The Good Oil Ed Harari

The Good Oil, from Ed Harari

Thursday, 28 April 2005

Is psychiatry wearing you down? Yes? Well, what are you going to do about it? See a shrink? Talk with colleagues?

And how on earth do we get a handle on those complex cases anyway? And what's psychotherapy got to do with it?

Questions, questions...Well, we find the answers from this issue's Mentor of the Month,Ed Harari.

He is a consultant psychiatrist at St Vincentâ€™s hospital in Melbourne who also works in private practice. He is well known as a family therapist and takes tutorials for St Vincentâ€™s mental health staff on a weekly basis, presenting psychiatry and its practice with a non reductionistic yet integrated biopychosocial perspective. His opinions on managing complex patients are extremely valued by those who work in the service.

NB: What were your training experiences when you started in psychiatry and how did you come to be working in the way you do?

EH: At the time that I started, the system was divided between the general teaching hospital system and the mental hospital system. Trainees in the public hospital system did rotations to the mental health hospitals, Larundel, Royal Park, Traralgon or wherever. But the focus (of academic psychiatry) was on the teaching hospitals.

That had advantages and disadvantages. From my point of view the advantages were that there were consultants who worked in both the public and private sectors and senior consultants who had a wide range of experience both in biological psychiatry and psychotherapy.

These consultants, (especially those who had experiences in the private sector and had trained overseas in places like Rochester in New York with George Engel) had a model of teaching psychiatry that was very hands on. We got to see them interview a patient not just for 10 minutes during a ward round but some of them allowed us to see them struggle with a patient week in week out. Then in the true apprenticeship model they allowed us to do the same things.

We interviewed patients and families in the outpatient clinics for weeks with the consultant supervising in vivo. This was at the Royal Melbourne Hospital. It was a fantastic introduction to psychiatry and quite a different experience to what I originally expected.

I had done two years general medical training, actually starting doing neurology. This was quite a different model of working. I think I learnt as much in that first year, with the genuine apprenticeship model of learning, than any other time. It has stayed with me that hands on supervision is the only way to work, doing more and more clinical work under consultants who have the skills, and then increasingly with peers who have similar skills.

It is the best way to learn the practice of psychiatry. It was the training experience that affected me the most.

After I got my membership I ran the inpatient unit at the Austin for a couple of years. I tried to set up a model that was â€˜biopsychosocialâ€™ and tried to bring together these aspects. Many of these units have had bad press since the reforms were introduced, as if to prove that before the reforms there were was darkness in the land of psychiatry. I donâ€™t think that was the case at all. Many of these units actually worked with very difficult patients. Families were seen and psychotherapy was conducted, as well as the ECT three times per week. So running a unit like that for 2-3 years was quite a challenging experience.

I then went the States, to Philadelphia, in the Department of Psychiatry at the University of Pennsylvania, to do family therapy and child psychiatry in the heyday of family therapy.

The particular advantage of Philadelphia was that there were several of the most eminent psychiatrists and psychotherapists in the field who were in the one town, or in the same institution.

It was like a watering hole where all the great names came through. We had Aaron Beck who was in the faculty,as were Lester Luborsky in psychoanalysis, Sal Minuchin and Carl Whitaker in family therapy, Bowlby came and gave seminars.

It was a great time to see the great names but also the limitations of their clinical models. Each of them had limitations and despite the enthusiasm of the guru,one had to modify the model when working with patients. Philadelphia was a city of 60% blacks with the enormous psychosocial problems of an impoverished and alienated population, living side by side with the upper class elite.

One of the consultants I originally trained with, in Melbourne, had trained with the late George Engel.

Engel used to have this thing where heâ€™d present a series of patients with diabetes ranging in age from 4 to 84.

You had the same syndrome, but could see the enormous variation in the manifestations of it and the problems it caused patients, and the therapeutic needs they had.

A similar thing happened for me in Philadelphia, working with people with psychosis in inner urban populations. To see psychosis in the street dwelling criminal youth sub-culture, and at the other extreme in elite classes, and see how this thing manifest itself in people, and the range of manifestation in people with ostensibly the same diagnosis, was hugely instructive .

The second thing that shaped me was watching the advent of DRG (Dignosis Related Group) funding and Managed Care programs which very quickly cut the guts out of much of the good work.

In the space of 2Â½ years you could see programs that were fantastic and innovative being gutted by managed care protocols. At the time, this was early 1985, I was scornfully confident that this wouldnâ€™t happen here.

I would actually boast to my colleagues that although you American are so fantastic in so many ways, how can you be so naive and short sighted to think you can practice psychiatry and psychotherapy and family therapy with letâ€™s say the ghetto populations using DRGâ€™s which allow you X sessions for psychosis. Sometimes it takes 50 session to figure out there is incest in the family, so how can you possibly believe that in 10- 20 sessions, following a protocol, you are going to treat recurrent psychosis. So I used to boast that it was impossible that this could ever happen in Australia. Of course I am profoundly concerned that in the last 10 years things are in fact heading that way.

NB: I have been interested in how you have put together different schools of thoughts and an approach to psychiatry that I consider is truly biopsychosocial. I would like to hear about that, but also how you apply this to your clinical work at the moment, especially with the kind of limitations put around you by current situations in psychiatry.

EH: I guess it is a bit theoretical. There is always a gap between theory and practice. I think the guiding principle in psychiatry is that we try to understand the individual in his or her context, and that therapeutic interventions have to take that totality into consideration.

So the context could be the family, or the hospital ward, or the half- way house that the person in living in.

The reciprocal connections between the patientâ€™s inner life and his or her context that is the basis for the intervention, rather than the diagnosis.

The diagnosis is an important aspect but it is only one, and often as time goes on the diagnosis becomes less relevant. It canâ€™t be discarded all together, you need to make a diagnosis, but the intervention is pitched at the individual- in- context.

That makes it a lot harder to decide, on the basis of the diagnosis alone, what is going to be the most fruitful intervention. If it was just a matter of following protocols and flow charts that were developed from pooling statistical results from mass studies, then you could do it by computer.

In fact that is what happens in Managed Care. Someone who is sitting at the computer who has psychology 101 or is a retired naval surgeon dictates that if the patient has a bipolar illness we will fund you 10 visits to the psychiatrist for pharmacotherapy and ten visits to the social worker for psychoeducation.

There is no consideration for the clinical relevance of the personâ€™s context in terms of both his developmental context and current context. So, in a patient with bipolar illness, in whose context there is marital breakdown, or violence, or unresolved grief all going on concurrently with the bipolar illness that is ignored.

So my overriding frame work is to try and get an understanding of the individual in his or her context and from that interventions of a variety of sorts may offer themselves. It may be biological, or individual psychotherapy, or family therapy. Sometimes the main emphasis is on the environment, the milieu in which the patient lives.

NB: At St Vincents there is quite an emphasis on the psychodynamic. But in other places in Australian at the moment that is not necessary the case. I wonder what you think about current training experiences and how you see the importance of bringing those other aspects, the contextual; the family; the developmental aspects of psychiatry into a model that can fit into current funding and resources.

EH. The emphasis has to be on what has been called practice- based evidence rather than evidence- based practice. That is not just a catchy throw away line.

Evidence that comes from practice is urgently needed in psychiatry rather than the current emphasis, which is from the other way, which is to try and skew practice according to evidence.

I think you get a kind of procrustean frame, in which the evidence is imposed on practice rather than the practice informing the evidence. So for example we know without even doing any more high- powered research that probably about a third of people seeking psychiatric help have suffered some kind of significant developmental trauma, in the form of sexual abuse or domestic violence.

As well, but less know statically, are the people who have less pervasive but equally destructive forms of developmental trauma such as failed empathy; or witnessing recurrent violence between parents; or death of siblings or family members at times in their lives when the individual is developmentally vulnerable.

Putting all that together, you have to say that some where between one third and one half of people presenting to any psychiatric setting are going to have quite profound developmental trauma, regardless of their presenting diagnosis.

So any service that you set up, and any training that you offer people, one would assume would start with the axiom, the self evident foundational view, that probably Â½ of the people they are going to help are going to have this profound developmental trauma as a factor, not the only factor but a powerful one, either past or present or both.

So any training program and any treatment that you undertake, you assume, has to take that into account. In any other area of medicine that kind of vulnerability factor would be absolutely the focus of profound attention.

Imagine trying to develop a community treatment of coronary artery disease and not taking into account that one third of the patients had hypertension. In psychiatry the programs have been set up, by and large, without taking this fact into account.

Psychodynamic thinking (not necessarily psychodynamic therapy and not at all psychoanalysis which as a pure therapy is only relevant for a small percentage of people) is the most profound and extensive way of understanding how developmental trauma manifests itself in the life of a person and his or her relationships with others including relationships with care givers; GPâ€™s; case managers; inpatient staff.

Psychodynamic thinking gives us a detailed understanding of not just how the patientâ€™s developmental trauma affects his or her presenting problems; depression; psychosis; phobia , but also how they are likely to interact and respond to the help that is offered. So I think that the psychodynamic formulation is the heart of psychiatry. I think Engel said that. It is not all, but it is the heart.

NB. I have recent training in family therapy and was struck by the lack of psychiatrists in the field, or training in the field currently. I understand that in the 70â€™s there would have been a lot of psychiatrists involved in this work. I believe it is a similar case in psychodynamic training as well. My question is why there has been a loss of an overriding interest in thinking about systemic and psychodynamic principles, and what has driven this.

EH. I think the professional pathway to senior positions in psychiatry, both in academia, and in senior positions in the College and politics, doesnâ€™t lend itself to spending a lot of time with patients. There are many people in senior positions in psychiatry whose experiences, especially long- term work with difficult patients, is limited.

For example,they would not have had supervision of their work of the type that psychodynamic training requires.

It is incompatible with the professional life style that constantly demands the person rushes off to meetings, travel oversea; develop a CV with lots of papers and research projects.

All that kind of thing tends to produce a distance from the day- to- day work with patients. The solution used to be, that there was a kind of leavening of consultant psychiatrists who had had that kind of experience with patients, close- quarter reflective work over a long period of time, who were welcomed into the service on a visiting basis and demonstrated the principles of individual and family work and supervised that kind of work.

So trainees had access to that. And the senior academics were also there, of course, and tended increasingly to put emphasis on biological treatment, organising community based interventions, and doing research. The trainees saw both worlds. But the former element has now virtually disappeared.

If in addition to that the senior academic has made it a habit to constantly deride psychodynamic thinking, whether in their writings or personally in their teaching with students, there is no way they are going to admit they are wrong now.

For example in the last 15 years there has been explosion of interest of the neurosciences in psychoanalysis and a very fruitful dialogue between the two with conferences, journals and text books. As you would know I have talked about this neurobiological model for phenomenon such as transference; splitting; projective identification.

Some of the most mysterious psychodynamic principles, that are very real in the life of people, now have neurobiological correlates.

One would think this news would be greeted with great enthusiasm because it lies at the heart of integration of the mind and brain which has been the dream of psychiatry for centuries. But in fact very very few of the senior teachers and Directors of Training, and especially those who have the ear of the governments, have shown any interest.

In any other field of medicine it would be considered an era of major excitement and interest equivalent to genetic molecular biology in the field of biology or quantum mechanics in physics, something of that order. But with very few exceptions, - a few honorable exceptions, there has been silence.

I think it is because the leadership of psychiatry, some of who have made a name for themselves scorning and mocking psychodynamic thinking in the name of science, are not going to admit they were wrong. I think that is that sad truth.

NB As a trainee I am interested in this. I know some trainees feel there is a mindlessness about psychiatry at the moment that can really wear you down. How do you think, in the current structure you best go about nurturing an interest in understanding the individual and their developmental experiences, while passing exams!

EH. and looking after one's patients, self, family, friendships, life, passing exams, getting acareer.

They are all happening at the same time for many people while they are getting young families. I think there are a number of things that help. One is the support of peers; the other is having a stable personal life. An understanding partner is extremely important. I think if the personâ€™s personal life is in turmoil it is extremely hard to do a good job in training and the practice of psychiatry, especially that kind of psychiatry that demands that you open yourself to what patients project into you. As well as keeping a clear head for studying and preparing for exams. So if you canâ€™t get a supportive group of peers then find them!

And if you are having trouble in you personal life get help, even if it means deferring the training for a year, it is probably the best way to do it. Or if you are so close to the finish line and you want to sprint to the finish, then take time off after and get your personal life sorted out before taking on onerous consultancies and working in overburdened and under funded clinical postings.

I think in the work itself, and again this comes back to the time that I was training, to have personal therapy was understood to be helpful not only in your personal life but also in oneâ€™s work. It could help one understand more clearly, in psychodynamic terms, what was being asked of one by patients and colleagues and staff . So that understanding projections, idealisation and coercions (we read during the year a couple of papers on collusions that occur in suicidal crises) is vital to helping in positioning oneself in relation to the patient.

If you don't do that you develop a kind of cynical pseudo-rational way to distance yourself from thepatient. You can practice that kind of psychiatry and it is one that is based on brief intermittent contact and delegating the care of the patient as quickly as possible to others in the service.

That happens throughout the public health service, unfortunately.That is quite different to a carefully thought out management plan that is multidisciplinary. I am talkingabout this brief intermittent contact and delegating the care to someone else basically because thepsychiatrist doesn't have the skills, or can't stand being with the patient for longer than 10minutes.

NB It is interesting because I think that getting you own psychoanalysis is a very denigrated part of the training now. In the past it was considered what you had to do, now it is very much â€˜why would you do thatâ€™ and if you do â€˜is there something wrong with you?â€™ It has been my experience that among my college there is a lot of reticence to talk about getting that kind of personal support.

EH And it goes beyond reticence to denigration dismissiveness, derision, and contempt.

One of the things that psychodynamic thinking teaches very clearly is that to have a person or a thing that one can project scorn or derision or contempt (even if it is disguised as an altruistic manic defense) helps the individual feel good about themselves.

I think that psychoanalytical thinking to some extent plays that role in psychiatry. In Australia and the UK and in some parts of America, where psychoanalysis has never even had much of a foothold in psychiatry, people still talk about as it as if it is responsible for any and all of the deficiency of psychiatry. As though we were betrayed by psychoanalysis and are still suffering the effects of that. In fact there has been no strong presence of psychoanalysis ever in Australia. That is not to say psychoanalysis doesnâ€™t have its imperfections.

Anyone who wants to get their own therapy and at the same time practice psychiatry is viewed with some anxiety because that person represents the bringing together of derided aspects and valued aspects of psychiatry. They have to be scorned or viewed as weak minded in order to make the projector feel confident about themselves. And I have an underlying view that many, and I canâ€™t put a figure on it, are drawn to psychiatry because we have at least curiosity, and many a wish to understand ourselves and our families. We have some awareness that we can do that through being helpful to others and understanding ourselves at the one time. I think a lot of people are drawn to psychiatry for that reason, and yet in the practice and training of psychiatry a split occurs and our anxieties about ourselves are projected onto the patient who is then going to be treated and we are OK. If we are not OK then it is a problem with the system.

NB. I am interested in that. I was told recently by a psychiatrist that he felt people went into psychiatry for two reasons; one to understand themselves; the other to draw a line between themselves as healthy and others as unhealthy.

EH But in fact they are both two sides of the same coin, the idea that you can differentiate between the sane and insane implies some kind of splitting for which there is objective evidence.

To some extent there is objective evidence, however one only needs to see how one can rationalise doing the most awful things to others either individually or collectively and justify it in the name of the system or reform.

Most of the awful things that happen in a society or a marriage or a battle field or in a consulting room are not due to a sadistic wish, but because they feel it is necessary for some higher reason. Some capacity to rationalise and delude oneself is exactly what psychoanalytical thinking takes as its centre piece of interest.

And I am sure this, is again, why there is such derision of it.

NB Thank you very much for that.

The psychodynamic formulation is the heart of psychiatry. I think Engel said that. It is not all, butit is the heart.

For example,they would not have had supervision of their work of the type that psychodynamic training requires.

It is incompatible with the professional life style that constantly demands the person rushes off to meetings, travel oversea; develop a CV with lots of papers and research projects.

Some of the most mysterious psychodynamic principles, that are very real in the life of people, now have neurobiological correlates.

EH. â€¦â€¦and looking after oneâ€™s patients, self, family, friendships, life, passing exams, getting a career.

If you donâ€™t do that you develop a kind of cynical pseudo rational way to distance yourself from the patient. You can practice that kind of psychiatry and it is one that is based on brief intermittent contact and delegating the care of the patient as quickly as possible to others in the service.

That happens throughout the public health service, unfortunately. That is quite different to a carefully thought out management plan that is multidisciplinary. I am talking about this brief intermittent contact and delegating the care to someone else basically because the psychiatrist doesnâ€™t have the skills, or canâ€™t stand being with the patient for longer than 10 minutes.

EH And it goes beyond reticence to denigration dismissiveness, derision, and contempt.

EH But in fact they are both two sides of the same coin, the idea that you can differentiate between the sane and insane implies some kind of splitting for which there is objective evidence.

And I am sure this, is again, why there is such derision of it.

NB Thank you very much for that.

Nicky Beamish