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 stations 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 all 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 onto 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 appointment 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.  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 review 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.  Question 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 phenomenon that may not apply. In the context of emphatic 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

 

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. 

Listening with the Third Ear….

 

I joined a group co-teaching a resident seminar in psychotherapy a few weeks ago.  It is an interesting exercise blending didactics and experience.  The format is an hour of psychodynamic focused didactics followed by an hour-long discussion of a transcript by everyone in attendance including residents and 4 faculty. That is an interesting discussion of the technical aspects of therapy as well as individual differences in interpretation and intervention.

Today’s session was about listening and how listening in therapy may be different from what people consider to be typically focused or unfocused listening.  There was some discussion of how you listen to friends as opposed to strangers.  There was a secondary discussion of the depth of listening with a focus on unconscious determinants.  It led me to reflect on a couple of things during the session.

The first was focus.  Very early in my discussion with patients I was focused on what they were saying.  My focus was the same focus I would have with friends or family even though none of my patients would ever enter that sphere. People knew that I was serious and took them seriously.  As I thought about the way I interacted with people over the years – it was apparent that even though patients are technically not friends within a very short period, I would know more about them than I knew about most of my friends.  In some cases, I was more worried about them and spent more time worrying about them than I ever worried about most of my friends. The difference was in the relationship.  With friends there is a mutual affiliation and expectation of support.  In the case of patients – the relationship is for the benefit of the patient. Apart from payment, the gratification of doing good work,  and the occasional thank you -  the therapist should expect nothing back from the patient. 

The focus in both diagnostic interviews and psychotherapy was meditative to me.  I felt extremely comfortable in that setting.  I looked forward to seeing people.  It was the place in life where I felt the most comfortable. I was not particularly interested in one problem compared with another – just hearing every unique story.  When you get to a certain point in your career you are full of confidence.  You no longer have to worry about running into an issue that you don’t know how to address. You know that most people will leave your office feeling better than when they entered – even if it is an initial evaluation. 

Focus in a psychiatric interview is multifaceted.  It involves hearing both the content of what is being said and whether it makes any sense.  Do all the elements hang together in a cohesive picture or not?  If not, the job is to immediately clarify what is happening.  That always leads me back to think of an Otto Kernberg seminar that I attended 30 years ago.  Kernberg described the process of confrontation as exactly that – an indirect inquiry that would facilitate bringing these seemingly disparate elements together.  An extreme example that I frequently use is from acute care settings.  In those settings, my first task of the day was to interview people who had been admitted on involuntary holds.  They were often very angry to be hospitalized and demanded to be released. Their first words were typically: “I want you to discharge me.  You have no right to hold me in this hospital and I want to be discharged.”  The reality is that I had never seen the patient before.  I had nothing to do with how they came into the hospital or the fact that they were on an involuntary hold. Restating those facts to the patient was the type of confrontation Kernberg discussed and it most frequently led to a more productive reality-based conversation.

The focus for me always has the elements of attention, testing what is being said against my internal knowledge of reality and doing the same with any emotional content, and thinking about underlying theories for what I am seeing. At times I will explicitly ask the patient for their theories about what is happening to them to see if they have any and if they do whether they are plausible.  It is generally important to try to figure out the meaning of certain patterns of thought and behavior including dreams fantasies, and other potential unconscious content.

There is also a focus of kindness toward the patient.  The relationship is one of beneficence.  It always reminds me of Jerry Wiener’s comments about the essence of psychotherapy “Be kind and say something useful to the patient.” When I bring that up – many therapists bristle at the apparent oversimplification.  Kindness does get directly to the point that the therapeutic relationship is different from the patient’s perspective in that they should experience the therapist as unique relative to the common experiences in their life. Some therapists I have encountered over the years have talked about “reality therapy” to mean that the therapist should be reacting to what the patient does just like everybody else.  This misses one of the main advantages of psychotherapy as an opportunity to examine what is really going on in those other relationships and correct it if necessary.        

I addition to attending to the primary problem in sessions the therapist must also have a focus on the relationship and empathic responses to communicate to the patient that he had an adequate understanding of the mental problem that the patient is describing and what all the elements may be.  The relationship aspect may include the stimulus value of the therapist and how that varies with age, sex, physical appearance, and communication style.  To cite age as an example – it is common for early career psychiatrists just out of residency to be greeted with: “You are too young to be a psychiatrist.  I have never seen a psychiatrist as young as you are”. Those statements come with varying degrees of enthusiasm and carry several implications that can be explored.  On the other end of the spectrum I have not had anyone comment on my advanced age directly – but have heard comments that some doctors are so old “they did not know I was in the room.” 

Transference and countertransference are obviously relevant here but I want to stay with the focus in interviews and sessions.  In the seminar today, a paleontology metaphor was described about mining the different layers of the unconscious and how to get there.  That suggests a lot of heavy lifting to me. I see it as a much more dynamic situation.  After all – here I am extremely comfortable and interested listening to people and editing their comments for plausibility, cognitive and emotional content, defensive patterns, and their own theories about what may be happening to them.  Together we are defining what brought them in to see me along with all the relevant cultural, social, biological, and developmental factors.  This is all unfolding in the context of a specially defined relationship.  Throughout that session I am switching between listening mode and an interventional mode that involves supportive, clarificatory, and interpretive remarks.  That switching needs to be dynamic, context based, and is not the same for any two patients.  There is also the practical or real relationship including payment arrangements, appointment times, call instructions, and emergency contact instructions.

There is a check that must happen during or between sessions. Every therapist has to ask if they really understand what this patient is saying and if the patient is being helped.  That check can occur as early as the first interview.  In some cases, the therapist may consider the patient’s problem to be outside of their field of expertise. This can also happen after prolonged therapy where the benefit to the patient is uncertain – but they want to continue the therapy.

The title of this blog post refers to a famous book called Listening with the Third Ear by psychoanalyst Theodor Reik. I purchased the book in 1986 on the recommendation of one of my psychotherapy supervisors.  The subtitle of the book says it all: “the inner experience of the psychoanalyst.”  Reik was one of Freud’s first students.  In the chapter “The Third Ear” he describes attending to various cues of the unconscious life of the patient as well as what may prevent the analyst from perceiving them. He illustrates how the subjective reaction of the analyst to the patient can be one of those clues.

Reflecting on this essay so far – the one dimension that needs additional commentary is the non-linear nature of listening and the interview process. It is easy to think of the process as a matrix dependent on focused attention and a long sequence of questions.  That is the format of a structured interview. In many cases these interviews are algorithmic based on hierarchies and inclusion and exclusion criteria.  In a clinical and psychotherapy setting the focus is more on all aspects of the presenting problem. What the patient brings in to the session and the continuity over multiple sessions is more of a priority. Reik describes a patient who caused him to feel annoyed, two different patients walking by a mirror outside his office and how they react to the mirror, and the way a patient looked at him as well and what that meant for their unconscious life. 

In a subsequent chapter he goes on to describe how the analyst must avoid selective attention to what they might want to hear and how they must attend to everything.  He points out that Freud used the term gleichschweben  that has the connotation of equal distribution and revolving or circling (p. 157).  He suggests the terms freely floating and poised attention.  He adds Freud’s rationale for this type of attention as being two-fold.  First, it avoids exhaustion since it is impossible to attend to anything for an hour.  Secondly, it avoids biasing the interview or session toward a particular aim or goal.  The session after all is directed at what the patient is deciding is relevant.

As I revisited my technique, this captures what I tend to do in interviews and sessions. Since I read this book nearly 40 years ago – I cannot claim to have invented it.  I can add a little to what Reik and Freud have to say especially in diagnostic interviews.  It is possible to incorporate free-floating attention and transition to a more structured interview as necessary. Most psychiatric practices these days require that psychiatrists seen anywhere from 2 to 5 new patients per day.  Most of those patients will not be seen in either psychoanalysis or psychodynamic psychotherapy. But most of those patients will benefit from the listening techniques and interventions that can be attributed to the early analysts. It is also possible to add a psychotherapy component to practically every patient seen by a psychiatrist over time – even in relatively brief appointments.  

 

George Dawson, MD

 

References:

Reik T.  Listening with the Third Ear. Farrar, Strauss, and Giroux. Toronto. 1948: 144-172.

 

Supplementary 1:  Both Drs. Otto Kernberg and Jerry Wiener in the above essay are psychoanalysts with extensive teaching and publication experience. They are both medical doctors.  I left the qualifications out for the sake of brevity. I heard Dr. Wiener’s remarks at one of the Aspen Psychotherapy Conferences organized by Jerald Kay, MD.   

Supplementary 2: According to Reik, The metaphor listening with the third ear was borrowed from Nietzsche -  Beyond Good and Evil, part VIII, p.246.  A partial excerpt follows:

"What a torture are books written in German to a reader who has a THIRD ear! How indignantly he stands beside the slowly turning swamp of sounds without tune and rhythms without dance, which Germans call a "book"! And even the German who READS books! How lazily, how reluctantly, how badly he reads! How many Germans know, and consider it obligatory to know, that there is ART in every good sentence--art which must be divined, if the sentence is to be understood! If there is a misunderstanding about its TEMPO, for instance, the sentence itself is misunderstood!..."

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.