The mainstream of our profession has ceased paying much formal attention to the help our patients get from the doctor-patient relationship itself. But patients are stubborn. They still expect to have helpful relationships with us! Witness the ill-informed boyfriend of a public-clinic patient who asked me, at the close of a medication visit, "But when is she going to see a psychiatrist? She has things to talk about!" Equally disturbing was the well-meaning enthusiasm of a young psychiatrist interviewing for work at the same facility when I told him that I use my psychotherapy training in many a patient encounter there. "Oh, like if there's time, you might do a little cognitive therapy on 'em?"
We psychotherapists have ourselves to blame for this state of affairs, having husbanded our subspecialty's development in two narrow directions while psychopharmacology and neuroscience have dramatically broadened their own worldviews. Some of us have manualized and proceduralized psychotherapy (or rather, certain psychotherapies) in imitation of procedural, technology-driven medicine, so as to be good citizens in the world of indications, interventions and outcomes. Most new psychiatrists have had some exposure to these techniques, but few seem inspired by them.
Another potentially influential group has circled the wagons for psychoanalysis and psychodynamic therapy. The large body of literature this group continues to generate takes many fascinating forms, from the quasi-literary to the quasi-neurological, but few psychiatrists-in-training read it.
Neither of these two currents in psychotherapy convincingly illuminate, or render more effective, our work with the entire spectrum of patients we see in everyday general psychiatric practice.
What sense can we possibly expect our trainees to make of this Tower of Babel? Unless they are unusually persistent, they will either stick to the DSM and the meds and/or develop their own ways of conceptualizing personality and human nature, often with the help of pop psychology or New Age spirituality. In both cases, this dooms them to repeat sundry mistakes of the past, because an intellectually rigorous psychology of relationship, cognizant of boundaries and power arrangements, is missing. Should those of us who still try to teach psychotherapy in this inhospitable clime simply accept that the next generation will have to reinvent the wheel, or can we do any better for them?
We can, and it isn't all that hard. A global overview of the psychotherapeutic enterprise, based not upon theory but upon what therapists actually do, is easy to provide and reveals that there are really only three kinds of psychotherapy. I will begin my description with the rather typical odyssey of a real patient at a residency training program.
This patient's prolonged panic attack began when her mother arrived from out-of-state at the local bus terminal in a hospital johnny, seeking her care. Unable to cope, the patient was brought to the emergency department by her husband. She was so desperately anxious as to admit to suicidal ideation: the "Open sesame!" of our triage culture. At age 31, this secured her first psychiatric hospitalization and evaluation.
The patient settled down quickly with the help of anxiolytics and an alternative placement for her regressed, mentally ill mother. But during her brief stay, an alert inpatient resident noticed that she engaged in several classic compulsive rituals, including much hand-washing and showering. Referral was made for outpatient psychotherapy with another resident who would obtain supervision in the cognitive-behavioral treatment (CBT) of obsessive-compulsive disorder (OCD) in addition to the usual medication trials.
The outpatient resident got more than he had bargained for. It was difficult for him to concentrate on response-prevention and thought-stopping techniques under the silent, watchful eye of the patient's husband -- and she insisted upon his presence in order to "feel comfortable." The resident kept trying, and one day when the husband had to leave the session early, the patient volunteered that in her own mind, the pervasive sense of dirtiness that kept her always washing had something to do with repeated episodes of sexual abuse by her mother in childhood. There was also fear of retribution by her mother for "not being a good girl," which transferred in the present to her husband. His idea of good behavior was that she never leave their apartment alone.
It became clear to this intelligent resident that, beyond the illness dimension of Axis I OCD, a relational dimension would have to be entered to treat this patient successfully. A newcomer to the incoherent shipwreck of non-psychopharmacological psychiatry, he understandably groped for some of the remaining scraps of a psychological outlook that are still afloat. Childhood trauma...pathological dependence...Axis II borderline personality disorder (BPD)? Well, close enough to try dialectical-behavior therapy (DBT), opined the supervisor.
And so, aided by the husband's periodic departures after check-in, the resident soldiered on with chain analyses of anxious thoughts and other such techniques in a DBT-like individual therapy (the skills classes, of course, were unacceptably anxiety-provoking). Eventually the patient stopped coming, and when the resident finally called, she told him that she was afraid she would always be a disappointment to him and was wasting his valuable time. Could she see the hospital resident who had originally admitted her, "just to talk?"
To the second resident's chagrin, the patient proceeded to settle in comfortably with the original resident, attending regularly although she (the hospital resident) was even more of a therapeutic neophyte and knew no specific techniques. In fact, she said, "I have no idea what I'm doing!" But she is clearly doing something specifically effective for the first goal of any therapy: keeping the patient in the room. The patient is comfortable enough to dispense with the husband's presence. A second "safe place" is emerging that can compete with the safety of the husband's total control, and within which she can begin to take possession of herself.
We can imagine where things might go from here if the utilization reviewers are kept at bay. Perhaps patient and resident (or the resident's successor) will feel ready to retry the response-prevention strategies that failed at first, building on the strength of a working relationship. Or perhaps they will work directly on that relationship itself, when the idealized "safe" therapist inevitably falls from grace and disappoints (or enrages) the patient. Ideally, the patient will eventually work on both behavior and relationship, although not necessarily with the same therapist.
This patient exemplifies the everyday complexity of the real-world population psychiatrists treat. Hers is not a pure form of a DSM-described illness that dutifully improves like the cases in academic studies ("OCD+CBT=OK," "BPD+DBT=OK" and so on, as I like to joke). Instead, she is the usual biopsychosocial layer cake (Table 1) of Axis I syndrome (bio-), relational disturbance (psycho-) and developmental damage (-social). Because of this, benign power -- here, the doctor who tries to do response-prevention -- is not a viable reality for her. Before she can get help, she needs help with getting help. And that is what the resident who "doesn't know what she's doing" is giving the patient.
