Swimming Upstream

Teaching and Learning Psychotherapy in a Biological Era

Jerry M. Lewis

• Éditeur: Routledge
• Année: 2013
• ISBN:
  9781135822279
• Édition: 1
• Sujet: Psicología
• Sous-sujet: Psicoterapia

First published in 1991. The experiential base from which this book is written the author's seminar for psychiatric residents which emphasizes that self-disclosure with colleagues is an important aspect of becoming a therapist. The ability to look at and listen to one's own work along with one's peers is important in the maturation process. In order to construct a context in which it is possible to learn from each other, I share many of my own psychotherapeutic experiences. More than this, however, Lewis shares personal experiences when they seem appropriate to the teaching-learning process.

CHAPTER 1

Psychotherapy: An Uncertain Future

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This book reflects 25 years of experience teaching basic psychotherapy skills to beginning residents and other professionals. An earlier book was published over 10 years ago (Lewis, 1978), and since that time I have learned more about teaching, the seminar has broadened to include additional components of the psychotherapeutic process, and it seems appropriate to summarize the current state of my experience.

The major factor in the decision to write this book, however, is my deep concern about what may happen—or is happening already—to the role of learning psychotherapy in the education of psychiatrists. Case conferences in some academic centers have senior residents who respond to the request for a clinical formulation and treatment plan with only a DSM-III-R diagnosis and a discussion of various psychopharmacologic approaches to the patient. Professional debates argue whether or not psychodynamics and psychotherapy should be a part of a residency program's curriculum. Possibly the next generation of psychiatrists is being trained to know even less than we did about the process of psychotherapy.

This development is alarming; the reasons are diverse and powerful. In this chapter I wish to explore briefly some of the more obvious reasons, to emphasize the various effects on psychiatric practice brought about by the economic crisis in health care, to examine the impact of the rapid growth in the neurosciences, and to explore the difficulties involved in using a complex model of psychopathology such as a biopsychosocial approach. Finally, I will speak to the problems that arise in maintaining a balance between our own collective definition of psychiatry's core distinctions and responding to forces from without that seek to shape what we do—thus, how we are defined. The issues for me are what are psychiatry's core distinctions and how can we avoid having them molded entirely by forces impinging upon us from without.

Even a casual reader of newspapers and periodicals knows of the growing wave of resentment of rising health care costs. Each day brings yet another statement that this country must change its approach to financing health care; that the 11 + percent of the GNP we spend is far more than other industrialized nations; that over 30 million Americans are without any form of health insurance; that only the wealthy receive the full advantage of this country's preeminence in scientific medicine. The suggestion that we adopt a British type national health insurance financed almost entirely by general tax revenues is frequently counterbalanced by analyses of the British system with its long lists of those waiting for elective surgery, decaying hospital physical plants, and the less than intensive treatment, for example, of some severe congenital defects in children.

At the time of this writing, it is even more popular to consider the adoption of the Canadian system, but here, too, appear analyses of the deficiencies of that system. Recent surveys indicate, however, that Americans are less satisfied with their health care system than are either the British or the Canadians (Freudenheim, 1989; Whitney, 1989). Clearly, the time is ripe for changes, but nobody really knows what will work.

We know that we can't do everything we know how to do and meet other government objectives. Years ago, the medical economist Fuchs (1974) entitled his essays on this topic, Who Shall Live? Ex-Governor Lamm (1989) of Colorado speaks eloquently about the need to define “appropriate” health care and construct a system that insures that all Americans receive it. His persuasive voice is but one among many, but the difficulty is in the definition of “appropriate.” Such a definition will surely mean that some of what we do will be defined as “less appropriate” or even “inappropriate.”

One experiment in defining appropriate health care is now under way in the Oregon medical rationing system for the indigent. Although all the details are not available, early press reports indicate that when the money is limited the treatment of certain diseases will be financed, others will not be. The ethical issues are profound, and it has been said that it is like dropping bombs on people you cannot see and do not know (Gross, 1989).

Others write about our failure to approach an even more basic issue: the need to decide what ends or purposes we believe a health care system should serve. Churchill (1989), for example, emphasizes the profound ambivalence underlying this unwillingness to decide, perhaps because most Americans oppose additional taxes to enact that right.

It is also clear that we have tremendous expectations regarding health care; the advances in scientific medicine are well publicized because they have great impact upon our collective fear of dying before our time.

The problems are complex, and the attempted solutions will almost certainly change the basic fabric of medicine as we know it. Although much more is being said about these issues by individuals more knowledgeable than this writer, the focus for purposes of this chapter is on how such changes will influence psychiatry and, more specifically, the practice of psychotherapy.

We do not know. Although the American Psychiatric Association is vigorously leading the attempt to preserve and improve the position of psychiatric patients and has been joined in this battle by increasingly powerful advocacy groups, we simply do not know what the outcome will be. There are, however, some ominous signs. One is the poor faring of psychiatry in the proposed Resource-Based Relative Value Scale (RBRVS). Although the intent of this effort was to increase payment for cognitive services (internists, family medicine specialists, etc.) and decrease payment for procedure-oriented specialists, psychiatry, one of the most cognitively oriented specialties, will be hurt even more than some branches of surgery (Evelyn, 1989). The American Psychiatric Association has taken the position that the evaluation of practice costs was inadequate and that more difficult clinical situations were not covered in the vignettes used to assess the time and skill required of the psychiatrist. Despite this effort, there is doubt that any really basic change in the RBRVS will be made.

What does this mean? First, the proposed use of the scale is for Medicare payments, a system that has characteristically given psychiatric treatment very low funding. The concern, however, is that the RBRVS, if adopted by Medicare as proposed, will become the standard for all third-party payers. The issue is not the reimbursement of psychiatrists relative to other medical specialists; rather, it is the continuing operation of the stigma regarding mental illness and the continuing low assessment of psychiatry within medicine generally. The joke about “real” doctors and psychiatrists is the ambiance in which relative values are assigned.

If the proposed RBRVS is not exactly a rosy sign for psychiatry's future, what about insurance coverage for both outpatient and inpatient psychiatric care? I have seen no systematic studies and, thus, must rely on personal experience: Policies that support psychiatric hospitalization do so only for very short hospital stays. Most often the provisions of such policies allow the pharmacologic management of acute clinical episodes like a major depression with significant risk of suicide or a serious manic episode. They fail miserably, however, to provide for appropriate treatment of many more chronic conditions such as severe borderline states, psychoses which do not respond to psychotropic agents, and severely disturbed patients for whom the establishment of a treatment alliance takes many months.

Recently, for example, I saw in consultation a hospitalized 16-year-old girl with a two-year history of gradual change involving school refusal, intravenous drug use, prostitution, and participation in a variety of criminal activities. She vigorously denied any need for treatment, blamed her parents and their unreasonable expectations for her situation, and had successfully resisted outpatient psychotherapy, a trial of antidepressives, family therapy, and several short-term hospitalizations.

I thought she needed intensive hospitalization until an alliance with her and her family could be forged, a treatment relationship with a psychotherapist established, and appropriate psychotropic agents tried. Following this initial stage of treatment, it was likely that she would require a series of increasingly less structured residential treatment facilities, all the while maintaining continuity of care with both an individual and a family therapist.

This youngster may represent the exception, the child who cannot be treated without a very inclusive long-range approach. The irony is that up until a few years ago the very agency for which both her parents work provided employees with insurance coverage that underwrote such treatment. Because of economic considerations, the coverage for psychiatric disturbances was reduced to 30 days a year of hospitalization and 30 outpatient visits each year. Psychiatric disturbances came to be excluded from coverage under the major medical illness portion of their policy. Thus, one is left with a life that is bleeding out and without the provisions to help.

Existing research data are sufficient to document the most probable untreated outcome for this youngster (Robins, 1966; Rutter & Quinton, 1984). Probably, she will survive for some time, perhaps have a child whom she cannot mother adequately, and quite likely a transgenerational cycle will begin. Imprisonment or premature death through murder, suicide, or disease is a real possibility. Our own follow-up study suggests that the lives of over three-fourths such seriously disturbed adolescents can be salvaged with appropriate treatment (Gossett, Lewis, & Barnhart, 1983, p. 68).

This clinical dilemma is faced every day by clinicians harried by third-party payers pressing for a rapid discharge. Although such pressure may facilitate creative and workable approaches to the treatment of some, for others it means simply no real treatment is possible.

The same movement to shorten and circumscribe psychiatric treatment is present regarding outpatient services also. Experience with traditional health insurance affords little optimism about how psyschiatric treatment will fare in the future, particularly if it involves intensive outpatient psychotherapy or hospitalization other than the briefest sort.

The outlook is no different regarding managed health care. Here, also, no systematic studies document trends, but my experience with these intermediaries suggests that the contracts they establish provide only relatively short-term outpatient psychotherapy, at a level of once-per-week for a total of 15-30 sessions a year, and only very brief crisis-oriented inpatient care. The chronic, severely dysfunctional patient often requires intensive treatment, but is deprived of adequate psychiatric care.

Finally, what is the outlook for psychiatric patients when there is explicit rationing of health care for the poor? At the time of this writing, Oregon is the only state that ranks all illnesses in terms of which services will be underwritten. Newspaper reports indicate that prenatal care and the immunization of children will be high priorities when such rankings are made. Eating disorders, most often treated by psychiatrists, will be a low priority, although, in general, mental disorders and chemical dependency are covered by other state agencies. How will pervasive developmental defects of childhood be ranked? What consideration will be given to the recent Institute of Medicine report (Johnson, 1989) indicating that at least 7.5 million—12 percent of the nation's population under age 18—suffer from a mental disorder or emotional disturbance requiring treatment, with only one of three such children receiving treatment in 1985. Mental health professionals are deeply concerned that mental health service may be considered separate from other services and, and if included in any forced ranking, would not be accorded the funding so badly needed.

Although the final funding of psychiatric treatment is yet to be determined, the information at hand is not encouraging. Whether it is the Resource-Based Relative Value Scale, traditional health insurance, explicit rationing, or managed health care programs, pressure mounts to treat patients briefly in an acute illness or episodic model. Patients whose illnesses are chronic and require long and intensive treatment will receive grossly inadequate treatment. The economic forces pushing toward brief treatment will mold treatment in the direction of relying only on psychotropic agents. Psychotherapy, particularly if it is required more than once a week for any extended period of time, will not be covered.

If this scenario is valid, organized psychiatry must continue to do everything possible to avoid this external definition of how psychiatrists treat patients, and ultimately, conceptualize their disorders. In addition to these political activities, psychiatry needs to emphasize internally and through the curricula of our residency training programs, the broadly based and comprehensive models of psychopathology and the central role of psychotherapy as core distinctions. To allow the learning of psychotherapy to become an auxiliary elective, to be studied only by those who are so inclined, participates, however inadvertently, in a definition of our profession dictated by outside forces.

And such oversight is easy in these heady days of remarkable advances in the neurosciences. The biological revolution of recent decades has added enormously to our knowledge of the central nervous system and directly influenced diagnosis and treatment approaches. The practice of psychiatry has been changed forever, and clinicians have an ever increasing number of diagnostic techniques and drugs with which to help patients. Advances in neurobiology, genetics, and immunology portend new insights for the future. Never before has psychiatry had such remarkable data with which to understand and treat mental illness.

Our challenge is to integrate the new biological findings with equally important psychological and social system findings. As Eisenberg (1988) has said, psychiatry is moving from brainlessness to mindlessness. Despite the evidence that psychological, family, and cultural factors influence each of the major mental illnesses, we often hear statements like, “Now that we know that schizophrenia is a brain disease. . . . ”

This form of evangelical reductionism is not new. My generation of psychiatrists participated in several earlier periods in which the collective reductionistic fever ran high. These periods can be described as bandwagons: intensely exciting movements that dominate the entire field. They are characterized by a shared belief that definitive answers are now available, answers as to the “real” causes of psychiatric disturbances. Thus, all that remained was “a little more research,” devising treatment interventions based upon the new and “definitive” facts, and training appropriate numbers of clinicians in their use.

Funding for research is heavily influenced by whatever system of variables rides the bandwagon. The curricula of residency programs come to be skewed in a similar way. Other systems of variables lose their importance; the excitement and ferment invite all associated with treatment to climb aboard.

During my residency, the bandwagon was psychoanalysis. The first cause of all psychiatric syndromes was psychodynamics. Depression, the schizophrenias, the neuroses—every syndrome was viewed as a direct reflection of psychodynamic conflict. Further, each syndrome had a specific psychodynamic conflict, and in the hands of the most convinced, if that conflict were not present, the diagnosis was in doubt. Departments of psychiatry reflected this reductionistic ...