Issues in Psychodynamic Psychiatry

Premiere Date: July 20, 2014

Expiration Date: July 20, 2015 [Expired]

This activity offers CE credits for:

1. Physicians (CME)

2. Other

ACTIVITY GOAL

This article reviews the organizing model of the brain, which is at the core of psychodynamic psychiatry.

LEARNING OBJECTIVES

At the end of this CE activity, participants should be able to:

1. Understand the psychodynamic perspective underlying psychiatry.

2. Recognize when psychotherapy must be provided by a psychiatrist and when it may be provided by an allied health professional.

3. Define what constitutes the psychodynamic approach in psychotherapy.

TARGET AUDIENCE

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

CREDIT INFORMATION

CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of participation for educational activities certified for AMA PRA Category 1 Credit™.

DISCLOSURE DECLARATION

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Richard C. Friedman, MD, has no disclosures to report.

Eric M. Plakun, MD (peer/content reviewer), has no disclosures toreport.

Applicable Psychiatric Times staff have no disclosures to report.

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Psychodynamic psychiatry is a psychiatric discipline that arose spontaneously as a result of clinical need and scientific necessity. Its roots are in academic psychiatry, neuroscience, extrapsychoanalytic psychology, and psychoanalysis.¹

To understand this unusual phenomenon, a historical perspective is necessary. During the years following World War II, when DSM-I and DSM-II were published, psychiatric thought about psychopathology was based on a psychoanalytic paradigm. There were advantages and disadvantages to this, but a crucial disadvantage was that it was not possible to achieve reliability of diagnoses. Independent health care professionals who interviewed the same patient often arrived at different diagnoses.

DSM-III (1980) abandoned the psychoanalytic perspective and replaced it with an atheoretical descriptive format. This led to increased diagnostic reliability, but it was not without limitations. One such was that many aspects of psychological functioning were not captured by the symptom list format. New developments led to substantial progress but also to knotty problems, including the pharmacological revolution; the evolving efforts to create an insurance-based system for psychiatric treatment; the emergence of time-limited, manual-based psychotherapies; the increasing emphasis of American medicine on a public health rather than a tertiary-care perspective; and the demedicalization of organized psychoanalysis in the US.

Taken together, these trends exerted a synergistic effect on the psychiatric climate. The professional identity of psychiatrists was and still is gradually being re-configured as a result. For example, there is currently great emphasis on the salience of time-limited symptom reduction. This influences the identity-role construction of psychiatrists as if psychiatry were a profession dedicated to the management of acute, relatively short-term problems using evidence-based treatments. It is not.

Although manual-based therapies prove useful for some patients and provide productive avenues of research, they do not offer adequate guidelines for the treatment of all or even most patients with psychiatric illness. Psychiatry must remain a profession defined by an organizing model of the mind, rather than by specific treatment techniques. Psychodynamic psychiatry offers such a model, and it is applicable to all psychiatric patients.

The unconscious: mind and brain

The recent attention of organized psychiatry has moved away from unconscious motivational influences on behavior. The way psychiatrists think about psychological functioning has changed radically in a relatively short time, and with it the education of psychiatry residents and the composition of psychiatry journals. Except for Psychodynamic Psychiatry, it has become rare for major mainstream psychiatry journals to publish scholarly work on psychodynamic psychiatry (the discipline). As a result, modern psychiatry has been left with what might be termed an “unconscious” gap.

A vacuum in modern psychiatry has replaced assessment of the influence of unconscious irrational wishes and fears on psychopathology and coping behavior. This has occurred even as neuroscience makes rapid and dramatic progress in clarifying unconscious-conscious relationships and intermediate brain-mind mechanisms.

Demedicalization of psychoanalysis

Perhaps the movement away from acknowledging the role of unconscious motivation was influenced by the demedicalization of psychoanalysis in the US. A positive aspect of this is that nonmedical colleagues are now able to use psychoanalytic techniques to treat the vast numbers of people with major psychiatric disorders with psychodynamically informed techniques.

An unhelpful consequence, however, which can be thought of as collateral damage, is a regrettably common belief that psychiatrists should treat disorders of the brain, and nonmedical colleagues, those of the mind. I reject this view as do most psychodynamically oriented psychiatrists. The idea that psychotherapy by nonphysicians can and should be provided to many patients is quite different from the notion that psychiatrists should never provide psychotherapy because nonmedical therapists can do it equally well and less expensively.

The belief that nonmedical therapists can provide psychotherapy to all patients is not evidence-based because the way in which patient diversity influences treatment choice and treatment outcome has not yet been adequately researched with appropriately designed studies. Optimal care for some patients, such as those with serious medical disorders comorbid with psychiatric disorders, with psychoses, or with frequent emergencies (eg, repetitive suicidal and/or violent behavior), mandates psychotherapy by a psychiatrists and, if necessary, the use of adjunctive pharmacotherapy.

My point here is not to suggest that administration of psychodynamically informed psychiatric interventions be restricted to specific providers, but to illustrate that so-called split treatment administered by nonmedical therapists and psychiatrists is not always practical or ideal.²

Psychodynamic psychiatry emphasizes the need for psychiatrists to relate to the patient as a whole person, including his or her unconscious aspects. Treatment planning emphasizes not only drugs prescribed and standardized interventions implemented but also the importance of the therapeutic relationship. In that sense, psychodynamic psychiatry is part of the Hippocratic tradition of medical care. It applies and broadens the ideas of Adolph Myer,³ George Engel,⁴ and others.

Psychodynamically informed assessment

Most behavior is influenced by unconscious factors. These are sometimes irrational wishes and fears that motivate maladaptive, repetitive patterns of activity. The relative weight that unconscious influences exert on conscious mental life varies from person to person. Such influences may be substantial (eg, in conversion reactions) or apparently less important than primary biological influences (melancholia). A closer look at a patient with melancholic depression, however, reveals the relevance for psychodynamic thinking.

CASE VIGNETTE

Mrs H, who is 55 years old, presents with symptoms of melancholic depression that began on the anniversary of her husband’s death (5 years earlier). In addition to her melancholic symptoms, she complains of a foul vaginal odor and of hearing voices accusing her of being “a whore.” She has also been having thoughts of suicide to escape from her suffering.

Following hospital admission, findings from a gynecological examination are normal and symptoms remit with treatment. On further discussion with Mrs H, it emerges that shortly before her present illness, a friend of her late husband had asked her out on a date. Although the relationship did not progress romantically, she felt anxious that sexual feelings had been mobilized; the hallucinations and delusions manifested soon thereafter. Psychosocial and psychodynamic factors influenced the psychological context in which the biological determinants of melancholia were expressed. The treatment plan included psychodynamic psychotherapy to ameliorate her guilt and pharmaco-therapy to treat her psychotic and melancholic symptoms.

In thinking about Mrs H, one cannot cite research that proves that assessing and treating irrational guilt prevents recidivism. In fact, one would be hard put to find adequately designed studies that demonstrate that psychosocial context influences illness presentation and outcome. Common sense, clinical experience, and psychiatric judgment indicate that it often does, however. Much decision making about therapeutics, not only in psychiatry but in medicine and surgery, is based on judgments that take into account clinical experience as well as scientific advances.

A good deal of psychiatric practice does not involve the application of standardized techniques in specific and well-understood situations. Rather it involves using evidence to make inferential leaps in situations that are complex and often unpredictable.

Biopsychosocial assessment

“The past is never dead. It is not even past.”⁵ Psychiatrists are indebted to Faulkner for expressing so evocatively what we have traditionally understood. The past is folded into the present in many ways and influences both psychopathology, resilience, and coping.

Patients with serious psychiatric disturbances tend to suffer from multiple disorders, many of which have their onset in childhood or adolescence. They tend to have family histories of psychopathology and/or past histories of exposure to serious adverse events during early childhood. In a prospective study in New Zealand, 1037 consecutively born children were evaluated every 2 years from age 5 to age 21, with a follow-up at age 26. At age 26, about 20% had received treatment for a psychological problem, although usually not from a psychiatrist. Most of these individuals experienced the onset of the disorders before age 18 and 55% before age 15. The researchers recommended that clinicians who treat adults must assess the age of onset of disorders to formulate an adequate treatment strategy.⁶

The onset of a psychiatric disorder is likely to be associated with adverse psychosocial events. In a nationally representative sample of 9282 adults, events such as parental death, divorce, neglect, and/or abuse were associated with adult psychiatric disorders.⁷ The more events experienced, the greater the association and the greater likelihood that the disorder would be chronic or recurrent.

Comorbidity is relatively common among psychiatric patients and is often associated with severity of illness.⁸ The National Comorbidity Survey revealed that about 14% of the population had severe disorders and that most of these had comorbidities.⁹ This figure illustrates how severe the problem of mental illness is in American society. A very broad, vigorous, and flexible approach to prevention, diagnosis, and treatment must be used. The presentation of a particular patient at a particular time must be understood, not only in an immediate psychosocial context but also longitudinally-as part of a timeline constructed in the past and extending into the future. Multiple adverse events have additive and cascading effects throughout development.

CASE VIGNETTE

Virginia was hospitalized at age 19 following a suicide attempt precipitated by a lover’s rejection. Virginia was an only child whose parents divorced when she was 2 years old. Her mother could not take care of her, and by age 6 she was placed into foster care. At age 9, she was repeatedly sexually abused by a foster sibling-a boy several years older. This went on for 3 years, until he was arrested, never to return. Virginia was deeply attached to him and became severely depressed when he disappeared.

Eventually she was adopted and her depression abated. At age 14, she began a sexual relationship with her adoptive father. When her adoptive mother learned of this, Virginia was exiled from her home. She became seriously depressed as a result of her multiple losses but did not seek assistance from mental health professionals. Virginia traveled to a distant city, where she became a street prostitute. Her first suicide attempt at age 17 occurred after a beating by a pimp.

This vignette presents only a few snippets from Virginia’s life, but it illustrates the different and sequential trauma and deprivations she endured. Following her parents’ divorce when she was a toddler, she experienced the loss of her father, who had been somewhat involved with her before the divorce. Her mother withdrew as well and more or less vanished from her life. Virginia’s situation got worse after that and, over time, worse again. Sex became interwoven not only in the pattern of her recurrent psychopathology but in coping efforts as well. The many adversities she suffered occurred against a background of chronic poverty.

Unfortunately, histories similar to Virginia’s are the rule, not the exception, among the 15% or so of the most seriously disturbed segment of the population. One cannot adequately convey a sense of the circumstances patients like Virginia endure by listing past and present psychiatric diagnoses.

Compassionate care

It is best to conceptualize treatment planning for patients like Virginia in terms of multiple, flexibly administered interventions provided in a caring context by professionals who are aware that some of Virginia’s behavior is likely to be shaped by unconscious factors. This may influence her conduct in therapeutic situations, including her motivation to participate in treatment(s). For example, Virginia’s sexually seductive interactions with a male therapist can be best understood in the context of her past sexual history. These experiences are intimately connected subconsciously to feelings of depression. She is not aware that her seductiveness is based on a pattern of relating to powerful authority figures that had been internalized since childhood.

Psychodynamic understanding of Virginia is partially based on decoding messages that influence her behavior, which she is not aware of and which are layered in her mind, sometimes in an apparently illogical manner. For example, one message might be, “If you have sex with this man he will not leave you,” whereas a contradictory message might be, “You deserve to be abandoned by sexual partners; this is fit punishment for a bad person like you.” Therefore, Virginia might think of herself as an alluring enchantress and simultaneously worthless-“like garbage.” Awareness of this type of complexity assists treatment planning, although it is not captured in DSM.

Narrative construction

Psychodynamically informed interviewing is based on the idea that people tend to construct personal stories or narratives that attribute meaning to past experience and guide future action.¹⁰ Narrative construction begins in a familial or caregiver setting. One way of thinking about narrative construction is that it is a transmission of guidelines for interacting in the human environment, beginning with cross-generational (family) guidelines and later moving outside of the family setting.

Narratives involve not only simple interpersonal dramas but also the integration and regulation of emotions (affects). These narratives may be adaptive or maladaptive. Maladaptive narrative construction is more likely in settings of caregiver psychopathology and exposure to adverse life events.¹⁰

Once maladaptive patterns of integrations of feelings and interpersonal relationships become part of internal programming, they may be repeated time after time impervious to immediate negative experiences. Psychodynamic assessment detects such patterned pathology and influences treatment planning.

Psychotherapy

The frequency with which psychiatrists administer psychotherapy is diminishing, and the frequency with which they prescribe psychoactive drugs is increasing.¹¹ It is fortunate that many allied health professionals (eg, nurses, social workers, psychologists, pastoral counselors) are qualified to practice psychotherapy, given the high prevalence of psychiatric disorders and consequent disability in the general population.¹² It is increasingly recognized in other countries that psychotherapy is an effective and cost-effective treatment for patients with diverse mental disorders, including lower-grade anxiety and depressive disorders and personality disorders.^13-16 This has yet to be fully recognized in the US and acknowledged by third-party payers.¹⁶ Many individuals with psychological problems avoid seeking assistance from psychiatrists or other mental health professionals, most likely because of associated stigma.

Among the total population of patients, there are many who can and should be treated by psychiatrists-eg, patients with concurrent medical and psychiatric disorders; patients with psychotic disorders; and patients with multiple psychiatric disorders, such as addictions and personality disorders; as well as those with histories of complex trauma and those with multiple psychiatric and/or medical disorders. Across diagnostic categories, many patients with suicidal and/or homicidal potential would also be included. Many patients who need different combinations of psychotherapy and medication over time might be best treated by psychiatrists as well. These patients frequently need alteration in type and/or dose of drug and in frequency of psychotherapeutic sessions. Psychiatric residency training programs recognize that competence in psychotherapy should be part of every psychiatrist’s therapeutic armamentarium.

Although the assessment of every patient should include a psycho-dynamic component, many patients need some other type of treatment or combination of treatments than psychodynamic psychotherapy. The needs of patients who are severely and chronically psychiatrically disturbed may be different from those who are at the other end of a health-illness spectrum. One of the traits emphasized in psychotherapy is empathy. Other attitudes, including sympathy, compassion, practical realistic therapeutic judgment, unsentimentality, flexibility, readiness to recommend multimodal treatments, and willingness to collaborate with other therapists, are also useful. The notion of a weekly meeting in a therapist’s office may not be practical for many patients, but a psychodynamically informed attitude always will be!

Psychodynamic awareness may inform techniques such as confrontation, clarification, and psychoeducation. For example, a teenage girl with suicidal fantasies and borderline personality disorder might have a history of being relentlessly criticized by a verbally abusive father, with whom she feels embattled. She is frequently late to sessions with a male therapist. Because of the influence of transference, the patient expects to be criticized by the therapist. Indeed, she provokes criticism. The therapist must try to confront the patient about her lateness without seeming like her hypercritical father. He might do this by participating in the session as usual, perhaps concentrating on supporting his patient’s self-esteem but ending the session on time. If the patient objects and asks to stay overtime, he might respond: “I was hoping to have more time with you too. When you were delayed, I was concerned and hoped you were okay. We have to stop promptly today but perhaps next session we can get started a bit earlier so we can have more time to work on helping you feel better.”

The therapist would also need to understand the circumstances that led to the patient’s late arrival. Her lateness might have been a response to stressful events, not necessarily part of a repetitive pattern determined by her personality disorder. If she experienced a traumatic event immediately before the session, for example, the therapist’s approach would be different, but it would still be informed by the need to be unlike the patient’s transference expectation that he would act like her father.

Patients with histories of complex psychopathology often need treatment combinations that may change over time. For example, a patient with dysthymia and alcoholism might be treated with psychodynamic psychotherapy and participation in alcoholics anonymous. Either treatment might persist even if the other was temporarily or permanently discontinued. A patient with anxiety disorder and chronic depression who is the victim of spousal abuse might be treated with psychodynamic psychotherapy, antidepressant medication, and marital therapy. Any of these might be discontinued while the other treatments are continued. A patient with severe anxiety and depression and borderline personality disorder might be treated with transference- focused psychotherapy and psychotropic medication in combinations that vary over time. These are examples of combination therapy that often occur in clinical practice.

Most of these combination treatments have not been adequately researched. This is a point that deserves emphasis because it bears on data that are available to insurance companies and may influence reimbursement practices. The rationale for refusing to reimburse for combination of treatments for patients with complex disorders may be that controlled studies of particular treatment combinations have not been done. The insurance company might argue there is no evidence that a particular combination of therapeutic modalities will be effective. Centralized micromanagement (in the form of regulating reimbursement) must defer to the judgment of clinicians if the best interests of patients are to be preserved.

Individual psychodynamic psychotherapy

Psychodynamically informed psychotherapy may be from a single session to several years in duration. Researchers generally consider psychotherapy to be long-term if it lasts a year or longer, although this, too, is arbitrary. Psychotherapists tend to share the view that unconsciously motivated maladaptive behavior can be positively influenced in the context of a trusting and intimate relationship with a psychotherapist. The relationship must be organized around the patient’s needs and not the therapist’s.^17-19

In psychotherapy, patient and therapist work together as a team to further therapeutic goals. These goals include diminution of specific symptoms and of suffering in general, and increased functioning. Long-term psychodynamic psychotherapy with properly selected patients has been demonstrated to be an effective form of treatment.^16,20,21 Sometimes it is administered without concurrent pharmacotherapy.

Conclusion

The usefulness of psychodynamically informed assessment of psychiatric patients is universal. It is especially necessary because of substantial diversity in all aspects of behavior and socioeconomic circumstances. The type of treatment recommended depends on assessment, and only some patients need psychodynamic psychotherapy. Of these, a substantial number are best treated by psychiatrists. Competency in psychodynamic assessment and treatment, including its usefulness in the treatment of the chronically mentally ill, must continue to be a core part of the identity of all psychiatrists.

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Disclosures:

Dr Friedman is Clinical Professor of Psychiatry, Weill Medical College, Cornell University Medical School, New York.

References:

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2. Kalman TP, Kalman VN, Granet R. Do psychopharmacologists speak to psychotherapists? A survey of practicing clinicians. Psychodyn Psychiatry. 2012;40:275-285.

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4. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-136.

5. Faulkner W. Requiem for a Nun. New York: Vintage Books; 1951.

6. Kim-Cohen J, Caspi A, Moffitt TE, et al. Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort. Arch Gen Psychiatry. 2003;60:709-717.

7. Green JG, McLaughlin KA, Berglund PA, et al. Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders. Arch Gen Psychiatry. 2010;67:113-123.

8. Friedman RC, Garrison WB 3rd, Bucci W, Gorman BS. Factors affecting change in private psychotherapy patients of senior psychoanalysts: an effectiveness study. J Am Acad Psychoanal Dyn Psychiatry. 2005;33:583-610.

9. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617-709.

10. Kächele H, Schachter J, Thomä H. From Psychoanalytic Narrative to Empirical Single Case Research: Implications for Psychoanalytic Practice. New York: Routledge Press; 2009.

11. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962-970.

12. Lazar SG, ed. Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness. Arlington, VA: American Psychiatric Publishing; 2010.

13. Clark DM. Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. Int Rev Psychiatry. 2011;23:318-327.

14. Richards DA, Borglin G. Implementation of psychological therapies for anxiety and depression in routine practice: two year prospective cohort study. J Affect Disord. 2011;133:51-60.

15. Holmqvist R, Ström T, Fodemo A. The effects of psychological treatment in primary care in Sweden-a practice-based study. Nord J Psychiatry. 2014;68:204-212.

16. Lazar SG, Yeomans F, eds. Mental health parity and the Affordable Care Act: special issue. Psychodyn Psychother. In press.

17. Gabbard GO. Long-Term Psychodynamic Psychotherapy: A Basic Text. 2nd ed. Arlington, VA: American Psychiatric Publishing; 2010.

18. McWilliams N. Psychoanalytic Psychotherapy: A Practitioner’s Guide. New York: Guilford Press; 2004.

19. Cabaniss DL, Cherry S, Douglas CJ, Schwartz A. Psychodynamic Psychotherapy: A Clinical Manual. Oxford, UK: Wiley-Blackwell; 2011.

20. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65:98-109.

21. Leichsenring F, Rabung S. Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis [published correction appears in Br J Psychiatry. 2012;200:430]. Br J Psychiatry. 2011;199:15-22.