On Psychotherapy

By Harold I. Eist, M.D.
APA President

We have solidly established over years of successful practice the high value of psychotherapy as a core psychiatric discipline, in spite of those who dismiss psychotherapeutic interest as a mere fascination with the idiosyncratic. Our special interest in the individual both distinguishes us from other medical specialties and is critical to our effectiveness as healers. The latest compelling numbers, hot off the press and speaking the language of cost efficiency, control groups, outcomes, and efficacy, have just been published in the 1997 supplement of Psychoanalytic Inquiry. Joseph Lichtenberg, M.D., is the editor in chief of this journal, and Susan G. Lazar, M.D., is issue editor of this superb supplement, titled "Extended Dynamic Psychotherapy, Making the Case in the Era of Managed Care." I commend this excellent, convincing periodical, as well as our APPI Journal of Psychotherapy Practice and Research, to every member of this Association.

I remember years ago, when we had a relatively small armamentarium of medications, that, almost on a daily basis, inner-city patients compellingly appealed to me to provide them with psychotherapy. Regularly, patients said, "Doc, don't give me a pill and send me away. I need therapy to help overcome or change patterns that keep tripping me up. What good does it do to help me feel better with a pill, if I just end up falling on my face again and again?"

"Don't treat me as if I'm invisible," my patients were saying. "Treat me as a person of value."

The poignant request for comprehensive care that I heard in the late 1960's is being urgently echoed again and again today. The suffering of the mentally ill is being ignored, denied, and made invisible on the altar of managed care's bottom line, and our patients know this. This dehumanization is intolerable, and regardless of "contracts," we have to ask how physicians can participate in it. At a meeting convened last winter by Mary Jane England, M.D., with family practitioners, they added their voices to those of our patients, students, and residents, emphasizing the importance of one-stop, integrated care by the psychiatrist. They all clearly shared the concept of a psychiatrist as a multidimensional psychotherapeutic specialist in the broadest sense. Family practitioners know that they can't do psychiatry; however, they firmly believe that they can effectively prescribe psychotropics.

We know this. We fully appreciate that, without understanding of and respect for the inner world of being, of the experience of our patients, we cannot treat them optimally. We know that the ultra-brief therapies are a put-off and a put-down, not allowing for the openness essential to even adequate medicating.

in his novel Amerika, Kafka captured what happens to humans when we intentionally ignore their individualism. Milan Kundera, in his recent seminal book, Testaments Betrayed, put it well: "In Kafka's Amerika we find ourselves in a universe of feelings that are inappropriate, misplaced, exaggerated, unfathomable, or--the reverse--bizarrely missing." In his diary, Kafka characterized Dickens's novels by the words: "heartlessness masked by a style overflowing with feeling." Those who attempt to rationalize profit taking at the expense of care do so with "heartlessness masked by a style overflowing with feeling." Remember the Harry and Louise ads? They were concerned about patients having a choice of doctor. Do we see this in current managed care programs? They continue to advertise an interest in traditional medical values while undermining them.

James Joyce, as Kundera points out, demonstrates, "A single second of the present becomes a little infinity."

A case example will demonstrate the importance of these little infinities. A schizophrenic man on antipsychotics appeared for his medication session wearing a faded, long, white lab coat, over the top of which he had a leather vest. As he sat down and spread his legs, his lab coat fell open, and his penis and testicles popped out through the torn crotch of his pants. Remembering Osler's admonition that the good physician remain, at all times, imperturbable, I struggled to remain imperturbable. I said, "George, your penis and testicles are hanging out."

He responded, "What's the matter, Doc. Haven't you ever seen a set?"

I asked, "Are you showing me your penis and testicles because you think you have a problem with them?"

"Maybe," he said, seeming a little less confused. (Interpretation frequently has an integrating and clarifying effect, even for psychotic patients who are very confused.) "They poisoned our food in the hospital with saltpeter."

"Do you want me to determine if your penis and testicles are all right, whether they were damaged by the hospital?" I asked.

"Right, right, Doc," he answered, his confusion lifting.

"Do you think the hospital damaged them?"

"That's it," he said. "I tried to have sex last night, and I couldn't ejaculate."

"You are wondering, too, if the Mellaril could be a factor in this?," I asked. (Remember the transference.)

"Yes, I was worried about that," he answered.

"It could," I said. "I think we should change your medication."

"Thanks," he said, much clearer now. "I knew I could count on you, Doc," he said as he crossed his legs and covered himself with his coat.

Without attention to his inner world of being, his bizarre behavior would very likely have resulted in an increase in his medication dose, with a resulting increase in the severity of his side effect and the possibility that he would have precipitously discontinued his medication, with serious consequences for both the patient and his family. Unless we hear our patients psychotherapeutically, we can never know that the medications create, for many of them, unpleasant feeling states that they endure because they remove something worse. A bad side effect can change the balance against cooperation and lead to traumatic recurrence.

The longer we take with these single seconds, the more respectful, self-esteem-enhancing, individuating, growth-inducing, and, yes, less costly will our treatments become. (Psychiatric News, February 7, 1997)