The Changing Role of Dynamic Psychotherapy in Psychiatric Practice
Abstract
The author reviews the range of accepted indications for dynamic psychotherapy when he first began practice after World War II and describes factors that have played a role in the current undervaluing of this treatment approach. He attributes much of the change to research that has produced a different understanding of many of the conditions treated by psychiatrists and has placed greater emphasis on their medical and biological aspects than on their psychological aspects. He also attributes many alterations in current practice to the change from a two-party to a three-party reimbursement system for psychiatric services. On the basis of his practice, the author illustrates his belief that dynamic therapy continues to have a role in today's psychiatric practice. He describes one category of patients in particular—those who seek treatment for "problems of living"—who can be helped by dynamic psychotherapy. The author makes a case for freeing dynamic therapy from the need to rely exclusively on the criteria of the medical model for its legitimacy.
When I began seeing patients in 1946, psychoanalysis or dynamic psychotherapy, derived from Freudian principles, was the gold standard for treatment of a large number of conditions in the domain of psychiatry. The pre-DSM era "neuroses," consisting of a variety of symptomatic disorders that did not fit the criteria for psychosis, were considered to be the primary indications for dynamic psychotherapy.
Personality disturbances, although not excluded from such treatment, were thought to be more inflexible and less available for positive change. Schizophrenia and the manic-depressive psychoses, while outside the usual range of indications for dynamic psychotherapy, were the subject of intense, spirited investigation at such institutions as Chestnut Lodge, where innovative therapists were attempting to apply psychodynamic theories to the origins of these illnesses—and that's what they were called, illnesses, not disorders—and to relieve symptoms through modified psychotherapeutic exploration directed at the individual or the family (1,2).
There was also a great deal of interest in psychosomatic medicine at that time. A number of illnesses so classified might be treated psychotherapeutically by therapists who would, for instance, apply the theories of Franz Alexander (3), who hypothesized that unresolved dependency might go one way to produce bronchial asthma and possibly another way to cause peptic ulcers.
Homosexuals, especially males, were held to be sick people whose sexual orientation stemmed from aberrations in infantile development or family life. Theoretically, they were "curable" with psychotherapy, as were patients suffering from a number of dysfunctions of the sexual life—impotence, premature ejaculation, erectile insufficiency, anorgasmia, and inadequate libidinous response.
In addition to, and overlapping with, the symptomatic indications described above, many people undertook psychoanalysis or dynamic psychotherapy because of a variety of problems that adversely affected their well-being, their level of functioning, and their relationships with others—conditions that did not qualify as illness. Patients of this kind are now labeled, somewhat pejoratively, as "the worried well" or, more neutrally, as suffering from what may be called "problems of living," a category about which I shall have more to say below.
Psychoanalysis was also sought by people who did not have such specific concerns, with the hope that intensive self-exploration would improve the quality of their lives, and even make them happier and more productive.
At least in terms of acceptance and prestige, although possibly not in terms of consistent therapeutic success, this was a golden era for physicians employing dynamic psychotherapy, especially because of the lack of serious competition by therapists with other professional backgrounds. The situation is, of course, vastly different today.
Changes in the role of dynamic psychotherapy
To begin to catalog these differences, it is useful to consider the former neuroses, now the axis I nonpsychotic anxiety and depressive disorders. These conditions were formerly treated almost exclusively by psychoanalysis or dynamic psychotherapy. Now these treatment approaches are increasingly challenged by interventions that combine psychotherapy with medication, or by medication alone, or by cognitive-behavioral forms of psychotherapy. An example is obsessive-compulsive disorder, for which medications and combined therapies are now important interventions.
The acceptance of psychotherapy for some of the other conditions I have mentioned has also changed considerably. Although a few hardy souls still cling to psychodynamic formulations and treatment of the major psychotic and affective disorders, they are for the most part voices crying in the wilderness. Illustrative of the current view is a brochure I recently received from the National Alliance for the Mentally Ill summarizing accepted treatment for schizophrenia (4). After reviewing several pharmacological agents, the brochure states that the right kind of psychotherapy is also helpful, followed by an emphatic warning against any psychotherapy that seeks the origin of the patient's symptoms in his or her psychological roots or family dysfunction.
Although there is still active interest in psychodynamic approaches to the so-called psychosomatic conditions, the scope of these approaches has been limited by advances in the genetic and organic origins of some of these illnesses. One example is the now-accepted relationship of peptic ulcer to Helicobacter pylori infections.
I was formerly consulted by male homosexuals whose goal was to change their sexual orientation. Because of meager success in such endeavors and a very different view of the nature of homosexuality—as well as ethical conflicts—these consultations are no longer a feature of my practice. However, an unlikely combination of a few psychoanalysts and some religious zealots still maintain that such change is possible.
The significant change in addressing inadequacies and disabilities of sexual function is the extent to which effective treatment now involves mechanical devices, drugs, and behavioral conditioning techniques. For example, a former patient of mine, a man whom I had been able to help psychotherapeutically on several occasions over the years, consulted me at the age of 74 because his previously vigorous sexual life with his wife had deteriorated due to erectile insufficiency. He knew about Viagra, but he also had benefited from psychotherapy, so he came to me for advice. After listening to him and asking some questions, I advised him to try Viagra, which he did, with quite satisfactory results.
What are the reasons for this sea change in the role of dynamic psychotherapy in psychiatric practice? A number of factors are at work, some obvious, others less so. I began practice during a time when the influence of Sigmund Freud was at its height, constituting a climate of opinion that not only penetrated social and cultural life but also, with the seductive promise that psychoanalysis could relieve mental dysfunction, exerted a very strong influence on psychiatry. As expressed by a former analytic patient in a recent book, "In those days it was thought that analysis could cure anything" (5). More pragmatically, Freudian approaches were virtually the only game in town. The principal alternatives for the major disorders were hydrotherapy, forms of shock treatment, psychosurgery, and, for less severe cases, a variety of sedative drugs, principally barbiturates.
The fact that psychoanalysis and psychoanalytically derived psychotherapy did not achieve regular success in relieving symptomatic disorders could be glossed over, in a sense, by changing the goal and pointing to improvements in interpersonal functioning. I might also mention that 50 years ago was not too far from the time when doctors generally had relatively little to offer as definitive cures for many maladies.
However, it cannot be denied that the major changes I have outlined in the role of dynamic psychotherapy resulted from research that produced a very different understanding of many of the conditions treated by psychiatrists and placed greater emphasis on their medical and biological rather than their psychological aspects. The apparently greater efficacy of drugs and cognitive-behavioral therapy, compared with the relative ineffectiveness of dynamic psychotherapy for some symptomatic psychiatric disorders, constituted the principal reason for reassessing the role of and the indications for dynamic psychotherapy. However, less obvious factors have also played a part in the decline of confidence in the therapeutic value of dynamic psychotherapy.
The most important of these factors has been the gradual change from a two-party to a three-party reimbursement system for psychiatric services that has occurred during my career (6). Only those who have been in practice for as long as I have can appreciate the extensive effects of this change. Insurers initially had a rather accepting attitude toward dynamic psychotherapy, but this has since been replaced by a generally skeptical view, especially for long-term psychotherapy. Their reasons are ostensibly financial, but there is evidence that no real cost savings are achieved by placing highly restrictive limits on psychotherapy (7).
I believe that insurers are also troubled by what they see as the difficulty in squaring this treatment approach with standard medical criteria for diagnosis, duration, and outcome (8). Research on dynamic psychotherapy has found evidence of its efficacy (7), but, in my opinion, these studies are somewhat problematical, and in general this form of treatment does not readily lend itself to "scientific" outcome research (9). For example, a well-planned and well-executed study by the National Institute of Mental Health conducted in the 1980s that compared two forms of psychotherapy for depression with drug treatment produced less than convincing results (10).
Klein (11) has asserted that to be meaningful, outcome studies of psychotherapy must use a pill placebo control and be conducted jointly by a psychopharmacologist and a psychotherapist. Perhaps more emphasis should be placed on the intensive individual case study method advocated by Strauss and Goering (12).
Economic factors have played an important role in the increasing medicalization of psychiatry. Medicalization has contributed to the decline in the indications for dynamic psychotherapy and to a diminished emphasis on the psychological component of psychiatric disorders, both in the training of psychiatrists and in their clinical practices. Another reason for the increased medicalization of psychiatry may be the way in which DSM-IV, with its emphasis on specific objective criteria rather than on dynamics, has come to dominate psychiatric diagnosis and treatment.
Dynamic psychotherapy in current practice
Having undertaken this bird's-eye review of the vicissitudes of dynamic psychotherapy over the past 50 years, it is necessary to address the question of the appropriate place of dynamic psychotherapy in the armamentarium of psychiatrists in practice today.
First, I believe it is necessary for dynamic therapists to come to terms with the corrective alteration that was inevitable as new developments mandated a more objective evaluation of an era when those who were furthering the legacy of Freud did so with a certain arrogance and with unrealistic expectations. However, I do not want to convey the message that the era of dynamic therapy is over and that the knell of doom has sounded for its value. Taking into account reasonable constraints and realities, I believe that this modality remains useful for a wide scope of psychiatric practice.
Although evidence for the efficacy of dynamic therapy in the treatment of schizophrenia is sparse, psychosocial methods have proved useful in supplementing drug treatment in the form of supportive and reality-oriented therapy and psychoeducational interventions (13). The therapists who administer these treatments are likely to be more effective if they themselves have training in dynamic approaches that enables them to recognize the tangled interpersonal currents that are inevitably present and that influence the course of the illness.
Studies have found evidence of greater emotional disturbances and suicidality among homosexuals (14,15). Treatment of these disturbances constitutes a fertile field for dynamic intervention for therapists who have no ambitions to alter sexual orientation. As for sexual dysfunctions, whether among homosexuals or heterosexuals, not all dysfunctions are amenable to drug or mechanical interventions alone. For example, a significant number of cases of impotence are psychogenic rather than organic, and in many cases, whatever the origin, psychological factors such as performance anxiety play a significant role. In these instances as well as in the treatment of physical disorders with or without a significant psychological component, dynamic therapy can be helpful in enabling a somewhat disabled person to come to terms with his or her grief and anger and the need to adjust to reality.
In the face of a veritable onslaught of drug treatments for axis I anxiety and depressive disorders, dynamic therapists have far from abandoned the field. Many believe that their approach is effective, as exemplified by a recent book reporting the successful dynamic treatment, without drugs, of a group of patients with panic disorder (16). Also relevant is the recent protest by groups representing psychotherapists of what they see as inadequate attention to dynamic psychotherapy in current guidelines for panic disorder developed by the American Psychiatric Association (17).
I believe it is fair to state that no consensus has been reached about the current proper treatment for axis I anxiety and depressive disorders, and that although treatment approaches are changing, appropriate treatment is still the subject of considerable controversy. A consensus, which may be emerging, would support the use of both drugs and dynamic therapy in the treatment of these disorders. Support for the use of combined approaches seems even more widespread in the treatment of personality disorders, particularly borderline personality disorder, in which a joint approach employing both drugs and dynamic psychotherapy is now widely used (18).
What about the treatment of depression? I must confess to being somewhat underwhelmed by all the hosannas celebrating how regularly depressive illness can be remedied by antidepressant medications. Like any experienced psychiatrist, I have seen good results, but I also have seen many depressed people whose response to drugs is not particularly striking, as is attested to by the frequency of articles offering suggestions for new drugs for treatment-resistant depression. A recent meta-analysis found that about 40 percent of drug-treated patients improved, compared with 30 percent of those given placebo (19)—not a spectacular advantage. In my opinion, such equivocal results occur not only because patients do not always receive the right drug but also because in some cases the depressive affect may be only one component of a pattern of disturbed living marked by manifestations in addition to depression.
Questions can be raised about the ability of DSM-IV criteria to infallibly differentiate clinical depression from unhappiness. Unhappiness is an inescapable component of the human condition and sometimes must be borne rather than banished with some magical potion like Aldous Huxley's soma (20). I am uneasy about the creation of what might be called a "furor psychopharmacologicus," engendered by a tendency to label every vagary of the human condition with a diagnostic label, a DSM-IV code number, and a specific drug recommendation in a way that amounts to the trivialization of the deeper currents of life.
I believe that depression sometimes is better understood under the rubric of problems of living, defined as conditions affecting people who consult psychotherapists with evidence of psychopathology sufficient to negatively influence their well-being and relationships but not to justify a diagnosis of illness or disorder. Such patients have been a consistent part of my 50 years of practice and the practices of many of my colleagues, despite what I believe is a tendency to downplay this patient category.
I offer an example of what I mean by a problem of living. When Mr. B consulted me he was in his early sixties and had been involved for many years in a series of entrepreneurial ventures usually instigated by him. In the course of organizing these ventures, he somehow regularly failed to take into account his own legitimate financial interests. He was aware of this pattern and had tried to correct it, but whenever the issue arose, he hurried over it or put it aside. The result was that Mr. B and his wife were now forced to live in much more straitened circumstances than should have been the case in view of his industry and very considerable abilities.
Although troubled and concerned, Mr. B was generally a cheerful, optimistic person with great energy and vitality. He sought help in correcting his maladaptive financial behavior. It seemed likely that an unconscious psychological conflict was responsible for his self-damaging actions. Thus Mr. B was an excellent candidate for dynamic therapy, but under what diagnosis? It would be possible to include him under adjustment disorders or personality disorders, but at the cost of real accuracy and with some element of gaming the system. This dilemma exists only if the patient is seeking reimbursement under Medicare or some other third-party insurance system. If he or she is paying out of pocket, the problem does not arise. However, out-of-pocket payment is no longer a viable option for many people.
How to deal with patients like Mr. B is a troublesome question for psychiatrists and other professionals who undertake psychotherapy as well as for the organizations to which they belong. Our diagnostic system depends to a considerable degree on medical-model criteria, although this dependence is not entirely acknowledged. These criteria are not applicable to people with the kind of problem I am describing, although their psychopathological difficulties are ample reason for seeking psychotherapeutic help.
In general, I feel that the distinction between these two categories of psychotherapeutic indications—illness or disorder and problems of living—is too rigid and has been forced on us in this era of managed care by the need to conform to the dictates of medical necessity (21). As I have previously stated (22), I believe medical necessity has become a bugaboo that has outlived its usefulness as a gatekeeper for psychiatrists' services. I am concerned that under its dictates we are being impelled to try to medicalize not only psychiatry but also the human condition itself in order to receive insurance reimbursement. We may even be exposing ourselves to ethical hazard. Problems of living, whether "medical" or not, cause a great deal of suffering that dynamic psychotherapy is uniquely equipped to ameliorate. The medical model is not a sufficient foundation to account for all the ills that are inevitable in life.
Conclusions
Despite the considerable changes that have taken place in the indications for dynamic psychotherapy, this modality continues to have a significant role in the treatment of symptomatic disorders. Its role in dealing with problems of living that are not necessarily medical must be accepted and acknowledged. Harry Stack Sullivan said, "We are all more simply human than otherwise." It is these human failings, diagnosable or not, that we all must endure and that are the province of the emollient ministrations of dynamic psychotherapy.
Footnote
Dr. Chodoff is in private practice. He is also clinical professor of psychiatry at George Washington University in Washington, D.C. Address correspondence to him at 1904 R Street, N.W., Washington, D.C. 20009.
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