Psychodynamic Psychiatry in the Medical Setting

The following is an extended version of a talk given by Dr. Michael Blumenfield at the World Psychiatric Meeting in Madrid Spain on September 15, 2014

Screen Shot 2014-07-27 at 1.28.50 PM

Introductory Case :

I would like to start off with a case history

Screen Shot 2014-07-14 at 6.17.34 PMThe patient is a 21 year old woman who has some paralysis in the right upper extremity and partial paralysis of the left lower extremity, weakness of the neck muscles, periods of persisting sleep walking as well as many other symptoms including a cough.

The symptoms came on after the patient’s father of whom she was very fond had become ill and subsequently died.

The patient’s internist Dr. B noted that the patient seemed to have alternating states of consciousness, which developed with regularity every day, during which she would talk and tell stories. She would talk about her past and how it was when she was a little girl as well as things that happened in the not too distant past. She would wake up feeling quite calm and then would go back to her usual clinical state.

Her internist became very interested in this patient and began to see her on a daily basis. He began to assist her to get into these altered states of consciousness by using a hypnotic technique. During the states he asked her to concentrate on each symptom. Eventually, she began to tell him about the circumstances that had occurred the first time that each of her symptoms had developed. When she came out of the trance, that particular symptom was gone. For example she told him that she began coughing for the first time while sitting at her ill father’s bedside and hearing the sound of dance music coming from a neighbor’s house. She had felt a sudden wish to be there and became overwhelmed with self reproaches and guilt feelings. Thereafter, whenever she heard music, she developed a cough. After this was brought out in the hypnotic state, the symptoms of coughing disappeared.

In the same way, her paralytic contractions, her numbness, hearing problems and other symptoms all disappeared.

The internist completed his treatment. While it was not in his original write up, some subsequent fact surrounding the case were not documented. Since the patient was cured of all her symptoms Dr. B. told her that he was Screen Shot 2014-07-14 at 6.23.51 PMterminating treatment and said good bye to her. However, that evening, he was called back to her house to find her in the throes of an hysterical childbirth.

We now understand that this was related to the patient’s “transference” which had been developing for some time. When the internist came into the room and asked what was wrong, the patient said, “ Dr. B’s baby is coming!” The doctor was overwhelmed by the situation and he had no way of understanding what was happening. He became profoundly shocked and took flight abandoning the patient to a colleague.

In retrospect, we understand that the internist had developed strong “countertransference feelings for his beautiful patient. He had been spending a good deal of time with her away from his family. He was emotionally involved with the patient and interested in her case. In his own background, his mother ( who happened to have the same first name as the patient) had died in childbirth when he was 5 years old. Unconsciously, he had become for his patient, the father whom she had lost and she was in turn the mother he had lost as a young boy.

Screen Shot 2014-07-26 at 9.53.55 PMThis case occurred more than 115 years ago. The internist was Dr. Joseph Breuer, who subsequently collaborated with a young neurologist by the name of Sigmund Freud who encouraged him to publish this case history. This case marked the beginning of psychodynamic psychiatry.

It is known as the Anno O case. In it we can see evidence of early childhood feelings impacting on neurotic symptoms, a conversion disorder as well as examples of transference and countertransference.

Screen Shot 2014-07-27 at 1.31.38 PM

Screen Shot 2014-07-27 at 12.40.54 PM Screen Shot 2014-07-27 at 12.44.48 PMScreen Shot 2014-07-27 at 1.07.32 PMScreen Shot 2014-07-27 at 1.47.54 PMScreen Shot 2014-07-27 at 3.25.22 PMScreen Shot 2014-07-27 at 3.37.16 PMScreen Shot 2014-07-27 at 3.50.22 PMScreen Shot 2014-07-27 at 3.54.07 PMScreen Shot 2014-07-27 at 3.59.00 PMScreen Shot 2014-07-27 at 4.02.07 PMScreen Shot 2014-07-27 at 4.06.12 PMScreen Shot 2014-07-27 at 4.12.12 PMScreen Shot 2014-07-27 at 4.14.38 PMScreen Shot 2014-07-27 at 4.20.00 PMScreen Shot 2014-07-27 at 4.22.14 PMScreen Shot 2014-07-27 at 4.24.01 PM      Screen Shot 2014-07-27 at 8.54.46 PMScreen Shot 2014-07-27 at 9.00.16 PMScreen Shot 2014-07-27 at 9.23.02 PMScreen Shot 2014-07-27 at 9.26.48 PMScreen Shot 2014-07-27 at 9.31.01 PMScreen Shot 2014-07-27 at 9.34.26 PMScreen Shot 2014-07-27 at 9.37.01 PMScreen Shot 2014-07-27 at 11.53.29 PMScreen Shot 2014-07-27 at 9.50.37 PMScreen Shot 2014-07-27 at 9.51.37 PMScreen Shot 2014-07-27 at 11.58.36 PM

Screen Shot 2014-07-27 at 11.59.43 PMScreen Shot 2014-07-28 at 12.01.37 AMScreen Shot 2014-07-27 at 9.56.18 PMScreen Shot 2014-07-28 at 12.08.41 AMScreen Shot 2014-07-27 at 9.58.25 PMScreen Shot 2014-07-27 at 10.07.43 PM

Screen Shot 2014-07-28 at 12.12.21 AM Screen Shot 2014-07-28 at 12.15.01 AM

Screen Shot 2014-07-27 at 10.21.24 PM

Screen Shot 2014-07-27 at 10.42.44 PMScreen Shot 2014-07-27 at 10.43.35 PMScreen Shot 2014-07-27 at 10.51.28 PMScreen Shot 2014-07-27 at 10.52.23 PMScreen Shot 2014-07-27 at 11.00.49 PMScreen Shot 2014-07-27 at 11.08.30 PM

The American Academy of Psychoanalysis and Dynamic Psychiatry – 75 Years from Now

The following is a shortened edited version of the Presidential Address which I gave at the 2014 Annual Meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry held in New York May 2014.  This article in edited form will also appear in the next issue of the The Forum, a magazine published by the American Academy of Psychoanalysis and Dynamic Psychiatry , Any comments are welcome at the end of this article

 

The American Academy of Psychoanalysis and Dynamic Psychiatry 75 Years From Today

Michae Blumenfield, M.D.

President 2012-2014

 2089

The theme of this meeting has been 75 Years After Freud and my talk in closing this meeting is the Academy 75 Years from today

Screen Shot 2014-07-14 at 12.27.04 AMNow let us look 75 years into the future – The year is 2089. I have a fantasy that the President of our organization will be my grandson Obi, who recently turned 5 years old now but at that time he will be 80 years old….. in the PRIME OF HIS LIFE. Obi’s life expectancy is to be 79-86 by projections today but many believe with scientific advances that we will have, it will be much longer. In fact,  in an article in the Journal of Anti Aging Medicine a few years ago, 60 gerontologists from leading universities all over the world were asked for estimates regarding the development of future life expectancy for a person born in the year 2100 – 86 years from now. The median prediction was 100 years whereas the mean was 292- since 3 people predicted over 1000 years. – showing that there were some Death deniers.

Screen Shot 2014-07-14 at 12.30.29 AM

Screen Shot 2014-07-14 at 12.30.13 AM

 

 

 

 

I am doing a project where I am recording an audio interview with the past Presidents of the Academy and I had the pleasure of doing interviews with Milt Zaproloupus and Mary Ann Eckhardt both over 100 year old and going strong

So perhaps 80 year old Obi in his prime will be President of the Academy and he will be standing here or perhaps he will be speaking to us via Hologram .

One of my son’s is a TV producer and he said to me why don’t you do a live demonstration and project yourself into the lecture hall. I looked into this technology which is definitely available but now costs $100,000 so I thought I would save the Academy some money and let’s wait until the cost comes down. Holographs or not – In 75 years from now our President will be here surrounded by large screens where perhaps simultaneous gatherings will be taking  place all over the world in lecture halls or in their offices watching and participating in this meeting

 I believe it is fair to say that we will be an international organization. This year during my presidency we changed the international dues schedule based on World Bank calculations so our international colleagues can afford to join. Those of you teaching in the CAPA (Chinese American Psychoanalytic Alliance) know about the nascent but growing interest in psychodynamics in China which will be full grown in 75 years. In fact I predict before 75 years we will change our name from the American Academy of Psychoanalysis and Dynamic psychiatric to just the Academy of Psychoanalysis & Dynamic Psychiatry. I believe we will still be aligned with the APA and American Psychiatry …but if we follow the trends of international psychiatry so we can also be aligned with international psychiatrists who value psychodynamic psychiatry.

Screen Shot 2014-07-14 at 12.40.18 AMScreen Shot 2014-07-14 at 12.40.03 AM

 

 

 

 

 

 

 

We are in the midst of a technology revolution that clearly affects the way we communicate with each other. Many of us are doing therapy using Skype or newer technology. I am treating a Chinese psychiatrist in China via this video technology 2x/week as part of the CAPA program Chinese American Psychoanalytic Alliance. I have treated college students who when they left to go to out of town college continued seeing me via Skype . Many of you are doing similar things

In 75 years from now we will also be teaching psychodynamic psychiatry via the latest technology. Many of you are already teaching and supervising via Skype or similar technology. I have had the exciting experience of teaching a class by SKYPE in psychoanalytic technique to Chinese students simultaneously in three different cities in China for CAPA

Screen Shot 2014-07-14 at 12.47.15 AM

My colleague Jim Strain and I have set up a program where we have offered long distance courses to 3rd world countries and have taught psychosomatic medicine via Skype or similar technology in Colombia South American and Rwanda.

It is also interesting to consider what role will the Academy play in providing teaching courses in psychoanalytic and psychodynamic theory and treatment in the United States. While at present this is being provided by the residency programs and psychoanalytic Institutes, there are many changes going on now in the systems of post graduate education. It may very well be that in future years the Academy will take a very important role in providing the latest teaching of psychodynamic psychiatry and will do much of it using the latest techniques delivering classes and perhaps supervision directly. 

Screen Shot 2014-07-14 at 12.49.32 AM After I prepared this talk, I opened the NY Times and I learned that 3D Virtual Reality will be here very shortly. Facebook has paid 2 Billion dollars for a Virtual Reality Company that will give people the illusion that they are physically present in a digital world. The translation to Long Distance Learning and Therapy sessions won’t be far behind

But the BIG question is what will our theory and therapy look like in the distant future???? 

 In order to anticipate the role of psychodynamic and psychoanalytic therapy in 75 years from now we have to try to anticipate what will the state of the art of science, medicine and general psychiatry?? Let’s remember how far psychiatry, medicine and modern technology has come in the past 75 years

 Although the effects of penicillin was discovered a few years earlier it wasn’t until 1939- 75 years ago that a usable product was developed which we would say was the first antibiotic

 In 1938 76 years ago Cerletti and Bini introduced ECT therapy

75 years ago – it would be another 10 years until Lithium therapy for bipolar was discovered by John Cade

 75 years ago it would be another 12 years before chlorpromazine the first antipsychotic medication would be introduced.

Forget about computers 75 years ago regular TV was just started in the US Bill Gates father was 14 years old and his mother was 10 years old

 We know scientific advances occur exponentially – meaning that they will occur much faster in the next 75 years then they did the previous 75 years ago.

So what clues do we have what psychiatry will be like in 75 years from now? And what predictions can we make?

 

Screen Shot 2014-07-14 at 1.00.18 AMWe will have a much more complete understanding of the genetic and biological nature of Major Depression, Schizophrenia, Bipolar Disorders, PTSD and Dementia as well as entire new sophisticated methods of treating them and preventing much of the symptoms manifestations. Just looking at the journals which come across my desk in one recent month I noted:

 The role Apolipoprotein e-4 allele gene and depressive symptoms as well as the relationship to cognitive disorders

 Psychosocial risk factors associated with elevated plasma peptide endothelium

 Genetics predicators of lithium response

 Relationship between heart disease and depression

Relationship between depression and diabetes

 Role of inflammation and psychiatric symptoms

 The Role of Transcranial Stimulation on Depressive Disorders

 Neuroimaging differences in patients with Borderline Personality Disorder

 You also may have seen a recent article the Academy Journal by Michael Stone which discussed Borderline personality related to hyper-reactivity of the Limbic System

I believe that it is fair to say that in 75 years from today, modern medicine will have extremely effective medications, injections of genetic material, brain stimulation , possibly even some type of surgery as well as techniques we have never heard of that will be effective in eliminating, controlling and preventing so much the psychiatric manifestations that we see today in our psychiatric practice. Treatment will be complicated and will require not only a understanding of the state of the art science and medicine but an understanding of human behavior and interactions. Therefore they will still be best treated by physicians who are especially trained in medicine as well as in human behavior and interaction by which I mean psychiatric specialists. Of course it is possible that some of these treatments will be relative simple and will not require specialists and many conditions may be treated by general medical physicians as they often are today.

Screen Shot 2014-07-14 at 1.05.34 AM

However- No matter how effective these treatments are, they won’t be able to eliminate the effect of human interaction especially during child development on personality development, conflictual feelings such as love, hate, guilt, empathy, object choice, positive and negative identifications, competitiveness, passiveness, creativity adaptation, maladaptation, happiness and sadness, fulfillment and lack of fulfillment.

I believe that EVIDENCE BASED Research will continue to accumulate which will show that the state of the art intensive psychodynamic psychotherapy undertaken in adulthood will be the most effective therapeutic method to bring about an emotionally full filling life. It will become known and accepted that the previously mentioned biological based treatments although immensely successful in treating major depression, OCD, bipolar, PTSD, panic disorder, perhaps social phobia, hopefully Schizophrenia , hopefully various forms of autism WILL NOT be able to address the effects of human interaction, thoughts and fantasies on the developing personality nor on the ultimate satisfaction with self and relationships and with one’s place in the world BUT a meaningful modern psychodynamic therapy will do so.

Screen Shot 2014-07-14 at 1.09.13 AM I believe evidence based research will show that biological based treatments mentioned previously will be extremely effective in eliminating biological and genetic psychiatric conditions and may very well be able to mitigate the emotional response to relationship issues, the emotional response to loss self esteem, PTSD   etc.  but certainly will not prevent these situations, external and internal which cause anxiety and depression,  from reoccurring. But I also believe that evidence based research will build on the existing body of knowledge that strongly suggests that meaningful intensive psychodynamic therapy – let us say for sake of discussion – about two years of psychodynamic treatment- will be the most effective for doing such and produce the best results for having the least debilitating symptoms and the opportunity for a more full filling life. In the past 10 years there has been an increasing amount of Evidence Based Research and discussion about the efficacy of Psychodynamic Therapy.

If science research shows this form of treatment is effective – People will want it and expect it! The questions remaining are who will do it, who will pay for it and how will it be different than the treatment we do today ??

 WHO WILL DO IT?

 Most likely the newer form of psychiatric treatment dealing with newer medications, genetic treatment, brain stimulation, other biological interventions yet to be conceived will be handled by physicians with special interest and training in human behavior – in other words, psychiatrists. As is often the case today- when psychotherapy is indicated the same doctor who is handling the biological forms of treatment if trained in psychotherapy is in the best position to do psychotherapy also . And that would be psychiatrists.

 Recently I have been interviewing past presidents of the Academy and asking them about the pathway of their career. Many of them as have I, were drawn into this field by first being fascinated with the working of the brain and then ultimately finding that, as challenging as the interventions we could do as physicians- it was even more interesting and rewarding to interact with patients and help them make meaningful changes through psychodynamic therapy. I can see his happening in the future, as generations of medical students will gravitate towards psychiatry as tremendous advances are made in treating mental conditions BUT ultimately they will realize that in addition to these interventions, the ultimate intervention for many people will be a period of intensive psychodynamic therapy.

 OF course as is the case now- the amount of people of wanting and needing psychodynamic psychotherapy will well exceed the number of psychiatrists available to perform this therapy. So there is every reason to believe that our colleagues in other mental health professions will continue to develop their skills in psychodynamic psychotherapy and will be performing this service as many of them are now.

 But let us imagine for a moment that time and research has determined that even after all the latest bio-genetic, brain stimulating, psychopharm forms of treatment, it has been clearly shown that an intensive psychodynamic therapy makes a big difference in people’s lives…… WHO WILL PAY FOR IT?

 

 In 75 years from now it seems clear that we will have some form universal health care program – maybe single payer or maybe more like the current health care that is being rolled out. IT most certainly will cover the biological, genetic, new medical brain stimulating, modern psychopharm treatment etc and if the scientific evidence is clear the people will demand and our universal health care could very well cover the 2 years of psychodynamic treatment I envision will be needed and wanted by so many people.  BUT what if evidence is there to prove that it is worth the time and money but the future political climate won’t allow it……?

Are there any other possibilities other than the rich shell it out and it becomes a treatment for the elite?  Remember we anticipate that median life span may very well be 100. People are going to living longer and be healthier longer. People will be working and living much longer than today.

Today, if we get a mortgage on our home it is for 20 or 30 years because people are expected to have that long of a productive working life.  That also was the basis for college and post graduate loans. It is worth it, if people correctly believe that psychodynamic therapy in their 20s 30s or 40s will make a difference in  the next 60 to 80 years of their lives,  but intensive psychodynamic therapy is going to cost them over a two year period maybe 5-10 % what their mortgage might be worth, why not take a mortgage on their psychological well being?  It could be attached to their mortgage which will will be 30 \or 40 year loans or have such loans institutionalized as education loans are these days especially since people may be living and working 10 or 15 years  longer then anyway.

How will Psychodynamic therapy be different than it is today?

 In order to anticipate this question , we would have to know how our lives will be different. How will childhood experiences be different? How will families be different ? How will technology impact our lives? What degree of poverty will IMPACT child development or lack of it . We are pretty sure that people are going to live longer and therefore people’s psychodynamics are going to be influenced by growing up in multigenerational families. There will be more great grandparents as well as grandparents interacting with the developing child . Perhaps more complicated patterns of competition and identification.

Screen Shot 2014-07-14 at 8.46.08 PM

What will we learn about children being raised by LGBT parents ?

 How will some of the assumptions and psychodynamic theory be changed and modified as we understand the kids developing in same sex families? Similarly, new understandings will emerge as in the future as  we have large numbers of people who are test tube babies perhaps genetically altered.

 I have observed and have written elsewhere on this blog about the tremendous drive of adopted, children or children raised by one biological parent to connect in some way with their both biological parents and their families whenever possible –even if adopted at birth or raised by one biological parent.

 

Screen Shot 2014-07-14 at 8.50.54 PMWe just now beginning to see the emergence of children who are digital natives. – meaning they have been using digital devices since they their earliest memory – often starting at age 2 and 3 . How will this play out in 75 years after 3 or 4 generations of this child raising component with even newer technology? How will their object relations, socializing patterns etc be impacted by this this technology in their lives?

 The latest statistics show that today 1/3 of people getting married have met online. So it is probably safe to assume in 2089 most serious relationships will be started online. Those of you who saw the movie HER realize that people are considering that it may be possible to establish a meaningful relationship with a so called person who is only a computerized program. Consider the psychodynamic implications of that!

Screen Shot 2014-07-14 at 8.52.49 PM

Screen Shot 2014-07-14 at 8.56.16 PM

As therapists we are always interested in the patients emotional reactions to their thoughts and fantasies, especially when they occur during a therapy session. This is also an important aspect of transference and countertransference. We also use our own emotional reactions to what is being discussed in therapy. We know also that emotional reactions are accompanied by physiological changes throughout the body including changes in activities in various parts of the brain. All of these emotional responses   can occur before there is conscious awareness of the emotional reactions. I usually wear a fit bit on my wrist. This is wrist band which measures my heart rate and  number of steps I take – it also recognizes when I am sleeping. This is a first generation device. Similar devices are being developed that measure BP, pulse respiration rate and future devices are expected to have the capacity to measure cortisol levels and even other hormones including sexual arousal etc.  Perhaps a little band around the head would measure electrical activity of the brain.  The capacity to wirelessly project any measurements to a computer screen or projection screen already exist. So I can imagine that if the patient and the therapist each wore these devices we would have the ability to measure all these internal manifestations– ALL which could be observed by the therapist or the patient or possibly both during the therapy session.

 

Screen Shot 2014-07-14 at 8.58.48 PM

 

Obviously I really don’t know what is in store for our organization or the future of psychodynamic psychiatry and our profession. I do know that there is going to be lots of change. The tradition of our Academy has been one that respects the work done in the past but always has a willingness to consider new ideas. I hope we will continue to do this and that we will take steps to continually change our organization to meet the needs of our profession and embrace what is to come 75 years from now or 150 years after Freud AND BEYOND

 END

 Any comments are welcome below

 

 

 

 

 

 

 

 

 

 

 

 

Suicide: Main Theme of Meeting in San Francisco May16-18 2013

images-5

Suicide is the 11th leading cause of all death in the United States. It is one of most important issues which mental health professionals are concerned about in their clinical work. The American Academy of Psychoanalysis and Dynamic Psychiatry of which I have the honor of currently being President, has designated the title of its 57th annual meeting as: Psychodynamics: Essential to the Issue of Suicide and Other Challenges to Modern Day Psychodynamic Psychiatry.  It is fitting that the meeting is being held in San Francisco which although not on the top 15 cities with the highest suicide rate does have the Golden Gate Bridge as its symbol which is the second most common suicide site in the world.(see previous posts on this subject)  Any mental health professional is cordially invited to register and attend this meeting (see AAPDP.org) which will take place May 16-18 2013.

images-1Mental health professional must always consider the suicidal potential of any patient especially when that patient is depressed or experiences significant distress. I recall as a junior psychiatry resident when I first was given the responsibility of making a decision to hospitalize  patients (even against their will) because I felt he or she was a danger to themselves (or others). As much as this is a heavy burden, it is likewise a major responsibility not to hospitalize a suicidal patientand face a situation where this person has ended their own life.  In the latter case there also is the possibility of legal consequences.

If a person is determined to end his or her own life, they will ultimately succeed. However when the desire to do it is due to a mental condition that we can treat, there is a good chance that we can prevent the suicide if we can intervene and facilitate proper treatment. Unfortunately this is not always the case since patients who are in treatment or who have had treatment do kill themselves.

Depression is the most common condition which has the potential to lead to suicide. This may be part of biological condition with genetic components which brings about severe bouts of depression. Depression may be part of the grieving process or it may be due to complicated psychological reasons which lead  some people  to be so depressed that they want to end their lifeimages-2.

Sometimes there is anger at a lost object (person) that gets turned inward leading to self destructive acts. When the ability to test reality is lost, the  reasoning for suicidal actions can be quite bizarre and may include internal voices commanding the persons to hurt or kill themselves. There are still other situations where a person does a self destructive act, not with intent to commit suicide but rather with an intent to suffer or manipulate others but inadvertently does die as a result of this gesture. There are certain personality patterns where there may be repeated suicidal gestures which have the potential to be fatal or very harmful. Drugs and alcohol and complicate the problems and may actually be the cause of suicide.

There are some special circumstances where a patient with a serious, very painful  or perhaps  fatal illness may want to end his or her life or may ask the doctor  to facilitate their demise. There are ethical discussions how should this be handled. In some of these situations, if pain and discomfort is better controlled this may not be an issue.

The treatment for a patient with suicidal potential is a delicate situation. First the decision needs to be made if the treatment is to be inpatient or outpatient (sometimes a combination of both). There needs to be a treatment plan that will almost always require psychotherapy frequently with a combination of psychopharmacology. In rare situations ECT (Electric Convulsive Treatment) will be utilized. Family and close friends often play an important role in the support of the person with suicidal thoughts. While psychotherapy needs to be confidential, the patient needs to understand that under certain circumstances where the therapist believes that the patient is an immediate danger to self or others, the therapist may have to break the confidentiality for the benefit of the patient. It goes without saying that there needs to be a trusting relationship with the therapist so the patient understands that there are two people working together in the best interest of the patient.

Many of these  topics and others  are going to be addressed at the San Francisco meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry  May 16-18 at the Westin St Francis Hotel which was mentioned at the beginning of this blog.  All mental health professionals are welcome to register  either in advance or onsite and attend the meeting . Go to AAPDP.org for more information or you can contact me if there are any questions. There will three plenary sessions by Drs Mardi Horowitz, Jeste Dillip and Herbert Pardes as well as  many panels and workshops. There will also be a very interesting documentary about suicide titled, Don’t Change The Subject  with a discussion with Mike Stutz,  the filmmaker after it is shown. A few of these presentations will be made available to Auto-Digest subscribers but if you are able to attend in person, I suggest that you  do so. I look forward to meeting any attendees at the meeting.

 

My Introduction to Telepsychiatry

The following is an article which I wrote for the current issue of the Forum. This is a publication of the American Academy of Psychoanalysis and Dynamic Psychiatry of which I am the current President.

images-1President’s Message: My Introduction to Telemedicine/Telepsychiatry

By Michael Blumenfield, M.D.

 

There are many psychiatrists and other therapists who have been involved for at least several years with using   computers and video cameras through the Internet to see patients and teach. From time to time over the years I have attended presentations that described the pros and cons of this activity. I recall some of my skeptical colleagues saying until you can smell the patient, they were not getting involved. I always thought that was extreme but recall another statement bandied around that you have to be able to get a very good look into the patient’s eyes in order for this technique to be useful. Still others likened this approach to therapy on the telephone which some favored in rural areas with circumstances where there were no access to in-person therapists.

My interest in this subject was renewed about 3 years ago when I left New York Medical College. I established a practice in Los Angeles and began to explore some new venues. Dr. Elise Snyder asked me if would like to teach and do other activities with the Chinese American Psychoanalytic Alliance program (CAPAChina.org) that used SKYPE and OooVoo to teach classes, supervise therapists, and treat therapists who were in their training program. By this time I had experience using SKYPE communicating with family members and sharing some travel experience live online from far away countries.

CAPA is an extremely well organized program that continues to grow and offers eager Chinese therapists a chance to receive a high-quality two year training program in psychoanalytic therapy. Within a short time after connecting with them, I could not believe that I was sitting in my office talking and interacting with 10-12 Chinese students in three different cities. Needless to say, I do not speak Chinese and to be accepted into the program the Chinese students must be fluent in English.

I was re- reading and discussing some classical psychoanalytic papers which I hadn’t read in many years. I was also learning about some subtle cross cultural concepts. For example, the concept of shame in China is a very important one and is quite different than the concept of guilt which is so important in western culture. I recall one homework exercise I gave the students which was to discuss clinical examples of shame in their therapy work or alternatively from their own life experience. One bright student told how he as a young boy would make up stories of things he said that he did wrong order to show shame which pleased his grandparents and made them very happy.

The opportunity to do one to one supervision and also some individual psychotherapy also revealed new issues reflecting the Chinese experience. For example, a patient after several months in treatment began to mention that when she was five years old, she and her family had to move to the countryside. Her memories about that time seemed to be very benign. Doing some calculations in my mind about the little Chinese history that I did know, I inquired if that wasn’t a difficult time when many people were being punished and treated badly as part of “re-education “ measures. This inquiry led her to begin to rock and back and forth and cry as she recalled that that was a terrible time in the history of her family.

P1000104

       CAPA Graduation Ceremony in Beijing

In other ways the issues of trust, speaking freely and the resistances to doing so are important in therapy but are colored by the Chinese culture and the prevailing changing atmosphere in China. All this was very enlightening to me and emerged from my limited work with CAPA and telepsychiatry. My work with CAPA led to me to going on a CAPA study tour where I was able to lecture in China, meet some the students in person and attend the student graduation program in Beijing.

GlobeHands

Our experience with CAPA led my colleague Dr. Jim Strain and I to set up a non-profit teaching program in Psychosomatic Medicine for third world countries (PSMWW.com). We had decided to do this rather than write a second edition for a large textbook we edited in the above field. We thus far have taught two 8-session courses in South America and in Rwanda via teleconferencing. One of the systems we use allows us to share our computer screen and that makes the projection of PowerPoint sides particularly useful. However the most meaningful part of the teaching is the direct interaction with the students. This exposure, and the nature of the teaching material we have chosen that is greatly influenced by psychodynamic experience, is also proving to be  interesting from a cross cultural point of view.

I had a completely different experience when I signed up to work one half-day a week with the California Telepsychiatry Group (caltelepsych.com/) that is part of American Telepsychiatrists led by Dr. John Schaffer. This group has a contract to provide psychiatric care via video conferencing for several mental health clinics in central California.images-2 They use a system called Web-Ex which seems to be even better than SKYPE and OOVOO. They also have a sophisticated online electronic medical record that I can easily access as well as an online prescribing system called Infoscriber where I can directly prescribe to any pharmacy in California.

American Telepsychiatrists has many other sophisticated features. The sessions take place in a private room in a clinic while I am comfortably in my office in Los Angeles.  I  have a psychiatric nurse present with the patient and/or a translator when needed. While I am doing mainly psychopharmacology, I can refer the patient to individual and group therapy, to primary care physicians, and to substance abuse programs, and I can order lab work, communicate with other health care workers, and send patients directly to the hospital or do anything that I might do from my private office. The psychiatric nurse with whom I work, and the staff, are helpful and supportive. Patients adjust easily to this form of communication and most of them are extremely appreciative of the care that thteleconferenceey are receiving.

Only recently have I considered using telepsychiatry in my private office practice. There were two instances where college students with whom I was working were going back to college and they wanted to continue their sessions while they were away at school. They were very comfortable with SKYPE and one of them used it on his i-phone. The therapy didn’t miss a beat. One session took me zooming from room to room as the student’s roommate had unexpectedly appeared and the patient was trying to keep his therapy confidential.

I started using SKYPE to treat a new patient who was from another city and expected to be traveling to Los Angeles from time to time for occasional face-to-face sessions. Of course resistance and transference issues have to be considered when there is the lack of an in-person presence. Recently a patient being seen through SKYPE asked if I would mind if he lit up a cigarette. That issue hasn’t come up in over 20 years since I removed the ash trays from my office. So while the smoke wouldn’t bother me, of course I had to explore the patient’s state of mind for wanting to light up at that time.

We are becoming more of a global society. AAPDP is having an increasing number of international members. We comfortably travel in airplanes and through the Internet. It seems only logical that we should take our professional lives with us on these journeys.

Let’s Talk About Suicide

Suicide is the 11th leading cause of death among persons over age 10. Patients with Major Depression or Bipolar Depression have a 20-60 fold increase of mortality rate over the general population. The role of medication and psychotherapy is can be important in preventing suicides. This topic will be discussed in future blogs and is the theme of the annual meeting of the
American Academy of Psychoanalysis and Dynamic Psychiatry which will be held in San Francisco Aug 16-18 2012.

Both attempted and completed suicides represent a major clinical and public health challenge. The CDC has ranked suicide as the 11th leading cause of death among persons over age 10 (33,289 suicide deaths were reported in the United States in 2009.

In a recent article in Psychiatric Times Dr. Tondo and Baldessarini  noted that 90% of suicides occur in persons with a clinically diagnosable psychiatric disorder. Patients with Major Depression or Bipolar Depression have a 20-26 fold increase of mortality rate over the general population. It was also stated in this article the fact than fewer than 1/3 of persons who commit suicide are receiving psychiatric treatment at the time of their deaths. The authors further state that there is only inconsistent evidence that antidepressants may help prevent suicides.

It was thought that the strong association between the rapidly expanding use of antidepressants and the moderately declining suicide rate in the US and in other countries were indirect evidence of effectiveness of antidepressants in reducing suicide.

Several recent studies have shown that mood disorders have been associated with increased suicidal behavior. This is especially true in patients with a mixed, manic-depressive, or dysphoric-agitated state, and perhaps also in those with anger, aggression, or impulsivity—all of which are particularly prevalent in Bipolar Disorder and may contribute to the unusually high suicide risk in persons with this disorder. In patients with such conditions (especially young patients), antidepressants may lack a beneficial effect or even increase suicide risk, at least early in treatment. Long-term treatment with mood stabilizers, particularly lithium, may be a more effective component of comprehensive clinical management aimed at suicide prevention.

From clinical experience we know that psychological conflict, psychological trauma, grieving, interpersonal conflict and other psychological issues can all contribute to self destructive behavior which can result in suicidal behavior. Suicidal gestures which may have been initiated to get attention or manipulate others can inadvertently result in a completed suicide. There are special issues concerning suicidal behavior in the military where recent studies have shown more soldiers are killed by suicide than in combat. There are special issues concerning suicidal behavior in children and adolescents. Bullying behavior including cyber bulling has been shown to induce suicidal behavior in young people.

Suicidal behavior can be quite complex as well deadly. It should go without saying that psychotherapy is usually necessary in treating patients who have suicidal ideation or who have demonstrated such tendencies or actions. Frequently, it may be combined with medication and sometimes it is the treatment of choice without medication.

Suicide prevention is a challenging issue not only for mental health professionals but for leaders in the military, teachers, parents and for us all. We also need to recognize that there are many mental health issues that have to be faced in the aftermath of a suicide.

We shall try to discuss many of these issues in future blogs. I am also pleased to announce that suicide will be a major part of the theme of the May 16-18 meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry (of which I am the current President) which will be held in San Francisco (just prior to the meeting of the American Psychiatric Association in the same city). A very interesting and informative program with outstanding speakers is being developed and will be announced shortly. I will also provide further information about this program in future blogs and you can contact me  if you have any questions at this time