Psychotherapy as generic conversation — Sloppy thinking in psychiatry 4

This fourth installment in my “sloppy thinking” series turns to psychotherapy, or what passes for it in some psychiatric practices.  A very brief history: Sigmund Freud, a neurologist, invented psychoanalysis and its offshoot, psychodynamic psychotherapy, about 120 years ago.  It was, first and foremost, a treatment that involved talking — not merely a conversation that happened to make the patient feel better.  Years later, the object-relations school of psychoanalysis and the humanistic psychology movement of the 1960s partly shifted the focus of dynamic psychotherapy away from technique and toward a healing relationship, a shift prefigured by pastoral counseling and by the ministrations of the nursing profession.  Nonetheless, dynamic psychotherapy remained a treatment: a professional service with clear goals and a coherent rationale, aimed to remedy defined psychological conflicts or deficits.  Meanwhile, over the same century or so, academic psychologists developed the theories and practices of behaviorism via experiments with animals, and later applied behavior modification and various behavioral and cognitive therapies to human suffering.  While such treatments could be offered in a humane and caring manner, the relationship itself was not considered curative.

Psychoanalysis and psychodynamic therapy originated in a medical context, and psychiatrists historically have been trained in its theory and practice.  (In contrast, psychologists historically tended to practice the empirically based behavioral and cognitive therapies developed in academia, although this distinction between the disciplines has faded.)  Prior to the advent of psychoanalysis, psychiatry was a medical specialty focused on the management of severe mental illnesses that rendered sufferers incapable of living in mainstream society.  But by the mid-20th century, the field had adopted the new “talking cures” to treat higher functioning patients.  For a few decades, roughly 1950 to 1980, the popular image of the psychiatrist was a psychoanalyst with the trademark couch in the office.

The emphasis in psychiatric training and practice shifted dramatically away from psychotherapy and toward medication treatments in the 1980s as a result of several factors.  Promising classes of medications such as SSRI antidepressants and atypical neuroleptics were developed; federal research funding shifted toward biological psychiatry; psychiatry’s new diagnostic manual (DSM-III) encouraged medical-model thinking; managed care tightened the screws on reimbursement; and competition from non-physician mental health professionals heated up.  Psychopharmacology became a defensible niche for psychiatry, unlike psychotherapy which saw increasing competition from psychologists, social workers, marital and family therapists, and others.

Currently, many American psychiatry residencies offer minimal training in psychodynamics, or psychotherapy in general (interesting debate here).  I consider this very unfortunate.  Psychodynamically informed treatment is far richer and more sensitive — ultimately, I have to believe, more effective — even if psychodynamic psychotherapy itself is not offered.  For example, unconscious dynamics can help explain medication non-compliance, and can shed light on difficult psychiatric consultations on medical or surgical inpatients.  It’s hard to deny that a mental health professional with a deeper appreciation of human emotions, conflicts, and psychological defenses has an advantage over the same professional without this appreciation.

Where’s the sloppy thinking?  It results from the inescapable fact that most psychiatric patients harbor thoughts and/or feelings they want to talk about.  A psychiatrist who avoids all such conversation feels like an “ape with a bone,” a medication technician who does his own little piece of work well, but misses the big picture.  So the psychiatrist talks with the patient for 30, 45, or 50 minutes, which makes both the psychiatrist and patient feel better in the moment.  It is billed as psychotherapy, but is it?

That depends on what happens in those 30, 45, or 50 minutes.  Is it well-conducted cognitive-behavioral therapy?  Hardly ever.  Nor is it psychodynamic psychotherapy if it’s no more than a conversation that temporarily makes the patient feel better.  Dynamic psychotherapy is a structured treatment that includes a dynamic case formulation, a coherent rationale, strategic interventions, and treatment goals — features uniformly absent in this typical scenario.  Some call these unstructured conversations “supportive psychotherapy,” but even that has a technical definition and clear goals.  Supportive psychotherapy is more than letting the patient “vent,” or chat as though it were a social visit.  Perhaps all this mislabeling is an unfortunate mistake by well-meaning practitioners who were never trained to perform or recognize actual psychotherapy.  Or maybe it’s intellectual laziness.  Or insurance fraud.

An honest profession would call such encounters what they are: Humane medication visits.  Stripped of the pretense of psychotherapy, we might admit that it often takes more than ten or 15 minutes to find out how a patient is doing, and that conversely it doesn’t require aimless (yet remunerated) chatting for the better part of an hour either.  By clearly differentiating psychotherapy from generic doctor-patient conversation, we’d regain respect from other mental health professionals who have come to believe that psychiatrists don’t take psychotherapy seriously, or that we pompously claim we know what we’re doing when we don’t.  These criticisms really boil down to irritation at psychiatry’s sloppy thinking about psychotherapy, a tragic irony considering the field’s long history with this treatment modality.

You guessed it: photo courtesy of Petr Kratochvil.

14 comments to Psychotherapy as generic conversation — Sloppy thinking in psychiatry 4

  • Jeff G.

    Dr. Reidbord,

    I appreciate your continued investigation of sloppy thinking in psychiatry, as no matter our difference in opinions, I do believe that critical thinking about mental health is better than sloppy thinking.

    On my first read through, I have a few points I want to engage on.

    “It’s hard to deny that a mental health professional with a deeper appreciation of human emotions, conflicts, and psychological defenses has an advantage over the same professional without this appreciation.”

    This seems to be reasonably easy to test hypothesis, though “advantage” would have to be further operationalized. My opinion doesn’t really differ from yours in this matter though, but I do recognize this is something we could actually demonstrate with more confidence one way or the other.

    I suppose my bigger issue is the insinuation that non-dynamic informed treatments somehow don’t appreciate emotions, conflicts, and defenses or appreciate them less. For example, perhaps therapists informed by other models don’t put importance on dynamically formulated unconscious processes in the same way, but they may appreciate how social, historical, systemic, oppressive, etc. forces interact unconciously with people’s experience, desires, or troubles more than dynamic therapists and in more sophisticated ways.

    Regardless of whether or not having greater appreciations of people’s emotional and internal life gives therapists “advantages,” lots of evidence-supported therapies and folks who practice them demonstrate appreciation for internal life, and often in ways that are ignored or denigrated by dynamically informed treatments.

    My other point is related to case-formulation and goals. I agree with you that psychological treatments like psychotherapies are active interventions/treatments and should be studied as such and considered differently than “mere talking.” Having goals for treatment, a plan to reach those goals, and a rationale for pursuing that plan are important factors in distinguishing treatment from talking. In talking to various dynamically-informed therapists about their practices and in my own experiences, I find many of these goals, plans, and rationales are created without much input or consultation with clients/patients. This happens in non-dynamic therapies as well, but intentional obfuscation, vagueness, and anxiety-provocation are often key components of dynamic treatment. How often does a clinician share case formulations with clients as they develop them? How often do they inform patients when they change that formulation. How often are processes of dynamic therapies fully explained to patients before treatment is initiated? How often are goals of therapists different than goals of patients without patients knowing?I find formulation and initiation of treatment to lead to particular goals that are initiated by therapist without open and continued consultation with patients to be lacking in proper informed consent. I often feel, and I could be mistaken, that many dynamic therapy encounters develop in order to achieve clinician goals and not client goals, or to persuade patients to value clinician goals. Whether or not dynamic therapies are helpful or meaningful for what they purport, I believe that all treatments/interventions (especially ones delivered by doctors), require extensive consent procedures that would include explanation of formulation, treatment rationale, treatment interventions, and goals before active treatment can begin and when clinician formulation/strategies/goals change. I don’t think this happens consistently well in dynamic psychotherapy.

    • Hi, and thanks for writing. I apologize for any insinuation that non-dynamic therapists as a rule fail to appreciate emotions, conflicts, and defenses. Many cognitive therapists, for example, are also trained, at least to some extent, in dynamic concepts. Also, many sensitive people appreciate such matters without any professional training at all. Nonetheless, I maintain that systematic training in psychodynamics confers deeper appreciation for, and recognition of, conflicts and defenses. Conflicts and defenses are psychodynamic concepts in the first place; it’s virtually impossible to talk about them without invoking dynamic theory at some level.

      Your point about social, historical, systemic, and oppressive forces is a good one. These factors are not taught in dynamic training. Presumably psychotherapists who are trained to recognize and deal with these factors have an advantage. I would not claim that psychodynamic understanding is “superior” or “better” than understanding these other factors, just that they are all complementary. It has not been my experience that a dynamic perspective actively discounts these forces, but others may have a different experience.

      Setting treatment goals is a subtle matter in dynamic therapy. The model itself holds that emotional difficulties lie outside of conscious awareness, and that treatment is a gradual uncovering of material previously unknown to the patient and the therapist. I’ve taught dynamic formulation for many years, and can assure you that plans, goals, and rationales are intended to be disconfirmable working hypotheses, essentially educated guesses, on the part of the therapist. It is impossible to apply an informed-consent model directly to such an intervention. Instead, informed consent has to happen at the level of process. The general approach can be explained clearly, in detail, and non-mysteriously — including potential risks and benefits, as well as they reasonably can be estimated. Unfortunately such explanations are often omitted based on a mistaken idea that the patient’s confusion and uncertainty about the process somehow moves the work forward. This, too, is a type of sloppy thinking, and perhaps will give me another chance to post the chimp photo. I appreciate your thoughts, and welcome your further commentary.

  • Jeff G.

    I suppose some of this discussion again hinges on what we mean by “advantage.” Your assertion that formal training in dynamic concepts provides deeper appreciation for conflicts and defenses and that appreciation is generally advantageous beyond other training because conflicts and defenses are dynamic concepts is a tautological. Whether or not deeper appreciations of concepts learned primarily by dynamic therapists leads to better therapy, outcomes, etc (and how those are defined) can be scientifically assessed, but your first paragraph ends with basically the circular rationale “dynamic therapists make better therapists because their therapy is dynamic.” Shedler basically made this argument when trying to show that the benefits of non-dynamic psychotherapies were actually only beneficial because the helpful parts of them were dynamic. I think this point was well rebutted.
    My example was partly intended to demonstrate other ways people deal quite differently with what might be similar concepts to “conflicts”, “defenses”, “emotions”, and “unconscious” as dynamically framed in their case formulations and treatment . Other understandings of aspects of human experience, distress, wellness, etc. may also provide “advantages” to therapy. I agree that many perspectives may be complimentary, but I can think of and I’m sure you know of clinicians who avoid non-dynamic theorizing even where dynamic understandings and formulations were not helpful (and possibly or definitely harmful) to clients.

    This leads to further discussing of informed consent. Informed consent is defined in all sorts of ways, but given someone has intellectual, maturational capacity to consent, I tend to distill it to making sure clients receive and understand the information that could influence their decision to participate in or abstain from a treatment. This is certainly hard for psychotherapy, particularly dynamic therapy. I full-heartedly agree with you that it is sloppy to omit consent processes because confusion and uncertainty is thought to be helpful. I would also add that I think this is dangerous and unethical. It is also all too common(I don’t want to generalize too much from this study of New York area psychiatry residents (lack of) initiation of informed consent http://www.ncbi.nlm.nih.gov/pubmed/17474811). I’m glad you value explaining general approach non-mysteriously, but I do think informed consent does require more than that.
    This relates to what I was trying to bring up about the differences of understanding and transparency about treatment processes between therapists and clients. Whether or not and to whatever extent a therapist believes something is in the best interest of a client, it is ultimately the client who has to live with the effect of treatment, good or bad. To me, this means that clients bear the responsibility to make decisions about what they are willing to risk and for what goals, and therapists ethically have to be clear and thorough in the information they provide so that decision can be informed, including: goals/intentions (hopefully developed by client in collaboration with clinician), likely benefits (and from what evidence therapists draw from to determine that likelihood), risks (including risks of things like starting and then preliminarily terminating and particularly worsening of or developing new symptoms), risks/prognosis of abstaining from treatment (ex. vast majority of people experiencing grief recover on their own), expected costs (money, time, energy), explanation of process (including functional definitions of key concepts used in psychodynamic psychotherapy), roles/expected commitments of therapist/client, boundaries, limits of confidentiality, rationales for why therapists suggest particular treatment, and treatment alternatives (and their risks, benefits, and costs). It also means therapists are upfront about the extent of their own uncertainty in their current rationale, acknowledgement that the previously discussed information can change as therapy progresses, making initial evaluation of costs:risks:benefits irrelevant.

    I think this is a lot to cover and that many therapists don’t and won’t do this. However, I think not doing so does not provide clients with information that could reasonably influence their decision, which is what I consider the central component of informed consent. If you don’t know something that would affect your decision, the informed part of the consent is not present. The meaning of “reasonably” can be debated here, but I think it is generally better for patients and clinicians to err on a more cautious interpretation of the term. I don’t know of other treatments where informed consent procedures are avoided or sidestepped because of the subtlety or uncertainty of case formulation. I don’t like using analogy/metaphor but I’ll use one here to demonstrate:
    Perhaps presenting issues in of someone walking into a therapist’s office are similar to a strange-looking growth on someone’s skin a patient would seek consult with a dermatologist for. They are both on the “surface,” they are concerning enough for someone to seek consultation, and there may be more to them than what can be directly/consciously observed. A dermatologist or oncologist would explain to a patient the best of their abilities what they could tell about the growth so far, but recognize they are limited without further investigation. They may recommend a biopsy and/or radiological imaging of some kind and explain why (to gain more certainty about the dangerousness of the growth and if it is related/indicative of other health issues). They would explain the reasonable risks of those procedures and what information they hope to get from those procedures and the likelihood they could get it (based on past research). They also would explain the risks of not seeking further information about the growth (perhaps using epidemiological data about skin cancer prognosis). They would let someone know the cost of the biopsy/imaging/lab tests. If a patient decides to go ahead with the further investigation, some uncertainties of the growth would probably be eliminated but new potential decisions/options would present. If it is benign, a patient might reasonably do nothing or after being informed of costs/risks decide it is in their benefit to just remove it for vanity’s sake. If the growth is malignant, a host of other treatment decisions may be made (surgery, radiation, chemotherapy, energy healing etc) with the oncologist perhaps making and explaining a reasoned recommendation but also explaining treatment alternatives. Lab tests/imaging may show/point to internal growths that aren’t skin related that could be dangerous. Every step of the way though, to the best of her abilities at the time, the dermatologists engages in informed consent procedures. She even does this when she has little information about the presenting issue, in the process of getting more information, and in the process of making decisions about how to proceed with new information.

    I know psychotherapy lacks the physical testing of medicine, but dynamic case formulation is based well fleshed theories of analytically informed human development, personality, and psychopathology. Dynamic therapists do exploratory “tests” informed by those theories as particular responses of or interactions with patients may indicate different personality deficit, conflict, defense/relational structure, pathology, etc as expected by theory. As therapists get new information from this process, different and perhaps more detailed understanding of contributing unconscious patterns that affect patients are developed and treatment goals and strategies are changed to address them. This isn’t all that different from what an oncologist would do, except that it is far more clinician controlled, with patients left out of the loop and required to be fully trusting of their clinician’s judgment. I suppose people also trust their oncologists judgment too (oncologists tend to know more about treating cancerous growths than patients do), but at least oncologists are usually willing/able to explain their thought process and base their recommendations on the best evidence available, discuss alternative treatments, and oncologists don’t pursue any aspect of treatment without patient consent or have their goals guide treatment as opposed to patients(though perhaps this view is a little too idealistic).

    While many dynamic therapists do not believe they can or should follow more typical informed consent processes, I do think it can benefit dynamic therapy. I would hypothesize that taking the time and energy to have thorough discussions of consent can be helpful in building stronger alliances from the start which could be invaluable if client decides to engage in further treatment, especially if the discussion of consent includes some troubleshooting about what therapists/clients would do to mitigate the extent of adverse effects if they occur. I would be very interested to see more systematic assessment of effects of informed consent processes if such serious engagement of informed consent issues provides “advantages” to treatment. If such a model of consent is impossible, than I do believe treatment has flagrant ethical flaws.

    • I agree I’ve been using “advantage” as a kind of vague shorthand. In my own defense, it was an aside in the original post, not the main point I was trying to make. However, I respectfully disagree that my argument was tautological or circular. I mentioned two scenarios where dynamic insights could resolve a problem: In some cases of medication non-compliance, and in some consultations on medical or surgical inpatients. I didn’t flesh these out, but could if you wish. I’m also not denying that other understandings, say economic, could explain other instances of medication non-compliance, for example. Knowledge of psychodynamics does not preclude sensitivity to economics or other factors; they are complementary. I never said that “appreciation [for conflicts and defenses] is generally advantageous beyond other training because conflicts and defenses are dynamic concepts.” That would certainly have been circular.

      “I can think of and I’m sure you know of clinicians who avoid non-dynamic theorizing even where dynamic understandings and formulations were not helpful (and possibly or definitely harmful) to clients.” Sure. But they’re in error. The same may be said of some radical feminist therapists who help clients externalize blame instead of looking at what they can change in themselves, or CBT therapists who doggedly give homework assignments that the client doesn’t do owing to unacknowledged resistance, or psychopharmacologists who keep throwing useless meds at a psychological problem. There are incompetents in every field, and no field should be judged by its weakest practitioners. There are also flexible, open-minded dynamic therapists, feminist therapists, CBT therapists, and psychopharmacologists.

      I have two thoughts regarding informed consent. First, I think you unfairly single out dynamic psychotherapy. Your list of what constitutes “informed” (in your 2nd paragraph above) would not be fulfilled by psychotherapists of any school, nor by most medical practitioners. In receiving antibiotics over the years I’ve never been informed of “risks/prognosis of abstaining from treatment,” rationales for why that particular antibiotic was advised, or several other listed issues unless I asked. (Surgery is different. Long written consent forms are the norm — and patients often say they don’t read the whole thing.) Along similar lines, I’m not surprised by the study of New York area psychiatry residents you cite. “Necessary components of an informed consent discussion were defined a priori by means of a literature review and consultation with experts in informed consent.” We can assume this a priori definition was a legalistic, one-size-fits-all standard. But as just mentioned, even internists and surgeons don’t use the same standard. Is it so surprising that psychiatrists don’t either?

      And that brings me to my other thought. The study also found differences in how three hypothetical patients were informed: a depressed “medication patient,” a patient with borderline personality disorder, and a patient with neurotic character traits. Rather than being damning evidence, I find this not only entirely expected, but commendable as well. You compare psychotherapy to a dermatological work-up, yet the scenarios are different in just the ways that are most important. There is a well-defined work-flow for working up a strange looking growth (and for prescribing an antidepressant). In contrast, Freud famously noted that psychoanalysis is like a chess game: There are defined openings and endgames, but the middle is too variable to predict. As I mentioned above, neither the patient nor therapist knows ahead of time what will come up. And most crucially, in psychotherapy the patient’s need to keep certain feelings out of awareness may be the very problem at hand.

      I’ve had patients come to me for anxiety, describe what sounds like infuriating frustration, and yet calmly deny any anger. My initial formulation might posit that anxiety was a manifestation of unacknowledged anger. How would I include that in “informed consent for treatment”? I can’t. The treatment I’m proposing assumes that the patient initially disagrees with this formulation, and will only recognize his anger later. So instead I obtain informed consent for the process: “Uncovering and exploring feelings may lead to anxiety relief. It also may not, and sometimes the feelings uncovered are painful.” This is the best I can do under the circumstances, just as it was for the studied psychiatry residents in New York. It’s a tribute to them that they know enough not to attempt the same “informed consent” script with a psychotherapy patient that they use when writing an antidepressant prescription.

      Of course, therapists must be ready to re-formulate if new information arises. I might learn about other reasons my patient is anxious, such that my initial idea about repressed anger fades into the background. This work requires humility. I don’t believe, however, that closed-mindedness or lack of humility can be remedied by forcing psychotherapy into a legal framework that doesn’t fit. Thanks again for your thoughts.

  • Jeff

    Thanks for responding and elaborating. Quickly I want to clarify what I thought was tautological. “Nonetheless, I maintain that systematic training in psychodynamics confers deeper appreciation for, and recognition of, conflicts and defenses. Conflicts and defenses are psychodynamic concepts in the first place; it’s virtually impossible to talk about them without invoking dynamic theory at some level.” If you believe that appreciating conflicts and defenses advantageous for therapists, dynamic therapists get training in appreciating defenses and conflicts, and any dealing/discussing of such or related issues, no matter from what perspective, is actually dynamic because they are dynamic concepts, then either dynamic therapists have advantages over other therapists in these emotional concepts and non-dynamic therapists who do are actually invoking/utilizing dynamic therapy when they do. This seems tautological to me, in that no matter anyone’s appreciation for people’s internal life, it is analytically-informed appreciation that is advantageous, and no matter what someone calls themselves, if they have such intentional appreciation, they are dynamically inclined. I see now that you were talking about this as a specific advantage, not an encompassing one, and that other theorizing can also be specifically advantageous.

    On to informed consent. Singling out dynamic psychotherapy is definitely an overreach, as many fields fail at quality informed consent. I should have acknowledged that originally. I do find this observation even more unsettling than if it was just limited to dynamic psychotherapy, as I believe consent is key component of treatment decision-making. However, I do not want to let psychodynamic therapy off the hook just because other fields also fail, it just means that they all have to do better.

    In regards to this discussion, I also want to point out that I believe the study I mentioned is more focused on dynamic psychotherapy consent. Though I’m sure consent issues extend to other therapeutic modalities, considering the authors of the article I cited are analyst-academic-psychiatrists getting information from residents attending the greatly analytically-informed New York training programs, and one of the vignettes was about psychotherapy for “neurotic” character traits, that these residents were thinking about dynamic psychotherapy when engaging in the survey.

    You mention you provide more information when specifically asked, and that also seems to be a key finding of the study. 40% of residents were willing to provide adequate informed consent for psychotherapy if asked. This means that 60% still would not, even if directly asked, but 40% willing to provide at least a more passive consent is much higher than the 1-3% who were proactive. I have learned from my own bad experiences regarding consent to push myself to ask anything I think may be important, and gauge my willingness to consent not just on responses on the comfort/willingness of the clinician in responding. More unsettling, patients do not generally have anywhere near the knowledge about their conditions and treatment options as clinicians do, so they have no idea what are the “right” questions to ask. Patients don’t know what they don’t know (so asking for the information that would be useful is not an easy task and the whole point of seeking professional support is that someone does know more than you and can explain what is going on), so passively providing consent information by relying on questions from patients is still, though a start, not enough from treating clinicians to provide adequate consent.

    What was considered minimal informed consent was established before residents took the survey. This does not mean it was legalistic or unpractical. The residents all looked at the same case vignettes, and had the same information as everyone else who took the survey. I don’t think it is unreasonable that similar expectations of consent would apply given the nature of the survey. From an news article about the survey:

    “‘We set a bare bones set of criteria of what would constitute informed consent,’ said [co-author]Dr. Rutherford of the Columbia University Center for Psychoanalytic Training and Research, New York. This included information about diagnosis and prognosis, treatment options, details of recommended treatment, side effects and logistics of treatment, and their own educational and personal background.’ (http://www.clinicalpsychiatrynews.com/search/search-single-view/psychiatric-residents-lax-on-informed-consent/79cc8f66a4.html)

    All of the suggested information is either known and can be shared with patients, and if some of the information is not known or uncertain, then that fact can also be shared with patients. Also, this was less than the optimal consent process I offered, and seems reasonably minimal. Only six residents were able to meet the criteria for at least one of the vignettes, and it was mostly for the more straight-forward consent for pharmacotherapy for depression. Only one resident of over 100 met minimal consent procedures for both psychotherapy vignettes. This is shocking for me.

    As for your notion of process consent, I think it is important part of informed consent procedures for dynamic psychotherapy. Somehow when explaining to me what you are thinking about the case and the process of treatment, you get a lot more information about process out than you did in your talking to your example patient. I think it would be great to just tell people up front what Freud said, something like (and this is rough), “there are typical starts and ends to dynamic psychotherapies, but it’s difficult to know what the middle will look like. When we begin we will likely talk about x, y, and z (free association, childhood experiences, transference, etc.), and as we come to a close, these a, b, and c issues will have to be discussed (transitioning out of therapy, internalizing, etc). In your goal to reduce anxiety, this process may help in that, it may not, and it may make you feel worse. It actually is likely that you may have unexpected negative feelings during the process, but talking about them together and in context of this experience usually helps us get through those feelings and may actually lead to more relief. Because we will be trying to access unconscious information, information not readily accessible to you or me, it just really hard to know at this point what those feelings might me. There are other treatments for anxiety (CBT, medications, meditation, etc) that may also be helpful (cheaper, shorter), but they also might not help as much as this therapy, depending on to what extent unconscious issues are at play in leading you to feel this way. When we learn more, I might suggest other treatment options that are more appropriate given the new information.”

    As for expecting clients to initially disagree with you, I don’t see why that can’t be part of consent. If you establish that you are working with unconscious material and a patient is willing to recognize that that means they themselves are not aware of everything about what they are experiencing, have adequate information about your credentials, and are provided expected benefits and risks of treatment as documented in past research, then I believe a client can reasonably consent to such treatment, even while recognizing their initial disagreement. If they don’t consent to dynamic therapy based on this disagreement, then offering to do another treatment that may be helpful for them or refer to another therapist is fine. Folks who try other viable treatments for anxiety that don’t succeed often find themselves looking toward dynamic treatments because they may have come to understand, as in your example, that unconscious anger may be a part of maintaining their anxiety.

    Especially for an open-ended therapy process, taking a few more minutes to talk about consent doesn’t seem excessive or damaging. I think it serves everyone’s interest involved, especially if therapists are clear about the issues of uncertainty (as this protects therapists too). I don’t mind more legalistic informed consent procedures, but psychotherapy has historically been exempt from such legal requirements because there is no good definition of what therapy is and the research is too muddled to actually provide reliable information about prognoses and risks. I don’t think this is a triumph for therapy or therapists.

    As an aside, I was reminded of some changes in prescribing procedures for people presenting to primary care doctors with flu-like symptoms of unknown origin (bacterial or viral). It has been common practice to just give antibiotics just in case and to avoid lawsuits, even if the complaints were likely not bacterial in cause. New data shows that people recover from such complaints in the same amount of time, whether they have antibiotics or not. New prescribing practice guidelines now I believe are to still prescribe antibiotics, but tell patients to wait 3-4 days before filling it to see if they start to get better. If they do, then they don’t need to take them, if they don’t, it is a greater likelihood the complaints are due to a bacterial infection and antibiotics would be warranted. Perhaps if doctors educated patients about prognosis of such complaints without taking antibiotics (the same as those who do), and the risks associated with antibiotics (GI problems, more population level issues of antibiotic-resistant bacteria, etc.), folks would make informed decisions to wait out their symptoms and rely on OTC treatments in the meantime.

    Thanks again for the stimulating discussion.

    • It’s important to distinguish psychodynamics from other models of the psyche. References to mixed feelings and to motivations hidden from the self can be found in classic Greek texts, and abound in Shakespeare’s plays. However, a systematic account of repression, defense mechanisms, and symptom production as a result of intrapsychic conflict originated with Freud and his contemporaries. While Aristotle and Shakespeare offered many subtle and profound insights into the human condition, these were not psychodynamic insights. Thus my comment: “Conflicts and defenses are psychodynamic concepts in the first place.”

      Regarding the New York resident study, I confess that I only read the abstract via the link you provided. Since I don’t have access to the full text, I can’t comment on the informed consent criteria they used, or many other issues that may have affected the results. I do want to mention that early residents are instructed not to disclose personal details about themselves to patients. It is only after years of experience that they learn to make finer distinctions, and to disclose personal material judiciously and in non-harmful, even beneficial ways. The study cites failure to disclose personal information as a major lapse, yet one could hardly have expected otherwise. It’s interesting to me that the webpage for the study’s first author lists not only his educational background, but adds that he was raised in suburban Chicago, and currently lives in Scarsdale, NY with his wife and two children. While such information may often be found via online research these days, many psychoanalysts and dynamic therapists would be less sanguine about offering this kind of information to patients. In my view, even if such disclosure is harmless it has no bearing on informed consent.

      Your sample script for informed consent (starting with “there are typical starts and ends to dynamic psychotherapies…”) is more or less what I say. I’ve quoted Freud’s chess analogy to plenty of patients, and nearly always mention alternatives, including CBT or other treatments I don’t provide myself.

      We may continue to differ about including dynamic formulation in the consent process. “If you establish that you are working with unconscious material and a patient is willing to recognize that…” That’s the “process” consent I spoke of earlier; I consider it both necessary and sufficient. It’s not at all the same as telling a patient, “My current thinking is that you’re angry but won’t admit it to yourself…” The latter will reliably meet massive resistance, and psychotherapy will never start. If one believes the same dynamics that cause symptoms also keep unacceptable material out of consciousness, there is no way to bring that material into consciousness before therapy in order to consent to treatment.

      Psychotherapy is not “exempt” from legal requirements involving informed consent. Informed consent varies among medical specialities, and among other fiduciaries (e.g., attorneys, accountants, general contractors, and many others). Roughly speaking, interventions with more potential health or financial hazard require more “informed” in their consent. This is why surgeons have long printed consent forms and general contractors have detailed contracts, but dentists obtain only brief verbal consent to drill a cavity. Where psychotherapy falls on this continuum is governed by case law, where any exists. If this topic interests you (and it clearly does), you might want to investigate this. I certainly agree that “taking a few more minutes to talk about consent doesn’t seem excessive or damaging” and that it serves everyone’s interest. Thanks again.

      • Jeff

        I think a lot of folks seeking psychotherapy have some interpersonal issues they would like help with, including ones involving spouses, family, and children. I think then it is important for patients to know if their clinician is married or not or has children or not. What that means to patients may be different and may actually be useful in treatment, but again, as patients have to live with the results of treatment they get to decide to what extent having that information is important to them and how it influences their decision to pursue or not pursue treatment with a particular clinician. Educational background is similar, and I think it is a right for a patient to know and make assessments about their clinician’s education before agreeing to psychotherapy. Again, if they continue with treatment, what their assessments mean to them may be important to treatment, but it is still up to patients to decide their involvement based on that information. Less importantly, though I think shows some sense of amiability and may help in relationship building, it is nice to let patients know where you are from and where generally you live, though I think it is less essential than family status/educational background.

        “Excempt” was too strong a word. What I intended was that psychotherapy is often thought of very differently in malpractice cases than other treatments, as other treatments can be much more straightforward with deviations without good rationale that cause harm easier to document. Many state laws, even through case law, do not have useful definitions of what psychotherapy is (let alone dynamic psychotherapy) and what it is supposed to help, making harm from treatment hard to identify (let alone what constitutes harm) and whether appropriate consent was offered ambiguous. It is only in the case of gross boundary violations (affairs, sexual abuse, careless breach of confidentiality, etc.) with negative outcomes where there is some consistency in legal outcomes. I think then that psychotherapy is “exempt” from more definitive application of case law and precedent and from more concrete legislative regulation/definition than other medical treatments.

        • While would-be patients are free to use whatever criteria they prefer to select a psychotherapist, there are inevitably limits on what anyone is entitled to know about a professional provider. A victim of childhood sexual abuse may prefer to see a psychotherapist who has first-hand experience of this trauma (to enhance empathy, etc), but it’s unreasonable to expect psychotherapists, or any professional provider, to lay themselves bare for such scrutiny. The types of questions that would otherwise be fair game are virtually limitless (“Do you have sexual fantasies about your own kids? Because I won’t see a therapist who can’t relate to my dilemma.”) Some line has to be drawn, and that line is at the level of professional qualifications. Patients are entitled to know type of training, relevant degrees and certifications, that sort of thing. Anything more is at the therapist’s discretion. Dynamic psychotherapy in particular leverages patients’ uncertainty to uncover and remedy unconscious conflict, so there are clinical as well as privacy reasons not to be an “open book.” More on this issue here.

          I essentially agree with your second paragraph. “Usual and customary practice” is used in psychotherapy cases, just as in alleged malpractice in other fields. It’s the same legal standard, just harder to apply.

  • Hawkeye

    “For example, unconscious dynamics can help explain medication non-compliance”

    Medication non-compliance can also be explained by the fact that psych meds are often dangerous and often don’t work.

    • When it’s straightforward, there’s no need to posit subtle, unconscious dynamics. Psychodynamic theory arose to explain “irrational” thoughts, feelings, and behaviors. An example would be a patient who feels a medication is helpful, but who “forgets” to take it anyway. Or conversely, a patient who feels medication is useless poison, but takes it against his better judgment and doesn’t know why.

      • Jeff G.

        A little tangential, but dynamic explanations are also not necessarily needed for the situations you offered. For the person who forgets their meds, perhaps they are forgetful about all sorts of other things too. Maybe the the placebo function of just knowing medicine is there is fine for them. For the person who takes meds against their own judgement, it could be that they are trusting a doctor who insists the medications will be helpful. Perhaps there are “issues” with authority here, but lots of people find it perfectly reasonable to follow doctors orders even if they don’t feel good about it. Again, just an aside. I will comment more on the previous discussion soon.

        • Naturally, there many non-dynamic accounts for forgetting to take meds: brain damage, Alzheimer’s Disease, cosmic rays, whatever. Nonetheless, there remains a large pool of such phenomena that are best explained dynamically — best in the sense of parsimonious yet comprehensive explanation, and also that bringing the idea into consciousness results in behavior change. I didn’t imagine that I needed to spell this out.

  • gold price

    After a course of psychodynamic psychotherapy has ended, the person should, overall, continue to handle difficulties in a more adaptive manner; experience improved interpersonal relationships and productivity at work; and continue to develop new insights into his or her thoughts, feelings and behavior. In supportive treatment, insight and personality change are not the primary goals of treatment; the therapist and patient work toward a continuation of general stability in the person’s life.

    [Spam link deleted — SR]

  • […] I continue to appreciate Stephen Reibord’s series of “Sloppy thinking in Psychiatry” which this week looks … part of the psychiatrist’s work. The whole shift towards a medical model really makes me […]

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