Academic Psychiatry 26:38-44, March 2002
© 2002 Academic Psychiatry
Lost in the DSM-IV Checklist
Empathy, Meaning, and the Doctor–Patient Relationship
Allan Tasman, M.D.
Dr. Tasman is Professor and Chairman of the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Louisville, Louisville, Kentucky 40292.
Key Words: Psychodynamic Psychotherapy Training • DSM-IV
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INTRODUCTION
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In the mid-1980s, I was presenting a workshop at the meeting of the AADPRT that focused on the integration of psychotherapeutic and psychopharmacologic treatment. As an illustration of this education issue, I presented a young woman patient who had problems with both severe manic-depressive illness and borderline personality disorder. After I presented a videotaped treatment hour, a training director in the audience said, "I don't know why you showed this videotape. This woman has manic-depressive illness and needs medication, and that's that."
Too many clinicians, and even apparently at that time some residency directors, believed that good psychopharmacology practice required only knowledge of dosages, side effects, pharmacokinetics, and indications for the medication. To me, though, the essence of good psychopharmacologic management is how I respond when a patient comes into my office and says, "Dr. Tasman, I'm not going to take that medication you prescribed." Dealing with issues of resistance and treatment compliance, even in a busy medication clinic, an emergency room, or an inpatient unit, requires psychotherapeutic skill and knowledge—an ability to understand the origins and meaning of the patient's hesitancy and to use the therapeutic relationship with the patient as the force to maintain a treatment alliance and work through the sources of the resistance. This is especially important when we often hear reports that in the United States 50% of all prescriptions are either not filled or not taken correctly.
Fast forward to the present day. At a recent American Board of Psychiatry and Neurology examination, a young psychiatrist did a very interesting interview with a patient. It focused primarily on review of DSM-IV symptoms for the possible disorders that he was concerned about. It was just about as thorough a review as one could wish for, if one wanted to see if the patient met the DSM-IV criteria for various disorders. There was, of course, little time spent focusing on precipitants for the patient's illness or any antecedent developmental or familial influences.
During the discussion, the psychiatrist made an excellent presentation of symptom clusters and differential diagnosis. But when it came to treatment, the discussion took a turn for the worse. The patient had significant mood problems, but the primary issue seemed to be a borderline personality disorder. When we asked what the psychiatrist would do if the patient were his, we got a very nice review of options for management of medications in borderline patients who have mood disorders.
There was no mention of psychotherapeutic or psychosocial issues. When I asked specifically why this was omitted, the candidate replied with complete seriousness that those aspects of the patient's problems were the job for a social worker, and the psychiatrist would intend to refer the patient to a social worker for management of those aspects of illness. I asked what the goals of such treatment would be, and the candidate gave a reasonably appropriate answer. I said, "What would happen if you were in a very rural area, and there were no social workers to be found within hundreds of miles? What would you do then?" The candidate, with only the barest smile, said, "I'd try really hard to find a social worker."
This is an all too common experience. Clearly, a fair number of purportedly well trained psychiatrists either don't understand or don't see as part of their job dealing with anything more than prescribing medications. Since compliance is one of the biggest problems we face in psychiatry, how can we deal with these problems if we don't feel comfortable in either understanding or intervening to address psychological aspects of resistance to treatment?
The DSM-IV (1) represents tremendous advances in our approach to clinical diagnosis, but also illustrates the dilemmas about which I am concerned. We have had tremendous gains in our ability to structure a meaningful classification of illnesses, but the DSM-IV is still a symptom cluster approach, and we are still a long way from an etiologically based categorization of illness. It is true that the DSM-IV is a five-axis approach, and issues of precipitating stress and general level of function are included. But in only a few places in the DSM-IV is provision made for understanding the role of psychological conflict or developmental distress in the evolution of the symptoms we see. Moreover, in few places is the capacity for symptoms to have symbolic meaning taken into account. This causes a great problem. Because while we are doing a good job of training our residents to conduct thorough diagnostic exams based on DSM-IV symptom checklists, we are not doing a very good job with these other aspects of understanding. Nor are we training residents in an in-depth approach to DSM-IV diagnosis, as envisioned by its developers.
And what is the impact of the DSM-IV and other changes in residency education? We are in danger of training a generation of psychiatrists who lack even the most basic psychotherapeutic skills or a framework for understanding mental functioning from a psychological perspective. I am not talking about training sophisticated psychotherapists or psychoanalysts here; I am talking about training people who have the same expertise in understanding and managing the therapeutic relationship as they do in managing medications. And there is certainly very little curriculum time these days devoted to helping residents maximize their empathic skills.
Some might say that this is not too important, that with our increasing understanding of brain structure and function, future psychiatric practice relies primarily on somatic, not psychotherapeutic, interventions.
To respond to this concern, I will give a clinical illustration.
As in many residency programs, our department's outpatient program is designed on a preceptorship model. I saw a woman who had been followed by a nurse clinician and a resident in our clinic for several months but was not improving. Such interactions with the supervisor are scheduled for 15-minute blocks of time, so that everything I am about to describe transpired in that time frame. I was told that this woman in her mid-forties was suffering from a delusional disorder, DSM-IV 297.1. The woman had been placed on an antipsychotic medication, which had been gradually increased over the last several months without any positive effect on the patient's condition or symptoms.
I interviewed the patient with the nurse and resident for about ten minutes. I was immediately struck by this woman's ability to relate to me in a human way in our interview, surprising in a woman diagnosed with a psychotic disorder. I tried to find out precipitating causes for her symptoms and asked about changes in her family, her work, or some other aspect of her personal life. She said there had been no changes. For a reason that I still cannot completely understand, there was something that I reacted to empathically in this woman, and a question popped into my mind. Although this is not a common question for me, I asked if there had been any changes in her neighborhood.
Her response made this case stick in my memory. She asked if I remembered a newspaper article about a young nine-year-old girl who had been killed in a drive-by shooting several months before. I said that I had. She said that the girl who had been killed was her next-door neighbor. I replied that that must have been incredibly upsetting. She said yes, it was even more upsetting because, when the girl was killed, she was on the patient's front porch playing with the patient's children.
Everything began to fall into place, and I knew this wasn't just a delusional disorder. I said to her that it must have been incredibly upsetting not only to lose this child in such an upsetting way, but to be fearful that could have happened to her own children or to her, and that it might happen in the future at any time. The patient immediately began to cry. I asked if she had ever mentioned this to anyone, and she said that she had not because she didn't think it had anything to do with how she was feeling. I asked if the medications had helped her at all. She said no, that they had only made her feel groggy and washed out, and were interfering with her ability to take care of her children or do her work. I told the patient that I thought that she was mainly reacting to this event, and that the emotional impact that it had on her was tremendous. I felt that the medication she was taking was unlikely to be helpful, but that instead she needed to talk about how she was feeling about this. The patient seemed taken aback as if this idea had never crossed her mind. I said that I assumed that no one had asked her about this or talked with her about this since she had not brought it up, and she said that was true.
What did I do that was so different from what had been done? Nothing dramatic, but something that I think was important. I was able to use my own emotional reaction to the patient and the way she was relating to me as a clue to what might be going on. Something about my empathic ability, something difficult to put into words, allowed me to find out information that had not been discovered before. Is it because I am a psychoanalyst? Is it because supervisors always find out things that the residents don't? I am sure it's a combination of many factors. But mainly, a very experienced nurse and a very good resident who were very concerned about the patient lacked some basic tools to do the best job possible. How did this happen?
In the United States, negative economic forces have significantly affected academic medical centers over the last several decades. Changes in reimbursement regulations and changes in care delivery systems have put increasing pressure on psychiatry faculty to generate revenues through direct patient care. This has not only meant less time available for teaching, even from committed clinicians, but also a shift in the role of the resident and faculty member in supervised clinical care.
Also, the explosion in neuroscience research and available grant funds to support such work have led to an emphasis on faculty with the potential of garnering such research funds and a relative de-emphasis on those who rely primarily on clinical service to provide salary support. These forces led to a mass exodus of psychoanalysts from departments of psychiatry in the 1970s and '80s. Feeling devalued and underappreciated, psychoanalysts reacted with anger and hurt, leading to a situation in which many departments of psychiatry today have little access to those psychiatrists most expert in teaching understanding of psychodynamic principles and techniques of empathic listening, appreciation of symbolic meaning, the role of trauma in symptom formation, and understanding transference and countertransference.
Further, the expansion in the knowledge base in psychiatry in the last several decades has led to intense competition for curriculum time—producing a situation in which there is decreasing curriculum and supervisory time devoted to psychotherapy training, at the same time that there are few faculty available to teach it and to advocate for curriculum time. The competition for what psychotherapy training time is available, furthermore, is now intensified with the growth of newer and more research-tested psychotherapy techniques such as cognitive-behavioral and interpersonal psychotherapy.
Even with delivery system changes and improved pharmacotherapy, I believe it will continue to be essential for psychiatrists to have the knowledge and skills base necessary for psychological understanding and intervention. This is true even when the primary treatment modality is psychopharmacologic, and it is true in every clinical setting. The best way to learn these skills, as demonstrated over many years of residency training in the United States, is through training in psychodynamic psychotherapy.
When we now underemphasize, for example, the role of empathy as a way of listening for the psychological aspects and symbolic meanings in a patient's presentation of his or her concerns, we lose essential data necessary to fully understand our patients. Thirty years ago it was still not uncommon for psychoanalysts to be directors of many clinical services and of both medical student and residency education programs. There was no question in that environment that residents would be exposed to the particular way of listening to and understanding their patients that I am advocating, and that I believe is necessary for optimal diagnosis and treatment. Another case example will illustrate.
A young woman came to me with a six-month history of severe anxiety, initially associated with her work environment but now having filtered out to all aspects of her daily life. This young woman was in her early thirties and was single. She said that she had initially been anxious at work, but now was anxious all the time. She easily met the diagnostic criteria for generalized anxiety disorder (GAD), DSM-IV 300.02.
Her insurance paid for only one diagnostic session and also reimbursed psychiatrists only for medication management, not for psychotherapy. At the end of our first hour together, I told her that I was still having difficulty understanding the nature of her illness, but that I knew her insurance company would not pay for another diagnostic session. Because she was able to afford it, and because she was motivated, she agreed to pay out of pocket. In the next two sessions, I learned that there were significant parallels between her father and her boss. Both were volatile but distant and hard-to-please individuals with high expectations for performance. Her father had been a mathematician, and she remembered how he had specifically focused on her math homework. She was now the financial officer for a small company with a demanding boss. Further, her relationship with her boss had become complicated by her having had an affair with him for a number of months, and, in fact, the anxiety symptoms began six weeks after he told her that they needed to break up. I suggested weekly psychodynamic psychotherapy with periodic reassessments.
If I am a physician on a managed care panel or a young psychiatrist just out of training, my first inclination is to probably start this young woman on an anti-anxiety and/or antidepressant medication. I know the managed care company will not pay me for psychotherapy, and I have been taught that the primary intervention for GAD may well include medications. Her treatment, though, followed a different course.
I saw her for a total of about 20 visits over a six-month period, during which time the main focus of our work was on identification and working through of the psychological conflicts in her relationship with her boss. We were able to tie these together with some unresolved issues related to her father. As the conflicts became more clear to her consciously, and as she began to work through them, her symptoms diminished.
At termination, she told me her treatment had been extremely helpful in way that she could not possibly have imagined when she began, and said that if any symptoms recurred, she would certainly give me a call. I wonder, though, what would have happened if I had been trained in the last 10 years in the average expectable residency program. My guess is that the evaluation and the treatment recommendations would have been very different, and the core of the origins of the illness might never have been addressed.
The issue of meaning, though, goes beyond even issues of developing an understanding of the etiology of illness, and directly to issues of treatment adherence and compliance. To illustrate, let me describe another patient I saw.
I was called by a professional in his early sixties who was complaining of depression. His history revealed that several months prior to our visit he had undergone a radical prostatectomy for what turned out to be a small, circumscribed, nonmetastatic prostate cancer with a nonaggressive cell type. He was told by the surgeon that the likelihood of complete cure was in the upper 90 percent range. While he had been quite upset, understandably I thought, about having been given a diagnosis of prostate cancer, and going through major surgery, he had as good a prognosis as he could have wished. He was surprised, therefore, that about six weeks after his surgery, he began to have an onset of depressive symptoms.
By the time I saw him, he had had significantly depressed mood for well over six weeks, and had lost interest and pleasure in all activities. He wasn't suicidal, but I thought he was close to being there. He felt that life really wasn't worth living if this was the way he was going to be for the rest of his life. He met the diagnostic criteria for major depressive disorder, single episode nonpsychotic, DSM-IV 296.23. I was concerned that he was in an age and demographic group that placed him at high risk for suicide and felt I needed to make a rapid intervention to alleviate his depressive symptoms. I recommended an SSRI antidepressant and concomitant psychotherapy. He responded that he didn't want to take any medication and wanted to know why we couldn't just talk about his problems. I spent some more time talking about depression, the nature of the biological changes he was experiencing, and the role of medication in overall treatment. At the end of what I thought was an informative but down-to-earth and understandable discussion, he said, in an annoyed voice, "Well, if you're not going to talk with me about my problems, just refer me to someone who will."
I was a little taken aback. Being an analyst, I am rarely accused by patients of not wanting to talk about their problems. For a moment I was not sure what to do, but I said, "Let's make a deal. I'll see you in psychotherapy alone without medications, but if you're no better in a month, I'm going to insist you go on medication. And if your symptoms worsen at all any time between now and the end of the month, I'm going to also insist you immediately go on medication. In the meantime, we'll just talk." He said that seemed reasonable to him, and he agreed.
While I had thought that his depression was clearly precipitated by his having gone through a cancer diagnosis and cancer surgery and the aftermath of it, I felt that his disorder had gotten to the point that he needed medication. As it turned out, and this was apparent quite soon, I was completely wrong about his need for medication. We met weekly for what would be generally seen as focal psychodynamic psychotherapy. Surprisingly to me, his symptoms began to resolve within several weeks, and by about 12 weeks, he was completely symptom free. It was clear during treatment that taking an antidepressant meant to him further loss of self-control, already a major issue because of his prostate cancer and surgery. Clearly, if I had not been willing to consider that there was an important psychological meaning associated not only with the symptoms of his illness but also with taking a medication, he would not have entered treatment in the first place and certainly would have been unlikely to comply with any medication regimen prescribed by anyone else.
So where is empathy and where is meaning in the DSM-IV, and, more important, where is our training about it in our residency programs? To me, these areas of knowledge and skills have been substantially lost as we have lost our training in psychodynamic theory and psychodynamic psychotherapy. This is not a new concern. A paper that Paul Mohl, James Lomax, I, and several others published in the American Journal of Psychiatry in 1990 (2) argued that there are at least 10 major reasons for continuing to teach psychodynamic psychotherapy. Three of these relate directly to the acquisition of skills that are necessary to deliver psychodynamic psychotherapy to patients, but seven others relate to the acquisition of skills, knowledge, and experiences important to other aspects of psychiatric and medical practice.
The 1990 publication described these seven issues:
- The concepts of psychodynamic psychotherapy are intimately related to the psychological and social concepts of all doctor–patient relationships. The psychotherapeutically competent psychiatrist should be able to provide more effective consultation to medical colleagues and be able to manage his or her own nonpsychotherapy doctor–patient relationships more effectively.
- Psychotherapy training also provides the resident with experiences that enhance learning about and management of other dyadic relationships within psychiatry, such as in supervision, consultation, and mental health administration.
- Psychotherapy training enhances basic interviewing expertise by providing the resident with an opportunity to observe longitudinally the course of psychopathological and normal mental phenomena present in an initial interview. This experience makes it possible for the resident to recognize emerging mental phenomena earlier, more accurately, and more confidently.
- Psychotherapy training provides the resident with an in-depth and longitudinal understanding of both conscious and unconscious mental functioning, which may be normal or pathological and which are related to the effort to change thinking, feeling, and behavior. Such an effort requires an ongoing relationship between therapist and patient and involves the inevitable obstacles, resistances, strengths, and opportunities related to such an effort. Understanding these phenomena is essential to treatment planning and management of virtually all psychiatric disorders.
- Psychotherapy allows the observation of complex pathological and normal mental functioning over time. In so doing it complements the observation of similar mechanisms in inpatient, consultation, and emergency room settings. Furthermore, it provides access to the primary materials that form a basis of general psychodynamic theory. As such, psychotherapy training enhances the learning of psychodynamics as a basic science within psychiatry.
- Many ethical difficulties result from psychiatrists' problems in managing their feelings and reactions to patients. With its emphasis on the complex dyadic emotional interplay between psychiatrist and patient, psychodynamic psychotherapy training enhances psychiatrists' ability to anticipate, analyze, and avoid ethical dilemmas and transgressions.
- Finally, practicing psychotherapy forces the psychiatrist-in-training to observe, analyze, and attempt to understand an extremely complex interactive phenomenon. This enforces an intellectual rigor and discipline in observing behavior, developing hypotheses, and analyzing theories and data.
Even if some are uncertain about the role conducting psychotherapy will play in psychiatrists' activities in the future, the above issues highlight the importance of psychodynamically informed residency education. There is little evidence that this other learning that occurs during psychotherapy training can as easily be acquired in other ways, and I do not think many residency programs devote adequate attention to this area outside of traditional psychodynamic psychotherapy training.
As mentioned earlier, I am fearful that we are in danger of training a generation of psychiatrists who lack the basic skills or framework for understanding mental functioning from a psychodynamic perspective. With the neuroscience knowledge explosion continuing and with the financial pressures on academic departments of psychiatry unlikely to diminish, there is little likelihood that we will have a major influx of psychoanalysts into academic departments at any time in the near future. And this will be a tragic phase of history in psychiatric education, because in addition to not acquiring empathic listening skills, in addition to lacking appreciation of the role of symbolic meaning in symptoms, we will have a generation of psychiatrists who even lack fundamental skills in understanding, using, and maintaining a therapeutic relationship. Let me provide a final clinical example.
Earlier in my career I evaluated a young woman in her late 20s who met the diagnostic criteria for anorexia nervosa of the binge eating/purging type, DSM-IV 307.1.
She was quite verbal and related well during our evaluation sessions, and quite motivated to begin treatment. We agreed to start with once-a-week psychotherapy.
During her first treatment appointment, for which she showed up right on time, she was unable to speak. She was clearly uncomfortable and anxious, and I tried everything I could think of to help her feel at ease and to understand what was making it difficult for her to speak. Unfortunately, I was not successful, and she remained silent a number of months. She appeared regularly for her appointments, came on time, and never missed an appointment. She also never called me between appointments or had any other emergencies for which she needed to contact me, but she was completely unable to speak during our meetings. I felt we had developed some kind of relationship, but I had no sense that it was a therapeutic one. Finally, after all those months, I said to her that while I appreciated that there was something that was making it difficult for her to even be able to speak, if she couldn't at least speak, our ability to make any progress at all in treating her illness was minimal. I told her I felt we should discontinue treatment until she was able to talk to me in our sessions. Her rejected-sounding comment and her first words in many months were, "I'm surprised it took you so long." The reader is likely wondering the same thing.
I told her that I was not pushing her out of treatment, although I could see she felt that way, but felt that we needed to take a break until she was able to engage verbally, as I had no particular ability at that stage to do anything more. Months went by, and I eventually forgot about her, having assumed that she would not call back or return for treatment. More than six months later, though, I received a call. She said she thought she now would be able to talk, and I agreed to see her again.
During the next nine years of two to three times a week treatment and a number of hospitalizations, I discovered some of the reasons that it was so hard for her speak. There is inadequate space to describe the details of her illness, but she also had a severe borderline disorder with nearly continuous severe suicidal ideation and intent. Her continuous bingeing and purging was the only way she knew to deal with her affect and prevent herself from acting on her suicidal urges. I have no question that my ability to develop and maintain a therapeutic relationship with this young woman is what kept her alive during the most difficult years of our work together. Toward the end of our seventh year of treatment I felt a barely perceivable shift beginning to occur, and the next three years were marked by halting, but continued improvement. When treatment ended following the tenth year of our work together, I felt that her recovery was as assured as possible and that she would likely continue to make progress.
Why do I discuss this patient? Because this was the most difficult and troubling, as well as troubled, person with whom I had worked, and her illness was so severe I was frequently concerned about whether my interventions were on the right track. Was the treatment psychodynamic therapy, was it cognitive therapy, interpersonal therapy, medication? (She was willing to give a clinical trial to many medications, and we did that as well over the years.) I am unsure. The only thing that I did feel certain about was that my ability to stay in a therapeutic relationship with her helped keep this young woman alive.
I have no doubt that a combination of my own residency training and my psychoanalytic training played a role in my treatment approach. I know that few residents have a training experience in this era that prepares them to deal with the difficulties and complexities of assessing, understanding, maintaining, and using therapeutically the relationship we have with our patients to further our treatment aims, especially with patients as severely ill as the one I have just described.
So, what do we do about this state of affairs? Dramatic changes in residency curricula are not likely to occur. Our knowledge base continues to explode. The discoveries we are making about the workings of the brain and our increasing sophistication with pharmacotherapy are impressive. Much of what we are learning today we could only dream about a decade ago. So my purpose is not to present a model curriculum for addressing empathy, meaning, and the doctor–patient relationship. Having been the chair of the curriculum committee of the AADPRT, I know only too well what happens to model curricula. I am also not suggesting a likely return to the psychotherapy training curricula of the 1960s and '70s.
So, I ask again, what do we do? My straightforward answer is that there is no simple answer. But we do have a major opportunity at present to reinvigorate our training in psychodynamic principles and treatment. The psychiatry Residency Review Committee, beginning January 2001, requires that residency programs attest to the competence of their graduates in five areas of psychotherapy: brief, cognitive-behavioral, supportive, combined medication and psychotherapy, and psychodynamic. Addressing these new RRC requirements will provide a substantial impetus to remedy some of the concerns I have discussed here.
It is true that we have a vast array of knowledge and skills to teach. But it is also true that for the foreseeable future and, undoubtedly, for our own practice lifetimes, therapeutic transactions in psychiatry will occur in the context of a relationship between a physician and a patient. It is also true that human beings have not suddenly lost the capacity for symbolic meaning, or the capacity to suffer from the vagaries and vicissitudes of developmental conflict and developmental deficit, just because managed care came along. If we expect to maintain and improve the excellence of our clinical work, we must rededicate ourselves to these psychodynamically based educational issues. I can think of nothing more important to ensure the continued excellence of our educational programs and our clinical enterprise.
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ACKNOWLEDGMENTS
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This paper was originally presented as the Harvey Shein Memorial Lecture on March 10, 2000, at the Annual Meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT).
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REFERENCES
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American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC, American Psychiatric Association, 1994
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Mohl PC, Lomax J, Tasman A, et al: Psychotherapy training for the psychiatrist of the future. Am J Psychiatry 1990; 147:7-13[Abstract/Free Full Text]
This article has been cited by other articles:
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L. D. Hirshbein
History of Women in Psychiatry
Acad Psychiatry,
December 1, 2004;
28(4):
337 - 344.
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