Discussion of the Patient Who Slapped a Child

During a recent blog , I presented two case histories which I thought might stimulate different points of view on how to react to the situations described . I asked two  colleagues if they would respond . Today I will restate the first case and then I will present their views. I will also print comments from readers  I encourage anyone therapist or not to weigh in on these cases in the comment section .

Case #1

The patient is a 26 year old young women who came into therapy because she was depressed about her inability to complete things. She had started college twice and dropped out and as a adolescent she came home from sleep away camp twice. Her goal was to go to nursing school some day in the future. She had many friends but had trouble keeping a boyfriend, She was attractive but was somewhat inhibited and only on occasion would allow herself to have sexual relations which she would enjoy. Her parents were divorced when she was 6 years old. Her father is a physician would visit her periodically as a child and when she was older she would visit him and his new wife . She always felt close to them and their two children. Her own mother was an alcoholic and when she was younger her behavior was quite erratic. At time she was physically abused by being slapped around. Other times she would have to take care of mother by making food for her and sometimes would even stay home from school . Despite poor attendance she got good grades. She herself does not drink or take drugs. She shows no evidence of a major depression or psychotic symptoms. She is often moody but doesn’t appear to have hypomania. She becomes angry when she is disappointed. As a preadolescent she saw several therapists and she had 2 or 3 brief trials of therapy in the past 3 years including several weeks of a trial on an SSRI which she didn’t feel made any difference. She is currently in treatment with psychodynamically oriented psychiatrist who has decided not use medication at present. She has been coming for 4 months 2x/week ( Tuesday and Friday). She says this is the first time she is making progress in therapy as she feels she can talk freely and is not being judged.

During her last session on a Friday very close to the end of session, she said , Whatever we say here is completely confidential, isn’t it?” The therapist replied, “Why do you ask this question ?” The patient then went on , “ You know that baby sitting job that I have been doing every Saturday nite for Mr. and Mrs. Woodman my neighbor’s 15 month child.?” Well last week the kid was a real problem. He was whinning all the time and wouldn’t listen to me. The final straw was that he spit on me. I lost it and slapped him real hard across the face. His face got really red and swollen. I put some ice on it. I will never do that again.” The therapist, was stunned and before she could say anything, the patient said , “Well, I know my time is up” and got up and left.

Should the therapist do anything with this information. Is the therapist required to notify anybody? What are the legal and therapeutic implications ?

Response from invited discussant Myron L. Glucksman, M.D. Dr. Glucksman is a psychiatrist and psychoanalyst practicing in Redding Connecticut and New York City. He is a Clinical Professor at N. Y. Medical College and a training analyst at the Psychoanalytic Institute at N. Y. Medical College.

In my opinion, the therapist has no legal obligation to report the slapping incident because, so far, it is an isolated episode and apparently did not result in a serious injury to the child. The therapist should explore the patient’s feelings about her behavior; in particular, her angry feelings when she feels disappointed. I suspect that her anger is, in part, connected to her feelings of rejection and abandonment by her alcoholic mother. Evidently, she was not adequately nurtured as a child, and was exploited by both her parents in regard to having to take care of her mother. As a babysitter, she again finds herself in a similar position and becomes enraged when the child spits on her – re-stimulating feelings of rejection and humiliation. However, I believe the therapist should warn her of the legal consequences of similar abusive behavior toward the child or others in the future.

Response from invited discussant Sheldon Frank. M.D.

Dr. Frank is a child and adult psychiatrist practicing in South Florida.

There is no doubt that the information must be reported to the state child protective services immediately, with, of course, communication to the patient that this is being done. The legal and ethical mandates are clear, regardless of effects on the therapy. The therapy may perhaps be unaffected or strengthened–though not necessarily. Certainly a therapeutic relationship which covers up a reportable abusive act and denies the possibility of future risk to this child or other children being cared for by the patient does not help her in the long run. The outburst of violence on her part was so impulsive, so over-reactive to the baby’s acting like a baby, that even her sincere conviction that she won’t do it again is suspect. In addition to dynamic interpretation, the patient might benefit from other psychiatric treatment tools. Her life pattern, her complaint about not finishing things, and, perhaps, this outburst, may reveal adult ADHD (a continuation of childhood ADHD). (One can’t say from the data in this case, but ADHD children are much more likely to be slapped, neglected, and/or abused than other children.) A trial on stimulant medications is a safe and effective way both of confirming the diagnosis and treating. Alternatively, a search for mood swings and bipolarity might establish a mood-based origin of her action, and a mood stabilizer could help her self-control. We child psychiatrists often confront these diagnostic alternatives, and usually opt to test first the ADHD possibility because of the rapid onset and cleaner side effect profile of stimulant medications.

Since the account came out at the end of the session a day before the next baby-sitting engagement, there is a quandary as to how and when communicating the report mandate to the patient is handled. Some state laws require a report within 24 hours of receiving the information–which is defined as information containing the suspicion of abuse/ neglect. (It is the agency’s job, not the therapist’s, to distinguish between abuse and, say physical discipline.) Hopefully, the child protective agency would act promptly. Professionals have the right to anonymous reporting, so the agency would not tell the patient the source of the report–it could have come, after all, from the child’s parents. Still, the chance of the therapeutic relationship being damaged is greater if the therapist waits until the Tuesday session to deal with this complication. If I were the therapist, I would call the patient and ask her to return the same day to continue the session, and use that extra time (? without extra charge) to communicate to her the necessity of reporting. The therapist didn’t answer directly the patient’s question on confidentiality; if pressed, he could have reminded her that the only exceptions were situations in which there was the danger of harm to herself or others.

Initial comments from readers of this blog :

Well, when you said “dilemma” you meant it. In the first case, it weighs the betrayal of trust of a confidential relationship for someone who appears to be genuinely interested in changing her anger responses, against the safety of a very young child from abuse. My response given the details here would be to file a CPS report, and talk to the patient about the legal reasons why that had to be filed in a candid way and trying to help her see the situation through several points of view. Though it would be tragic if the therapeutic relationship were not strong enough to withstand this, a child’s safety must take precedence.- Heather Fretwell

I certainly agree with Dr. Glucksman in this mater.  Dr. Franks by the book, rather concrete approach is useless and harmful, as long as the patient is cooperative and open to suggestions.  There is a question though of whether the child might need help in understanding and digesting what happened so that a traumatic scar is not left in his mind.  I might have insisted that the patient talk this over frankly with the parents and take whatever steps are needed to protect the child and see to the child’s mental health.
Arnold Robbins MD.
Cambridge, MA

Responses and opinions from any readers of this blog are welcome and will be added as comments. The second case will be discussed in a future blog





What Should a Therapist Do in These Situations?

Being a psychotherapist is a complicated job. Not only must you be knowledgeable about human behavior, psychodynamics and various techniques of doing therapy, but you have to be prepared for unexpected dilemmas . Two cases are presented below which bring up potential legal and ethical issues as well as technical considerations, which the therapist has to take into account to best help the patient.

These vignettes are based on real cases which I have  either been involved with as the therapist or as  the supervisor or I have read about them or have been told about them by a colleague. Some details may have been changed to protect confidentiality.

All the cases are at least 10 years old. Readers of this blog are welcome to express their opinion about the cases. We all recognize that in a real clinical situations, there would be much more information available about the patient which might help in making a decision.

In a future blog, I will present further discussion about these two cases.

Case #1

The   patient is a  26 year old young women who came into therapy because  she was depressed about her inability to complete things. She had started college twice and dropped out and as a adolescent she came home from sleep away camp twice. Her goal was to go to nursing school some day in the future. She had many friends but had trouble keeping a boyfriend, She was attractive but was somewhat inhibited and only on occasion would allow herself to have sexual relations which she would enjoy. Her parents  were divorced when she was 6 years old. Her father is a physician would visit her periodically as a child  and when she  was older she would visit him and  his new wife . She always felt close to them and their two children. Her own mother was an alcoholic and when she was younger her behavior was quite erratic. At time she was physically abused by being slapped around. Other times she would have to take care of mother by making food for her and sometimes would even stay home from school . Despite poor attendance she got good grades. She herself does not drink or take drugs.  She shows no evidence of a major depression or psychotic symptoms. She is often moody but doesn’t appear to have hypomania. She becomes angry when she is disappointed. As a preadolescent she saw several therapists and  she had 2 or 3 brief trials of therapy in the past 3 years  including several weeks of a trial on an SSRI which she didn’t feel made any difference. She is currently in treatment with psychodynamically  oriented psychiatrist who has decided not use medication at present.  She has been coming for 4 months 2x/week ( Tuesday and Friday).   She says this is the first time she is making progress in therapy as she feels she can talk freely and is not being judged.

During her last session on a Friday very close to the end of session, she said , Whatever we say here is completely confidential, isn’t it?” The therapist replied, “Why do you ask this question ?”  The patient then went on , “ You know that baby sitting job that I have been doing every Saturday nite for Mr. and Mrs. Woodman my neighbor’s   15 month child.?” Well last week the kid was a real problem. He was whinning all the time and wouldn’t listen to me. The final straw was that he spit on me. I lost it  and slapped him    real hard across the face. His face got really red and swollen. I put some ice on it. I will never do that again.” The therapist, was stunned and before she could say anything, the patient said , “Well, I know my time is up” and got up and left.

Should the therapist do anything with this information. Is the therapist required to notify anybody? What are the  legal  and therapeutic implications ?


Case #2

A senior therapist  is supervising the following case. The patient is a single 36 year old dental hygienist living in Manhattan who is in her second year of three times / week psychoanalysis. She entered treatment because of difficulty trusting men which has been related to an inconsistent and insensitive father who shared with the patient the fact that he was cheating on her mother. The therapy has been going well and the patient has made progress in her ability to accept interpretations, have her own insight and utilize insight through her understanding of the transference.

The patient came into a recent session a little anxious and perplexed. She related the following incident . The other day after coming home from work she  rode up in the elevator with a young man a few years younger than her  who lives across the hall from her with whom she has a causal acquaintance. She believes he has a minor position in the union and always viewed him as trying to act like a wannabe tough guy but “a nice kid.”  He was pacing back and forth and seemed scared and she asked if everything was Ok. He asked her if she had a beer or a drink. She invited him and gave him a beer. She distinctively heard him say half to himself, “ I can’t believe I helped put someone to sleep.” When she asked him what did he say, he said it was nothing. They chatted about incidental things and he thanked her for her time and left. She wondered if that were something serious like someone being killed but then became scared and changed the subject and got into talking about her family, dreams and other things that were all continuation of issues she had been recently talking about. The therapist didn’t see any direct or indirect references to this subject in the next two sessions leading up to the  supervisory session.

Does the supervisor t have any obligation to either to suggest  or urge his supervisee  to try to influence the patient to report this information to the authorities and  is the therapist or the supervisor  obligated to do so.? What are clinical and therapeutic implications for the therapist  to spontaneously bring up this incident if the patient is not talking about it ? 

Handbook AIDS Psychiatry-Review/Author Chat

A review of the book Handbook of AIDS Psychiatry co-authored by Mary Ann Cohen and six other authors is presented as well as a Q & A with Dr. Cohen. The book consists of 14 excellent chapters which reviews all aspects of this subject.

The following is a book review which I wrote which was published in the recent Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 38(4) WInter 2010 followed by a previously unpublished Q&A with the senior author.

Handbook of AIDS Psychiatry by Mary Ann Cohen, Harold W. Goforth, Joseph Z. Lux, Sharon M. Batista, Sami Khalife, Kelly L. Cozza and Jocelyn Soffer, Oxford University Press, New York, 2010, 384pp, $49.95

It is unusual for the Book Review Editor of this journal to request a review about a book that does not have psychoanalytic theory, dynamic psychiatry or the application of these ideas, as it’s main thesis. This book, which is about all aspects of AIDS, is such an exception. It is fitting that it be presented to the readers of this journal since this disease, more than any other modern day medical condition has impacted all aspects of psychiatry and mental health. Those of us who were practicing in the early 1980s, especially if you were doing hospital consultations, first saw this become known as a mysterious disease with dark spots on skin that was universally fatal. It then became associated with homosexuals and drug addicts The disease was believed to be highly contagious and caused by blood and sexual transmission. Medical personal became fearful of contracting the disease from patients. An accidental  needle stick while drawing blood or being nicked with a scalpel during surgery, which once was an inconvenience, now became a potentially fatal event. The disease weakened the immune system  and could lead to  deadly opportunistic infections. It ultimately was identified as being caused by the Human Immunodeficiency Virus (HIV). From it’s discovery in 1981 to 2006 AIDS killed more than 25 million people and is still counting.

Not only did psychiatrists and mental health professional see the impact of this disease in our hospital work but those of us doing outpatient psychotherapy could not help but appreciate the effect of this pandemic on many of our patients. Homophobias, which could be multidetermined at any point in time, became greatly exaggerated because of fears of contamination from AIDS. There was a reexamination of all sexual behavior as people began to realize that heterosexual transmission of this disease was also a reality. Questions were being raised whether couples should exchange HIV testing results before engaging in sexual relations? Then there was the realization that AIDS was devastating the gay and bisexual community. We saw a grieving response that extended beyond immediate close friends and families. People throughout the country visited exhibits of  traveling AIDS quilts with patches made as a memorial to individual patients. There were forensic issues encountered by some of our colleagues where people were acting out their anger about being HIV positive by having unprotected sex . There were discussions among therapists of how to deal with a patient whom they  knew was HIV positive but was not telling his or her partners.

The NIH and the NIMH has awarded huge amounts of grant money directed towards AIDS and HIV research in the past 25-30 years. As a result many of the psychiatrists practicing today were supported by these grants at some time in their career or were trained by people who had such support and were well oriented about the psychiatric and psychological aspects of AIDS.

All of this is what makes this 2010 first edition of the Handbook of AIDS Psychiatry such a valuable book. Psychiatrist Mary Ann Cohen, a pioneer in the AIDS field and her six outstanding colleagues have written a book, which includes just about everything we should or might want to know about HIV and AIDS. It is billed as a practical book, which it is, but it is also a definitive work on this subject with over 1500 references. Some of the chapters are adapted from an earlier book titled Comprehensive Textbook of AIDS Psychiatry edited by Drs. Mary Ann Cohen and Jack Gorman, published in 2008 also by Oxford. Seven of the contributors to the earlier work took on the task of developing this current book.

This is not an edited book. All the 14 chapters are written by some combination of the seven authors. Dr. Cohen was involved in all but two of the chapters. Drs. Battista and Soffer were listed as residents at the time the book was published. The first 13 chapters were each followed by multiple pages of references and the final chapter on resources had addresses, phone numbers and web sites.

The widespread imprint of this disease and the comprehensive approach of this book is illustrated in the first chapter where the authors lay out the setting and models of AIDS psychiatric care. They start with effective parenting and prevention of early childhood trauma and conclude with the sections on education, HIV testing, condom distribution, rehabilitation centers, chronic care facilities and nursing homes. They touch upon the prejudice and discrimination labeled as AIDSism which unfortunately is ubiquitous and is also discussed in other chapters in the book.

Chapters titled Biopsychosocial Approach and HIV Through The Life Cycle cover material with which a psychiatrist trained in the past twenty-five years should be quite familiar. However the authors are not content with just reminding the reader to take a comprehensive history in areas relevant to this disease, but they offer over 100 suggested questions in doing a sexual history, suicide evaluation, substance abuse history or a violence evaluation. The following are examples of a few questions, which you may not have thought to use:

1. (Taking a sexual history) How do your cultural beliefs affect your sexuality?

2- Are you aware that petroleum-based lubricants (Vaseline and others) can cause leakage of condoms?

3- (To an LGBT person) What words do you prefer to describe your sexual identity?

4- (Evaluating suicidality) Do you plan to rejoin someone you lost?

5- (Taking a substance abuse history) What led to your first trying (the specific substance or substances)?

6- What effect did it have on the problem, crisis, or trauma in your life?

While it is stated that little is known about the relationship between aging and manifestations of psychiatric disorders in HIV positive persons, the discussion and questions raised about this topic in these chapters seem particularly important as treatment is now allowing people with AIDS to become senior citizens.

In the chapter titled Psychotherapeutic Treatment of Psychiatric Disorders it was noted that the enhanced understanding of the conflicts and struggles of the HIV positive  patient afforded by psychodynamic psychotherapy  has been described by multiple authors. This modality of treatment may be especially suited for patients with a trauma history as physical changes in the body and relationship stresses can awaken conflicts triggered by early trauma and neglect. This history of childhood emotional, physical and sexual trauma as well as neglect is also reported to be associated with risk behaviors and is prevalent in persons with HIV.  Other major themes, which were identified, that could surface in psychodynamic work include fears about mortality with the erosion of defensive denial as the illness progresses and conflicts surrounding sexuality. There also was a review of interpersonal psychotherapy, CBT, spiritual focused care, and various group therapy formats.

The chapters on psychiatric aspects of  stigma of HIV/ AIDS  will also be of  particular interest to the readers of this journal who are usually quite involved in dealing with subtle nuances in psychotherapy. Victim blaming, addict phobia and homophobia also called heterosexism are discussed in this context. While clinicians usually don’t have any trouble identifying stigma when they see it, there are scales which can be administered in both research protocols and clinical settings.

Dr. Cozza is the lead author in the chapter concerned with psychopharmacologic treatment issues. It is the longest chapter in the book and can best be summarized by their conclusion that the prescribing of psychotropic or any other class of medications to HIV positive patients taking ART is a complicated undertaking. The chapter provides an explanation of this statement in a narrative style as well as with some detailed tables showing the propensities of various medications to cause inhibition and induction.

Although psychiatrists are usually not involved with the treatment of physical symptoms or the actual administration of therapeutic drugs for  medical conditions, if they work with patients with AIDS they will be discussing various symptoms and complications. Dr. Goforth and Cohen put together two chapters which clearly explain symptoms of AIDS, as well as the medical illnesses associated with them. They review fatigue, sleep disorders, appetite problems, nausea and vomiting with a complete differential diagnosis and intervention options. The full range of endocrine problems, dermatological disorders , HIV associated opthamalogical diseases, malignancies, liver and kidney disease as well as the potential symptoms of these conditions are covered.

The one chapter, which was written by four authors, was titled Palliative and Spiritual Care of Persons with HIV and AIDS. This not only covered a discussion of the management of pain, other physical symptoms, behavioral symptoms including violent behavior and suicidality but it offered a review of models for spiritual care. The work of Breitbart and colleagues with cancer patients using meaning  centered interventions based on Victor Frankels ideas was introduced as was Kissane and colleagues description of a syndrome of  “demoralization” in the terminally ill which is distinct from depression. It consists of a triad of hopelessness, loss of meaning and existential distress expressed as a desire for death. A treatment approach for this state is outlined. This chapter concludes with a review of the role of psychiatrists and other clinicians at the time of death and afterward. This includes a discussion of anticipatory, acute and complicated grief.

Although HIV disease and AIDS is no longer the mysterious disease which people are afraid to talk about and healthcare workers dread seeing patients with, nevertheless it is a very serious illness which cuts across all specialties and has great relevance for psychiatrists and other mental health professionals. It is estimated that more than one million people are living with HIV in the USA. Even now with retroviral treatment available, this disease is expected to infect 90 million people in Africa resulting in a minimum of 18 million orphans. Needless to say, this book should be translated into many languages and should be available internationally. This book gives us a full background about AIDS and allows psychiatrists and other mental health professionals to have this fund of knowledge at our fingertips. Also, if and when there is another deadly virus that appears on the scene, our profession will have a model and a valuable compendium of how to approach it, which is something we did not have thirty years ago.

Take Five with the Author

Questions answered by Lead Author Mary Ann Cohen

MB: How did you get involved in studying AIDS and working with HIV patients?

MAC: During my residency in psychiatry at Albert Einstein College of Medicine in 1972 I observed that some of our patients with psychiatric illness and comorbid complex and severe medical illnesses were not getting adequate medical care nearby city hospitals. It seemed to me that discrimination and stigma led to disparities in the health care they received. As a resident, I sought to address these disparities by establishing a psychosomatic medicine service in one of the hospitals closest to our community-based residency training program in the South Bronx. My goal was to establish a health care environment to meet patients’ needs and use role modeling and education to help to humanize and de-stigmatized mental illness. Subsequently, as a fellow and then as an attending in psychosomatic medicine at Montefiore Medical Center, I worked in the general medical clinic using a similar approach. In July 1981, I re-established a psychosomatic medicine service at Metropolitan Hospital Center, a city hospital in Manhattan, only one month after the first article about AIDS appeared in the MMWR. We were at one of the epicenters of the drug and AIDS epidemics. For me, AIDS was a paradigm of the complex and severe chronic medical illnesses that I had been working with until that time. It had all of the aspects of diabetes mellitus, coronary artery disease, hypertension, and cancer but was also infectious, highly stigmatized, and was associated with complex risk behaviors that posed public health risks as well. It was clear that there was a dire need for establishing another health care environment to meet the needs of persons with AIDS and provide education and support for their caregivers. I was inspired by the fears of patients, families, caregivers, and hospital administrators to work toward humanizing and destigmatizing this new illness. Caring for persons with HIV and AIDS is a challenge and inspiration that continued over the ensuing 30 years and continues to this day.

MB: Are third world countries adequately addressing the psychosocial factors involved with AIDS?

MAC:That is a very complex question that I will address with a very simple answer. The care in resource-limited countries cannot be characterized easily. It is varies from country to country and area to area. Only a small percentages of persons with HIV and AIDS have access to adequate HIV medical care and there are some areas where the only psychosocial support is that provided for dying patients. In some areas it is outstanding and in some it is entirely absent or provided by the small children of dying parents as it was in some of the homeless shelters of the early 1980s in New York City. These disparities in care are evident in resource-limited countries. The lack of access to skilled HIV specialists in medicine and psychiatry as well as lack of access to  antiretroviral medication are glaring and tragic disparities that are inadequately addressed in resource-limited countries. In some areas of the United States as well as other countries with resources, care is also less than adequate for some persons with HIV and AIDS.

MB: To what degree has the social stigma with HIV disease diminished in the U.S. and what is the main reason for this change?

MAC:The social stigma of HIV has diminished to a small to moderate degree. The main reason for changes made has been a combination of education, legal strategies, and public health efforts directed at decreasing discrimination.Initially, persons with HIV and AIDS were experiencing overt discrimination that led to loss of homes, jobs, education, and even health care at hospitals, doctor’s offices, chronic care facilities, nursing homes, some houses of worship, and even funeral homes. While legal safeguards and education have led to improvement in all of these areas, the discrimination in family and society is harder to regulate or eliminate. There is still discrimination by some clinicians, in some health care facilities, in schools, and in camps. Although most discrimination is subtle and covert some is still obvious. Some of my own patients in New York City continue to experience this discrimination. In 2009 a 75-year-old retired university provost and minister was admitted to an assisted living facility in Arkansas to be closer to his daughter. He was discharged the next day because when the facility administrators realized he was HIV positive. The with the help of Lambda Legal, the family sued the facility for discrimination, the decision was upheld on appeal, and the case was settled out of court in September 2010.

MB: Is there evidence that psychosomatic factors  influence the immune system and therefore effect the course of HIV disease?

MAC:There is evidence that psychosomatic factors influence the immune system in many illnesses including HIV and AIDS. As in many illnesses, depression (Katon et al. NEJM, 2010) can have a direct impact on immune system function, an indirect impact on adherence to medical care, and thus effect the course of illness. In persons with HIV and AIDS depression and stress (Antoni et al, 1996; Cruess et al, 2003, 2005; Leserman et al. 1997, 2000, 2002), PTSD (Cohen et al. 2001), substance use disorders, as well as HIV-associated neurocognitive disorders can have direct and indirect effects on the immune system, adherence, course, and prognosis. Since persons with HIV and AIDS with access to medical care have other multimorbid medical illnesses, psychosocial and psychological factors can have a profound influence on the course of all of these illnesses.

MB:What are the most common reasons that patients with HIV disease or AIDS come to see you as a psychiatrist ?

MAC: Persons with HIV and AIDS are referred or self-referred for many of the same reasons as are persons with other severe and complex medical illnesses. These include depression, PTSD, bereavement, substance use disorders, cognitive disorders, and psychotic disorders as well as for relational problems and crisis intervention. Specific issues related to HIV include depression and suicidal ideation due to HIV stigma, relational issues in serodiscordant couples, reproductive issues, and concerns about disclosure of HIV infection. The care of persons with HIV and AIDS includes crisis intervention, individual psychodynamic psychotherapy, couple therapy, family therapy, addiction treatment, geriatric psychiatric care, couple therapy, group therapy, and family therapy as well as coordinating the complicated psychopharmacological treatment of persons on a multiplicity of other medications. Most important of all, psychiatric care includes collaboration. This entails becoming a part of an integrated health care team of HIV specialists as well as other physicians and health professionals who are caring for the patient.

First CAPA Graduation Held In China

CAPA stands for Chinese American Psychoanalytic Alliance which is an organization created by Dr. Elise Snyder a New York psychoanalyst. The organization runs a training program where mostly American psychoanalysts teach Chinese psychoanalytic students theory and technique as well as providing individual supervision all via Skype. The first graduation of this two year program was recently held in Beijing China .

Report From Beijing

In the future when Chinese psychoanalysts look back at the beginnings of what may be a vigorous psychoanalytic movement in China, they will remember October 24, 2010 when The Chinese American Psychoanalytic Alliance (CAPA) held the first graduation ceremony of it’s psychoanalytic training program at the Mental Health Institute of Peking University. I had the pleasure and the honor of attending that graduation.

Elise Snyder, M.D. Driving Force Behind CAPA

Elise Snyder, M.D.

The creative and driving force behind CAPA is a New York psychoanalyst by the name Elise Snyder. It all began several years ago when she was visiting China with her husband Michael Holquist who is Professor Emeritus of Comparative Literature at Yale University and was attending a conference there. Dr. Snyder met several Chinese mental health professionals who were very interested in learning more about psychoanalytic theory and practice. This led to a series of visits to China by Dr. Snyder where she gave lectures, held various meetings and did some consultations. She returned several times and also became very involved during a subsequent major earthquake where she was helpful in advising about mental health services.

Dr. Snyder was encouraged to set up a training program for Chinese therapists and students interested in learning about psychoanalysis and psychodynamic psychotherapy. She began to involve American colleagues and utilized Skype an Internet Video Conferencing tool. This evolved into a program which was training Chinese psychiatrists and other mental health professionals in 4 different cities. There would be 4 hours of classes per week via SKYPE. Each class would be an hour taught by an expert mostly in the United States, although psychoanalysts in Canada, Australia and France also were recruited as teachers. In addition the students were required to have one hour per week of a supervisory session for their own clinical work also done by Skype with CAPA instructors. Many students chose to have their own psychoanalysis or psychoanalytic therapy mostly via Skype.

CAPA is Non Profit but Students Pay a Fee

CAPA is a nonprofit organization. The students do pay a tuition, the equivalent of about $1500 /year, which goes towards administrative expenses. The teachers donate their time for teaching classes and supervising students. Those students, who are being treated, pay very modest fees in the range of $5-25/session, which means that most of the therapists are essentially donating their time. The students themselves are usually employed as mental health professionals. Some are psychiatric residents working in a hospital or if graduated may be working in mental health clinics or a few may be in private practice. There are even medical school faculty members in China who have chosen to get the credential as a CAPA graduate. Others are psychologists, counselors or other mental health professionals who may be working in clinics, hospitals or other settings.

I was asked to participate in in the CAPA teaching program about one year ago. I subsequently have taught classes in Wuhan and Shanghai, both via Skype. I am now supervising a young psychiatrist who is in Qingdao, Shandong Province, an eastern coastal city of China. There is a 16 hour difference between China and Los Angeles where I am located. So for example, on Tuesday evening at 11pm I sit in my office and fire up my computer and will be viewing my supervisee and chatting with him for his supervisory session on Wednesday at 3 pm in China. While I was in China  with the recent CAPA tour I  meet with him in person.

CAPA has caught on in China and in the United States. There are over 200 faculty members who donate their time to the training of psychoanalytic theory and therapy in China. Approximately 30 students were graduated in Beijing in October. There were also informal graduation ceremonies for another 20 students in Shanghai and Wuhan. This means that  this nascent organization of Chinese and American professionals has close to 350 members and counting. In Beijing and in other cities where I traveled as part of the three week CAPA tour, I met Chinese professionals and professional students who were eager to learn about CAPA. Many were preparing themselves for a career in the mental health professions and were anxious to get training through CAPA.

The Historic First CAPA Graduation

Prior to the historic graduation and the handing out of diplomas, there was an academic program for the CAPA students, the faculty and for other guests from the Mental Health Institute at Peking University. The moderate size auditorium was quite filled. First, there was a case conference, which was led off by Dr. Ba Tong, one of the graduates who presented a clinical case in which she demonstrated her knowledge of transference and countertransference. Dr. Cecile Bassen, a psychoanalyst form Seattle, sensitively discussed the case. We later met Dr. Ba Tong who came across as a very capable young woman who showed us pictures of her new private office, which she will be sharing with a colleague as they start their private practice in Beijing. The second part of the academic program was a presentation by Dr. Shari Thurer from Boston who gave a lecture on Sexuality and Gender identity in which she reviewed homosexuality, transgender sexuality and transsexuality. There was a very interested response from the students in the audience some of whom told of their clinical experience with patients.

The program concluded with a few words from Dr. Snyder who is now seeing her “baby” coming to fruition. She seemed quite proud, as she should be as she called the graduates to the podium. There were also many beaming faculty in the audience. Dr. Snyder announced that there would soon be an advanced additional two year segment available in the CAPA training program, making a total of 4 years of training being provided by CAPA. I later asked Dr. Snyder what she was thinking as she saw the graduates come up to the podium to shake her hand and receive their certificate.  She said, “I felt overwhelmingly moved. I felt happy. I started to cry and couldn’t believe it was happening.” She want on to explain how proud she was of the students and the faculty. She viewed  this event as an historical moment . She ended by saying “This is really the  beginning of an interest in psychoanalytic therapy (in China) that arises from the bottom rather than from the top down.”

Psychodynamic Therapy is Effective

A paper written by Dr. Jonathan Shedler and published in the American Psychologist is reviewed and discussed in which a meta-analysis of evidenced based research supports the efficacy and effectiveness of psychodynamic therapy in the treatment of a variety of mental disorders including personality disorders. The benefits of this therapy appear to increase with time whereas the benefits of other non-psychodynamic therapies tend to decay over time. Evidence is also presented which points out the role of psychodynamic processes in non psychodynamic therapy such as CBT.

Jonathan Shedler, PhD
Jonathan Shedler, PhD

Every once in a while a paper emerges from the literature, which has a major impact on the delivery of treatment in a particular area. A recent article in American Psychologist titled  The Efficacy of Psychodynamic Psychotherapy by Dr. Jonathan Shedler, Associate Professor of Psychiatry at University of Colorado School of Medicine, may be such a contribution

Bias Against Positive Psychodynamic Research Findings

Dr. Shedler introduces his piece by noting that many people including academicians, healthcare administrators, and health care policy makers believe that psychodynamic concepts and treatments lack empirical support or that scientific evidence shows that other forms of treatment are more effective. He states and eventually demonstrates that scientific evidence proves quite the opposite in that considerable research supports the efficacy and effectiveness of psychodynamic therapy.  One of few things  that Dr. Shedler postulates without evidence, is that the reason for this bias, is related to American psychoanalysis being “dominated by a hierarchical medical establishment that denied training to non MDs and adopted a dismissive stance toward research.” He believes that these circumstances led to academicians embracing empirical findings of non psychodynamic treatment and overlooking evidence that supported psychodynamic concepts and treatment.

Distinctive Features of Psychodynamic Technique

Inherent to this paper is a description of the characteristics of psychodynamic (which are equated with psychoanalytic) therapy. He notes that the essence of this therapy is exploring those aspects of self that are not fully known, especially as they are manifested and potentially influenced in the therapy relationship. He distills the following seven features concerning process and technique which have reliably distinguished psychodynamic therapy from other therapies (especially CBT) based on empirical examinations of actual session recordings and transcripts.

1-    Focus on affect and expression of emotion

2-    Exploration of attempts to avoid distressing thoughts and feelings (often referred to as defense and resistance)

3-    Identification of recurring themes and patterns

4-    Discussion of past experience (developmental focus)

5-    Focus on interpersonal relations

6-    Focus on the therapy relationship (often referred to as transference and countertransference)

7-    Exploration of fantasy life

He states that the goals of psychodynamic therapy include, but extend beyond symptom remission. This would mean that successful treatment should not only relieve symptoms but also foster the positive presence of psychological capacities and resources.

This idea would have particular resonance in research that is subsequently presented which shows the long lasting effects of psychodynamic therapy beyond just the improvement of symptoms.

Method of Analysis the Research Data

Shendler describes the technique of  meta–analysis which he relied upon in writing this paper, as a widely accepted method for summarizing and synthesizing the findings of independent studies. Meta-analysis makes the results of different studies comparable by converting findings into a common metric such as effect size, which is the difference between treatment and control groups expressed in standard deviation units. An effect size of 1.0 would mean that the average treated patient is one standard deviation healthier on the normal distribution or bell curve than the average untreated patient. At the other end of the scale an effect size of 0.2 is considered a small effect.

Effectiveness of Psychodynamic Psychotherapy.

A review of major meta analysis of psychotherapy outcome studies from more than 500 individual studies by different authors is presented and showed an overall effect size of between 0.75 and 0.85 compared to untreated controls. As a point of reference, the effect sizes for antidepressant medication (usually comparing active drugs vs. placebo ) was reported as running between 0.17 (for the older tricyclic medications) to only as high as 0.31 for some of the new antidepressants.

Findings Hold Up in Looking at a Variety of Disorders

In specifically looking at the effectiveness of psychodynamic therapy through this method of meta analysis, Shedler sited mostly recent studies from the past several years with a range of common mental disorders seen in patients who received short term (less than 40 hours) of psychodynamic therapy using controls or waiting list, minimal treatment or treatment as usual. There was an effect size of 0.97 for general symptoms improvement, which increased to 1.51 when patients were, assessed at follow-up, more than 9 months after treatment. There were other studies showing similar results when specifically looking at the improvement in somatic symptoms and health care utilization all related to psychodynamic therapy. Similar results were also found in looking at the efficacy of psychodynamic therapy in treatment for personality disorders, eating disorders, and substance related disorders.

Even Better Effects At Long term Follow-up

In the most recent and rigorous studies of the evaluation of psychodynamic therapy, the recurring findings are that the benefits of psychodynamic therapy not only endure but actually increase with time. This is a finding that is reported to have emerged from at least five independent meta analysis. In contrast the benefits of other non-psychodynamic therapies tend to decay over time, particularly for the most common disorders such as depression and generalized anxiety. The trend towards larger effect sizes at longer term follow-up were felt to suggest that psychodynamic treatment sets in motion psychological processes that lead to ongoing change, even after therapy has ended.

Role of Psychodynamic Processes in Non Psychodynamic Therapy

One of the most revealing and interesting aspects of this paper is the analysis of the role psychodynamic processes in non psychodynamic therapy. For example, Shedler discusses available evidence, which indicates that the mechanisms of change in cognitive therapy may not be “the cognitions” which are presumed by the theory. He notes that studies that look beyond “brand names“ (just labeling the type of therapy),  by examining session videotapes or transcripts, indicate that the active ingredients of other therapies include unacknowledged psychodynamic elements.

Putting the Microscope on CBTMICROSCOPE

He describes an instrument called the Psychotherapy Process Q-Sort ( PQS) which consists of 100 variables that assess therapist technique and other aspects of the therapy process which can be used to objectively analyze sessions. In looking at archival session of both CBT and psychodynamic therapy researchers could analyze where therapists were in fact adhering to the usual protocol of the therapy which they believed they were doing. The findings showed that therapists adherence to the psychodynamic protocol predicted successful outcome in both psychodynamic and cognitive therapy.  Therapists adherence to the CBT protocol showed little or no relationship to outcome in either forms of stated therapy.  This finding was replicated by a another study that employed a different methodology and also found that psychodynamic interventions, not CBT interventions, predicted successful outcome in both  cognitive and psychodynamic treatments.

In one study of the manualized CBT it was found that the identification of  “working alliance“ (also known as therapeutic alliance), which is an essential feature of psychodynamic therapy, predicted improvement in all outcome measures.  Also in the same study, the psychodynamic process of “experiencing” (which refers to talking about ideas with or without emotions, referring to inner feelings or self understanding)  predicted patients improvement on all outcome measures. A subsequent study of manualized CBT found that interventions aimed at cognitive change predicted poorer outcome whereas discussion of interpersonal relations and exploration of past experiences with early caregivers, both core features of psychodynamic technique, predicted successful outcome.

What Are The Implications of These Findings?

This outstanding paper is an eye opener. While there  are hardly any original ideas put forth but yet the author has essentially nominated psychodynamic psychotherapy as the evidence based  treatment of choice for many conditions. It also makes an implicit  case for our new US   health care system to financially support the use of this form of treatment.

There will need to be a continued flow of this kind of research and meta analysis

There is also the question of determining who are best therapists to administer this treatment and how should they be credentialed?

The author may have been correct in his opening assertions that earlier efforts of  the medical establishment to attempt to control psychoanalytic therapy may have contributed to the bias to against accepting the emerging  research presented in Shedler’s  paper. However, that does not change the imperative that patients with mental disorders need to be skillfully screened for underlying medical conditions. Also, for some patients properly prescribed psychotropic drugs will be the treatment of choice, with or without psychotherapy. For a certain subset of patients this can life saving.

Dr. Shedler’s paper is stirring up quite a tempest. This has led him to try to establish a dialog on some of these issues on the Internet. He has set up a facebook discussion group in order to facilitate this discussion.

I also encourage interested parties to feel free to comment on this blog below.