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

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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.

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When the Therapist Dislikes the Patient

This blog examines that situation where a psychotherapist realizes that he or she doesn’t like a particular patient. The therapist needs to understand this feeling within him or herself. Referring the patient to a colleague is discussed as an option as well as getting help from a colleague or supervisor in sorting out these feelings. The awareness of negative feelings and countertransference by the therapist can helpful in doing effective psychotherapy.

What should psychotherapists do if they realize that they don’t like a particular patient who has come to them for help?

First of all, we should realize that it is a virtue that a therapist can recognize and acknowledge to themselves  negative feelings towards a particular patient. One can’t expect to like every person you meet and just having some negative feelings isn’t necessary a contraindication to working with someone. If the feelings are minor it should not interfere with the treatment and the therapist would keep these feelings in mind but proceed with the treatment. In fact as will be described, the awareness of such feelings may actually assist the therapist in carrying out effective therapy.

Therapists are usually trained to reflect on their own feelings as they work with a patient, particularly when they are aware of strong positive or negative feelings. In the case in question, where the therapist is becoming aware that he or she doesn’t like the patient, the self oriented question is “Why don’t I like this patient?” The answer may  be obvious, such as the patient is inconsiderate, self centered, prejudiced , anti my political or religious beliefs etc. One doesn’t necessarily dislike a person who meets such criteria and therapists in their self reflection need to include the contemplation of “What do I know about myself that might help me to understand these feelings?” It may be that the patient reminds you of a significant person in your life or certain situations which have occurred to you. One more additional self directed question should be “Can I work with my own feelings and try to help the patient or are these feelings too strong for me to objectively work with the patient? Also, am I just not inclined to work with the patient even if I understand why I feel this way?”

If the awareness of the dislike for the patient comes during the initial consultation and the therapist is not inclined to work with the patient,  it may be relatively easy to refer the patient to a a colleague. A therapist not uncommonly will refer a patient to another therapist after the initial consultation if a therapist with special expertise might be better suited to treat the patient or if the therapist and the patient’s schedules don’t mesh for setting up ongoing therapy. On occasion, the consulting therapist might feel, after an initial consultation, that the therapy should be by a person of another sex, background or age. While these situations are less common, it may happen. Therefore referring the patient to someone else whom you feel will work better with the patient after you have initially examined the patient is ethically proper. Our guideline is to do no harm to the patient and do everything in the patient’s best interest. Therefore it most likely would only be hurtful to the patient to explain that you don’t like the them and that is why you are making the referral, therefore you shouldn’t do that. This may put you in the position of having to tell a “white lie” by saying that your schedule doesn’t work or that you are sending them to another therapist whom you feel is better suited for them (although this may technically be the truth). The therapist has to make the decision whether to discuss the reason for the referral. If the reason was one which there was a good possibility that another therapist might have the same problem ( ie. The patient was a member of the Klu Klux Klan or was a psychopath etc,) it would be best to discuss this with the potential new therapist in order to find someone who could separate their own personal feelings and work with the patient. When the reasons were totally personal  (the patient reminded the therapist of someone or some personal situation ) such a discussion would not be necessary. In such case, a general reason or a scheduling problem could be given for the referral or you could share this information with the new therapist.

When the awareness of the dislike for the patient occurs during ongoing therapy, referring the patient to someone else becomes more complicated as interrupting the therapy would have to be weighed against the therapist concluding that they can’t help the patient due to their own feelings. Psychodynamically  trained therapist are usually trained to recognize and work with their own countertransference and this would be the preferred mode of operation. This approach not only facilitates insight into self but also has the opportunity to facilitate the ongoing therapy. The therapist should always have the option to seek the assistance through a consultation with a colleague, a clinical  supervisor or their own therapist and certainly if they themselves are in ongoing therapy – this situation should be closely examined. Therapists should be constantly monitoring their own feelings and the awareness of some negative feelings about the patient is not unusual.

In fact the experienced therapist knows the kind of issues which push their own buttons and an emotional reaction to the patient may be the first opportunity to identify some conflict within the patient that both the therapist and the patient may not have had a conscious awareness.

Psychiatry in Palliative Medicine

The 2nd edition of the Handbook of Psychiatry in Palliative Medicine is reviewed. The book should be read by all health professionals with interest in this area. The book covers the cutting edge of science as well as clinical and ethical issues. It also discuses psychotherapy including countertransference as it applies to palliative care. There is also a 5 question Q &A with one of the editors.

Handbook of Psychiatry in Palliative Medicine, 2nd ed., by Harvey Max Chochinov, M.D. and William Breitbart, M.D. New York, Oxford University Press, 2009, 592 pp., $89.50.

Book Review and Q & A with Editor

Harvey M. Chochinov, M.D.  Co-editorHarvey M. Chochinov, M.D. Co-editor

I have reprinted the review of this book which I wrote in the April issue of Journal of the American Psychiatric Association. At the conclusion of the review I have added a five question and answer interchange which I had with Dr. Breitbart.

Palliative Care

What Do Dying People Want?

Potential readers of this book no doubt will be concerned about what dying people want, which is a theme examined throughout the book. It is discussed and answered by Khul in his chapter on this subject as follows:

“People at the end of life want adequate pain and symptom management, and desire to participate in a process of clear decision making to achieve a sense of control, to relieve burden, to be affirmed as a whole person, and to strengthen their relationships with loved ones.”

Who Should Read This Book?

This book offers an excellent introduction to those who have any interest in palliative care or who,  from time to time, deal with issues of death and dying. It will even be more useful to those who work in the field on a regular basis. It certainly is a necessary reference book to both of these groups of professionals, and it provides the in-depth discussion on just about all the pertinent subjects in this fast-growing specialty. While the title of the book indicates that psychiatric issues are the main focus, the editors have used a wide-angle lens to examine this subject. In addition to psychiatrists, other physicians, nurses, and any mental health professional will feel comfortable with this book.

The volume editors are well-known sensitive giants in a field that requires a balance of scientific evidence-based thinking and empathic humaneness, which are not easy to combine. They have brought together on the pages of this book outstanding contributors who embody these characteristics and who know their subject matter extremely well. There is some duplication and overlap, but some subjects, such as existential approach to patients, benefit from multiple discussions.

Second Edition Makes New Contributions

The first edition of this book came out 8 years ago, and many new chapters have been added to this second edition. These new contributions have homed in on hospice, persons with serious mental illness, patients with substance use disorders, and patients with personality disorders. They also include a new look at interdisciplinary teamwork, cultural diversity, families, spiritual issues, and an interesting view of special care considerations for the seriously ill older patient.

Many of the chapters will take the reader to the cutting edge of science, as well as clinical and ethical issues. You will learn that two renowned ethicists, Pellegrino and Sumansy, believe that intensive comprehensive palliative care is the rational alternative to euthanasia and physician-assisted suicide.

Many of us who did not have the opportunity to train under or work with Ned Cassem will get an invaluable view of his clinical insight and very humane approach to patients in his chapter on the management of the patient at the end of life. Examples of some of the questions he often asks patients and discusses in his outstanding chapter are: “As you look back what are you proudest of?” “Did you play mischievous pranks on others?” What are the most meaningful joys in your life? The things that you wish you could do again?”

Palliative Care-1Diagnosis and Management of Depression in Palliative Care

There is a comprehensive chapter on everything you might want to know and should know about the diagnosis and management of depression in palliative care by Wilson, Lander, and Chochinov. They provide a very good review of medications for depression but also state that medication without ongoing contact is often experienced as abandonment and is not an acceptable approach. Roth and Massie do a similar good job with anxiety in palliative care, noting that between a quarter and a third of patients with advanced cancer receive anti-anxiety medication during their hospitalizations. They also make a plea for testing new psychotherapies (such as meaning-centered or dignity-conserving therapies) for effectiveness in decreasing anxiety in the palliative care setting. Breitbart’s vast experience with AIDS and cancer is reflected well in the chapters on delirium and pain management in which he is the lead author. Throughout the book, studies are cited, reporting that as many as 90% of patients with terminal cancer or other advanced diseases experience unrelieved pain. The likelihood of insufficient treatment of cancer pain is higher if the patient is female, elderly, a member of an ethnic minority, a child, or a substance abuser, according to one study cited. An equally high percentage of disturbing pain has been reported in patients with AIDS.

Full Spectrum of Psychotherapy

The full spectrum of psychotherapy approaches is covered comprehensively in various chapters, including  psychodynamic, cognitive-behavioral, narrative-writing, family-focused therapy and group therapy. In regard to this latter treatment, Spiegel and Leszcz discuss the follow-up of Spiegel and colleague’s early groundbreaking research, which raised the possibility that psychotherapeutic group interventions may affect survival time as well as quality of life. Subsequent research has been mixed in this regard, but the authors cite a recent trial finding that among 227 women with primary breast cancer, those randomly assigned to a 1-year program of training in active coping, communication skills, and symptom management had significantly lower rates of relapse and mortality at 11-year follow-up.

Countertransference

Countertransference is discussed by Vachon and Muller in their chapter on burnout in staff working in palliative care, as well as by Stuber and Bursch in their chapter on psychiatric care of the terminally ill child, and it is also covered in Kissane’s chapter, which included co-authorships by the two co-editors. It would probably be quite worthwhile if the editors in future editions could coax more discussion of how the experienced contributors to this book handle their personal reactions to working in this field.

However, do not wait for the next edition, as this book should be currently in the hands of anyone who does work in consultation-liaison psychiatry or any aspect of palliative care. You may be able to Google some of the factual material contained here, but you can never find the empathic, in-depth presentations and discussion on the Internet that are packed into the 592 pages of this book.

TAKE FIVE WITH THE AUTHOR- Dr. Bill Breitbart answers five questions which I asked him about the subject of this book

  • William Breitbart, M.D. co-author
  • William Breitbart, M.D. co-editor
  • #1  Do you feel that most patients with terminal illness in this country get adequate palliative care and what can be done to improve it?
    `The development of academic palliative care in the US had lagged well behind the UK, Australia and Canada, However the last 10-15 years has seen great advances with the establishment of Academic palliative care medicine Departments and with ACGME accredited fellowship programs in Palliative Medicine. While these academic and hospital based palliative care programs are great  resources for clinical research in palliative care and in- hospital palliative care programs, they still fall quite short of accessing all hospitalized patients who need palliative care , or who die in hospitals and nursing homes. A great deal of palliative care is provided by hospice care programs with care provided at home. Despite the fact that there are over 4,000 hospice programs in the US, we still have fewer hospices per capita than countries like Canada, the U.K. and Australia. In terms of whether most terminally patients receive adequate palliative care, the answer depends on what one considers “adequate” palliative care. For the most part, palliative care and hospice teams are most competent and have the skill set required to focus on pain and physical symptom control. That of course is fundamental to all palliative care. I believe  what remains inadequate is the ability of the interdisciplinary palliative care or hospice team to expand the concept of adequate palliative care to include psychiatric, psychosocial, existential and spiritual aspects of palliative care. Part of the problem is that most teams are not truly fully interdisciplinary. They do not include a psychologist or psychiatrist. The second problem is a knowledge, skill and intervention development gap. That is why we edited this textbook on Psychiatry in Palliative Medicine; to teach assessment and management skills pertinent to psychiatric and existential issues, and to inform clinicians of new intervention development in addressing psychiatric and existential despair near the end of life.

    #2  What grade would you give each of the following medical specialties in so far as they train residents in palliative care : Internal Medicine, Oncology Fellowship Program, Pediatrics, Psychiatry, Family Medicine ?
    It’s difficult to give any of these residency programs a passing grade overall, however I believe that there are unique programs in each of these disciplines that expose trainees to palliative care and are examples of what is possible.

    #3 How do you feel national health care might change the delivery of palliative care?
    Palliative care, like psychiatry has its reimbursement problems. They are both time and communication intensive without high cost interventions. It is difficult for hospital based palliative care programs to sustain themselves financially merely based on billing. Hospice care is a Medicare benefit, and one hopes that health care reform does ot negatively impact on hospice reimbursement. There are encouraging signs that health care reform may help the delivery of palliative care. The element of the Health Care Reform Act that was labeled “Death squads” in fact was a dictate to reimburse clinicians for the time spent in discussing care options including hospice care. I believe that was a step in the right direction.

    #4 Why do women and minorities get poorer palliative care than others?
    Minorities are underrepresented in hospice programs . Most people think this is a result of a discriminatory historical legacy where minorities had less access to acute care or advanced treatments (and were subject to unethical research experimentation). This legacy has led to a mistrust of the health care system, and minorities sometimes see referral to hospice as being deprived of available, potentially curative treatments. I am not sure that women get poorer palliative care, but studies of my own suggest that both women and minorities get undertreated for pain. Women seem to get undertreated for pain because their somatic complaints are sometimes seen as hypochondriacal or exaggerated. Minorities are often stereotyped as potential opioid abusers. Both stereotypes are unjustified and are quite destructive.

    #5 Do you have any advice how physicians might deal with personal reactions or countertransference to terminal illness  which could interfere with them providing optimal palliative care for their patients?
    We all have personal reactions to working with patients who are dying, especially if we can identify with them ( same age, same gender, similar family structure, similar profession etc.). The reactions can range from denial and avoidance of dealing with the suffering these patients experience, to become anxious, panicky or depressed. Having the skills to be able to make some impact on suffering is very helpful. Anytime we can be effective and helpful I think we feel we are doing something meaningful as physicians. So learning how to treat pain, or learning how helpful it is for patients to reflect on the lives they have led and transmit a message that the patient continues to have a life of dignity, meaning and value , even in the last months of life, can be very rewarding. Most physicians will tell you that it is the moments of connection on a human level with patients ; recognizing that we are both human beings, sharing the human condition despite being physician and patient ( An I thou moment as Buber might describe it), that are the most rewarding in a life time of practice. We learn great lessons from our patients, We see courage that inspires. We see acceptance of death that can comfort us. Compassion has infinite rewards for physicians.