The Psychiatrist as Psychotherapist | The Retreat at Sheppard Pratt

The Psychiatrist as Psychotherapist

January 22, 2010 —

“I just can’t shake this depression.” Although only 35, the woman in my office who spoke these words looked worn and battle weary. In the course of the introductory interview, she told me that her life had fallen apart, one bit at a time, slipping out of her control. Symptoms of depression had grabbed hold of her insidiously. Sleep was spotty, then tortured, then non-existent. Pleasure in relationships dulled into duty and shifted to irritation and avoidance. Confidence in her skills at work was replaced by diffidence, frank anxiety, and then avoidance. Options narrowed, disappeared. “My father suggested I see you, even though you’re not in network. Maybe some medication can help me. I don’t know.”

I reassured her that some antidepressant medication certainly might be helpful in lifting this heavy depressive mood state. But here lay a critical choice point in our initial session: As this patient’s psychiatrist, do I now address the depression as illness as my primary focus, or do I tune into the individual person suffering with a depression as my primary focus of concern? The former path would lead me one way – towards an interview weighted along the lines of a bio-medical investigation, gaining details of family history, differential diagnosis, medical history, possible co-occurring drug and alcohol problems, and leading to an informed choice of antidepressant, followed by patient education, and accompanied by appropriate support and re-moralization. The later path would open up an exploration of patient’s “life story” and offer the possibility of a psychotherapeutic relationship between us in which the meaning of her experiences is valued alongside a medical treatment of her depressive illness. I was quite aware that if I ignored this second path it would likely stay closed to me.

I chose the second path and asked her how things had started to fall apart in her life. I waited as she gathered herself. She told me of two miscarriages in the past year, which her family blamed on her stressful job. Her husband now wanted to leave her and she suspected he was having an affair. He stopped sleeping with her and they both lost interest in having a child. All her mother talked about now was the time she would become a grandmother. Since her brother was gay, she felt tremendous responsibility, guilt, and anger around this. She loved her job, but it was stressful and she couldn’t seem to get that under control. She took this job in favor of a higher paying one because she thought it would be less stress and more manageable hours, but more work kept getting piled on her. Her husband was resentful over the lower pay and long hours. Her girlfriend told her to leave the husband. Her mother told her to leave her job. She had no one to talk to about this that didn’t make her feels worse.

It was clear that she felt better opening up. She had more to talk about, fidgeted, and told me about an abortion in college, the first she had spoken of it in 15 years. She feared she was damaged, that was why she couldn’t implant a child in her womb. She felt better having told me this. I suggested it would be useful that we meet to talk more, but perhaps we now should discuss medications for her depression as well. She agreed, and we shifted gears. We went through an abbreviated bio-medical interview, and I prescribed duloxetine with instructions. We set up an appointment for the following week and started ongoing psychotherapy.

I worked with this patient for just over a year with weekly psychodynamic psychotherapy and medication management. After that, she continued on antidepressant medication for another two years and saw me every 2 months for 30 minute follow-up sessions. She was very satisfied with the outcome and I was personally and professionally pleased as well. (This “patient” is a composite construction to protect confidentiality.)

I find it hard to imagine that treatment would have started out as successfully if I had followed the first path and contented myself to be her medication doctor. Still, it is possible that the outcome ultimately would have been good if she had found a qualified psychotherapist who worked in tandem with me. However, I find it impossible to imagine I would have had the same personal and professional satisfaction in my work. Certainly, more difficult patients than this have less certain outcomes and often are less gratifying to work with in psychotherapy. But it is often those patients who need the skills of psychiatrists who can provide sophisticated therapy and medication management merged in one person. For example, patients with borderline dynamics often split multiple care providers and require frequent and cumbersome communications between providers to assure adequate treatment. When the therapist is also the prescribing psychiatrist, this is not necessary.

Given the advantages to patients and psychiatrists, why is it that fewer psychiatrists provide psychotherapy to fewer patients today? This is more than just an opinion, as a recent study in the Archives of General Psychiatry demonstrated a sharp decline in psychotherapy provided by psychiatrists over the past decade (1). This is ironic, as more evidence is accumulating that psychotherapy, especially when combined with medications, is effective in treating major psychiatric conditions. Cognitive behavioral therapy and interpersonal therapy have extensive track records of published studies documenting efficacy, and now a landmark meta-analysis of long term psychodynamic psychotherapy published in JAMA has shown its effectiveness in the treatment of complex mental disorders (2).

Still, there are powerful reasons that pull psychiatrists away from providing psychotherapy to their patients. Basically, these factors conspire to create a hostile environment to the development of a professional identity in which future psychiatrists can grow into the role of psychotherapist during the formative years. Throughout training, the idea that a modern psychiatrist can and should learn and practice psychotherapy needs to be nurtured by valued mentors. Instead, it is often devalued and questioned by core faculty who directly and indirectly push the agenda of research-based psychiatry and “evidence-based” practice guidelines because that is what they focus on in their research. During residency training, psychotherapy training has lost its place in the center, instead focusing on manual-based therapies during the smaller and smaller time slots within the curriculum. Residents don’t really get time to do ongoing psychotherapy until their third year of training, which is very late to start to develop a core skill. Most supervision and teaching is done by volunteer faculty, who are ambivalently regarded by the core faculty as perhaps necessary, but often out of touch with the realities of modern psychiatry. Finally, those residents who persevere with psychotherapy training and see patients in therapy once they are in practice have to deal with the devalued compensation system for psychotherapy relative to working exclusively within the medical model.

Of course, overcoming this hostile environment is only half the battle around becoming a psychotherapist. If a psychiatrist is to develop a psychotherapeutic mind set he or she must overcome internal resistances as well. The internal resistances have to do with facing personal conflicts (wishes, anxieties, and defenses) that are inevitably stirred up when working in depth with patients who are struggling with similar issues on a regressed level. It takes both personal courage and a supportive professional environment to develop the skills and temperament to do psychotherapeutic work.

Ultimately, what is at stake? The welfare of our patients is fundamentally affected when we can no longer think psychotherapeutically nor offer them combined treatment. Simultaneously, our identity shifts to that of a medical specialist rather than a primary care provider for our patients. Perhaps one might argue that is for the best. While I am sure third party payers would happily take the “pro” side of that argument (at least in the short run), I don’t think many patients would. However, if all we can offer our patients is a circumscribed piece of what they need, then they will know nothing different. If we are trained only as bio-medical psychiatrists, we will know nothing else either. What we don’t know, we will inevitably devalue.

Also at stake is our professional fulfillment in treating the patient as a full person. Knowing the patient thoroughly, caring for the patient as a healer rather than a technician, and working with him or her from start to finish are the rewards of being the primary care physician. Helping, within the therapeutic boundaries of the professional relationship, becomes renewing and expanding in a deeply personal way. Not just psychiatry, but the broader field of medicine needs to find its way back towards this ethic.

This touches upon yet another set of rewards in psychiatry when you are the psychotherapist. It is in the personal realm and involves values of knowing yourself better, as you work with forces within the mind and life of your patient that tap into your own mind and life experience. As Harry Stack Sullivan said, “We are all more human than otherwise.” You are never more aware of this than when practicing psychotherapy with another person who is suffering in areas that you understand because you understand your own humanity as much as you understand your textbook psychopathology. As Irvin Yalom says so eloquently in his book, The Gift of Therapy, “How can one possibly guide others in an examination of the deep structures of mind and existence without simultaneously examining oneself?” As a therapist, you must stay immersed in areas of human suffering that are constantly alive and meaningful in order to be helpful to your patients. As a consequence, you keep your feet to the fire of many of the most important questions of emotional and relational life. You are always growing, and it is never dull.

References

1. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008; 65(8):962-970.
2. Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA. 2008; 300(13):1551-1565).
3. Yalom I. The Gift of Therapy: an open letter to a new generation of therapists and their patients. 2001; HarperCollins:NY, p.256.

- Don Ross, MD

 

Originally published in The Maryland Psychiatrist, Winter 2009, Vol 35, No 3
Reprinted with permission of the Maryland Psychiatric Society