs in a previous post. A common one is “people would be better off without me”. In the early stages most people can examine that thought and conclude that it is at least partially false based on their relationships to the people in question and the assessment of their realistic value to those people. With time and continued emotional intensity any objective assessment of their value in relationships might diminish and disappear. At that point they are in a very high-risk state because they believe in the statement that “people would be better off without me”. Clinicians are often taught to ask about deterrence to suicidal ideation, but they are rarely taught to assess the degree of belief a person has in high-risk suicidal thinking.  There are non known ways to determine is a person who is delusional or quasi-delusional about suicidal thoughts is disclosing those thoughts or hiding them.

What can clinicians and patient do in these circumstances?  My previous posts suggests that an analysis of the thought patterns can be useful. I routinely review those ideas with people I see who have suicidal thoughts.  At some point the goal would be to see if talking about suicidal thoughts in this way would improve the level of resistance to these thoughts and make it less likely that people will act on them. I also believe that a public health message should discuss the same approach,  So far the only public health measure seems to be advice on calling suicide hotlines or crisis lines. 

I have had several people who I know as friends let me know that they have been able to analyze these thoughts on their own and come up solutions to contain these thoughts and get enough emotional distance from them to the point that they were no longer bothersome.  I know it can be done and encourage public health officials to take it to the next step.   

In closing, this post emphasizes a unique conscious state or states associated with suicidal ideation and suicide attempts. Nothing in this post should be construed as interview or treatment suggestions.  A more comprehensive understanding of  suicidal thinking and behavior requires more than a rating scale approach or risk factor analysis.

George Dawson, MD, DFAPA

References:

1.  PHQ-9 is copyrighted by Pfizer, Inc. Full rating scale is visible at many sites by searching on PHQ-9.  https://www.ncbi.nlm.nih.gov/pubmed/?term=PMID%3A+20219811

The Balanced Rhetoric Against Neuroscience

The New York Times editorial pages continue to be a place where anti-neuroscience rhetoric can be expressed primarily as decreased funding or more accurately portion of the available NIMH funding.  Maybe there has been some pro-neuroscience opinion expressed there and if there was I have missed it.  I recently posted an exciting development in neuroscience teaching for psychiatrists and psychiatric residents.  In that post I reference an opinion piece by Richard Friedman, MD a psychiatrist (1).  Dr. Friedman makes several arguments for psychotherapy as if it is unrelated to neuroscience and based on that premise concludes that there is no substitute for psychotherapy, that people are more than a brain in a jar, and that anyone benefiting from psychotherapy seems to prove  that.  I found that to be an incredible statement considering that (according to Koch in above graphic):  "The brain is the single most complex object in the universe." There is also the fact that with 7.4 billion people on earth - there are 7.4 billion unique conscious states - the vast majority of which are not accurately described by any DSM or psychodynamic diagnosis/formulation.  All the time that Dr. Friedman is mounting this critique he also discusses the importance of clinical research and suggests shifting the funding balance away from neuroscience.

In the recent case John C. Markowitz a professor of clinical psychiatry at Columbia has a more subtle form of the argument.  In this case and the previous opinion piece the authors both endorse the importance of neuroscience to a point.  In this case the argument is - yes neuroscience is important but let's reestablish balance between neuroscience and clinical studies such as looking at the efficacy of psychotherapies.  Breaking it down, Dr. Markowitz makes the following points:

 1.  Under the directorship of Thomas Insel, the NIMH clinical research budget was "strangled" and the resources were diverted to neuroscience research.  The author acknowledges both the need for neuroscience research and the primitive stage of psychiatric diagnostics based on clusters of signs and symptoms.  This was really the basis for Insel's RDoC initiative looking at more reliable markers of psychiatric syndromes.  Any practicing psychiatrist who has seen all of the iterations of the DSM realizes that we are as far as we can go with this manual.  That includes from the standpoint of validity but also in terms of the clinical examination by psychiatrists.  As long as we are all contained by this manual, the clinical method of psychiatry will remain stuck somewhere in the 1940s.  That should be extremely disconcerting to the profession and future psychiatrists.

DSM technology is extremely limiting in terms of the usual clinical trials.  The NIMH sponsored Star*D study is a decade and a half old at this point.  It has defined the response rates for both antidepressant therapies and provided a discussion point for psychotherapy trials of depression.  Clinical trials of antidepressants provide an equally varied result.  Any practicing clinician knows that these studies are all seriously flawed out of the gate by using DSM diagnoses and also an intent-to-treat analysis that does not resemble clinical practice.  The variation in diagnoses from depression to anxiety to depression plus anxiety as seen in clinical practice should point to the fact, that patient selection into clinical trials currently results in very heterogenous patient populations in terms of both therapeutic effects and medication tolerability.  We can continue to spend large sums of money on these trials of mixtures of patient populations and post modest positive results or we can attempt to identify patients who will respond specifically and not experience side effects from a particular therapy.  That is the real promise of neuroscience based research.

2.  The patients who need help are poorly served by current neuroscience research.  The helpful psychotherapies listed by the author like interpersonal psychotherapy (IPT), cognitive behavioral therapy (CBT), and other psychotherapies have been around for decades.  I happen to have copies of Interpersonal Psychotherapy by Klerman, Weissman, Rounsaville, and Chevron and Cognitive Therapy of Depression by Beck, Rush, Shaw, and Emery.  The publication date of the former is 1984 and the latter is 1979.  Both therapies have been out there for over 30 years.  At this point both have been studied hundreds of times.   Looking at clinical trials on Medline yields 1711 for CBT and 261 for IPT.  Not only that but some of the clinical trials that were successful (like IPT for cocaine use) have never made  it into clinical practice.  In fact, in most places getting a therapist who actually practices any of the specific research proven psychotherapies is impossible.  The problem does not seem to be a lack of psychotherapy research but a lack of access to practitioners who use research proven psychotherapies.  Mental health treatment is the most highly rationed treatment resource and additional studies that continue to prove that existing psychotherapies work seems superfluous at this point.  Any current studies are often compared to existing therapies and with the DSM problem contributing to diagnostic heterogeneity.  Any new trials should only be funded for serious conditions where the therapy might be useful.  There is no reason to expect that a new therapy applied using the current diagnostic system or clinical trials technology will lead to any enhanced treatment effects.

3.  Existing treatments are not "good enough".  The author attributes this "good enough" statement to Insel himself.  I understand the point he is trying to make.  The author points to continued suffering, treatment failures and suicides as evidence that more is needed now.  The problem is that there is no assurance that clinical research will add any more at this time.  Certainly a focus on suicide as a stand alone problem (not suggested at all by DSM) and on serious disorders with no treatment like adult anorexia nervosa is warranted.  But even then we are left with a clinical trials technology that consistently produces modest results at best.  More multimillion dollar trials of psychotherapy that we already know is somewhat effective when patients have no chance of ever receiving it against a backdrop of "is this really depression or anxiety" seems like a waste of time and money to me.  It seems like a much better idea to develop a neuroscience method to determine who needs psychotherapy and who might benefit from medications.  But even then, the only treatments that will be readily available will be the medications and even then less than half of the affected patients will get access to treatment.  Good luck trying to find a psychotherapist and an insurance company willing to cover the cost of the number of sessions used in the psychotherapy research. Research proven therapies are only as good as the number of practitioners using them and access to those practitioners.

4.  The placing all of your eggs in one basket argument.  This is basically saying that if the ratio of clinical to neuroscience funding is 10% to 90% the risk is missing something big in the clinical research and not getting any useful results from neuroscience.  Given the history that I have provided, there needs to be a clear advance on the clinical side in order to fund large trials.  It does not make any sense to continue to  fund more of the same  or slight modifications of treatment for common disorders.  Our eggs have been all in one basket and I would call that treatment as usual.  In the 30 years that I have been in practice, there is nothing that I would call a major breakthrough.  Clinical research results come and go.  Effective psychiatrists are effective psychiatrists not based on breakthroughs but how they approach clinical practice.  Even that mode of treatment is threatened by widespread support for "collaborative care" that is being justified using the same kind of research that justified managed care in the first place.  In the end there has been nothing more destructive in terms of access to care for mental disorders than managed care.

In many ways these ongoing arguments resemble the arguments of the biological psychiatrists and psychotherapy psychiatrists that I trained under in the 1980s.  Many programs were split under this artificial division with the residents left to identify with biological or psychotherapy faculty.  It is interesting to note that this division occurred at a time when Kandel wrote a paper on how psychotherapy is neuroscience in action (3).  That may have been missed because the biologically based psychiatrists at the time were really focused on pharmacology and neuroendocrinology rather than a comprehensive neuroscience.  Neuroscience and the old diagnostic technology and clinical methods seem to be the current points of division.

A lot of the criticism is directed at Insel.  I have heard him talk about the initiatives and the rationale sounded clear to me.  I think that rationale is very similar to what I have discussed so far, but for clinical psychiatrists it is also the realization that as long as we live in an approximate world - we will get approximate results.  The inertia to stay in that place is always puzzling to me.

But - it is time to move out of the 1950s.

Clinical psychiatry the way it is currently researched and practiced holds no promise for understanding the most complex known object in the universe.  Neuroscience is one of the big ways out of that predicament.



George Dawson, MD, DFAPA      



References:

1:  Friedman RA. Psychiatry's Identity Crisis. New York Times July 17, 2015. p SR5.

2:  Markowitz JC.  There’s Such a Thing as Too Much Neuroscience.  New York Times October 14, 2016. p A21.

3:  Kandel ER. Psychotherapy and the single synapse. The impact of psychiatric thought on neurobiologic research. N Engl J Med. 1979 Nov 8;301(19):1028-37. PubMed PMID: 40128.

              

Regret

If you talk with people experiencing anxiety and depression for any length of time, one the the common recurring themes is regret.  Regret is one of those complex psychological dimensions that spills over into everyday life.  It is a significant disappointment somewhere on the trajectory of life associated with negative emotions.  It is such a common experience that friends and family members will sometime talk about their regrets, or the regrets of another friend or family member.  It is a universal human experience that can make you sad or anxious and also amplify those emotions when they are part of a more phasic mood disturbance.

In the above classic movie scene a young Marlon Brando playing Terry Malloy, a dock worker who is dealing with corruption and crime in that setting.  He had been a promising boxer until his brother Charley in this scene (played by Rod Steiger) convinced him to throw a fight in order to favor Charley's boss at the time.  Charley is also trying to dissuade Terry from testifying against that same boss in this scene.  Those are parts of a more complex plot, but it contains all of the detail that is relevant as Terry and his brother discuss the incident in this famous scene.  Terry seems to be expressing regret at two levels - one for throwing the fight and the effect it had on his reputation but more importantly for having an older brother who does not look out for his best interests and does not treat him well.  Charley seems to be treating him well in this scene only as a form of bribery.  He is offering him a paying job only to buy his silence.

People tend to regret a lot of things in the course of a lifetime - lost relationships, past behavior, missed opportunities, repetitive patterns of behavior that they don't seem to be able to break out of, and in some case entire periods of their life.  Common examples from the late teens to young adulthood include missed opportunities in relationships, school, and work.  It is very common to hear people complaining that they regret not applying themselves in school.  In some cases they regret choosing a particular career path and worry about whether it is too late to change.  There are myriad regrets possible just considering the family structure and the emotional reactions and expectations that people have of one another.  It can be combined with blame as in: "I wish you would have forced me to keep up those piano lessons."  At times people predict what might lead to regret in the future.  A common prediction is: "Your grandparents are not going to be around forever.  You might regret not going on this visit to see them."  In this era of social media, there are always posts about what you will regret on your death bed.  Apparently it won't be not spending enough time at work.  When I was a junior in high school, one of my friends predicted that I would regret not going to the prom.  In the decades since, I have had very few thoughts about high school and none on that dance.

One of the many questions that I find myself pondering in my down time is;  "What is the best conceptualization of regret?'  What is the best way to make sense of it?  What is the best way to adapt to it?  Does it make sense to think about getting over it?  At one point in my early 20s,  I took a harsh approach to some emotional thought patterns that could be troublesome.  My credo became "No guilt, no shame."  I started to spread the word.  I encouraged people to be proactive which is really the best approach.  If you make decisions on a daily basis that will not result in guilt or shame, what could be better?  No regret would be a welcomed by product.  Of course there were sacrifices along the way - spontaneity and risk taking being a couple of good examples.  You run the risk of being a "stick in the mud".  There is also the very real issue that you can just be wrong and despite your best intentions there are regrets along the way.

Regret is one of those concepts that seems to crossover from psychiatry to literature and English professors may do  better job of analyzing and appreciating it.  In Moby Dick, Melville introduces Captain Ahab's family in order to point out the contrast between an obsessive, all consuming pursuit of the white whale and time spent away from his family.  After casting a single tear of regret into the sea, a tear described as in the following passage:

"From beneath his slouched hat Ahab dropped a tear into the sea; nor did all the Pacific contain such wealth as that one wee drop."

Ahab launches into this soliloquy that is an ode to regret:  "Oh, Starbuck! it is a mild, mild wind, and a mild looking sky.  On such a day—very much such a sweetness as this—I struck my first whale—a boy-harpooneer of eighteen!  Forty—forty—forty years ago!—ago!  Forty years of continual whaling! forty years of privation, and peril, and storm-time! forty years on the pitiless sea! for forty years has Ahab forsaken the peaceful land, for forty years to make war on the horrors of the deep!  Aye and yes, Starbuck, out of those forty years I have not spent three ashore.  When I think of this life I have led; the desolation of solitude it has been; the masoned, walled-town of a Captain's exclusiveness, which admits but small entrance to any sympathy from the green country without—oh, weariness! heaviness!  Guinea-coast slavery of solitary command!—when I think of all this; only half-suspected, not so keenly known to me before—and how for forty years I have fed upon dry salted fare—fit emblem of the dry nourishment of my soil!—when the poorest landsman has had fresh fruit to his daily hand, and broken the world's fresh bread to my mouldy crusts—away, whole oceans away, from that young girl-wife I wedded past fifty, and sailed for Cape Horn the next day, leaving but one dent in my marriage pillow—wife? wife?—rather a widow with her husband alive! Aye, I widowed that poor girl when I married her, Starbuck; and then, the madness, the frenzy, the boiling blood and the smoking brow, with which, for a thousand lowerings old Ahab has furiously, foamingly chased his prey—more a demon than a man!—aye, aye! what a forty years' fool—fool—old fool, has old Ahab been!......." (Chapter 132).

His chief-mate Starbuck tries to talk him into ending the pursuit, but we all know how that turns out.  Even world class regret does not necessarily lead to self correction.  Similar statements cut across clinical and non-clinical settings.  I don't consider regret to be a symptom of any psychiatric disorder per se, but it will typically make things worse and in some cases be an unexpected point of focus.  What might be useful points for discussion?  A standard supportive approach would look at how human consciousness operates.  Whether you are a boy harpooner of 18 or a prize fighter in your early 20's, you are likely to make decisions at those times in your life that will not be the same decisions that you make 5 or 10 or 20 years later.  Eighteen year olds are energetic, eager to prove themselves, at their physical peak, and to a large degree see themselves as being invincible.  They are bound to make decisions much different than a 60 year who has battled life for 40 years and is left feeling spiritually withered.  Not being the same person at 60 as you were at 18, is not necessarily that intuitive in areas of life apart from the physical ones.  I think it illustrates that the situation remains dynamic and there is no reason to expect that different decisions can't occur.  In modern society, the decision to retire is a key decision that activates some of these thought patterns and associated regrets.

Physicians are professionals with some of the highest degree of regret.  There is the phenomenon of physician burnout fueled largely by the fact that they have limited control over what happens in clinical settings and that the people with more control don't know anything about medicine.  Many of the burnout surveys have to do with regret about going into medicine.  But there are also the inevitable mistakes in patient care.  I heard a neurosurgeon describe some of his regrets on public radio including a case where he tried to resect an additional amount of tumor that resulted in the patient being in a persistent vegetative state.  I was personally in a discussion of a transnasal resection of a growth hormone secreting pituitary adenoma that was wrapped around the internal carotid artery. The discussant was a neurosurgeon who had probably done more of this procedure by far than any other surgeon in the world.  That discussion went something like this: "This is the tumor and this is the artery (pointing to areas on an MRI coronal view of the pituitary gland and sphenoid sinus).  I am going to try to remove as much of the tumor as possible.  If I accidentally nick the carotid artery in this area, there is nothing that can be done about it.  That complication happens and I know good neurosurgeons  who have had that happen to them.  I can assure you I will remove only as much tumor as possible.  I will remove only as much as I would remove if you were one of my family members."  Since I heard that conversation, now 6 years ago, I have come to realize that it was more than just an informed consent discussion of the worst possible complications.  It was also a way that this surgeon had learned to set limits on himself and the drive to completely remove a tumor, even at a point where the risk may be  increasing exponentially.  I have seen good physicians who approached medicine as a science, who were not able to adapt to the inevitable mistakes or adverse outcomes.  Many ended up paralyzed with regret and needing to take time away from the field.  Some left for good.  I don't think we do a very good job with medical students and trainees in helping them develop a realistic view of the field.  A view that might temper them against the inevitable regrets.

As psychiatrists, we all need the vocabulary for discussing regret with our patients, because it is one of those things that crops up and takes over an appointment scheduled for another purpose.  We suddenly find ourselves in a supportive or psychodynamic or cognitive-behavioral or mindfulness mode dealing with the crisis.  Everything we had planned to do in that session, including assessing the patient's progress with their primary problem has gone out the window.  More importantly regret is part of life and not an error in thought or emotion.  Normalizing that experience will go a long way toward helping the person in crisis.

  

George Dawson, MD, DFAPA

Refs:

Herman Melville.  Moby-Dick or the Whale.  Project Gutenberg EBook.  Originally published in 1851.

Attribution:

The graphic of the original cover of Moby Dick is from Wikimedia Commons with the attribution line.  It is in the public domain:

By The original uploader was Chick Bowen at English Wikipedia (Transferred from en.wikipedia to Commons.) [Public domain or Public domain], via Wikimedia Commons.

Jimmy P. - The Psychotherapy of a Plains Indian

Every now and then Netflix surprises me and seems to include come content of interest to psychiatrists.  I watch a lot of Netflix basically because I have a WiFi ready TV planted in front of my ergometer.  I ride an ergometer at least 4 times a week and as anyone who has ridden indoor cycling trainers can attest, that can be painful activity without some diversion.  I had just finished watching a biographical piece about Harry Dean Stanton and found the movie Jimmie P.  It starred Benicio Del Toro and I started watching it on that basis rather than the description that had something to do about psychoanalysis.  Del Toro stars as Jimmie P. or Jimmie Picard a Blackfoot Indian who also happens to be a returning World War II veteran.  We subsequently learn he was a sniper in the war but never shot anyone.  We see a scene where he falls out of the back of a transport truck and sustains a severe head injury.  It is that head injury that sets the story line for the film, the story develops through flashbacks.

I decided to start watch this film based on two things.  The word "psychoanalysis" and the name "Del Toro".  I am not a psychoanalyst, but I have been trained in psychotherapy, have done psychotherapy, and have had a great deal of success with psychotherapeutic interventions.  At the time I was trained all residents did psychotherapy training and were supervised intensively.  One hour of supervision for every hour of patient contact.  A lot of that  supervision was painstaking.  Reviews of audio tapes, video tapes and process notes.  I was intensively supervised on 3 extended psychotherapy patients per week so that was 150 hours per year for three years.  There were also group seminars, group supervision and seminars that consisted of case discussions.  Much of the supervision I had was done by psychoanalysts or psychodynamically oriented psychotherapists.  There were also existentialists, cognitive behavioral therapists, and marriage and family therapists.   My experience with these supervisors was generally positive,  but as you might imagine it was also a grind at times.  At  times, I felt like I was too physically, mentally, and emotionally drained to go into these sessions, but I made them all.  I include this information to illustrate a potential bias in my viewing a psychotherapy movie.

Benicio Del Toro always piques my interest.  I don't think there is any other contemporary actor who can play the conflicted bad man as well as he can.  He is visually interesting to watch and has huge screen presence.  He is one of the few actors that will prompt me to watch a  film cold without much knowledge ahead of time.  In this film he shows his range in his portrayal of a very real guy coming back from the war.  He is a conflicted good man and in fact he is too good at times.  When I was a kid growing up there were many uncles who came back from the war, and as I grew up it was common to hear that a particular person was "never the same" after they came back from the war.   I am old enough to have observed that effect of war on another three generations.  Jimmy P. was one of those guys.

I didn't think of it at the time, but I also have in interest in Native Americans and their culture.  I was born and raised between two reservations.  I note that some of these reservations have been renamed as tribal homelands.  I went to school with folks from these reservations and played sports with them.   My uncle and I were fortunate enough to be on a baseball team that was predominately Native American ball players.  My grandfather and I fished on the reservation, almost exclusively.  Even though those experiences were always positive, the most instructive aspect about knowing about Native Americans and some of their personal situations was the development of biases against them.  Over the last thirty years, they have been more assertive and in some cases more successful.  They have been granted rights that are viewed as controversial by non-native groups, specifically fishing rights.  The backlash has been significant enough to lead any objective observer to conclude that relationships with the native population is actually worse than when I was sitting in a boat on Bad River with my grandfather.

These first four paragraphs are a good indication that there psychodynamic influences in the very decision to select a film.  Getting back to the movie - we first see Jimmie P. at his sisters home.  He is having difficulty functioning.  He is sleeping late, but also has debilitating headaches and a sense of dysequilibrium.  At times he collapses with headaches, chest pains and is sweating through his clothing.  We learn that he has already been medically assessed and that he has a significant scar on the top of his head.  He is eventually admitted to a VA facility that is headed by Karl Menninger.  The focus of the admission is to determine whether or not there are any organic factors involved in the presentation or whether a functional illness is present that can be treated with psychotherapy.  The diagnostic interventions are vague and understandably crude.   For some reason a pneumoencephalogram was postponed until near the end of the film and we learn that the goal was to rule out a cholesteatoma!

At the end of the initial evaluation Dr. Menninger's team is coming up with no medical explanations for Jimmy's symptoms.  Dr. Menninger places a call to Georges Devereux, who is identified initially as an anthropologist with a knowledge of Native Americans.  He convinces Devereux to come to the hospital and do an assessment on Picard.  It was unclear to me about his professional orientation apart from his qualification as an anthropologist but it became apparent that he was also functioning as a psychoanalyst and getting his own analysis from faculty at the hospital.  After several interviews he presents his formulation to Menninger and colleagues and they like what they hear.  They ask him to stay on and engage Picard in psychotherapy.   The bulk of the film is a detailed psychotherapeutic conversation between Devereux and Picard.

That is where the real work for the viewer comes in.  My speculation is that whether the viewer does stay engaged depends on their psychological mindedness or ability to stay interested in the narrative.  That narrative that is built on Devereux's interpretations and clarifications and flashbacks that are designed to elaborate on what Picard is describing in the sessions.  There are several indirect discussions and enactments of transference and countertransference in the film.  In one very good scene Picard gets angry with Devereux and they discuss the importance of discussing the anger and associated events with the therapist.  There were also many good examples of real situations and how they are handled well but at times imperfectly in therapy sessions.   Scenes like this can lead experts to take issue with the way they are portrayed in the cinema.  My usual standard for cinema is that it is well executed from a technical cinematic standpoint, that it is entertaining and that I like it as art.   It certainly passes that standard.   Since we are dealing with just fragments of therapy sessions, any errors are difficult to assess.  I found myself thinking about taking too many notes early in the course of therapy as a possible example.   Therapy was also portrayed as hard work that results in somewhat erratic progress.  The necessary relationship  for therapy and a working therapeutic alliance seemed to be emphasized in the film, but over the course of the film it seemed like Devereux became more distant.  It may have been written that way to show the effect of termination and possibly supervision on the part of the analyst.

Devereux's personal life is also a focus in the movie.  He is having an affair with a married lover Madeleine.  Many critics see this a a diversion away from the main text of the film, but I saw it as more important than that.  In many ways Madeleine is an idealized lover.  She is bright, very attractive, likeable, and at times dotes on Georges.   In my observation of Georges, he just does not seem to have a lot going for him.  He seems to spend a lot of time on anthropological junkets, is somewhat of a nerd, does not seem emotionally resonant with Madeline, and seems fairly indifferent when it is time for her to leave.  Madeline also has a statement and a soliloquy in the film that I saw as critical.  One is an overview of how the brain is the central organ in the body and the role of psychoanalysis in psychosomatics.  The other has to do with the impact that an idealized lover has on a person, why they do not need to be forgotten, and the ongoing impact on one's  life.   I think that she also provides contrast between the advice that the analyst gives his patient and how he runs his own life.  That is an interesting thought in a movie that includes Karl Menninger.   One of Menninger's theories is that there is not much difference between people with mental illness and people who don't have mental illness.   Jimmy P. is a great illustration of that idea extended to include the fact that there is really no difference between Native Americans and the rest of us.  People seeing this film can probably identify with many of the themes and conflicts that Jimmie P. had to deal with.

I had the usual associations to the film.  I have treated many people with psychosomatic problems like Jimmy P.  These days most of the work has to go in to the idea that there is not a pill for these problems, but that other strategies can be useful.  It is very probable in modern times that the correct treatment of these serious psychosomatic symptoms gets buried under a long series of "medication trials."  I could see Jimmy being diagnosed with Post Traumatic Stress Disorder, Panic Disorder, Major Depression, and possibly an alcohol use disorder.  I can see all of that happening in one 20 minute session by a nonpsychiatrist.  I could see him walking out of that first session with an SSRI, a benzodiazepine, and possibly prazosin - all medications high up on the PTSD algorithm.   The issue of diagnosis came up in the last meeting between Picard and Devereux.  After discussing the pneumoencephalogram results, Devereux asks whether Picard would like to know his diagnosis.   He hands him a piece of paper with the diagnosis "Psychic Trauma".

That's my initial review.  There are some addition reference materials I would like to look at including a suggested book and the actual script.  A script with dialogue this intensive probably requires an additional read or two.  There is a lot of information contained in the dialogue between Picard and Devereux.  As far as I know there are no good models or methods for analyzing the information content in therapeutic sessions and how that information is used.  I ended up rating the film 5 stars on Netflix.  But keep in mind that rating is from a guy who has talked to people at least 6-7 hours per day for the past thirty years.

George Dawson, MD, DFAPA

Matt Zoller Seitz.  Jimmy P.  This is a good review by a professional reviewer who thought this was a good film and has opinions about it that contrast with mine.
  

Supplementary 1:   Given my comments about psychotherapy and psychopharmacology it is easy to see how those issues can be politicized and how discussions about both of those modalities can be very polarized.  The fact that a person with complex problems is more likely to see a psychopharmacologist first should not mean that they are not receiving psychotherapy informed treatment.  One of the most striking examples that I can think of is a psychopharmacologist I worked with for many years.  He started and ran a psychopharmacology specialty clinic.  The people who saw him had a uniformly positive experience based on their relationship with him and what how he discussed problems with them.  He was and is certainly an expert in psychopharmacology but he was providing a lot more than that.

I think we are past the time where there needs to be an open discussion and guidelines about psychotherapeutically informed psychopharmacology.  That would include a focus on the relationship, a discussion about that fact that there are probably other things that need work in addition to the medication, and a discussion of the meaning of the diagnosis and meaningfulness in general in a persons life.

These ideas have obvious implications for the stilted billing and coding system and the idea that anybody can prescribe psychiatric medications.  Expert prescribing requires knowing about what is going on in addition to the diagnostic criteria and algorithms and what else can be done.

Psychotherapy Has No Image Problem - Psychotherapy Has a Managed Care Problem

There was an opinion piece in the New York Times a few days ago entitled "Psychotherapy's Image Problem".  The author goes on to suggest that despite empirical evidence of effectiveness and a recent study showing a patient preference for psychotherapy - it appears to be in decline.  He jumps to the conclusion that this is due to an image problem, namely that primary care physicians, insurers, and therapists are unaware of the empirical data.  That leads to a lack of referrals and for some therapists use of therapies that are not evidence based - further degrading the field.  He implicates Big Pharma in promoting the image of medications and that the evidence base for medication has been marketed better.  He implicates the American Psychiatric Association in promoting medications and suggests that the guidelines are biased against psychotherapies.

I am surprised how much discussion this post has received as though the contention of the author is accurate.  Psychotherapy has no image problem as evidenced by one the references he cites about the fact that most patients prefer it.  It wasn't that long ago that the famous psychotherapy journal Consumer Reports surveyed people and concluded that not only were psychotherapy services preferred, they were found as tremendously helpful by the majority of people who used them.  That study was not scientifically rigorous but certainly was effective from a public relations standpoint.

The idea that psychiatry is promoting drugs over psychotherapy seems erroneous to me.  The APA Guidelines certainly suggest psychotherapy as first line treatments and treatments that are part of selecting a therapeutic approach to the patient's problems.   Psychopharmacology is also covered and in many cases there are significant qualifications with the psychopharmacology. Further there are a number of psychiatrists who lecture around the country who are strong advocates for what are primarily psychotherapeutic approaches to significant disorders like borderline personality disorder and obsessive compulsive disorder.  Psychiatrists have also been leaders in the field of psychotherapy of severe psychiatric disorders and have been actively involved in that field for decades.   Even psychopharmacology seminars include decision points for psychotherapy either as an alternate modality to pharmacological approaches or a complementary one.  What is omitted from the arguments against psychiatry is that many payers do not reimburse psychiatrists for doing psychotherapy.

The author's action plan to politically promote the idea that psychotherapy is evidence based and deserves more utilization is doomed to fail because the premises of his argument are inaccurate.  There is no image problem based on psychiatry - if anything the image is enhanced.  There is definitely a lack of knowledge about psychotherapy by primary care physicians and it is likely that is a permanent deficit.  Primary care physicians don't have the time, energy, or inclination to learn about psychotherapy.  In many cases they have therapists in their clinic and just refer any potential mental health problems to those therapists.  In other cases, the health plan that primary care physicians work for has an algorithm that tells them to give the patient a 2 minute depression rating scale and prescribe them an antidepressant or an anxiolytic.

And that is the real problem here.  Psychotherapists just like psychiatrists are completely marginalized by managed care and business tactics.  If you are a managed care company, why worry about insisting that therapists send you detailed treatment plans and notes every 5 visits for a maximum of 20 visits per year when you can just eliminate them and suggest that you are providing high quality services for depression and anxiety by following rating scale scores and having your primary care physicians prescribe antidepressants?.  The primary care physicians don't even have to worry if the diagnosis is accurate anymore.  The PHQ-9 score IS the diagnosis.  Managed care tactics have decimated psychiatric services and psychotherapy for the last 20 years.

It has nothing to do with the image of psychotherapy.  It has to do with big business and their friends in government rolling over professionals and claiming that they know more than those professionals.  If you really want evidence based - they can make up a lot of it.  Like the equation:

rating scale + antidepressants = quality

If I am right about the real cause of the decreased provision of psychotherapy, the best political strategy is to expose managed care and remember that current politicians and at least one federal agency are strong supporters of managed care.

George Dawson, MD, DFAPA

Brandon A. Guadiano.  Psychotherapy's Image Problem.  New York Times September 29, 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.

Don Draper loses it - Can he be saved?

Don Draper, the main character in AMC's MadMen is without a doubt the most complicated character I have ever seen on television.  I have often thought about whether or not I have seen him over the years. What would be the most likely way that he would come to the attention of a psychiatrist?  I can remember several years ago he went in to see his primary care physician and was told that he had hypertension (150/100).   The prescribed course of action was a combination of a barbiturate and reserpine.  Being seen as a complication of that therapy might be one way.  He also has demonstrated that he has a progressive problem with alcohol.  Everyone on MadMen drinks at work, and it is typically hard liquor.  At one level it seems to be part of the Madison Avenue culture, but Don has taken it many steps beyond that to overt intoxication and vomiting in the office.  Even in the 1960s, this behavior could result in a period of detoxification and residential treatment.  If he really was mixing alcohol with barbiturates that is a setup for an accidental overdose or a withdrawal seizure.

Another avenue to consultation might have to do with his philandering behavior.  Over the course of the show he has had two wives and he has had extramarital affairs in both marriages.  During his second marriage, he befriends a cardiothoracic surgeon in his building.  He admires this man and he seems like the only real friendship that Draper has been interested in over the course of the series.  That does not deter him from sleeping with the surgeon's wife.  During his previous marriage, he had affairs with numerous women resulting in his wife finding out and on one occasion he was punched in the face by an irate husband.  None of that has had much of an impact on his lifestyle that consists of drinking a lot at work and frequently using work as an excuse to neglect his wife and family and continue extramarital sex.

Whenever I think of philandering, I think of Frank Pittman's work that I read fresh out of residency training.  In outpatient practice, anxious and depressed persons have two major sources of stress - their job and their significant relationship.  It is fairly common to see significant others and spouses during the treatment of an individual.  The usual requests are for a basic explanation of the diagnosis and treatment plan, but in more complicated circumstances an analysis of the spouses behavior.  I think that Pittman may have seen Don Draper as a subtype of philanderer that he refers to as a "hostile philanderer" who is not empathic toward women.  A more psychodynamic approach might suggest that Draper is narcissistic and that might be the driving force behind his lack of empathy.  In either case, the therapy focused on this problem is complicated and requires skills that focus on neutrality and a focus on the goals of therapy rather than an endless description of the problem.

A more recent approach might employ a model of sexual addiction rather than looking at the problem as repetitive marital infidelity.  One of the conceptualizations of the problem is that it can be a behavioral addiction like food and gambling and that it involves and activates the same neurobiological substrates that addictive drugs and alcohol do.  Some authors have developed criteria sets for sexual addiction based on the characteristics of substance use disorders, but this disorder is not listed in the main DSM or the section on "Conditions for Further Study."  Some people will come in for assessment based on someone telling them that they have a sex addiction or their participation in 12-step recovery groups with that focus.  Experts in the field have produced reviews of psychotherapy and pharmacotherapy that might be useful for this problem, but at this point most psychiatrists would see this as an issue for psychotherapy and would have reservations about the medical treatment of a model that has not been widely accepted.

There is also a more biological approach to infidelity.  Some people may present with requests for a medication that has decreased libido as a side effect or a medication that produces that result by its physiological effect.

In the season 6 finale, Don Draper is trying to seal an advertising deal with Hershey.  The staff knows they are swimming up stream, because Hershey has outstanding brand recognition and packaging.  Don has to sell them on a campaign that takes their advertising to a new level.  He tells a poignant story about mowing the lawn as a kid and his father taking him to the store later so that he could buy a Hershey bar.  That candy symbolizing the bond between a father and son and a bridge to those memories in the past.  His associates in the room are beaming.  They think he has hit it out of the park.  A few minutes later, he tells everyone in the room that the story he has just told never happened.  He says he was raised in a "whorehouse" and one of the prostitutes would ask him to go through the trousers of her clients, looking for extra money.  He would get some of that change and buy a Hershey bar.  When he ate it he was living vicariously like the kid in his original story.

Can Don Draper be saved?  In a way he already has.  He was at a clear disadvantage in terms of childhood trauma and adapted to that by becoming somebody who he was not and trying to consciously block out that previous existence.  We get a glimpse of one of his strategies from an earlier scene.  I think that from an artistic point of view the writers are saying that he cannot.  He could no longer suppress the truth about himself at a critical juncture in his career.  That is true not only with his clients and coworkers but also with his children.  In the final scene of the season, he is standing with his children in front of the whorehouse where he was raised.  His daughter looks at him for some kind of reaction.

From a psychiatric standpoint the answer is a qualified yes.  Certainly any psychiatrist could come up with a plan that might address some of the areas highlighted above.  It would take a comprehensive formulation of his problems.  Framing the problem as simple anxiety or depression or some other DSM-5 diagnosis is an obvious mistake.  In many practice settings that pressure is there.  There is also the chance that he might walk into an AA meeting for any number of reasons and make some changes to get his life back on track.  He might even get some advice from a friend or coworker about a particular aspect of his problems that he might decide to pursue and that could lead to some changes.  The main drawback to advice from a peer is that he has no peers and no close friends.   Human consciousness is complex and there are many roads to change.

George Dawson, MD, DFAPA

Frank Pittman.  Private Lies - Infidelity and the Betrayal of Intimacy.  WW Norton and Company, New York, 1989.

Shoptaw SJ.  Sexual addiction in Ries R, Fiellin DA, Miller SC, Saitz R. Principles of Addiction Medicine. 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2009:  pp 519-530.

Preference for Psychotherapy or General Dislike of Medication?

I haven't see the study mentioned in many places yet, but there was a meta-analysis of patient preference for psychological versus pharmacological treatment of psychiatric disorders in the Journal of Clinical Psychiatry.  It contained all of the usual buzzwords about evidence based medicine and why this is a hot topic to study because of the possible cost savings and potential for better outcomes if preferences were matched to actual treatments.  Interestingly, in the same month a more high tech approach to matching depressed patients with pharmacotherapy versus psychotherapy came out in JAMA Psychiatry where the independent variable was a brain imaging result rather than patient preference.

The authors here looked at a final sample of 34 studies out of 644 studies that were screened.  They end up with a chart of effect sizes with confidence intervals for each of the 34 studies.  There were a total of 90,483 participants but 78,753 were included in one study.  All of the studies are of depression and anxiety.  They had tried to include studies on schizophrenia and bipolar disorder and found that they were not published.  The authors conclude that their meta-analysis was valid and that there was a consistent preference for psychological treatment in the treatment seeking and non-treatment seeking or recruited patients.  From this the authors suggest that patient prefernce should trump other considerations if the efficacy of both treatments are equivalent.  They question why medication related treatments have increased and psychological therapies have dimished over the past decade.  They suggest that the patients who prefer medication related therapies are non adherent.

In their discussion of the limitations of the study they find there was not enough data to compare combination therapy as a choice, they excluded non-published studies and therefore included potential publication bias, and they were not able to address the question about why psychological treatments were preferred over medication based therapies by a factor of 3:1.

These and other important questions have already been answered on this blog, but don't expect to see any publications on this anytime soon.  Managed care has taken the very evidence based treatments that these authors emphasize and stood them on their head.  I have written many times about the diagnosis of depression using rating scales and the preferred treatment of antidepressants.  If you are using a primary care physician follow up code and a PHQ-9 score result to diagnose depression in ten minutes and treat all of these patients with a generic antidepressant ($4/month) - there is no psychotherapy that compares to that low cost.

All psychiatrists who are actively looking for psychotherapists to treat anxiety and depression encounter the problems of a lack of qualified therapists and more specifically a lack of therapist time in managed care systems.  Managed care systems especially those that are actively managed to reduce outpatient mental health treatment has reduced available therapy in many systems to 2 or 3 sessions of crisis management and essentially limited or eliminated additional services like psychological testing that some therapists require to do their work.  It is no accident that patients seeking psychological therapy can't get it.  It is a conscious business decision.

The second problem is the lack of availability to research proven psychotherapies.  Any psychiatrist doing patient evaluations will hear the story that therapy sessions are often very non-specific, lack goals, and often result in the patient losing faith in the process and stopping the therapy.  Being seen in a psychological therapy is no assurance of a good outcome.  Many patients who are provided with excellent research proven therapy are frustrated with the time commitment and stop because of the cost or number of sessions.  Psychotherapy may look a lot better on paper than the reality of the relationship with the therapist and the logistics of getting to and paying for the sessions.

What can be done to improve the situation right now?  The decision to take a medication for any reason is never a casual one.  Taking that medication reliably is even more significant.  Non medication alternatives and combination therapies to reduce exposure to medications should be available in every clinic.  Instead of screening everyone for a medication on day one, non-medication alternatives should be presented at that time.  There are innovative non-medication therapies such as computer delivered psychotherapy for depression, anxiety and obsessive compulsive disorder.  No clinic appointments.  The therapy is delivered online or by phone any time of the day or night.  With the appropriate implementation, these therapies could be offered as first line treatment to massive numbers of patients.  The human cost is so low they could essentially be made available across an entire health plan for free.  There is no reason why networks of therapy clinics cannot be linked to primary care clinics who see the majority of patients with depression and anxiety.  Any medication alternative can be discussed if the psychotherapy or non-medication intervention works.

From a research perspective if only 34 of 644 studies were suitable for inclusion in a meta-analysis, the problem is clearly not being studied very well.  I think it is important to ascertain patient preference for psychological, combination, pharmacological and other (eg. lifestyle change) therapies in all registered clinical trials.  In clinical practice, it is all part of informed consent for treatment.  I think it is the universal experience of physicians that most people prefer to not take medications.  The negative treatment of psychiatry and  psychiatric medications in the press create an understandable bias against psychiatric medications relative to others as a potential source  of the described phenomenon.   There is some evidence that the advertising of these medications is different and potentially stigmatizing.  We also need better design of clinical trials.  If therapies are in fact equivalent, they need to be tested in actual clinical populations where psychiatrists work.  That includes severely ill patients with comorbidity, patients who are acutely agitated and suicidal, women and children and adolescents.  Much of the discussion of equivalent therapies is based on extrapolation from populations of people who are mildly depressed and in some cases who have enrolled in a number of studies.

This study highlights the current weaknesses in studying how people actually receive psychiatric treatment and how to best approach that from a research perspective.  It points out that we need much better research designs and better patient selection in order to answer even basic questions about the treatment process.  It should be apparent that a research design that is not adequate to describe clinical practice is not a commentary on clinical practice.

George Dawson, MD, DFAPA

McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW.  Patient preference of psychological vs pharmacological treatment of psychiatric disorders: a meta-analytic review.  J Clin Psychiatry 2013; 74:6: 595-602.