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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We’re Not Providers For Consumers/Clients

The dictionary definition of ” consumer, client, patient, provider and care giver ” are examined under the thesis that “we are not providers consumers or clients. The special bond of psychiatrists as well as other mental health professional with their patients is noted and the potential erosion of that relationship is discussed.

Paul Krugman

Recently Paul Krugman wrote an interesting piece in the NY Times titled, Patients Are Not Consumers . In it he wonders what has gone wrong with us if receiving health care is like buying a car?

While he did not discuss specifically the treatment of mental illness and psychotherapy, those of us in this field have similar concerns.

Thinking about this article sent me to the dictionary (Webster’s Unabridged 20th Century-2nd Edition) to look up a couple of words that are used in this debate.

Consumer– A person who uses goods or services to satisfy his need rather than to resell them or produce other goods with them.

Client– A dependent one under protection or patronage of another person or company in its relationship to a lawyer, accountant etc, engaged to act on its behalf, loosely, a customer.

Patient– A person receiving care or treatment; especially, a person under the care of a doctor; as the physician visits his patient morning and evening.

It is wonderful to observe how inapprehensive those patients are of their disease- Blackmore

Provider– One who provides, furnishes or supplies; one who procures what is wanted

Care giver– (There is no single word as such)

Rather than further try to analyze or argue why and how these words should be used, I would like to present a few real situations and ask you to consider which words seem most appropriate :

1-Mrs. Jones as you know I check blood levels of Lithium and do other routine blood tests on my (choose one – patients, clients , or consumers) and I  have just received the results back. While the lithium level is right where we want it, I do note that your TSH is high which indicates that you may have a hypothyroid condition which could be contributing to your recent depressive symptoms. I would like to call your (choose one – primary care provider, medical care giver, health care provider, primary care physician) and I would like you to make an appointment with her.

2-(Phone call) Is this the emergency room (choose one – provider, care giver,  physician)? My (choose one- consumer, client,  patient) has just informed me that she took an overdose of tranquilizers and antidepressants which I have been prescribing for her and I have arranged for an ambulance to bring her to the hospital.

3-It appears that you are jealous of the other (choose one – consumers, clients, patients) in the waiting room as you were jealous of your siblings and you want to leave me as you left your other (choose one : providers, caregivers,  therapists)

I understand that some of the words with which many of us are uncomfortable  have come from the people who are trying to develop healthcare systems for large numbers of people. For  them, such words as providers, caregivers, consumers or clients may better suit the concepts  which they are dealing with in the abstract. One might argue that the meaning of words may change but if one is clear in regard to their own identity, perhaps it isn’t a big deal if a different word is used. If I have established a doctor-patient relationship with a patient and I am clear as to my code of ethics why should I get upset if a patient or an insurance company calls me a provider ? The problem is that there is a blurring of the expectations between  a casual sale of an automobile to a consumer and the expectation of a physician or other health care professional  who is entrusted with the care of a patient.

There is a special bond that physicians have with patients which has its origin with the Hippocratic Oath. It has come to mean a selfless dedication to doing everything in one’s power to help the person who has trusted us with their healthcare. There may be obstacles and complications related to third party payers, treatment being shared by multiple specialties and disciplines, patients being guided by information from the Internet etc, but we still view the patient as someone we owe a special obligation to do our absolute best to assist. The objective and subjective meaning of the words provider, client, consumer, etc. do not convey the relationship which we feel towards our patients and which they usually feel towards us . In the past many of our non-physician colleagues in the mental health profession also used this model and have a similar bond with their patients.

My generation of psychiatrists and other mental health professionals, I believe are clear in our  role and the expectations of our patients. However, it is somewhat more confusing for young people just out of training especially when they take positions in Mental Health Clinics where the newer terminology may be used. It may be easier for a young psychiatrist who has had some experience in medical school and during internship (PGY 1 year) where he or she has functioned in life and death situations.

Those experiences become the underpinning of how they will view the people that they will treat. Certainly that can become eroded if they are in an environment where other models are used. I also believe that it may be more difficult for young social workers and psychologists to appreciate the differences if they have only worked with these new terms during their training.

In ten years from now will this be a moot question?  Or will our attention to this debate now and the public’s desire for special relationships with the people who provide their health care treatment (physical and mental ) prevail in reality and in the terminology which we use?

I would welcome comment from anyone on this topic. I also am especially interested in the experience of our international readers of this blog (who make up about 50 % of the visitors to this site) Are there new words in other languages replacing doctor, physician and patient? Is this being discussed in other countries?

When A Nanny Slaps a Child

A nanny tells her psychiatrist that she has slapped the 18 month old child under her care. A course of action for the therapist could include filing a report of child abuse, a Tarasoff warning to the family and an involuntary hospitalization of the patient if indicated. The possibilities of what could happen if the therapist did the above or some other action were discussed.

(Due to technical difficulties this blog was offline the previous week so therefore it will be run for an additional week)

A few years ago I heard about a resident who presented the following case to his psychotherapy supervisor. (I have changed some details for confidentiality):

Case History

The patient is a  22 year woman who is working as a nanny for a  prominent celebrity. She entered twice per week psychotherapy two months previously because of difficulty in relationships with men. She has just started to talk about how she was physically abused by her alcoholic stepmother as a child. During a recent session she appeared to be distracted and wasn’t her usual organized self. Near the end of the session she blurted out that she became very angry with the 18-month-old child that she cares for and slapped the child . She was scared she might have hurt the child but he seemed to be OK. The therapist was stunned and for the first time was at a loss for words. The patient changed the subject and spoke about another subject and then the time was up. Her parting words were that she was really glad that the therapist didn’t condemn her. She knew that she did the wrong thing with the child and will try not to do it again. She added that if the therapist had reprimanded her, she never would come back again. She feels she can trust the therapist and is now very hopeful about getting help in therapy.

What Would You Do?

Before you read further, I would like to suggest that you jot down on a piece of paper if there is anything that you think that the therapist should do. Then let us see if the discussion below changes or supports your approach.

Mandatory Reporting of Child Abuse

It is well known that the there is a bond of confidentiality between a patient and a physician which is recognized by the law. This also extends to other licensed therapists, clergy, and attorneys. Recognized confidentiality is the keystone of our ability to do psychotherapy. Patients understand that they can trust us with their deepest secrets.

In fact our patient was initially concerned about talking about her stepmother because she has a 17-year-old sister at home and she didn’t want any repercussions to occur to her stepmother who she feels has been good to her  despite the  episodes of abuse when she was younger.  Most people have awareness that a special court order by a judge is required for a doctor to turn over medical records without permission of the patient. There are situations where doctors have even refused to do so even after such a court order and have faced the consequences. In this particular case there is obviously no court order. However there are some other reasons that the psychiatrist might feel compelled to break his patient’s confidence.

In some states including New York where this patient was being treated, there is a law, which mandates physicians to report any known or suspected cases of child abuse. When such reports are filed, there would be a case file opened and an investigation is supposed to be immediately conducted. In such a case the parents who are obviously responsible for the child would be questioned to determine if they have put the child in any jeopardy. It would seem that in such a case the parents would be informed that a physician has reported suspected abuse and would obviously act accordingly.

The Tarasoff Rule

On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff. Both had been students at the University of California at Berkeley. They had met a year earlier and  Poddar became convinced they had a serious relationship. Tarasoff told him she was involved with other men and not interested. Poddar became depressed.He talked to a friend and was eventually convinced to go to student health. He started therapy with a psychologist on staff. During his his ninth session, Poddar confided to his therapist  that he was going to kill Tarasoff when she returned from summer break. The therapist subsequently informed the campus police that he felt Poddar was dangerous and that he should be hospitalized involuntarily. The police picked up Poddar, but after questioning felt he had “changed his attitude” and released him after he promised to stay away from Tarasoff. Poddar stopped thaerapy and later went to Tarasoff’s house and stabbed her to death with a kitchen knife. He then called the police and asked to be handcuffed. Her parents then sued the psychotherapist for failing to warn them or their daughter about the danger. The California Supreme Court rejected the psychotherapist’s claim that he owed no duty to the woman because she was not his patient, holding that if a therapist determines or reasonably should have determined “that a patient poses a serious danger of violence to others, he bears a duty to exercise reasonable care to protect the foreseeable victim of that danger.” Many states including New York  followed California’s lead and now have expectations of a “duty to warn” potential victims. Under the Tarasoff Rule a therapist, therefore, does not incur any liability for breaking confidentiality to warn a victim who is in danger and is expected to do so.

Involuntary Hospitalization

If the patient were to have a serious mental illness such as severe depression with suicidal ideation or psychosis with command hallucinations, the psychiatrist could fairly  easily arrange an involuntary hospitalization for further evaluation and treatment. This apparently is not the situation in this case.

What Could Happen?

If the therapist attempted to do a Tarasoff warning, let us consider how this would work. First of call she would have to know how to reach the parent of the child to warn them. She wouldn’t necessarily have that information. In this case since the parent was a celebrity she might have some clues, but such attempted warning would no doubt involve some intermediary parties prior to speaking directly with the parents. This might involve publicizing the concern and the abuse, which might even end up in the media. This could embarrass the parents although one would think they would want to know. However, if the actual danger were exaggerated, then this could be creating bigger problems.

If the therapist were to submit a report of suspected abuse as mentioned, this would trigger an investigation, which would involve the parents. In the same way if the therapist had called the police and reported a potentially dangerous situation, the police would track down the nanny who could be caring for the child. They would have to take the child into protective custody until they located the parents  (who sometimes are out of town). Then they would turn the situation over to an agency which would investigate potential abuse.

As all the above were considered, the therapist also had to consider the strong possibility that any of above actions would most probably lead to the termination of therapy. In addition the patient who had resisted entering into psychotherapy in the past, would be further alienated from seeking help.  She would most probably obtain employment as a nanny in the future even if she didn’t have a letter of recommendation from her current employer. She interviews very well and actually had a letter of recommendation from a previous employers that would only show a two-month gap. She would then be in the same situation to potentially harm children with no one who would know about it. It is unlikely that there was sufficient evidence to support any charges being brought against the nanny that would lead to her being put in jail or hospitalized with a mental disorder.

On the other hand, the nanny could have seriously injured the child and there is an obligation to that child and any future children under her care.

What Did Happen?

The therapist ultimately decided with the assistance of the supervisor that she would not take immediate action which would lead to the patient leaving therapy and thus lose any chance of preventing this young women from abusing children in the future. During the next session two days later, she brought up the subject of her hitting the child. The patient said that she hadn’t done that again. The therapist said that she  was pleased about that but she shared the dilemma that that she would be obligated to warn the parents if she believed the child was in danger, as well as have to report abuse. She suggested that the nanny take a leave of absence for few weeks from her work which was easy to do since there were other nannies who also cared for this child . She was able to take on work which she had done before assisting elderly people where the patient had no inclinations for abuse. They agreed they would work on this problem and in the future they could decide when she was ready to return working with children. The patient was receptive to this idea and appreciated the concern of the therapist in wanting to help her and yet not get her into trouble, as well as understanding the legal and ethical obligations of the therapist.

Do You Have Any Comments On This Case

Your comments on this case are especially welcome since there is no easy answer here.