To The Editor: In contemporary psychiatric practice, psychodynamic theory is seldom thought of as being directly applicable in the psychiatric emergency room. Since the 1990s, neurobiological approaches have prevailed, with medications that lead to nearly immediate symptom improvement. One role of psychodynamic understanding in the psychiatric emergency room is to facilitate the development of empathy which can contribute to improved therapeutic alliance and outcomes. Moreover, a psychodynamic understanding complements the neurobiological one in providing a richer and more dynamic view of mental disorders and the human condition.
Every encounter between a patient and clinician takes place in a bi-personal field and entails a two-way psychodynamic interaction (1). Gabbard suggests that the goal of the psychodynamically oriented interview is to engage the patient actively as a collaborator in an exploratory process (2). While there is a need in the psychiatric emergency room to make a quick and firm assessment of safety and reach a diagnosis and plan, there is also a corresponding need to empathically connect. Sulkowicz advocates dynamic interviewing, not as a means to obtain detailed past history, but for facilitating the therapeutic alliance and dealing with resistances to speaking freely (3). This makes the emergency evaluation more informative and humanizing than a "check-list" interaction.
A question that thoughtful psychiatric emergency room clinicians might entertain is why some patients suffer so greatly or have such a difficult time living reasonably while others with the same diagnosis and treatment seem to "get by." The other related question is "Why now?" As an example, acute exacerbations in schizophrenic patients may be attributed in part to the natural course of the illness, medication inadequacy or noncompliance. However, psychic conflict may also be contributory: dysfunctional relationships at home may lead to maladaptive, regressive functioning. This understanding may help clinicians in contextualizing the patient’s mental state, developing the therapeutic alliance and drawing in family members for collaboration.
While the "revolving door" phenomenon in psychiatric emergency rooms typically has negative connotations, it can also be seen as repeated opportunities to develop therapeutic alliances. For example, while an alcoholic patient who returns repeatedly for detoxification may remind us of our failure in altering those behaviors, it may also suggest an attachment upon which any future forward momentum is dependent. One approach is to confront the patient with real observations about his or her life. The patient may not consciously register these the first time but may eventually take in some of the message and make use of it. This patient-centered humanistic approach may be more effective in the long run. Rosenberg (4) suggests that the goals of therapy in the psychiatric emergency room may be modest but still meaningful for the patient and produce enduring change in small increments. Hence even though the alliance formed is short- term, it can provide the patient with positive experiences for future interactions with clinicians. The psychiatric emergency room clinician should listen empathically and openly, paying particular attention to the affect, while focusing on current problems and precipitating crises (3). The clinician should not jump at the opportunity for psychodynamic interpretation if the patient is unable to tolerate it, or if it would adversely affect the ongoing relationship of the patient with the long-term therapist. The feelings associated with earlier phases of life may be evident to the clinician and provide glimpses of significant forms of relatedness that come readily to the patient (e.g., a patient in a locked unit may readily relate to the clinician as a distrusted authority figure). Moreover, behaviors like missing outpatient appointments and nonadherence to treatment can be seen as resistances to be addressed. The clinician may be curious to know what the resistance is protecting and how past experiences are being re-enacted, and thus held outside of the verbal sphere. The clinician may then choose to reserve the insights to him— or herself or share them with the patient.
There is a need for greater self-awareness and vigilance concerning transferential and countertransferential issues, which exist in addition to the real relationship. Feelings of boredom, antipathy, fear and impotence could be due to the patient provoking them or the interference from the clinicians’ own issues, and likely a combination of both. This can adversely affect the therapeutic alliance. For example, patients who are nonadherent to treatment or recidivistic substance abusing patients may evoke negative feelings among staff and a sense of failure and futility. Some psychodynamic understanding may help clinicians deal with their own emotions, foster a more positive therapeutic alliance and improve job satisfaction. Regardless of the symptoms or disorder, patients can be experienced in a broad human context as sick people rather than as collections of diagnoses and rule-outs.
In teaching the biopsychosocial model, it is recognized that the psychological dimension is often the most difficult for trainees to grasp, a difficulty which extends well into later phases of training. In the psychiatric emergency room, patients are seen in an acute state for a short time; hence there is enforced efficiency and a need to utilize all the biopsychosocial modalities available. Here trainees have the opportunity to employ psychodynamic tools to build therapeutic alliances, and set the stage for future psychic growth. Moreover, they get a longitudinal view of those patients who present repeatedly. This is the approach adopted at our psychiatric emergency room for the education of residents and students.
In the psychiatric emergency room, psychodynamic understanding is important for clinicians, residents and students. It plays a key, though often less appreciated, role in enhancing empathy and forging therapeutic alliances, and promoting greater self-awareness on the part of the clinician. It complements the biological and social approaches in a holistic and humanizing manner, while explicitly avoiding expressive interpretations and interventions when they are not indicated. Ultimately, more attention paid to subtle affects and nuances allows the psychiatric emergency room clinician to develop better rapport and a deeper appreciation of the patient’s condition and assist in postpsychiatric emergency room treatment. This understanding will likely ultimately lead to superior outcomes for the patient and greater satisfaction for the clinician.