A New Book From An Expert Psychotherapist

 

I first became aware of Mardi Horowitz’s work when I was researching adjustment disorders many years ago.  As an acute care psychiatrist that is one of the disorders that ends up on your unit that you must separate from severe mental illnesses and significant risks.  I wanted to do more than just make the diagnosis.  I also wanted to assist these folks with psychotherapy that might prove useful, even if I ended up discharging them the same day.  Dr. Horowitz has written extensively about that and many other topics.  I decided to buy his recent book Clinician Technique in Personalized Psychotherapy.  In the introduction he mentions watching decades of watching psychotherapy videotapes and trying to figure out what helped people change. 

In the forward by Roberta Isberg, MD – she mentions that therapists might see something in the book that they have been doing in practice for years.  That happened to me when I read the Chapter Confronting Dilemmas by Assertion of the Therapeutic Alliance.  In fact, I had mentioned this intervention just a few hours earlier in psychotherapy seminar that I coteach. In that seminar I discussed how making the therapeutic alliance explicit could be useful in resolving impasses.  Dr. Horowitz’s chapter uses a dyadic diagram of the therapeutic alliance (p. 103) that is good in that it delineates the roles of both the patient and the therapist and what the expected exchanges might be.  For example, the patient is disclosing and focused on problems while the therapist is intervening, supporting, and emphasizing adaptive changes by the patient. 

Dr.  Horowitz also presents a table of Common Dilemmas for a Psychotherapist.  He defines dilemmas as binaries where both poles are unlikely to be helpful.  A common example is encouraging further elaboration of a problem that the patient may find very problematic in terms of external relationships, the relationship with the therapist, or longstanding internalized patterns of thinking and behavior.  In the table he presents ten common dilemmas, the therapist’s intervention, and how it might be interpreted.  In the case of these dilemmas, he suggests clarifying the situation and trying to reach a middle ground:  “ The middle ground between the binaries of the dilemma may be reached if the therapists state the properties of the periodically experienced therapeutic alliance.” (p. 100).   

I thought I would present a frequent acute care dilemma as a vignette, but before doing that borrow another definition from Dr. Horowitz.  That is the idea that the vignettes are fictionalized composites of multiple therapeutic encounters.  In the case below it is hundreds of encounters:

Patient: “Are you the one holding me here?  Are you the one I have to talk to to get out of here?  I want to be released as soon as possible.”

MD: “I am the person who will make that decision….”

Patient: “Well what’s the hold up?  You can’t just keep me here.  There is no reason why I should be sitting in this hospital.”  

MD: “I will do what I can but I have to be able to make an independent assessment in order to do that….”

Patient: “Look – I don’t care about that.  You have no right to hold me here.  I want to go home right now and you are in my way.”

MD: “OK – this is the first time I am seeing you. None of the people who brought you to the hospital or admitted you to my unit have been in touch with me.  I have nothing to do with who is admitted to my unit and in fact have been told that I am supposed to discharge people as soon as possible.  But I can’t do that unless I am fairly certain that they will be safe….”

Patient: “So you’re just covering your ass doc?  Really?  You are just worried about getting sued?”

MD: “I am not worried about getting sued, but I do worry about not getting people the assessments and treatment they might need.  The way this is supposed to work is that you and I talk about what happened and try to determine if you have any problems that I can help you with. It is not me against you or you against me.  It is you and I working on an agreed upon set of problems.  Do you think we can do that?”

Patient: “I suppose…”

MD: “OK let’s give it a try.”

This is an example of a situation that many physicians find impossible to approach because their authority is questioned and the potential for escalation.  That escalation depends largely on the physician not taking the critical comments as a personal attack but rather as a process issue.  It requires the ability to remain neutral in addition to confronting the dilemma and establishing a middle ground to proceed on. This skill is critical in acute care psychiatry as well as in crisis outpatient situations.  And before I get too grandiose like all things in medicine there are no guarantees – only probabilities.  There are situations that will rapidly escalate out of control despite your best efforts – but in my experience they are rare.    

There are many other dilemmas facing therapists during assessments and in ongoing therapy.  More common examples arise from the situation where the patient is reluctant to disclose the details of certain events or has expectations of the therapist that are not consistent with the reality of the therapy situation.  The standard cinematic approach of reflecting the problem back to the patient (“well how do you feel about that?”) is generally not an optimal response and it is one that most people see as cliché these days.  Clarifying what is going on in the room and in the therapy is probably a better strategy.

I have written about the therapeutic alliance in several areas on this blog. Here is a post from 2012 and 2017.  I also posted diagrams of the therapeutic alliance in those posts and include my most recent modification below.  In the diagram I am using MD as the therapist since almost all the therapists I interact with are psychiatrists or psychiatric residents, but it also applies to non-physician therapists.

 

I use a tripartite diagram to highlight the problem space as being a specific focus of patient and therapist since it is the combined process of what is happening in the therapy rather than the isolated process of either person.  Some authors write about this as intersubjectivity (2) or the result of the interaction between two unique conscious states.  Most physicians are taught to observe and record findings from an objective third person position.  The exception is psychiatry where subjectivity has recognized value and the importance of the physician-patient relationship is emphasized.  

Intersubjectivity provides a more comprehensive look at what happens in the therapeutic alliance than seeing the interaction as orchestrated solely by an objective therapist.  The therapist and patient have complementary roles.  For example, empathy is a critical dimension of the therapeutic alliance and a critical skill for the therapist.  Empathy is also required on the part of the patient and its presence can be palpable to varying degrees.  Does the patient really understand what the therapist is trying to do?  Does the patient experience the therapist as a person who is trying to be helpful?  Intersubjectivity does not reduce the value of traditional concepts like transference and countertransference.  Both can exist in this intersubjective space.  It provides a more comprehensive framework for understanding.   

Intersubjectivity has developmental origins, is considered adaptive from an evolutionary perspective, and therefore most people have it to one degree or another. An exception might be autism where the absence of an intersubjective process has been considered as a deficit or a defense.  Along the same lines varying degrees of severe mental illness can impact it.   

In a therapy session, the process and content of the session are co-created rather than being dependent on the therapist.  As the therapy progresses the process may be more important than the content.  This is an obvious departure from criteria based diagnoses and highlights the social determinants of the problem. The underlying assumption of how the mind operates on an intersubjective basis is that the primary goal is to form object relations or real relationships and their internalized representations. That differs from some other assumptions of mind goals such as discharge for pleasure.  Like many technical terms used in therapy there is often confusion based on how they are used by different authors.  For example, when I have written about empathy on this blog I have used Sims very precise definition (par. 10). In the chapter I have referenced here, Stern suggests that intersubjectivity subsumes many dimensions including all the imprecise definitions of empathy, sympathy, and mind reading as ways to appreciate the subjective experience of another.  To further complicate matters, there are other descriptions of this phenomenon that are difficult to separate.  One is folk psychology which is defined as the intuitive way people understand and predict the behavior of others. Folk psychology (3) could be seen as the result of a long series of intersubjective encounters – the success of which will depend on both the quality of the interactions and the inherent properties of the subjects.

Before I get too far afield, I will add a brief comment about confusion over the objective and subjective in psychiatry. When physicians start out, the objective is highly valued.  What are the reproducible elements of diseases and treatments? Physicians leave medical school with a sense of medical science being like any other science until they start practicing and realize they are seeing hundreds of conditions that defy description and standard treatments.  In psychiatry there has been an historic move from an attempt at the highly objective approaches of the late 19^th century to the subjective wave of psychoanalytical dominance and back to the attempted objectivity of brain-based precision psychiatry.  That pendulum swing is more rhetoric than reality.  The reality is that in psychiatry we are privileged to work with the most complex organ in the body.  The brain has an obvious complex physical basis and an equally complex psychological basis.  Both must be understood as completely as possible.  That is difficult in that it takes a lot of time and effort – but that is the job.

On a practical note, what about the rest of the book and should you buy it?  I was pleasantly surprised to find what I have done for decades was recommended by an academic psychiatrist who is an expert in the field.  I am certain that most people who have been engaged in providing psychotherapy will find the same thing.  The overall advantage in this book is that it is an information dense text of 115 pages with additional pages for 84 references, an index, and a glossary.  It is set in what appears to be 10-point font and you can read it in one long sitting.  There is no elaboration on the history and technical details of schools of psychotherapy.  The chapters are matter-of-fact and straightforward. Every concept has a concise definition and definitions are added as needed as footnotes on the respective pages.  Since the author is a psychotherapy researcher there are some unique conceptualizations and jargon contained in the book.  There were well explained and not an impediment to understanding.  

The model of therapy described is described as an integrative cognitive-psychodynamic approach that consider both conscious and unconscious elements.  He takes the secret handshake elements out of psychotherapy by clearly stating what he is doing and providing many clinical examples.  When therapists are starting out especially in psychodynamic therapy – the goal of therapy is often not very clear.  It can seem like therapy hinges on definitive interpretations of unconscious wishes and the residuals of past interactions.  Even when a therapist gets to the point where they feel more competent to make those interpretations, they may be skeptical of their accuracy and concerned that they be trying to convince the patient to accept an inaccurate interpretation.  Dr. Horowitz is very clear that interpretations are not necessary for change and reviews several cognitive and behavioral interventions that can be useful. I counted about 39 of these interventions in the obvious places, but there are probably more.  In some spots it assumes that the reader has working knowledge of basic behavioral interventions (breathing techniques, relaxation, etc) for application in the early stages.   

This method of therapy – supportive interventions used initially and intermittently in association with more interpretive therapy is often not explicit in therapy texts, but I am convinced that it is the norm for people who learn psychodynamic therapy and apply it outside the context of psychoanalysis.  There are clearly times when people being seen strictly for therapy or psychiatric treatment are in crisis and need supportive interventions for stabilization or to assist them toward an intersubjective state consistent with more exploration and interpretation.

 The book benefits therapists at both ends of the training and practice spectrum.  If you are starting out – it is a good overview of the topics and skills that you need to provide psychotherapy.  If you have been working in the field for years or decades, it leads to reflection on what you have been doing, whether there is potential for improvement, and how what you are doing fits into the general scheme of things.

Either way Dr. Horowitz does not disappoint.     

 

George Dawson, MD, DFAPA

 

References:

1:  Horowitz MJ.  Clinician Technique in Personalized Psychotherapy.  American Psychiatric Publishing, Inc, Arlington, VA, 2025.

2:  Stern D.  Intersubjectivity.  In: Person ES, Cooper AM, Gabbard GO. The American Psychiatric Publishing Textbook of Psychoanalysis.  American Psychiatric Publishing, Inc, Arlington, VA, 2005, 77-92.

3:  Hutto, Daniel and Ian Ravenscroft, "Folk Psychology as a Theory", The Stanford Encyclopedia of Philosophy (Fall 2021 Edition), Edward N. Zalta (ed.), https://plato.stanford.edu/archives/fall2021/entries/folkpsych-theory

 

Should You Trust Your Physician?

As far as I can tell there are two basic considerations in whether or not you trust your physician. The first is combination of personality and cultural factors and the resulting expectations you have when you see a physician. That may have something to do with your actual experience, but also may have more to do with observations from the care of other people. As an example, you saw your father was cared for and thought it was excellent care and expect the same care for yourself. That can also backfire in the case where you believe the observed care was substandard and led you to be more skeptical of medical care administered by physicians. From a cultural standpoint, you may be from a culture that does not trust authority figures or even physicians.  These are all very complicated issues, that I will illustrate with personal examples of treatment I have received over the years.

The second approach to whether or not you trust your physician, is to adopt a very performance-based approach. That approach is the answer to the question: “What has this doctor done for me and do I like those results?” Medicine is a complex field made more complicated by subjective assessment of the patient in their experience of care and treatment. As a psychiatrist, I see people who are very satisfied with their care from physicians and surgeons and many who are dissatisfied. I see people who have had the exact same procedure – let’s say a hip replacement with identical functional results.  One of these patients will tell me, that they are doing very well and the other will describe disappointment.  The disappointed patient will often tell me they are only slightly improved than when their joint was “bone on bone”.

My own experience with physicians is mixed at best. When I was a teenager, was in a doctor’s office and developed acute facial swelling, wheezing, and my eyelids were swollen to the point I could barely see. The explanation was given to my parents at the time was it was “psychosomatic” I was not treated with anything. The next several years, the only treatment I got was to get up at night go out into the cool night air and drink caffeinated soda. Needless to say that was suboptimal. When I finally saw an allergist about six years later I was “allergic to everything” and finally started taking antihistamines. But eight years later when I was intern, I saw an allergy specialist who spent the entire interview demanding to know what I wanted to try immunotherapy. I guess it was his form of motivational interviewing.  I never went back.

In medical school, I started to get gout attacks. With the first attack I went the emergency department and spent six hours there.  I was discharged with acetaminophen and codeine – a medication that is essentially worthless for gout pain. During a follow-up appointment in the orthopedic clinic, I was told that I probably sprained my ankle in bed and they put a cast on it. Gout pain gradually resolves after about two weeks and that is what happened. But the gout saga does not end there. During residency I started to get acute wrist pain. I went to a primary care clinic where the physician learned my history and then tried to aspirate my wrist joint with a large needle. That was a skill set that he did not have, but he did end up aspirating some tissue into the syringe that was eventually identified as synovium from the joint.  At some point, I also had a left inguinal lymph node biopsy that went awry. I went back to work and started gushing blood all over my khakis. The surgeon advised me to come to his office right away and by then my shoes were full of blood. I left bloody footprints all over his carpeting.  He cut open the incision and tied off the artery in the office while two nurses held me down.

That is a sampling of my negative experience. There is actually a lot more, but despite these fiascoes I have been able to find physicians that I trust and routinely go back to see. I have been seeing the same primary care physician for the past 30 years - recommended by psychiatric colleague who worked with him.

From a cultural standpoint, I was taught to be skeptical of everyone. My father was a blue-collar worker who routinely talked about the abuses of the administrative class and how working people were taken advantage of. He was in a union and would routinely show me the house that the president of the union lived in compared to our house.  That perspective is still ingrained at some level, but it does not prove very useful when it comes to medical care. The reason is that at some point almost everybody needs medical care and that typically includes care that involves doing something that you would rather not do. That might be surgical procedure or taking medication for a long time or even getting an immunization. But the choices are often fairly dire and that is continue to be miserable or die or accept the recommended treatment. Despite my medical misadventures, I continue to accept doctor’s recommendations even when they have significant risk.

I also come at this from the perspective of interacting with thousands of patients, many of whom don’t trust doctors at all. In most extreme circumstances, I had to interact productively with people who not only did not trust doctors but were simultaneously being coerced into treatment by the probate court system. In other words they were on involuntary holds, probate court holds, or civil commitment. That was the best possible experience to conceptualize the physician trust issue. A typical exchange follows:

MD:  “Hi – I’m George Dawson and I’m the psychiatrist here. It looks like I am seeing you because you were admitted to this unit on a 72-hour hold.”

Pt: “I don’t trust psychiatrists. I just want to be discharged.”

MD: “In order to do that, I have to make an assessment of the situation and determine if you can be released or not.”

Pt: “Why should I trust you?”

MD: “I can’t think of a reason why you should. You just met me. I would suggest that we proceed with the evaluation and see how that goes. At the end of the evaluation I will let you know what my impression and recommendations are. You can decide whether or not you trust me based on what happens. If you decide to follow my recommendations you can also base your decision on whether or not those recommendations work for you. Does that seem reasonable?”

That is the basic framework that I tried to outline for people are focused on trust. The focus is on actual performance as well as subjectivity. The subjective elements are a number of factors on the patient’s side.  They include all of the conscious and unconscious factors involved in interpersonal assessments as well as any overriding psychopathology. The most important element of the patient’s conscious state is whether or not they can incorporate the information that they are receiving from the physician into their responses and adapt a different framework for the interaction. Not everybody is able to do that, but the great majority of people are to some degree.

The above example is from what is probably the most contentious situation.  I think the approach works even better in outpatient settings where people have had adverse experiences in psychiatric care like my experiences with medical care.  In some of those situations a description of the therapeutic alliance is useful. That might go something like this:

“It might be useful to discuss how these interviews work.  You and I are both focused on the problems that you identify.  We discuss them and at some point, my job is to give you the best possible medical advice on how to address them.  Your job at that point is to think about that advice and whether or not you find it useful and want to use it.  It is also possible that your problems are not medical or psychiatric in nature. I will let you know if I think so.”

That clarifies a few points.  The interview is not a unilateral “analysis”.  Many people have the psychiatric stereotype that a psychiatrist can just look at you and figure out the problem. To this day, many people that I casually meet still ask me if I am “analyzing them.”  It also points out that I am interested in what they identify as problems – not somebody else’s idea of the problem. Unless that is explicit, many people go out of their way to tell me that it was their idea to see me or go to treatment.  Most importantly – it emphasizes that this is a cooperative effort.  I have no preconceived idea about their problem or diagnosis.  My ideas develop from the discussion and there has to be agreement that I am on track.

That is my basic approach to the trust issue in interactions with patients.  There are many variations on that theme.  Although what I have written here is from the physician perspective – I can add that from the patient perspective the performance dimension is very important.  My personal internist always takes enough time to assess my problems and do an adequate evaluation.  He has made some remarkable diagnoses based on those evaluations.  That performance over time builds trust as well.  It also highlights another important aspect from the patient perspective and that is empathy towards the physician.  Is there an understanding of how the physician’s cognitive ability and emotional capacity can be affected by outside factors? Is there any allowance for even minor physician errors or lapses in etiquette – like being very late for an appointment?  People vary greatly in that capacity and often it is necessary to keep a productive relationship going.

Most medicine these days is run by corporations rather than physicians. That makes it harder to establish long term relationships with physicians. In the above narrative I hope that I outlined the advantages of that relationship as opposed to one that may be more like being asked 20 questions about a medical condition by different people every time you go into a clinic.

George Dawson, MD, DFAPA

Therapeutic Alliance - A Better Diagram

I posted on the therapeutic alliance about 5 years ago.  The goal of that post was to point out how psychiatric treatment occurs - specifically the idea that the physician and the patient need to collaborate and define a set of diagnoses and/or problems to work on.  They have to agree on the problems and also the plans to resolve (or not) resolve them.  In the case of a chronic illness  with no clear resolution, the goals are focused on optimizing function.  The is basically the ideal treatment model for any physician and any treatment - the only difference is that psychiatrists are trained to attend to the relationship between the patient and the physician in very specific ways.  That includes the concept of transference and countertransference or the emotional reaction and associated thoughts of the patient to the physician and and the physician to the patient based on their past experiences.  By attending to those patterns psychiatrists can develop insights into what is unfolding in the relationship and in some cases use defensive patterns to assist in the diagnosis and treatment process.

I had a few ideas about how I wanted this diagram to differ from the diagram in my previous post.  First, I wanted it to reflect treatment continuity.  Ongoing treatment is a dynamic process of multiple events across time in the case of ongoing care. It can also involve single cross sectional interventions that require a patient to complete a prescribed treatment and contact the physician if the problem is not resolved as expected.   There are several hard stops to a medical treatment process - cure, improved function without cure, increasing disability, care refusal, and death to name a few.  I decided to leave those implicit and not alter the basic diagram.  Second, I thought that triangles demarcating the physician-patient decision space would be a good idea because they are more open structures and were used in a recent example of how graph theory may be useful in neuroscience.  Third, I wanted to avoid jargon.  There are numerous conceptualizations of the conscious state of the patient and the physician and what that implies for the communication - but I distilled it down to the communication and collaboration parameters as noted above.  There is implicit informed consent in this model. There are far too may people who see physicians and adopt a passive role.  In some cases they request that the physician make important decisions for them: "What would you do if you were me?" The role of the physician is to communicate the information that the patient acts on with all of the attendant risks.

The general model is a good one for all medical specialties.  Psychiatrists are be trained to attend more the the relationship and overcome obstacles to treatment. A basic example would be the person who consults with a physician but who is skeptical of the physician's motivations or intentions.  In many cases this results in a disagreement and the relationship is terminated without the patient receiving treatment.  A psychiatrist should be capable of recognizing what is occurring in the interview and at least being able to point out the reality of the situation to the patient.  That reality is depicted in the diagram at the top.  I frequently tell people that I have no interest in telling them what to do or even prescribing a medication that they do not want to take.  My appropriate role in the model is to give them the best possible medical advice about resolving problems the we both agree on and that might benefit from treatment.  It is their role to decide among the options and consent to treatment.  Not consenting to any treatment is always an option.

The model also implies that both parties are competent to interact and make decisions.  In the case of physicians, states have a vetting and licensing process that is focused on public safety and it does a good job of removing most unsafe or incompetent physicians.  In the case of the patient, there are various contexts in which substitute decision-makers are engaged in the process including guardians, conservators, and judges.  The legal process to make that determination varies widely from state-to-state and even county-to-county within the same state.


George Dawson, MD, DFAPA
    

The Therapeutic Alliance

You + Me -> working on your problems.

That is the basic paradigm for treatment.  It assumes that the psychiatrists is competent and professional.  Assumptions about the patient are less clear.  In the ideal situation, the patient is aware of the therapeutic alliance and focused on examining and solving problems.  There are a wide array of problems that can be the focus of treatment.

The approach generally works very well but there are things that can derail it.  In the course of treatment, emotionally loaded topics are discussed.  In some cases the emotions of patients and psychiatrists impinge on the alliance and need to be clarified.  There are boundary issues that often bias treatment in a particular direction.  A common example is a friend or family member referring a person into treatment.  These days there are important factors outside of treatment that bias treatment as indicated in the following diagram.

In this case, the patient and psychiatrist can have an excellent working alliance.  They can be focused on solving problems by applying the best possible evidence based medicine or consensus guidelines, but the best course of treatment that they agree on is not funded by the managed care company or pharmaceutical benefit manager.  A common example these days would be a patient with depression and back pain.  I frequently recommend duloxetine, especially in the case of failed treatment with SSRI type antidepressants.  Even in the case where this treatment is effective for both depression and back pain,  the PBM can either refuse to pay for the medication or make the copay so high that the patient cannot afford it.  On the inpatient side, a common scenario is the manic patient who is not able to function unsupervised at home or in transitional care.  The managed care  company can say that the patient is "not a danger to self or others" and insist that they be discharged form the hospital.  That is probably one of the most frequent reasons for readmission.  In other cases, managed care companies declare that the patient is no longer at risk for suicide.  Their reviewers make this decision based on reading chart notes or talking to the doctor who thinks that the suicide risk is still high.  In the majority of cases they decide against the attending physician - probably the most egregious breach of the therapeutic alliance especially when the patient is as concerned as the psychiatrist.

The government also intrudes at multiple levels.  The biggest intrusion has been by facilitating the development of both managed care and PBMs.  These are businesses that were essentially invented by the government in order to reduce the cost of health acre.  After two decades it is clear that health care inflation is as high as ever, that mental health services have been cut to the bone, and that public mental health services that have adapted managed care strategies have a also dramatically reduced services.  In almost all cases, the government advances a purely political experiment that results in numerous inefficiencies that fails to produce results.  Some common example include failed pay for performance initiatives and a failure to reduce Medicare readmissions based on financial incentives and disincentives.  Practically all of these experiments use the administrators assumption that physicians don't know what they are doing in the first place.  That is probably not the best place to start.

There are many political influences that  are not on the diagram.  Direct to consumer advertising, the media, and various advocacy groups are additional examples.  Psychiatry is unique in that there are a number of causes dedicated to the most negative characterizations or destruction of the field.  That orientation not only precludes any therapeutic alliance but also may lead to intrusions on existing or initial alliances.

George Dawson, MD, DFAPA