is Instructor of Psychiatry at the University of Central Florida College of Medicine in Orlando, FL, and Adjunct Instructor of Psychiatry at Tufts University School of Medicine in Boston, MA. He is a psychoanalytic psychotherapist in private practice.

Mark L. Ruffalo, MSW, DPsa

A frequent criticism of psychiatry is that psychiatrists do not learn, practice, or value psychotherapy. Even critics within the field routinely complain that psychiatry has “lost its mind,”

 whereas outside critics frequently portray toxic biological psychiatrists in competition with humane psychotherapists from other disciplines.

 The psychiatrist, as the story goes, is interested only in diagnosing and medicating patients—not in understanding, supporting, or working psychotherapeutically with them. This story, widely reported as fact in the media,

 is an outdated, harmful myth—one that discounts the realities of psychiatric training, the complexity of the psychiatric treatment relationship, and the resurgence of interest in psychotherapy among psychiatry residents.

In the mid-20th century, psychotherapy was the treatment of choice for most mental disorders. Even after the development of the first effective psychotropic medications in the 1950s and 60s, psychotherapy remained the mainstay of psychiatric treatment, especially in the psychoanalytically dominated United States. By the late 1980s, however, the field had shifted in a biological direction. The development of selective serotonin reuptake inhibitor antidepressants in particular led to great excitement in the promise of biological investigation and treatment. Nevertheless, psychotherapy continues to be practiced by psychiatrists, with some devoting their academic and clinical careers to the study and practice of psychotherapy.

The idea that psychiatry is divorced from psychotherapy is, in fact, divorced from reality. Here are 4 fundamental examples of the union between psychiatry and psychotherapy.

1. Psychiatry residents receive significant formal instruction in psychotherapy.

One of us (DM) is director of residency training at a psychiatry department in the Northeast; the other (MR) teaches in that program and serves as codirector of the psychotherapy track for a psychiatry residency program in Florida. As such, we have direct knowledge of the quality and extent of training psychiatry residents receive in psychotherapy. By contrast, most critics of psychiatry do not teach in psychiatry departments and have little to no firsthand knowledge of psychiatric residency curriculum.

Training in supportive, psychodynamic, and cognitive-behavioral psychotherapy is nationally mandated for all psychiatry residents.

 Residents must also learn to integrate psychotherapy with psychopharmacology and spend substantial time practicing psychotherapy during their outpatient training. They attend several yearlong didactic courses in psychotherapy and are individually assigned psychotherapy supervisors (many of whom are psychiatrists). Didactic instruction typically covers a range of psychotherapy topics, such as case clinical formulation, transference, countertransference, and psychotherapeutic technique. Clinically, residents see patients for short-term and longer-term psychotherapy treatments.

Approximately a quarter of psychiatry residencies also offer specific psychotherapy tracks for residents with particular interest in psychotherapy and for those who plan to pursue additional training in specific psychotherapies (eg, psychoanalytic training) postresidency.

 Many individuals, even mental health professionals, assume psychotherapy training is weaker for psychiatry than for other mental health disciplines such as psychology and social work. Yet a national survey published in 2006 showed that psychiatry compared favorably to other disciplines for evidence-based forms of therapy training.

 Thus, the claim that psychiatrists do not learn psychotherapy is false.

2. Psychotherapy is a part of almost all clinical interactions.

Although most psychiatrists nowadays do not offer traditional 45-minute or 60-minute psychotherapy appointments to all their patients,

 psychotherapy continues to be practiced in some form by most psychiatrists. From a psychodynamic perspective, every interaction between doctor and patient, even in the hospital setting, is an opportunity to relate to the patient psychotherapeutically. Sudak and Taormina

 have described the integration of cognitive-behavioral therapy into medication management visits, and Iannitelli et al

 have recently discussed the application of psychodynamic principles during psychopharmacological treatment.

Undoubtedly, most psychiatrists engage in some supportive psychotherapy even during brief visits and even if they do not formally label or bill the sessions as such. Moreover, in their study, Tadmon and Olfson10 found that 47% of psychiatrists continue to offer 45-minute to 60-minute psychotherapy sessions to patients. Thus, claims that psychotherapy has simply disappeared from psychiatric practice are false.

3. In the past decade, there has been a resurgence of interest in psychotherapy and psychosocial approaches among psychiatry residents.

A 2012 survey of residents reported that 82% of them consider “psychotherapy to be integral to their identity as psychiatrists.”

 Another survey showed that residents want more psychotherapy training rather than less.

 Our experience matches the results of such research. In fact, we have observed an increasing number of psychiatry residents interested in learning and practicing psychotherapy during the past decade.

In recent years, psychiatry has become a popular and competitive specialty choice among medical students, who describe their interest in learning the art of engaging deeply with suffering patients and combining psychosocial treatments with biological interventions. Many residents are particularly eager to learn psychotherapy methods and rightfully view psychotherapy as a core, foundational skill in the practice of clinical psychiatry. Meanwhile, some professional organizations are specifically devoted to the advancement of psychotherapy training within psychiatry, such as the American Academy of Psychodynamic Psychiatry and Psychoanalysis.

4. Many leading psychotherapy scholars are psychiatrists, and this has been the case for decades.

Some of the leading figures in American and global psychotherapy are psychiatrists, including Otto Kernberg, MD; Glen Gabbard, MD; and the recently deceased Aaron Beck, MD, father of cognitive-behavioral therapy. Several psychiatrists who are leading researchers in psychopharmacology have also undertaken research validating medical psychotherapy.

 Psychiatrists make up a significant percentage of membership of the American Psychoanalytic Association. They are also frequent presenters at national psychotherapy conferences and contributors to psychotherapy journals. The American Journal of Psychotherapy, a leading journal of psychotherapy theory and practice, is a journal of the American Psychiatric Association. Thus, the psychiatric profession remains integral to psychotherapy development and research.

Psychotherapy continues to be a core aspect of psychiatrists’ training and identity. Psychotherapy training also continues to be a substantial and mandatory component of residency training for all psychiatrists. Contrary to popular assumptions, it is not critical that all psychiatrists conduct traditional psychotherapy as part of their practice. No one becomes alarmed if all cardiologists do not practice cardiac catheterization, and no one should worry that “only” half of all psychiatrists currently offer traditional 45-minute psychotherapy sessions. But all psychiatrists should continue to support psychotherapy’s place in mental health treatment and in the holistic, biopsychosocial treatment that psychiatrists routinely offer.

For decades, critics and leading psychiatrists have worried that psychotherapy among psychiatrists will one day die out and be forgotten. Yet for decades, reports of its demise have been greatly exaggerated.

 is an instructor of psychiatry at the University of Central Florida College of Medicine in Orlando and an adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts. He is a psychoanalytic psychotherapist in private practice in Tampa, Florida.

is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association.

Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession in Crisis.

Of Two Minds: An Anthropologist Looks at American Psychiatry.

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill.

5. Harris G. Talk doesn’t pay, so psychiatry turns instead to drug therapy. 

https://www.nytimes.com/2011/03/06/health/policy/06doctors.html

6. Psychiatry: Program requirements and FAQs. Accreditation Council for Graduate Medical Education. Accessed May 4, 2022. 

https://www.acgme.org/specialties/psychiatry/program-requirements-and-faqs-and-applications/

Psychotherapy tracks in US general psychiatry residency programs: a proxy for trends in psychotherapy education?

8. Weissman MM, Verdeli H, Gameroff MJ, et al. 

National survey of psychotherapy training in psychiatry, psychology, and social work.

Trends in outpatient psychotherapy provision by U.S. psychiatrists: 1996-2016.

Integrate brief CBT interventions into medication management visits.

12. Iannitelli A, Parnanzone S, Pizziconi G, et al. 

Psychodynamically oriented psychopharmacotherapy: towards a necessary synthesis.

13. Lanouette NM, Calabrese C, Sciolla AF, et al. 

Do psychiatry residents identify as psychotherapists? A multisite survey.

Psychotherapy training: residents’ perceptions and experiences.

Biological v. psychosocial treatments: a myth about pharmacotherapy v. psychotherapy.

16. Miklowitz DJ, Efthimiou O, Furukawa TA, et al. 

Adjunctive psychotherapy for bipolar disorder: a systematic review and component network meta-analysis.

Articles

A frequent criticism of psychiatry: psychiatrists do not learn, practice, or value psychotherapy. Is it true? 

Psychiatry and Psychotherapy: The Great Divorce That Never Happened

The psychotherapy frame refers to the basic ground rules for psychotherapy: the attitude of the therapist toward the patient, boundaries, meeting arrangements, and other contractual elements of the psychotherapy relationship. It can be conceived of as the environment and relationship in which psychotherapy takes place. The late psychiatrist Robert Langs, MD, devoted much of his career to the study of the frame, the maintenance of which he described as the therapist’s “most fundamental arena of intervention.”

In the past few decades, as psychotherapy has broadened beyond its psychoanalytic and psychodynamic origins, the concept of the frame has become less known in psychotherapy training and practice. Indeed, many modern therapists have never heard the term or, alternatively, view discussions of it as archaic and reflecting a bygone era of psychotherapy. This unfortunate misunderstanding has led to a shift in the view of the psychotherapy relationship wherein, to borrow from Kernberg, many modern therapists “let it all hang out”

 and adopt a theoretically loose or unprincipled stance. Such therapists may talk about themselves, give advice, or impose their personal beliefs and worldviews onto patients.

Given these recent trends, it may be helpful to revisit the concept of the frame and, in particular, the therapist’s attitude toward the patient in the psychotherapy relationship. Such a discussion may be useful not only to psychotherapists, but also to psychiatrists who may find value in these ideas as they pertain to the psychiatric treatment setting.

The basic attitude of the psychotherapist toward the patient represents the most important element of the psychotherapy frame since it informs the therapist’s role in the treatment situation. An understanding of the therapeutic attitude yields information about other components of the frame, such as the establishment of boundaries and meeting arrangements.

The therapist is a professional and expert on the workings of the human mind who is consulted by the patient because the patient is having some difficulty in their experience of life. At times, this is due to psychiatric disorder. The therapist must remember that their role is that of expert or doctor—not friend or acquaintance. Although a liking for patients often evolves during the course of psychotherapy, the psychotherapy relationship is not a friendship. The therapist who seeks friends in psychotherapy may do so for a variety of reasons: loneliness, a dissatisfying personal life, or their own pathological narcissism. The boundaries between therapist and patient must be respected and the power differential not ignored.

Most individuals who become therapists are motivated by a desire to help others deal with the burdens of emotional despair. Although a desire to help is undoubtedly a necessary trait in a psychotherapist, it has long been recognized

a desire to help. The goal of psychotherapy is to 

from the constraints imposed on them by their conflicts, problems, and symptoms; it is not to help by doing anything 

the patient. To put it another way, in ethical psychotherapy, the therapist must 

Langs, commenting on these ideas, writes that the therapist

“avoids being too supportive, because he hopes not only to offer sustaining help but also, through his therapeutic attitude of being nonjudgmental, noncondemning, nonsubmissive, nonanxious, noncontrolling, firm, consistent, and realistic, to have a modifying effect on the patient’s personality. He knows that the constant playing of the note of supportiveness is not enough. He knows, further, that a too empathic or too profound sounding of this note may infantilize the patient.”

Perhaps the most dangerous risk of psychotherapy is that the therapist will use the patient as a tool or instrument to gratify their own narcissistic impulses. This can take many forms, from gross boundary violations to more subtle attempts to persuade, manipulate, and control, or to model the patient after oneself. The patient’s autonomy—their right to make their own decisions—must be accepted and protected by the therapist. The patient must be seen as an autonomous individual—not an object to be fixed or controlled. It has become fashionable for some therapists to proffer in advice-giving. This practice is countertherapeutic and antithetical to psychotherapy; it infantilizes the patient and promotes helplessness and passivity. It deprives the patient of the very thing psychotherapy aims to provide: freedom.

Freud, writing beautifully on this subject, reflects, “We refused most emphatically to turn a patient who puts himself into our hands in search of help into our private property, to decide his fate for him, to force our own ideals upon him, and with the pride of a Creator to form him in our own image and see that it is good.”

A vital feature of psychotherapy is therapeutic neutrality. What this means is that the therapist maintains an observing stance in relation to the patient and avoids taking sides with any the forces in conflict in the patient’s life. The reason for this is that such a stance helps the patient observe and reflect themselves and eventually to solve their own problems. This does not mean that the therapist is indifferent or blank; the notion of the “blank slate” therapist itself has always been somewhat of a myth. It should also be understood that absolute neutrality is impossible, but the concept should guide therapists in their interactions with patients.

Psychotherapy is a contractual relationship. It is essentially the keeping of promises. The therapist promises the patient to do certain things (to analyze, to aid in understanding, to provide a safe environment), and those things the therapist must do. The therapist also promises not to do certain things (to speak to third parties, to moralize, to control), and those things the therapist must not do. It is the contractual nature of the psychotherapy relationship that permits the other therapeutic work to occur, but the contract itself—and the therapist’s maintenance of it—is a significant therapeutic intervention.

The psychotherapist’s attitude vis-à-vis the patient represents a fundamental, and currently underappreciated, element of the psychotherapy frame. It is the attitude of the therapist that opens the door to good psychotherapeutic work; the therapist’s stance, too, is a key intervention, since it places the patient in an autonomous position and fosters introspection and self-initiated growth. The therapist must be neutral but not indifferent; firm but not judgmental; warm and empathic but not overly involved. They must recognize that the way to help the patient is through exploration—not imposition. They must be and do all of these things, but above all, they must respect the uniqueness and creativity of the patient as an individual human being.

2. Rankin C. Otto Kernberg on Psychoanalysis and Psychoanalytic Psychotherapy. 2000. Accessed June 27, 2022. 

https://www.psychotherapy.net/interview/otto-kernberg

An Elementary Textbook of Psychoanalysis. 

The Technique of Psychoanalytic Psychotherapy. 

6. Freud S. Lines of Advance in Psycho-Analytic Therapy. In: Strachey J, ed & trans. 

The Standard Edition of the Complete Psychological Works of Sigmund Freud. 

7. Yeomans F, Caligor E. What is neutrality in psychotherapy anyway? 

https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.6a20

Let’s revisit the therapist’s attitude toward the patient in the psychotherapy relationship. 

The Therapeutic Attitude in Psychotherapy

A frequent criticism of psychiatry is that psychiatrists do not learn, practice, or value 

. Even critics within the field routinely complain that psychiatry has “lost its mind,”

 while outside critics frequently portray “toxic” biological psychiatrists in competition with with humane psychotherapists from other disciplines.

 The psychiatrist, as the story goes, is interested only in diagnosing and medicating the patient—not in understanding, supporting, or working psychotherapeutically with him or her. This story, widely reported as fact in the media,

 is an outdated and harmful myth—one that discounts the realities of psychiatric training, the complexity of the psychiatric treatment relationship, and the resurgence of interest in psychotherapy among psychiatry residents.

In the mid-20th century, psychotherapy was the treatment of choice for most mental disorders. Even after the development of the first effective 

 in the 1950s and 60s, psychotherapy remained the mainstay of psychiatric treatment, especially in the psychoanalytically dominated United States. By the late 1980s, however, the field had shifted in a biological direction. The development of selective serotonin reuptake inhibitor (SSRI) antidepressants, in particular, led to great excitement in the promise of biological investigation and treatment. Nevertheless, psychotherapy continues to be practiced by psychiatrists, with some psychiatrists devoting the entirety of their academic and clinical careers to the study and practice of psychotherapy.

The idea that psychiatry is currently divorced from psychotherapy is, in fact, divorced from reality. Here are 4 fundamental examples of the union between psychiatry and psychotherapy:

One of us (DM) is director of residency training at a psychiatry department in the northeast, and the other (MR) teaches in that program and also serves as codirector of the psychotherapy track for a psychiatry residency program in Florida. As such, we have direct knowledge of the quality and extent of training psychiatry residents receive in psychotherapy. By contrast, most critics of psychiatry do not teach in psychiatry departments and have little to no firsthand knowledge of psychiatric residency curriculum.

 Residents must also learn to integrate psychotherapy with 

 and spend a substantial amount of time practicing psychotherapy during their outpatient training. They attend several year-long didactic courses in psychotherapy and are individually assigned psychotherapy supervisors (many of whom are psychiatrists themselves). Didactic instruction typically covers a range of psychotherapy topics, such as case clinical formulation, transference, countertransference, and psychotherapeutic technique. Clinically, residents see patients for both short-term and longer-term psychotherapy treatments.

Approximately 1 quarter of psychiatry residencies also offer specific psychotherapy tracks for residents with particular interest in psychotherapy and for those who plan to pursue additional training in specific psychotherapies (eg, psychoanalytic training) postresidency.

 Many individuals, even mental health professionals, assume psychotherapy training is weaker for psychiatry than for other mental health disciples such as psychology and social work. Yet a national survey conducted in 2006 showed that psychiatry compared favorably to other disciplines for evidence-based forms of therapy training.

While it is true that most psychiatrists nowadays do not offer traditional 45- or 60-minute psychotherapy appointments to all their patients,

 have described the integration of cognitive-behavioral therapy into “medication management” visits, and Iannitelli and colleagues

Undoubtedly, most psychiatrists engage in some supportive 

 during brief visits, even if they do not formally label or bill it as such. Moreover, Tadmon and Olfson

 found that 47% of psychiatrists continue to offer 45- to 60-minute psychotherapy sessions. Thus, claims that psychotherapy has simply disappeared from psychiatric practice are false.

Some of the leading figures in American and global psychotherapy are psychiatrists, including Otto Kernberg, MD; Glen Gabbard, MD; and the recently deceased 

Aaron Beck, MD, father of cognitive-behavioral therapy.

 Several psychiatrists who are leading researchers in psychopharmacology have also undertaken research validating medical psychotherapy.

 Psychiatrists comprise a significant percentage of membership of the American Psychoanalytic Association. They are also frequent presenters at national psychotherapy conferences and contributors to psychotherapy journals. 

a leading journal of psychotherapy theory and practice, is a journal of the American Psychiatric Association. Thus, the psychiatric profession remains integral to psychotherapy development and research.

Psychotherapy continues to be a core aspect of psychiatrists’ training and identity. Psychotherapy training also continues to be a substantial and mandatory component of residency training for all psychiatrists. Contrary to popular assumptions, it is not critical that all psychiatrists practice traditional psychotherapy as part of their practice. No one becomes alarmed if all cardiologists do not practice cardiac catheterization, and no one should worry that “only” half of all psychiatrists currently offer traditional 45-minute psychotherapy sessions. But all psychiatrists should continue to support psychotherapy’s place in mental health treatment, and its place in the holistic, biopsychosocial treatment that psychiatrists routinely offer.

For decades, both critics and leading psychiatrists have worried that psychotherapy among psychiatrists will one day die out and be forgotten. Yet for decades, reports of its demise have been greatly exaggerated.

is instructor of psychiatry at the University of Central Florida College of Medicine in Orlando and adjunct instructor of psychiatry at Tufts University School of Medicine in Boston. He is a psychoanalytic psychotherapist in private practice in Tampa. He can be reached at 

is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of 

Science Over Stigma: Education and Advocacy for Mental Health, 

published by the American Psychiatric Association. He can be reached at 

Of Two Minds: An Anthropologist Looks at American Psychiatry. 

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. 

6. ACGME program requirements for graduate medical education in psychiatry. 2021. Accessed May 4, 2022. 

National survey of psychotherapy training in psychiatry, psychology, and social work. 

Trends in outpatient psychotherapy provision by U.S. psychiatrists: 1996-2016. 

Psychodynamically oriented psychopharmacotherapy: towards a necessary synthesis. 

Do psychiatry residents identify as psychotherapists? A multisite survey. 

Psychotherapy training: residents’ perceptions and experiences. 

Biological v. psychosocial treatments: a myth about pharmacotherapy v. psychotherapy. 

Adjunctive psychotherapy for bipolar disorder: a systematic review and component network meta-analysis. 

Psychotherapy: A Core Psychiatric Treatment

 The DSM diagnosis of major depression is made when the patient meets at least 5 of 9 criteria, some of which are opposites.

 Some cases remit without treatment, and others require lifelong management with psychotherapy, pharmacotherapy, or physical treatments like electroconvulsive therapy. Given this wide variability in presentation, severity, and course, the idea that all depressed patients are suffering from the same disorder seems unlikely.

While the DSM diagnostic system classifies all depressions as major depressive disorder or persistent depressive disorder (dysthymia), psychodynamic theorists have historically divided depression into various subtypes based on proposed etiology and manifest symptoms. Some of these types include endogenous or metabolic depression; exogenous or reactive depression; anaclitic depression; introjective depression; claiming depression; self-blaming depression; depressive personality; and others.

Identifying subtypes of depression helps us select appropriate treatment and can inform long-term prognosis. It also allows us to become particularly attuned to the psychological mechanisms underlying the patient’s depressive symptoms. In this article, I will briefly review the concept of self-blaming depression and its psychotherapeutic treatment, which differs in important ways from the treatment of other forms of depression.

Mrs Jones is a 60-year-old female who has struggled with depressive symptoms off-and-on throughout her adult life. Her most recent depression occurred following the death of her cat, who developed an injection-site sarcoma after a vaccination for feline leukemia. Upon evaluation, Mrs Jones states, “It is all my fault. I should have never had my cat vaccinated. I should have done my homework before taking her to the vet.” Prior depressions occurred similarly following events attributed by Mrs Jones to her own personal failings. In psychotherapy, she only becomes more depressed by words of hopeful encouragement, stating, “I do not deserve to feel any better. I am a failure.” Every life disappointment is interpreted as punishment for her badness and guilty deeds.

Psychoanalytic and psychodynamic theories have historically considered depression a reaction to loss.

 Something has happened in the life of the patient—the loss of a loved one; a job or position; a status; a concept of ourselves; an ideal—that leads to the onset of the depressive symptoms. Depression is thus a reaction to the loss of a key ingredient in our normal mental life. Like physical pain, depression, or psychic pain, has only one purpose: to be removed.

In the very early lives of individuals who go on to become depressed, there is often a period of intense gratification of needs followed by a period of relative deprivation. This change from a near-paradisal situation to an environment of unmet expectations sets the stage for the later onset of depression in response to loss. The child reacts to the change by working harder to reclaim the lost paradise. If he or she fails, it is because the child is at fault. The child must atone or work harder. Eventually, the child realizes that no matter what is done, the paradise will not be recaptured. It is this realization that brings about the depressed feeling.

In the self-blaming type of depression, this pattern is replayed in symbolic form. Some loss has been sustained, and the patient feels that his or her way of living has caused such a loss. This produces the manifest depressive symptoms. Arieti

 writes that in self-blaming depression, “the message the patient relays is not ‘help me,’ but ‘I do not deserve any help, any pity.’” He continues, “When suicidal ideas exist, the message is not, ‘you should prevent my death,’ but, ‘I deserve to die; I should do to myself what you should do to me, but you are too good to do it.’”

My experience has been that self-blaming depressed patients are deemed more difficult to work with and are thus more quickly referred for biological treatment than those with other types of depression. Yet, psychotherapy can be particularly effective for these patients, especially those with mild or moderate cases and those not complicated by comorbid mental disorder. The psychotherapeutic approach to self-blaming depression differs in significant ways from that used with other depressed patients, which I will discuss below.

In self-blaming depression, the patient comes to translate well-meaning, encouraging statements through a filter of self-accusation and guilt. Thus, for these patients, the therapist cannot assume the role of benevolent helper as they might in other cases. When offered kind reassurance and expressions of hope, self-blaming patients characteristically feel worse and more guilty, and reject the help. It is as if the patient says to the therapist, “I am unworthy of your help. Why can’t you see it?” McWilliams

 writes this about these types of patients:

Therapists often find that their efforts to improve their depressive patients’ self-esteem are either ignored or received paradoxically. Supportive comments to a person immersed in self-loathing may provoke increased depression via the internal transformation: “Anyone who 

 knew me could not possibly say such positive things.”

Other misinterpretations made by self-blaming patients, described by Frances,

 include some variation of: 1) “How nice you are; how terrible I must be”; 2) “How awful I am to fool you into saying nice things about me”; 3) “You would hate me too if you only knew how hateful I am”; and 4) “How dare you be hopeful when there is no hope.”

If the therapist is not supposed to offer hopeful or supportive statements, at least during the acute phase of the illness, then what is he or she to do? Arieti6 describes that an investigation of the family or relationship situation often reveals dynamics that increase the patient’s feelings of duty or guilt. For instance, a spouse may say to the patient, “You are too sick to do the housework now” or “For many years, you took care of me; now it is my turn to take care of you.” These statements are interpreted by the patient as criticism and only worsen the guilt feeling.

Eventually, it will become possible to point out to the patient that the losses and disappointments which have led to the depression are actually symbolic of earlier, greater losses and disappointments, and that the patient has come unconsciously to repeat these patterns in his or her adult life. Thus, interpretation of the meaning and symbolism of the depressive symptoms is of chief importance in the treatment of these patients—perhaps even more so than in other forms of depressive illness.

As treatment proceeds, the therapist must remain attuned to the ups and downs of the patient’s life, for any setback may trigger the state of sadness and guilt. For instance, the patient may get depressed over the fact that he or she becomes so easily depressed. At times, when the depression has improved, a relapse may occur if the patient is allowed to feel guilty for the allegedly undeserved improvement. At this point, the patient may become so discouraged by the relapse that he or she may abruptly discontinue therapy.

Throughout the treatment, the therapist must remind the patient that the minor disappointments of life—those to which the patient reacts so intensely—symbolize a much larger disappointment in early life, and that he or she is in actuality responding to an early loss of much greater and much more significant proportions. If this is not done—if the meaning of the symptoms remains uninterpreted and the focus of the treatment is solely on correcting cognitions—then the depression will be perpetuated.

Self-blaming depression reflects a unique subtype of depressive illness characterized by self-accusation, guilt, and an exaggerated sense of self-responsibility. Given its psychodynamic mechanisms, psychotherapeutic treatment of patients with self-blaming depression proceeds along different lines from treatment of other depressed patients. In particular, the therapist must be very carefully attuned to the patient’s tendency to interpret supportive statements as criticism and to the symbolic transformation of the early loss into present-day losses and disappointments. Psychotherapeutic treatment is possible and often effective in these cases.

is an instructor of psychiatry at the University of Central Florida College of Medicine in Orlando, and an adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts. He is a psychoanalytic psychotherapist in private practice in Tampa.

The heterogeneity of “major depression.”

The mistreatment of major depressive disorder

Diagnostic and Statistical Manual of Mental Disorders

 5th ed. American Psychiatric Publishing; 2013.

Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process

The psychic function of depression: a study in energetics

The psychotherapeutic approach to depression. 

7. @AllenFrancesMD. Other ways some self-blaming patients misinterpret well meaning reassurance: 1) How nice she is=How terrible I am 2) How awful of me to fool him into saying nice things about me 3) You would hate me too if only you knew how hateful I am 4) How dare you be hopeful when there's no hope. 

https://twitter.com/AllenFrancesMD/status/1430564200888168450

How does treatment for self-blaming depression differ from treatment of other types of depression?

Self-Blaming Depression: Theory and Technique

 is a leading cause of suffering and disability worldwide, affecting about 1% of the global population, community services for those with chronic schizophrenic illness are lacking in many areas. As a result, the emergency department (ED) often becomes a primary location for care of this severe mental disorder.

With our combined experience as an emergency medicine physician with interest in the management of acute psychiatric presentations (Furiato) and a psychotherapist with interest in the psychotherapy of schizophrenia (Ruffalo), we believe a psychologically (and psychodynamically) informed guide to the management of schizophrenia in the ED that incorporates relevant research from pharmacotherapy, psychology, and 

 can be very useful in the acute care of these patients.

Attempts to distinguish schizophrenia from the psychotic symptoms that occur in other mental and medical disorders date at least to Kraepelin’s pioneering work in the late 1800s. Another German psychiatrist, Kurt Schneider, proposed the “first-rank symptoms” of schizophrenia in 1939, and his theory held widespread popularity throughout the 20th century (

). A recent Cochrane review of Schneider’s first-rank symptoms (FRS) concluded that FRS correctly identifies individuals with schizophrenia 75% to 95% of the time.

 While reliance on FRS alone may not be sufficient to diagnose schizophrenia,

 recognition of FRS can aid ED physicians and mental health workers in the triage and care of patients presenting with psychotic disturbance.

Patients presenting to EDs may be well-known to ED staff; the course of schizophrenia is generally chronic and, in many geographic regions of the United States, comprehensive mental health systems are sorely lacking. In cases wherein the patient is a poor historian, or past records are otherwise unable to be obtained, reliance on clinical skill, such as knowledge of FRS, is necessary to ascertain the diagnosis of 

In certain instances, such as a clinical suspicion of new-onset schizophrenia or abnormal neurologic exam findings, use of brain imaging may be necessary to rule out organic disease of the nervous system. While a comprehensive review of brain imaging in psychosis is outside of the scope of this paper, Coentre et al

 note that neuroimaging is particularly useful in first-episode psychosis when patients are elderly, have neurological symptoms, or have an atypical clinical picture.

In the ED setting, the first and most important consideration upon presentation of the acutely agitated patient with psychosis or schizophrenia is the level of risk of harm they pose to themselves and staff.

 The resulting answer will help determine the route and type of medication for the specific patient. Speed of onset can dictate the route of administration, as those who are violent will need more rapid calming. These therapies should be used with verbal de-escalation techniques or directly after such attempts have failed.

Benzodiazepines, which are pharmacologically active on the gamma-aminobutyric acid (GABA) receptors, act on the central nervous system and are among the most common medications used for calming and sedation in the ED.

 The largest concentrations exist in the thalamus, cortex, and cerebellum. There are many different subclasses of GABA receptors, including the main α- and β- subunits. The biochemical neurotransmitter effects include reversable binding of the excitatory neuroreceptors and neuronal firing. The primary clinical effects are anxiolysis, 

 are also commonly used as the first-line agent of emergency treatment of seizure disorders and epilepsy.

 Potential adverse events include respiratory depression, hypoxia, hypotension, and paradoxical excitation reaction in those with organic brain disease. Depending on the lipid solubility of the agent and route of metabolism with patient comorbidities, half-lives vary widely (

 Common Benzodiazepines Used in the Emergency Department

Patients who are successfully verbally calmed and de-escalated can be considered for therapy with oral management with benzodiazepines alone or in combination with antipsychotics. Intramuscular medications combined with antipsychotics, often with the help of physical restraints, are used for those patients who cannot be de-escalated and pose a risk of injury to themselves and staff.

The 2 main categories of antipsychotics in the emergency setting are first-generation (typical) and second-generation (atypical) agents. The class distinctions are mostly important because of the associated adverse effects.

 First-generation antipsychotics were developed for the treatment of schizophrenia; they act on the multiple dopaminergic receptor, anticholinergic, and histamine pathways. Each drug has its own mechanism of action and level of antagonism of those pathways.

The hallmark first-generation drug is haloperidol, commonly used in the ED. It has been used with great success in treating the positive symptoms of schizophrenia. One of its main limitations, and ultimately a reason that prompted the development of the second-generation drug class, consists of extrapyramidal symptoms such as tremor, slurred speech, akathisia, dystonia, and 

The second-generation class of medications further treats the negative symptoms of schizophrenia and improves upon the adverse event profile of the first-generation group.

 Olanzapine and ziprasidone are common second-generation antipsychotics used in the ED. Significant adverse event of the second-generation drugs include sedation, hypotension, 

Many of the antipsychotics can be administered by mouth to those who are receptive to such and calm enough for safe administration. Antipsychotics can also be administered by intramuscular and intravenous injection for those who are severely agitated.

 Careful observation of the patient’s respiratory status by cardiac monitoring and continuous pulse oximetry must be done after administration, as adverse event can also include respiratory depression and hypoxia. The regular combination of benzodiazepines and antipsychotics can compound this risk. In addition, many of the antipsychotics can have adverse cardiac electrophysiologic effects, including prolonged QT intervals and the development of ventricular tachycardic arrythmias, necessitating electrocardiogram screening once the patient is chemically calmed.

 and antipsychotics used in the ED include lorazepam plus haloperidol or ziprasidone; and midazolam plus haloperidol or ziprasidone. The addition of the antihistamine diphenhydramine is also sometimes added to the aforementioned 2-drug cocktail for patients who are extremely violent. This practice is falling out of favor as seen in a recent retrospective cohort study.

 has also been examined for the acute management of the violently agitated patient.

 Ketamine is a dissociative agent that works at the N-methyl-D-aspartate (NMDA) receptor, which is thought to play a partial role in the development in schizophrenia. Ketamine, when given intramuscularly, can produce more rapid de-escalation and sedation vs the more traditional method of benzodiazepines plus an antipsychotic.

 The drawback to the use of ketamine is the theoretical possibility of exaggerating schizophrenic episodes due to activity on the NMDA receptors. There does not appear to be an increased need for inpatient psychiatric admission or ED psychiatric evaluation vs the traditional therapy.

 More research is needed to further assess the use of ketamine in the acute agitated schizophrenic patient.

Schizophrenia is a complex, multidimensional problem that requires appreciation of both biomedical and psychosocial aspects of disease management. This is true not only in the psychiatric treatment setting but also in the ED, since patients with schizophrenia may exhibit the most severe symptoms in the acute care setting.

Of greatest importance, perhaps, is the recognition that the patient’s heightened state of 

 has contributed to their current psychotic disintegration.

 The patient with schizophrenia often feels alone and afraid, isolated, and without any sense of basic trust or security. The threat of interpersonal contact is too much for them to bear, so they escape even deeper into their psychotic world. Care must be taken to avoid any unnecessary situations in which the patient’s anxiety is increased, as this will only worsen the psychotic symptoms.

Any attempt to challenge or question the validity of delusional themes will result in utter failure, so the ED clinician must avoid these types of confrontations. At the same time, the clinician should not tacitly agree with the patient’s deluded ideas but instead explain empathically that there are reasons they are experiencing things differently. Again, the clinician must do everything they can to foster an environment in which some semblance of trust can be established. For the patient who is mute or otherwise difficult to engage in an interview, speaking about neutral subjects, such as the weather or sports, may help alleviate anxiety and open up the patient to answering some basic questions.

While it is, of course, necessary to gather some information from the patient to establish a history and determine appropriate disposition, the patient with schizophrenia may experience too many questions as an imposition. As Silvano Arieti, MD, noted, “The request for information is often interpreted by the patient as ‘an attempt to take something from him.’”

 The aim of the ED interview should be less the collection of detailed information and more of a process of relating to the patient, while gathering an assessment of current symptoms, an attempt to relay a sense of warmth, security, and trust which will serve as the foundation for ongoing treatment.

As previously discussed, the administration of psychotropic medications in the ED is sometimes necessary to stabilize an aggressive or violent patient. In these cases, the ED physician and mental health professional should maximize the patient’s sense of autonomy and self-determination; for example, the staff can allow the patient to choose the route of administration. Most likely, the patient feels that they have been violated in some way—either due to intrusive voices, paranoia, somatic delusions, or some other terrifying symptom—so the ED clinician should attempt to avoid coercion to the greatest degree possible.

Lastly, in many cases of schizophrenia, psychotic symptoms are ongoing, sometimes in spite of good pharmacological and psychotherapeutic management. The mere presence of psychotic symptoms in a patient who experiences such symptoms at baseline does not warrant 

, and it is unlikely that any such admission would do anything to improve the patient’s chronic illness.

Schizophrenia is a complex, disabling condition that presents a challenge to psychiatric and emergency medicine providers alike. Due in part to the lack of a comprehensive mental health system in the United States, patients with schizophrenia frequently present to the ED for diagnosis, treatment, and acute stabilization. Knowledge of diagnostic, pharmacological, and psychosocial elements of schizophrenia is essential for competent ED care. Of chief importance is the recognition that the patient with psychosis is in a psychologically vulnerable state, worsened by anxiety, and improved with understanding, empathy, and evidence-based symptom management.

 is the program director of the emergency medicine residency at Brandon Regional Hospital and an assistant professor of emergency medicine at the University of South Florida Morsani College of Medicine in Tampa, Florida. He currently practices emergency medicine and specializes in substance use disorder care in the emergency department setting in Brandon, Florida.

is an instructor of psychiatry at the University of Central Florida College of Medicine in Orlando, and an adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Masschusetts. He is a psychoanalytic psychotherapist in private practice in Tampa.

1. Soares-Weiser K, Maayan N, Bergman H, et al. 