(There is a need to address the growing "generation gap" in our field between older psychiatrists, who have had substantial training in traditional psychodynamic psychotherapy, and their younger colleagues [the profession's heirs], whose education has been predominantly biomedical. The following was a response by Dr. Genova to an article critical of psychodynamic psychiatry and its practitioners, written by an articulate psychiatric resident, that appeared in a local newsletter. Some of the resident's objections are summarized in italics for the sake of clarity-Ed.)

I liked the energy, courage, critical thinking and fine writing style of your piece on psychodynamic education in residency. I encourage you to write more; the profession needs articulate voices desperately. I do, however, need to dis-abuse you of some of your notions about the cushy and complacent life of a psychodynamic psychotherapy-oriented psychiatrist in the year 2000!

(The resident questioned the relevance, for his high-pressure world, of the perspective of certain psychodynamically oriented attending physicians who appear to practice in "clean" and insular outpatient settings, and who appear to be less than rigorously scientific in their thinking-Ed.)

Recalling the hard and often thankless work of psychiatric residency, and the ethereal world some of the attendings seemed to inhabit while we house officers dealt with (as you so well describe it) the "dirt, smell and unpredictability" of emergency room and hospitalized patients, I can easily identify with some of the resentment expressed in your article. Unfortunately, your anger is misdirected at a caricature of psychodynamic psychotherapy as it should be practiced and its faded status in psychiatry today, and also at a mistaken idea of how most of us attendings apportion our time. More important, its conception of the sorts of mental rigor necessary to begin to understand patients is overly narrow.

The (unfair) fact is that medical training is a hierarchical system and residents are at the bottom of it. This is as true of the other specialties in a tertiary setting as it is in psychiatry. The mental health care system, in particular, often throws its least experienced people at the hardest cases in the middle of the night. This resembles, as a teacher of mine who died a few years ago put it, "Learning to paint by starting with the Sistine Chapel." Although I might not have your physical stamina anymore, I know that I would certainly do a far better and more efficient job in the ER or on the ward now than I did as a resident...if I could stay awake. It is a lot harder to come up with a way to change the perennial initiation rite (or blood sacrifice!) of training young doctors than it is to get angry at those of us who are a few rungs higher on the ladder and can choose our battles and when we fight them. Someday soon, a young resident will resent you for the same reason. Try to find a way to help him or her. 

(The resident imagined that most psychodynamic psychiatrists have little or no contact with severely ill patients-Ed.)

What is life for a psychodynamically oriented attending like? Most of us today spend a good deal of time doing medically oriented work with people with major mental illnesses, either in clinics (as I do) or as part of their private practices. I have always worked in such settings, feeling that 1) the perspective thus gained is invaluable for treating anybody; 2) my medical skills need to be maintained, again, for use in treating anybody; 3) my own personality just does not "fit" well enough, in the intimate context of traditional psychotherapy, with all patients; and 4) I would have nothing left over emotionally for my family if I did therapy all day, every day.

(The resident also has the mistaken impression that doing psychodynamic psychotherapy today is an easy way to make a lot of money-Ed.)

If I were interested in a lucrative psychiatric career, I would close my therapy practice now. I estimate that it costs me 20,000 to 30,000 a year to not do a routinized, prescription-driven, managed-care-friendly practice or simply take a full-time job (psychiatrists from other regions may give different figures). The psychiatrists I know who still seriously practice traditional dynamic psychotherapy, especially outside the few major cities where psychoanalysis remains strong, confirm my experience. They also confirm my conviction that it is worth every penny to do work that we love.

(The resident complained that some of his compatriots are eager to get through psychiatric training so they can call themselves "therapists" and leave medicine, and the need to keep abreast of the current medical literature, behind-Ed.)

In contrast to your perception, I do not find that most residents today really want to learn psychodynamic therapy. I have a hard time scraping up one per year from our local program who is willing to read some of the classic primary texts (there are more than a "handful" of such texts, by the way) or even newer books, to bring in process notes or tape recordings, or to really look at their own personal issues and how they influence the therapy process. It's sobering to find out that you've done all this science- and technology-oriented training, you have your M.D. or D.O., and none of it equips you to understand individual life stories and how they unfold; how personality develops, normally and pathologically. You may consider these latter concerns to be outside your chosen domain. They are often necessary concerns in effective psychiatric treatment, nonetheless.

And if one does want to do anything other than procedural psychotherapies (imitative of other procedures in medicine)-like the manualized ones whose studies you are willing to endorse-and med checks, one has to understand these things. Double-blind evidence is of very little help. So, if one wants to do this sort of work, in which preconceived notions take a back seat, one begins at the beginning again. If you happen to find any residents who are interested, send them my way! 

(The resident cited the so-called "Woody Allen syndrome" of excessive dependence upon therapists among the more affluent social classes and wonders whether psychodynamic psychiatrists cultivate such dependence as a means of maintaining a comfortable work life-Ed.)

Few people where I live can afford the 2,000 to 6,000 per year out-of-pocket investment that traditional psychotherapy typically represents (again, local figures will vary) just to maintain an "umbilical bond" indefinitely. They want to get better, too, and leave when they do. (In my own practice, this is typically anywhere from six months to three years after starting, and some will then "check in" every few months in an ongoing way.) I may miss seeing them, but I am happy for them and for having done my job well. The kind of improvement they experience is often cost-effective in terms of reduced future expense on medical and/or psychiatric treatment, as offset studies have apparently shown (and as my personal experience of 15 years practicing in one place has definitely shown). This is because underlying factors behind the superficial syndrome-and-symptom presentation, or intertwined with a major psychiatric illness, have been addressed more definitively.

The phrase "worried well" has always struck me as a particularly compassionless insult to highly functioning patients and psychiatrists who treat them. Sure, there are a few narcissists out there with the resources to purchase ego-bolstering services on demand, indefinitely, from dishonest therapists. Precious few in this area, I fear, and none of them in my practice-at least, not for very long!

Highly intelligent, productive people who earn good incomes can be abjectly miserable, too-and psychiatrically ill (about 50% of my private therapy patients are on psychotropic medications). When their lives go better, the world becomes a better place for their children, their employees, their patients, their clients. The decisions they make affect all of us. And their problems aren't so different from those of clinic and hospital patients, just the resources they have to deal with them. Sometimes, their resources and their class privilege even get in the way of appropriate treatment.

As a once-famous psychodynamic psychiatrist (Harry Stack Sullivan) said, "We are all more human than otherwise." And since you speak of smells and needing to endure them, I might venture the question of which smells worst: a homeless psychotic patient in the ER, or a wealthy businessman who refuses to take any personal responsibility for his out-of-control teen-ager and comes seeking "stress management" to help him cope with the result of his neglect? The ugliness we sometimes encounter transcends outward appearances.

(The resident opined that controlled clinical trials should be the gold standard not only in psychopharmacology, but in choosing and conducting any form of psychiatric treatment-Ed.)

If Sullivan was right, then we psychiatrists need to be human and to understand humans. The sort of intellectual rigor we need in thinking about the human condition goes far beyond that of clinical trials on "pure" forms of syndromic illnesses in academic settings. Evidence comes in many forms, and it falls to us practitioners to decide which kinds are relevant to the practice we choose to pursue. I read a lot of mainstream journal-article stuff and continually read in many other areas as well (a "handful of texts" isn't sufficient for any physician or therapist). Science also comes in many forms: from the double-blind trials that dominate academic psychiatric thinking today to the naturalistic observational tradition of Charles Darwin, Donald W. Winnicott (pediatrician/psychoanalyst), Daniel Stern (infant researcher/psychoanalyst) and Oliver Sacks (neurologist/writer). All of it is useful to me. Clinical trials have no special monopoly on the high intellectual road and certainly not on the truth about suffering people. Novels, philosophy, anthropology, sociology and economics are all useful to me in daily practice.

Do I ask every psychiatrist to always consider all of this or to think like a psychodynamic therapist? No, and I don't even ask this of myself at all moments. But any psychiatrist does need some awareness of just how complicated people can be, and some perspective on the limitations of his or her own preferred way(s) of thinking about, and working with, human beings. That is what is best for our patients.

Dr. Genova practices in Maine and is clinical associate professor of psychiatry at the University of Vermont. His book The Thaw: 24 Essays in Psychotherapy 

(Dorrance, 2000) is available at online booksellers.

Articles

Letter to a Young Psychiatrist: Confessions of a Psychodynamic Attending

Charles River Hospital, a 62-bed psychiatric facility in Wellesley, Mass., followed the trend of dozens of institutions, medical groups and some insurance companies last June. The hospital filed for bankruptcy.

By itself, one small hospital's financial woes would not be significant. But, Charles River typifies America's health care system, which many analysts believe is on the brink of financial disaster.

Thirty-five years of federal regulation through Medicare and a decade of radical cost-cutting by managed care companies have left many physician groups, hospitals and nursing homes struggling for survival. Some of the nation's largest health providers have been forced to seek protection in the bankruptcy courts.

" Thirty percent of the nation's hospitals are operating in the red,"  said Rick Wade, senior vice president of the American Hospital Association, in an interview with 

In California, the state medical society maintains a watch list of practice groups and medical groups that are teetering on the brink of collapse. In 1999, 19 groups representing 9,173 physicians filed for bankruptcy, closed their doors or were sold. Through the first nine months of 2000, six more medical groups have filed for bankruptcy, and two more have closed. Another merged, and still one other left its home county.

In New Jersey, more than 2,000 physicians are finally scheduled to begin receiving payments from a state-administered fund set up after the 1998 failures of two of the state's HMOs. Other HMOs have filed suit to block distributions from the fund, which is dependent in part on assessments levied against the industry.

Since the beginning of 1999, 1,857 skilled nursing facilities-more than 10% of the nation's total-have filed for bankruptcy. According to U.S. congressional testimony, almost half of the nursing homes in New Mexico and Nevada are operating in bankruptcy, and 12 other states have more than 20% of their nursing homes operating in bankruptcy.

Not far from Charles River Hospital, once-powerful Harvard Pilgrim Health Care, built on the framework of the famed nonprofit Harvard Community Health Plan, lost its financial battle at the end of 1999, when it was forced into receivership.

University of California, Los Angeles Healthcare acknowledged to the 

5 million in fiscal 2000, down from 51 million two years earlier. The institution has been engaged in a protracted dispute with many local physicians over its efforts to survive through expansion.

Meanwhile, health care providers in California pressured the state's legislature into creating a state department of managed care, designed to serve as a watchdog over the industry. The new agency will have the power to force managed care organizations to pay providers promptly and to arbitrate disputes between providers and third-party payors. The state's hospital association said that its 450 members had more than 

1 billion in bills more than 60 days old that were owed by health plans.

In short, the health care system is in trouble. Widespread bankruptcies and financial failures are leading to mergers in some regions and shutdowns in others. Communities are facing the closure of hospitals and nursing homes, and local physicians are questioning the sense in continuing to practice.

Managed care receives a substantial amount of the blame for the dire straits of health care institutions and providers, but it is not the only culprit. Analysts also blame the government's decision to reduce payments under the federal Medicare program as part of the Balanced Budget Act of 1997(BBA). More devastating was the government's decision to recapture money that had been paid under the old rules, money that officials claimed was overpaid by applying the 1997 act.

" Another factor is all of the fraud and abuse investigations,"  Nancy Peterman, co-chair of the American Bankruptcy Institute's (ABI) Healthcare Insolvency Subcommittee, told PT. " The government is coming in and levying a lot of fines or requiring payback of overpayments. The BBA of 1997 established new rates and then said providers had been overpaid for three years and would have to pay it back. It just wasn't feasible for most of these companies." 

Peterman said that the rate of bankruptcies grew so rapidly that the ABI published a handbook on how to handle health care insolvencies. " We saw the government start slashing reimbursement rates for Medicare. But there were also what you would call normal reasons. A lot of health care companies started thinking they needed to get bigger, either by going public or through acquisitions, and then having difficulty integrating the businesses. In some states, nursing homes had too many beds, and some hospitals did, too." 

Glenn Melnick, an economist at the RAND Corp. in Santa Monica, Calif., and a professor of economics at the University of Southern California, explained to PT that the wave of bankruptcies and financial instability-like managed care itself-started in California and is spreading east.

" We believe that California is the bellwether and laboratory for the rest of the country,"  Melnick explained. " Some of these trends are fairly extreme right here in California and have been for the last few years. Now we're seeing similar events in other parts of the country.

" The wave is finally hitting the East Coast shores,"  he said. " Managed care is starting to take a bite out of the health care establishment on the East Coast, where there still is a lot of excess in the system in terms of higher utilization, higher per capita costs. We're going to see much bigger impacts than here, because California was always a fairly slimmed health care system. It was a low-utilized state. As you move east you find a much richer utilization of services." 

Melnick added that a combination of factors led to California's woes.

" In California, we have tremendous competition among health insurance companies. They've been competing on price for the last five to eight years. Their profit margins fell and turned negative in a lot of cases, so they put the squeeze on the providers, both hospitals and medical groups.

" There were two sets of reactions. In the hospital sector, the squeeze hit first. We saw hospital financial performance really deteriorate. Since that time, there have been a lot of mergers and consolidations to maintain leverage, and some leveling out of the financial performance of hospitals. The BBA of 1997 cuts to Medicare and other programs hit hospitals pretty hard. Now the government is considering giving back additional funds.

" On the medical group side,"  Melnick continued, " We initially had very large medical management companies moving into California, buying practices, consolidating the market, trying to gain leverage with managed care plans. It was a spectacular failure. Most of the companies were not well-managed, not well-conceptualized and never really able to achieve efficiency or pricing goals. One group had literally thousands of doctors who were affected by its bankruptcy, as well as over a million enrollees." 

Melnick said that the collapse of MedPartners, an Alabama-based practice management company that was taken over by the California Department of Corporations in March 1999, was " almost like an earthquake or a ricochet. It broke up into a lot of smaller groups. A number of them are still floundering. The situation hasn't yet stabilized. We continue to see additional pressure and the failure of additional medical groups in the state." 

Practice management companies, like MedPartners, were formed by outside investors to provide doctors with some leverage in dealing with managed care companies. By combining several regional groups of physicians, they were able to negotiate capitation payments for large patient populations. 

A Kaiser Family Foundation briefing paper noted, " Capitation payments...generated higher net revenue for many of these groups than what they had received through fee-for-service reimbursement, since larger medical groups could retain greater savings from their utilization management practices." 

When the pressures for cutting costs swept through the managed care companies in the early 1990s, the practice management companies bore the brunt. The Kaiser report concluded, " Increasing numbers of managed care enrollees and lower capitation payments has made full-risk contracting a high-risk venture for many provider groups....The insolvency of physician organizations may jeopardize the quality of care patients receive and threaten the stability of the health care system." 

Peterman explained that the cumulative effect of managed care and government reimbursement cuts has been to shift risk from the insurance companies to providers. " Normally a company's cash flow is impacted by its relationship with a lender, such as a bank. The federal government also is putting cash into these companies. If they change the rates they're paying, it's like you're losing a loan. You have that much less. With the BBA of 1997-and, before that, the new model of managed care-all the risk is being shifted away from insurance companies and onto physician practice management companies, which were getting capitation payments. With the cuts, the capitation payments were not high enough, so the companies weren't able to service all their enrollees. That change, that risk-shift, also impacted the industry." 

Wade argued, however, that there is a more fundamental problem in treating health care as a traditional business. " We're not an industry,"  he stressed. " We don't manufacture anything. For the most part, we don't choose the hours at which we operate, and some of our customers don't have any money. We're social institutions that have a strong business imperative to operate well and profitably-even nonprofits, which have to stay in the black-to operate in a business-like manner. We operate many services that lose money in our communities and cross-subsidize with services that pay well. 

" Meanwhile, every level of government is trying to find a way to pay us less. The insurance companies and the managed care companies use three strategies to save money: low pay, slow pay and no pay. They can do this because they know a hospital has an obligation to stay and serve its community and to solve these problems. Insurance companies and managed care companies can move in and out of markets at will. Hospitals don't have that option, nor would they want to." 

" Physicians are severely impacted,"  said Peterman. " In a lot of these cases, doctors have contracted with the practice management companies or sold their practices outright. They really own nothing. They're supposed to be getting these payments back, but the payment streams are going to be drying up. It has been very tough on the physicians." 

Melnick agreed that there is not much optimism for the immediate future. " For doctors, it is not a rosy picture. To the extent managed care does move across the country, it reduces utilization of services. That in turn reduces the demand for providers giving those services. The demand for services will go down while supply, in the short run, is relatively fixed. Physicians will continue to see little or negative growth in incomes, depending on the local situation. A number of physicians' associations have proposed legislation to allow doctors to collectively bargain because they see the trend continuing and maybe accelerating if managed care gets steam across country." 

Ultimately, most experts believe government will have to step in to solve the financial woes of the health care delivery system. Wade said, " A number of people acknowledge the scope of problem, but the level of agreement that you could get on the scope of a solution is hard, because it could take you toward rationing and some other things that are very difficult to develop a national consensus on. We don't have a national health program at the moment. We're careening without a direction. Is it national health policy that we should have coverage for everyone, like a national health insurance? That's beginning to be talked about as a positive, but there's not much support for it yet." 

Peterman also pointed out another group that could be impacted by the financial crises in the health care system. " In a bankruptcy, the one group that's not represented in these cases are the patients,"  she noted. " There have been a lot of controversies over that issue. If a company is in bankruptcy, if it is no longer paying the physician the capitation amount, is the physician no longer required to see patients? The patients have no standing in these cases."   

Is Our Nation's Health Care System Collapsing?

Known as "the cancer of mental illness," schizophrenia can core a life, robbing a previously well-functioning person of what made the person uniquely them. Often, someone with chronic schizophrenia loses the capacity to cue into the basic signals of everyday life. The bizarreness so often evident with these individuals may be due to the lack of relatedness to others and the world that is rooted in this flaw, as much as it is due to the more obvious psychic perturbations caused by delusions and hallucinations.

For patients with schizophrenia, the most common signs of relapse are auditory and visual hallucinations, delusions, bizarre and sometimes violent behavior, paranoia, and insomnia, as well as decreased social interaction, poor hygiene, apathy and the inability to attend to the basic tasks of daily living.

From the many patients with schizophrenia I evaluated in the emergency room, I elected to tell Kim's story because it shows what this devastating psychiatric disorder can do to a person. How someone once healthy and highly functional can, during the gravest exacerbations of this illness, be reduced to thoughts, feelings and behaviors that are barely recognizable as human.

Kim was brought to the ER late one evening by the police on emergency petition. Several weeks earlier, the house she lived in and owned was damaged by a fire caused by an electrical short. It was October, but Kim had been living in the house without phone service, electricity, heat or hot water. Earlier that evening, a neighbor who knew of Kim's chronic mental illness, and had observed her during periods of relapse, noticed a candle burning in a darkened window. Thinking that the open flame might lead to another fire, the neighbor called the police.

Kim, 38, was born in the United States to Chinese parents, who returned to Taiwan after her father finished his medical training. Kim and her siblings remained in the United States. She graduated from a prestigious women's college and earned a master's degree in human development. Her marriage to an Asian man ended in divorce. She had not been employed for some time.

Kim was first hospitalized at the age of 26 with what was diagnosed as a psychotic mood disorder. It is not clear when the schizophrenia diagnosis was made. The records available to us did not provide any information about the early course of her illness, but they noted hospitalizations in 1992 and 1994, as well as admissions to our hospital in May and August of 1995.

When I entered the room to begin the evaluation, Kim was sitting on a gurney with a sheet pulled up around her. Her appearance belied what she was soon to reveal about herself. She was short with dark shoulder-length hair that was well cared for. This young woman was in no apparent distress and would have stood out in a crowd only for being attractive. Ontically cored, her outer shell seemed intact.

Kim knew who she was, where she was and the date. Asked about her mood, she replied that she felt "fine" and denied being depressed. She also denied having any intention or plan to hurt herself. Her records made no mention of any past suicide attempt. She had no significant medical history or current medical problems. She denied abusing alcohol or ever using illicit drugs.

Kim stopped taking her medication, she told me, because she had died in the recent fire and had been reborn with a new body and a new head, so she no longer needed to take the medication that her former body required. (In fact, she was not injured in the fire.) She told me that God speaks to her directly, not offering any further details. "I can see Europe," she said. "I have very different eyes." Her answers to even the simplest questions revealed strong underlying psychotic processes. "I am an Oriental woman. I eat and I sh*t. I don't know about American women." I cannot recall what question I might have asked to elicit that response.

I contacted the psychiatrist who had been following Kim for some time. He pointed out that her behavior in the ER was not very different from her recent baseline behavior. None of the neuroleptic medications tried, including fluphenazine (Prolixin), perphenazine (Trilafon), risperidone (Risperdal), pimozide (Orap) and clozapine (Clozaril), had benefited her significantly. Lithium was added to several of these neuroleptics, also with little effect. After her recent hospitalizations, Kim had been quick to go off whatever medication she was started on. The reason she gave me for doing so this last time was clearly delusional.

Kim had not responded noticeably to individual psychotherapy or benefited from the therapeutic opportunities offered by her most recent hospitalizations. She seemed drawn into a fragmented world out of which no intervention had any power to draw her out.

In spite of her obvious psychotic state, Kim's psychiatrist felt it was doubtful she would benefit from being hospitalized at this time. (She had come to the ER solely on a neighbor's assumption that a lighted candle in a house without electricity portended danger.) The psychiatrist felt she could be discharged, and he agreed to see her the next morning. He planned to restart her medication.

A man described as Kim's boyfriend came to the ER and volunteered to escort her home. He claimed to be negotiating with the insurance company on her behalf for a settlement on the fire damage to her house and to be making arrangements with contractors to have repairs made. A notation in the chart, however, raised questions about this man's integrity and stated there was reason to believe that he had already stolen 23,000 from her.

Three weeks after I discharged Kim from the ER, she was hospitalized on the inpatient psychiatric unit. And again five weeks later, and eight weeks later, and 12 weeks after that. Following each discharge from the hospital, she would stop taking the medication that was restarted.

The records showed that Kim was more grossly psychotic during these hospital stays than when I evaluated her in the ER. More withdrawn. More delusional. More hallucinatory. More disorganized. More thought-disordered. Asked a question, she seemed to respond to another question. She could still speak in full sentences, but the words made no sense.

Here are some of the delusional statements attributed to Kim during the four inpatient psychiatric admissions that followed in close order after my ER evaluation: "I am the Virgin Mary" (She then added, "The one thing I really enjoy is sex." Her pregnancy test on the admission five weeks after my ER evaluation was positive, and she had an abortion shortly after.); "God was downstairs in my house"; "The Virgin Mary [i.e., Kim] doesn't need electricity, heat or phone service [all absent from her house after the fire] because she lives on a higher plane"; "I am a Jew [her chart notes she is Presbyterian]"; "George Bush keeps running into my house"; and "I'm so superior to everyone."

During the hospitalization 12 weeks after the ER visit when I evaluated her, Kim reported these hallucinations: "Jesus told me I'm his mother"; "God touched me in my sleep"; and "I have communications with Joseph, and he tells me I'm his wife."

Prior to this hospitalization, Kim was seen begging for food from her neighbors. It was clear that she could no longer take care of herself. Adult Protective Services was called to investigate and was asked by the staff on the inpatient unit to look into the possibly exploitive relationship between Kim and her boyfriend. Other instances of Kim's disorganized behavior documented in the chart months earlier included her planting flowers in neighbors' gardens (without being asked to do so) and running nude through the alleys of her neighborhood.

During her last admission to our hospital, Kim was restarted on clozapine. She remained grossly psychotic, delusional and thought-disordered. It was felt by the staff that she needed intensive, long-term inpatient treatment, and she was transferred to a state mental hospital.

 Andreasen NC (1999), Understanding the causes of schizophrenia. N Engl J Med 340(8):645-647 [editorial; comment].


 Arieti S (1974), Interpretation of Schizophrenia, 2nd ed. New York: Basic Books. Carpenter WT Jr., Buchanan RW (1994), Schizophrenia. N Engl J Med 330(10):681-690 [see comments].


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 Vonnegut M (1988), The Eden Express. New York: Dell Publishing.


 Winchester S (1998), The Professor and the Madman: A Tale of Murder, Insanity, and the Making of the Oxford English Dictionary. New York: HarperCollins Publishers.


 Wyden P (1998), Conquering Schizophrenia: A Father, His Son, and a Medical Breakthrough. New York: Alfred A. Knopf.

Known as "the cancer of mental illness," schizophrenia can core a life, robbing a previously well-functioning person of what made the person uniquely them. 

Decompensated Schizophrenic Patient in the ER

A Tibetan monk was arrested and imprisoned by Chinese authorities after peacefully advocating for Tibetan independence. In repeated interrogations, the 32-year-old man was subjected to torture that included beatings; electric shocks from a cattle prod repeatedly applied to his mouth, abdomen and genitals; exposure to extremes of heat and cold; near suffocation by being placed in a plastic bag; and restraint in painful positions for hours. After his release, he fled across the Nepali border, made his way to India and then to New York City, where he was referred to the Bellevue/New York University (NYU) Program for Survivors of Torture.

He was diagnosed with pulmonary tuberculosis and was hospitalized for several weeks. He was also evaluated by a program psychiatrist and psychologist, who diagnosed him with depression and severe posttraumatic stress disorder (PTSD). He was placed on antidepressants and anti-anxiolytic medication and showed a marked improvement in his symptoms. He also began supportive therapy. Since his hospital discharge, he continues to be seen regularly by the program (Keller et al., 1998).

To help meet the needs of the estimated 400,000 torture survivors living in the United States today, the U.S. Office of Refugee Resettlement (ORR) will distribute $7.3 million in grants to 10 to 15 of the nation's most comprehensive torture treatment centers. The funding is a result of the Torture Victims Relief Act (TVRA), legislation passed by the U.S. Congress in 1998. Furthermore, President Clinton has requested that Congress approve another $9.8 million in grants for next year, according to an ORR spokesperson.

"All of us [centers] around the nation have been working so hard to get TVRA passed and the funding available," explained Edna Impalli, Ph.D., to

 Impalli, a clinical psychologist, is the clinical and education coordinator of the Bellevue/NYU Program for Survivors of Torture. "The population of survivors of torture is huge, and we need all the help we can get."

Impalli, along with a psychiatrist, co-facilitates a support group for Tibetan survivors. She explained that since March 1995, the Bellevue center has provided multidisciplinary care to about 450 torture survivors and their families from 52 different countries (about one-third are from Africa), in addition to conducting research and providing training to health care professionals and resettlement workers. Based in the primary care medical clinic, the torture center utilizes primary care doctors; psychiatrists and psychologists; gynecologists; rehabilitative physicians; occupational, physical and art therapists; and social workers.

The center was founded with hospital funds and donations from various private foundations and government agencies. All physicians and psychologists in the program have faculty appointments at NYU School of Medicine, and the program draws on other medical center resources including the Rusk Institute of Rehabilitative Medicine. For patients who do not have insurance, a sliding fee scale is arranged. For patients who cannot afford treatment at all, fees are waived.

Impalli reported that an estimated 5% to 35% of all refugees coming to the United States from countries where torture is systematically practiced have been tortured. There are an estimated 75,000 to 90,000 torture victims in New York City alone, making it one of the nation's largest such concentrations. In 1999, about 1,600 clinical visits were made to the program.

Impalli said that in July 1999, the program received a $400,000, two-year grant from ORR to provide 26 training sessions a year to health care professionals and resettlement workers about health and mental health care issues.

"All along, we'd been providing training sessions to immigration officers, presenting at Grand Rounds and other forums at medical schools, law firms and universities in the New York metropolitan area and across the country. And in 1998, we held two conferences-one for medical students and one for psychiatrists and other physicians-on how to get involved in providing documentation for asylum applications of torture survivors. This is a critical issue and one way psychiatrists can really help is to get involved in learning how to do these evaluations and providing them when needed."

With last year's ORR funding, the program expanded its training efforts. Program staff have already conducted more than 20 training sessions and workshops for health care professionals. The program also co-sponsored a training conference for these groups in March.

"We're trying to reach out to anyone who may come into contact with torture survivors and traumatized refugees and would like to receive training in evaluating and treating these individuals," Impalli explained. "We can provide consultations for those already working with these patients or conduct training for groups of psychiatrists who would like to learn about this population."

Impalli reported that the program's mental health treatment team now includes two attending psychiatrists, seven full- and part-time senior clinical psychologists/supervisors, and 20 psychology interns and externs.

"A large number of our clients come in first for non-psychiatric medical problems because it's more acceptable to them culturally to ask for that kind of help rather than mental health assistance. But we always try to provide initial assessments by a mental health professional and primary care physician within the first several appointments. Not all patients recognize the need for mental health services, but in our program, we are seeing increased utilization [for mental health services] each year," Impalli explained, adding that such services were provided to about 130 clients in 1999.

Presenting physical sequelae include broken bones, joint and muscle pain, headaches, dizziness, burns, neurological damage, hearing loss, loss of sensation, and tuberculosis. Psychological and emotional sequelae include memory disturbance and difficulty concentrating, sexual dysfunction, emotional irritability, social withdrawal and loss of trust, insomnia, flashbacks and nightmares, and difficulty feeling or expressing emotions.

Impalli noted that, in addition to providing individual therapy, the program offers group therapy in both culturally homogeneous and mixed groups. Currently, there are groups for Africans, Bosnians and Tibetans. Psychological treatments include cognitive-behavioral therapies, psychodynamic therapies, family therapy, narrative/solution-focused therapy, group therapy, testimony therapy, hypnosis and EMDR (eye movement desensitization and reprocessing), activity therapies, and expressive art therapies.

The program also collects descriptive data on demographics, types of torture and trauma, sequelae of trauma, and physical and psychological symptoms and diagnoses. A database form with standardized measures of PTSD and psychological symptoms is completed on each client, and these data are analyzed to explore specific effects of torture and trauma on refugees, adaptive capabilities important to survival and recovery, and the efficacy of various treatment approaches.

Impalli added that program staff had developed a screening instrument for identifying torture survivors among immigrant patients, and a pilot study was conducted at the Bellevue clinics to determine prevalence of torture survivors among immigrant patients seen in general medical settings. A research study of health care access and health status among asylum seekers in detention facilities is in a preliminary stage.

Asher Aladjem, M.D., associate director of consultation psychiatry services at Bellevue Hospital and assistant professor of clinical psychiatry, is director of psychiatry consultation-liaison and has been with the program since its inception. Formerly, he had worked with Holocaust survivors and Israeli soldiers suffering from PTSD.

"I got involved through the consultation-liaison psychiatric service as a liaison to the Primary Care Medical Clinic working with Dr. [Allen] Keller [M.D., program director]," Aladjem told PT. "This was an important liaison, although a little unusual, because we usually are involved with people who are medically ill, and we didn't consider the survivors of torture to be particularly medically ill. But they all were referred to us by their internists, and that's how the liaison developed, and over time I started seeing more and more patients and then helped develop the program."

Aladjem does not view PTSD or symptoms of survivors of torture as one thing. "It's a very diverse group of symptoms and there are very diverse diagnoses dealing with a lot of comorbidity-psychiatric and medical-and a lot of premorbid psychopathology," he explained. "For example, a bipolar, manic-depressive, flamboyant dancer from the old Soviet Union who was tortured clearly developed PTSD, but it did not eliminate the bipolar [disorder] he had much prior to that, so we're dealing with PTSD imposed on premorbid psychiatric diagnoses, and that's something we've seen quite a lot of. I think this is a little controversial because, in many ways, we have tried to shelter our patients and advocate for them that everything they suffer in life is a result of one trauma, and that may be so in some cases, but clearly not in all of them. So people would say, 'Is somebody more vulnerable to develop PTSD as a result of some premorbid [condition]' and the answer to that clearly is 'yes.'"

Keller AS, Saul JM, Eisenman DP (1998), Caring for survivors of torture in an urban, municipal hospital. Journal of Ambulatory Care Medicine. Available at: 

www.survivorsoftorture.org/news_ambulatory.html

After this Tibetan monk's release, he fled across the Nepali border, made his way to India and then to New York City, where he was referred to a program for survivors of torture.

Psychiatric Times Vol 17 No 12

Letter to a Young Psychiatrist: Confessions of a Psychodynamic Attending

Is Our Nation's Health Care System Collapsing?

Decompensated Schizophrenic Patient in the ER

Bellevue's Torture Survivors Program Aids Victims