Less Time To Do More….
As part of my brief series on the role of psychotherapy in
psychiatry I thought I would pull this book off my bookshelves and discuss
it. It was published in 1993 and that
was about the time I bought it. At that
time, I had just finished working as the Medical Director of a CMHC and
consulting at a local hospital and was about 4 years into my role as an acute
care psychiatrist on an inpatient unit.
I was trained in psychotherapy in residency and provided it across all
of these settings as well as individual and group supervision to masters level
psychotherapists. That supervision
included accepting cases referred from them for psychotherapy if they felt
uncomfortable treating that person.
Managed care hit hard from my first day on the acute care
unit. Companies decided that they could
easily deny care to psychiatric inpatients by using what was eventually became
their dangerousness standard. In other
words, if a reviewer made an arbitrary decision that the patient was no longer
dangerous, they would stop payment and the patient would be discharged. As someone who did this work for 22 years
that is a bizarre standard designed primarily save the insurance company money
and they were very good at that. They were also successful in setting up a sham
appeal process that could not be challenged.
The result is suboptimal care and inpatient units that are essentially
revolving doors that discharge patients before they are stable.
If you think of a competency-based standard for
psychotherapy – that is the ability to manage your own life and medical care,
make decisions in your best interest, and problem solve and make good decisions
in novel situations that was all a second priority to symptom
stabilization. If a patient was admitted
because of mania and grandiose delusions – those symptoms were targeted with
pharmacotherapy and once they were mostly gone – the patient needed to be
discharged. At some point in the late
1990s – public payors like Medicaid and Medicare stopped using contractors to
do these utilization reviews and the process was internalized by health care
organizations. Instead of being harassed
by an outside reviewer – the harassment became internal for patients covered by
public insurance.
The additional context at the time was a rift in psychiatry
between psychiatrists who identified as either biologically based, therapy
based or eclectic meaning a combination of both (2). This paper was written at the time I trained
but even that description was an oversimplification. There were medical
psychiatrists, consultation-liaison psychiatrists, neuropsychiatrists, and
community psychiatrists. They all had
their models of care and their own ideas about how psychotherapy should or
should not be integrated into that care.
I was fortunate to have access to a wide variety of psychotherapists and
very active didactics. But nobody really
talked much about how psychotherapy fits into typical psychiatric practices. In
a previous post, I listed supportive psychotherapy resources and that was an
obvious skill needed across all settings.
It was occasionally demonstrated by attending physicians but most of
what they seemed to do were diagnostic interviews.
Less Time to Do More seemed to take on that problem
specifically in the inpatient setting. The introductory chapter on
therapeutic communities discussed a common model used to run inpatient units. The regulatory function of the community was
discussed to help patients with severe mental illnesses reintegrate following
an episode of decompensation. Kohut’s self-psychology was presented as a
possible model of the self-object matrix critical for early childhood
development with groups and group processes taking on that role. Groups leaders need to monitor the level of
cohesion in both patient and staff groups to main their roles in assisting in
self-regulation and reinforcing adaptive behavior.
I have seen
psychiatrists operate at two extremes in the acute care inpatient environment. At one end I would call it the old hospital
visit model. The assumption is that
inpatient care is basically a side hustle and most of the serious work
occurs in this physician’s outpatient practice or clinic. They appear briefly early in the morning on
the inpatient unit, talk to the patients under their care briefly, do not
participate in any team meetings, and may or may not talk with nursing staff. They may depend on nurses to call them at
points during the day with progress reports and decide whether to make
medication changes or discharge the patient.
Before a hospitalist model in medicine – this is how many primary care
physicians worked as attendings at hospitals.
At the other end is
the full time attending. The inpatient
unit is his or her primary job. They
have daily team meeting with all team members in attendance and discuss
progress as well as problems. Those problems can be at the level of the
individual patient, their family, the staff, the administration, the probate
court, outside consultants, law enforcement, and the physical environment. Team
meetings are necessarily complex and in a less time environment rapid
decision making is the rule rather than the exception. The schedule of
when patients are seen depends on what happens in that team meeting. Any acute medical or psychiatric problems take
priority, followed by systems problems like conflicts between staff and administrators,
followed by discharges. That all happens
before noon and individual patients are seen (along with new admissions) over
the rest of the day. That is the most straightforward description of this model
where most days are far from routine.
A psychiatrist
operating in that second environment needs certain technical skills. Above all
else – they need to be aware of their personal reactions to what is going on in
the inpatient environment. How much of
that reaction is reality based and how much is based in countertransference? I heard a quote recently from Kernberg where
he said the most significant work of a therapist is to contain their countertransference
aggression and there is no better place to practice that than an inpatient
unit. The psychiatrist operating in that environment is often a flash point for
scapegoating when anything goes wrong or even not as well as expected. During
my tenure it was common to see psychiatrists blamed for being assaulted by
patients, for not discharging patients fast enough, for ignoring nursing staff
requests, and for being too authoritarian. In todays overmanaged health care environment
any one of those complaints can trigger a major investigation by hospital committees
and result in reports credentialling agencies or medical boards whether they
are factual or not. Controlling countertransference aggression in such an
environment can be an impossible task.
Ideally the
psychiatrist is in a role with reasonable team members and can interact with
them in such a way they recognize their value.
That occurs by genuine active dialogue with them discussing patient care
and any problems that the staff member might be having. This may seem obvious but
it was not until my first few years as an inpatient psychiatrist that I
realized the only reason my patients were in the hospital was that they needed nursing
care. I could do my 30–60-minute visits
anywhere. The nursing staff was with them 24/7 and for clear reasons. Other disciplines also need support form
psychiatry. Inpatient social work is a clear example. The social workers I had the privilege of
working with were all excellent and found themselves doing the impossible job
of discharge planning. They were calling
20-30 places a day for a single patients trying to get them out of the hospital
(we rarely discharged anyone to the street).
That is a high stress situation especially when you have a supervisor
asking you why you have not seen enough of the other patients.
All of these
scenarios require a psychiatrist who can intervene supportively (education,
encouragement, problem solving) and existentially (empathic listening and
reflection) with fellow staff members.
That does not mean they are doing supportive psychotherapy with their
colleagues. It does mean that the
genuine and human interactions they have with their valued coworkers may translate
well into the therapy they are able to do to assist patients. It may also lead to valuable insights like
the one I had about the nursing staff.
Additional chapters
in this book provide good information on interacting with outpatient therapists
and the importance of recognizing potentially disruptive defense mechanisms
like projection, projective identification and splitting and how they can be
contained on inpatient units. Containing countertransference aggression was emphasized
especially because it can be magnified more in an inpatient setting where there
are more possible recipients.
The authors were
generally confident about providing inpatient psychotherapy to a patients with
a diverse number of conditions. Some of
the time frames discussed approximated 2 weeks and these days that is about a
week longer than many these days. Some variables affecting length of stay (LOS)
were not discussed. The most important one
of these is involvement in civil commitment and how that is handled. I looked
at the issue on my unit and it added another 21 days and even longer after the
State of Minnesota passed a law allowing county sheriffs to send mentally ill
inmates directly to state hospitals on a priority basis. Like all inpatient
factors it was a mixed blessing – more time for all therapies and recovery but
the wrath of administrators blaming staff for not using enough medication fast
enough, doing too many civil commitments, or not discharging unstable patients.
My approach in the
inpatient setting was to have daily team meetings, engage my team in productive
patient focused discussions, and see all my patients for at least 30 minutes a
day. I would also see family members at
their request when they came in to visit or scheduled family meetings with or
without my social work staff and at times nursing staff of they had available time.
I was very focused on the
phenomenological-empathic approach to interviewing people with severe problems.
I generally felt that patients realized that I was very interested in talking
to them about more than symptoms. Just that
aspect had significant effects on people who were angry, non-disclosing, paranoid
and accusatory, and used projection and splitting defenses. I was able to
establish long term relationships with many people who were considered
refractory to treatment and they were able to make progress.
Part of those
discussions involved a detailed discussion of delusional thought content and
how it was affecting their life. I commonly asked for their initial experience
and the very first time they had those thoughts. We would reconstruct that incident and
discuss what happened as a place to begin. From there we would discuss how these thoughts
affected their relationships and ability to manage their lives. I found that asking them about their theory
of what happened or was happening to them was a useful question. Once their
theory was discussed we could discuss whether they were aware of other possible
theories to explain what happened. This
is a much better approach than getting into an argument of who believes what. “Well, I understand you believe that!” is a
judgmental rather than an empathic statement that simply states that you are
not interested in what the patient has to say.
Inpatient
psychotherapy is also a place where competency can not only be emphasized but
it may be critical for survival. Exploring
why a patient believes that they do not have diabetes or a fatal illness and
trying to help them with a working solution is one example. Working with them on how to avoid confrontations
with the police is another. I have worked with many manic patients who found themselves
in life threatening situations when they overestimated their physical abilities
due to mania. And there are the more frequent discussions of how to avoid hospitalizations,
how to manage severe psychiatric illnesses including suicidal thoughts and
inability to function at times.
The thousands of
discussions I have had with these folks over the years led me to the conclusion
that supportive psychotherapy is the language of psychiatry. On the inpatient unit it operates at multiple
levels in a very high stress environment. In the next few posts, I will look at more
specific interventions.
The main theme I am
hoping to stress in these posts is that no matter what you are going as a
psychiatrist – a psychotherapeutic intervention should be part of it. It
reminds me of a thought experiment one of my brightest teachers presented to ma
as we were talking after clinic one day:
“OK George - suppose
you are out there as a psychiatrist for a few years and you are at a
party. A woman comes over to you at that
party that you don’t know and starts to make small talk. Are you thinking like
a psychiatrist or not?”
The tenor of these
posts should suggest the answer…..
George Dawson, MD, DFAPA
References:
1: Leibenluft E,
Tasman A, Green SA (eds). Less Time To
Do More: Psychotherapy on the Short-Term Inpatient Unit. Washington, DC. 1993.
This is a 1993 publication so I am not recommending it at
this point. It is a good outline of necessary psychotherapeutic concepts but is
not long on specifics apart form some vignettes.
2: McHugh PR. William
Osler and the new psychiatry. Ann Intern Med. 1987 Dec;107(6):914-8. doi:
10.7326/0003-4819-107-6-914. PMID: 3318611.
3: Silver PA,
Goldberg RL. Integrating Somatic and
Psychological Treatment in Inpatient Settigs. in: Leibenluft E, Tasman A, Green SA (eds). Less Time To Do More: Psychotherapy on the
Short-Term Inpatient Unit. Washington,
DC. pp: 23-38.