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.