Empathy, Meaning and the Therapeutic Alliance
Allan Tasman, M.D.
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The Context of Care and Education
A large number of global forces are affecting psychiatry:
Political, economic, technological, demographic, and workforce
Excellence relies on combining knowledge from our latest scientific advances with our traditional humanistic values
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A Record of Progress
100 years ago, Freud was working on two manuscripts
The Interpretation of Dreams A Project for a Scientific Psychology
Not discovered until the 1950’s Attempt to describe the neurophysiological basis for mental processes Attempt was abandoned due to inadequate knowledge at the time This quest, however, has been a central focus for psychiatric research
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A Record of Progress (continued)
In spite of economic problems, significant global inadequacies in service systems, and severe global shortage of psychiatrists, this is the most exciting time in history for psychiatry.
Our knowledge base is expanding dramatically: molecular genetics, functional neuroanatomy, neurochemistry and neurophysiology, new psychotherapeutic and psychopharmacologic treatments, new approaches to diagnostic classification
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An Example of Research Advances Improving Clinical Care
Cytochrome P450 enzyme system P450 plays a major role in hepatic metabolism of medications Depending on subtype rate of metabolism is affected
Poor metabolizers have long half-lives and higher risk of toxicity Extensive metabolizers have difficulty reaching therapeutic blood levels
Testing for P450 subtype is becoming available This illustrates how neuroscience and genetics research support advances in clinical practice
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Pharmacotherapy alone is insufficient
No matter how advanced pharmacotherapy practice, patients will still require psychotherapeutic and psychosocial treatments for optimal outcomes Clozapine introduction supports this view
Positive response to medication was not sufficient for discharge Psychosocial and psychotherapeutic treatment was needed to address long-term effect of psychotic symptoms
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Impact of Systems of Psychiatric Diagnosis
DSM and ICD are still non-etiologic approaches based on symptom clusters DSM revisions were designed to stimulate research, which has occurred No provision for role of psychological conflict or developmental distress No provision for symbolic meaning or cultural influences on symptoms Trainees emphasize symptom checklists without psychological understanding
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Impact of Systems of Psychiatric Diagnosis (continued)
Emphasis on symptom cluster approach as primary framework for understanding illness during residency also diminishes learning in psychological, social, or cultural areas Under emphasis on role of empathic listening for developmental distress, psychological conflict, cultural influences, role of trauma, and symbolic aspects of symptoms results in loss of essential information to fully understand our patients Symptom cluster approaches have led to an emphasis on pharmacotherapy
This occurs in spite of evidence of superiority of combined medication and psychotherapy for many patients
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Why continue to emphasize a biopsychosocial approach?
It is difficult in the present global environment with shortage of psychiatrists, economic constraints, limited time with patients, inadequate access to care – including medications Essential because decades of clinical experience and emerging research supports the view that this approach is the ideal towards which we should strive
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Clinical Outcomes Research Findings
Outcomes are improved when treatment occurs within a positive therapeutic relationship
HIV/AIDS outcome is improved
Even in serious illnesses, such as schizophrenia, with multimodal interventions outcomes are better with single clinician coordinating treatment In mood and anxiety disorders, improvement is greater, and persists longer after treatment with combined psychotherapy and pharmacotherapy
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Compliance Issues
Compliance is a major under recognized factor in poor treatment outcome A number of published studies show over 50% of all prescriptions are either not taken to the pharmacist or not taken properly Empathic listening skills and psychotherapeutic skills are needed to ensure optimal outcomes
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What is good pharmacologic practice?
Knowledge of mechanism of action, pharmacokinetics, drug interactions, side effect profiles, correct dosing schedules UNDERSTANDING AND DEALING WITH RESISTANCE TO TREATMENT REQUIRES PSYCHOTHERAPEUTIC UNDERSTANDING AND A THERAPEUTIC DOCTORPATIENT ALLIANCE Compliance with treatment is enhanced through a trusting, collaborative, therapeutic alliance
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A prescription is given meaning by both doctor and patient
There are at least two forms of meaning
“Illness belief system” – the nature of the theoretical explanation for the illness
Patients may have a variety of emotional reactions Especially a problem in patients with psychotic disorders or severe personality disorders Medication may be perceived as a threat to internal control and autonomy
Meaning is also attributed to the medication itself
Meanings effect how patients view drugs, the prescriber, and themselves
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How do we assess and predict possible maladaptive reactions to medication treatment
A thorough history is essential
Includes history of important relationships and typical patterns of interacting Assessing potential difficulties in the therapeutic alliance based on patterns of behavior in other relationships
The assessment concerns the potential for transference in the patient
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Transference
We may tend to unconsciously “transfer” reactions from previous relationships earlier in development to present relationships Influenced by characteristics of physician, illness belief system, and reactions to medication May have positive, negative, or both components Especially problematic in psychotic patients and those with severe personality disorders
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Evaluating Possible Transference Reactions
External (real) issues Positive Factors
Psychiatrist Professional appearance Confidence and trust
Transference feelings
Observance of social conventions Empathic listening Patient education Patient involvement in decision making Adherence to scheduled appointment times Prompt, focused response to telephone calls Courteous, efficient support staff
Validation of symptoms and distress Nurtured Cared for Educated
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Evaluating Possible Transference Reactions
External (real) issues Transference feelings
Positive Factors
Medication Highly effective Favorable side-effect profile Easy to use Rapid response Benevolent gift Healing remedy Useful tool Validation of suffering Source of hope Transitional object
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Evaluating Possible Transference Reactions
External (real) issues Transference feelings
Negative Factors
Medication Limited effectiveness Unfavorable side effects Difficult to remember Gradual response Crutch Artificial treatment Poison Deny or avoid real issues Minimize interaction with therapist 19
Evaluating Possible Transference Reactions
External (real) Issues
Psychiatrist Disorganized Odd behavior, grooming, or dress Rude interactions Uninterested in patient Careless Dismissive of complaints Authoritarian
Transference Feelings
Distrust Lack of confidence Rejected Disregarded Demeaned Confused
Negative Factors
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Countertransference
The physician’s transference reaction to the patient In the present economic and workforce environment, with severe constraints on psychiatrists’ ability to provide care, a variety of feelings may be stimulated which deserve self-reflection
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Educational Implications of Current Environment
For optimal clinical care skills, strong psychotherapy education, including empathic listening and therapeutic alliance skills within a biopsychosocial model, is needed Treatment occurs within the context of a therapeutic alliance
Educational programs must teach the necessary knowledge and skills Many national accrediting bodies have recognized this with specific educational requirements
These skills are of more importance in our present technological age
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The Information Technology and Genetics Environment
Genetics and information technology will allow modification of mental processes Direct human brain-computer interfaces now exist and are becoming more sophisticated Devices, or genetic manipulation, to modify memory or change patterns of emotional responsiveness will be developed Control of this technology will be a critical societal decision
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The Information Technology and Genetics Environment (continued)
Unparalleled opportunities and challenges as information technology, genetics, and psychiatry intersect
Many uses in research, education, and clinical missions
Nature of reality and its modification via technology addressed by science fiction writer Philip K. Dick
His “machines” often more “human” than real people
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The Information Technology and Genetics Environment (continued)
Psychiatry is the arbiter of sanity and reality by virtue of training and societal sanction
Will become more important as information and genetic technology progresses
Even with these changes therapeutic transactions will continue in the context of a therapeutic relationship
We must assure young psychiatrists are trained to provide sophisticated and comprehensive treatment
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The Information Technology and Genetics Environment (continued)
Advances in genetics and neuroscience have not changed human capacity to respond to trauma, developmental conflict, or developmental deficit Understanding complexity of genetic/developmental interaction supports the importance of a therapeutic relationship as an agent of change
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Neuroscience Support for the Value of the Therapeutic Alliance
The work of Nobel Prize winner Eric Kandel has had substantial impact The microstructure and function of the brain is continually remodeled from birth by ongoing developmental experiences Physical and psychological status is related to an interaction between genetic endowment, prenatal influences, and life experiences
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Gluckman et al. Science, 305:1734, 2004
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Summary
Experimental and prospective clinical research support the suggestion that developmental experiences have significant effect on disease risk
Future challenge is to better understand the interaction between genetic endowment and the impact of developmental experience
Freud emphasized early developmental influences, the role of which is still under study
Full array of skills will be required for high-quality care including ability to listen empathically, understand the psychological meaning of symptoms, and intervention within a therapeutic doctor-patient 29 relationship
Modulation of this interaction will require a culturally sensitive biopsychosocial approach to understanding and intervention