Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Monday, March 13, 2017

Manualized Treatments

I'm sorry I've been gone so long. There, I got that out of the way. I have been exquisitely busy, with mostly good things, so no complaining. But really no time to blog. I have missed it, though, and I've also felt strangely guilty, as though having embarked on this journey, I need to see it through, whatever that might mean.

I assumed no one would be reading the blog, once I stopped posting regularly. I haven't even checked in much to see the stats. But when I did, recently, I was shocked to discover how many hits the site is getting on a regular basis. It's a nice feeling.

So now that I'm back, there's the question of what to post about. I've decided, at least for this return post, to ignore the Republican in the room. With my apologies to those who voted for Trump, I find the current political situation in this country very disturbing. And that's all I'm going to say on the subject, for now.

Why manualized treatments? Lately I've been involved in some committees that are debating the nature of an analytic curriculum, and whether it should include psychotherapy training. This goes to the question of what the difference is between psychodynamic psychotherapy and psychoanalysis (these days, I believe the therapy is referred to as psychoanalytic psychotherapy). That's a very tough question, with lots of controversy about a spectrum of treatment, the use of the couch, the frequency of sessions, goals of the treatment, whether analytic training makes for better therapists, the theoretical bases, overlap in technique, the list goes on.

At a recent meeting, one suggestion was to include courses in Transference Focused Psychotherapy (TFP) and Panic Focused Psychodynamic Psychotherapy (PFPP), both manualized treatments, in the first year of training, and the point was made that it may be helpful early on in ones training to have this kind of framework for thinking about what one is doing, rather than just learning to sit with the chaos and confusion.

Oh, this was funny. I got to that meeting a couple minutes late, and everyone was sitting around in a big circle, and it was crowded, so I went and grabbed a chair from a stack and just plunked it down in the outermost circle. Then I started to look around for my analyst so I could figure out how uncomfortable I should feel. At first I didn't see her, then I realized I was sitting directly behind her. About five minutes later I started to laugh because I thought, "Well this is backwards."

I disagree with the framework point for several reasons. First, it's not the only way to create a framework. The current trend in teaching psychotherapy is to use a book by Cabaniss, Psychodynamic Psychotherapy: A Clinical Manual. The idea behind it is that there are now core competencies in psychotherapy that residents have to meet, and it's structured in a way that fulfills those competencies. It's brilliant in the way it breaks things down into simple pieces, but it's very algorithmic, and in my opinion, it infantilizes the residents for whom it's intended.

I've been teaching in a psychotherapy program for several years, and we don't use that book. Instead, we use Rosemary Balsam's, Becoming a Psychotherapist: A Clinical Primer. It's a bit outdated (it includes a section about whether you should have an ashtray in your office), but when it comes to teaching newbies how to work with patients, it's brilliant. Completely non-algorithmic, it still manages to create a solid framework for how to think about what one is doing in terms of technique. Every time I read it I think, "I wish I had had this when I was a resident."

Second, teaching beginning psychodynamic psychotherapy with manualized treatments is analogous, for me, to using a GPS to get someplace new. This happens to me all the time. I use the GPS, I have no problem getting where I'm going, and I have no idea where I am. Not a chance that I could get home without the GPS. I just did as I was told, (drive 158 miles, then turn left) but I'm clueless. Whereas back in the days before GPS's, I had to look at a map, and maybe I got a little lost and had to pull over and look at a map again. It was more of a struggle, but by the time I reached my destination, I could get home on my own.

That said, I think manualized psychotherapy treatments are good things. I just don't think they're the first way one should learn to do psychodynamic psychotherapy. So let's go over the two I mentioned above. Please note that I'm writing about manualized psychodynamic psychotherapy treatments, which is why CBT is not included in the discussion.

Transference Focused Psychotherapy (TFP):

TFP is a manualized evidence-based treatment for borderline and other severe personality disorders. It is based on psychoanalytic concepts and techniques that have been modified and organized into a systematic approach to address severe personality pathology. TFP posits that the specific symptoms of borderline personality disorder (BPD) stem from a lack of identity integration, corresponding with a lack of coherence in the individual’s experience and understanding of both self and others. This unintegrated psychological state, referred to as “identity diffusion,” is associated with reliance on defensive strategies involving dissociation of conscious aspects of experience that are in conflict (“splitting-based defenses”) and with a vulnerability to experiencing cognitive distortions in the setting of affect activation.  (Yoemans, et al)

TFP meets twice weekly for an indefinite period. Its objectives include improved behavioral control, and an increase in reflection and affect regulation, both of which ultimately promote identity integration. The success of TFP rests on three central tasks for the therapist: setting and maintaining the frame; containing and making use of the therapist's own affective responses (countertransference); and interpretation.

The frame is set via a collaborative negotiation of a treatment contract-how frequently they will meet and why that's important, what happens if sessions are missed, etc. The therapist needs to be flexible and open, and to address any concerns the patient might have. This creates a safe environment for the patient, and allows for later discussion and exploration of deviations from the contract.

Work with Borderline patients can produce intense affective reactions in the therapist. The goal is for the therapist to recognize and accept those affects, rather than denying their presence, and to use them to help understand what the patient is feeling. For example, Borderline patients can project a lot of their own negative and aggressive feelings onto others, so the therapist's awareness of his own affective reaction can help him recognize an affective state which the patient may be experiencing, but unable to recognize in herself.

The interpretive process includes the triad of clarification, confrontation, and interpretation, itself.

"Clarification involves drawing attention to an area of psychological conflict by tactfully and specifically exploring the patient’s conscious experience."

Confrontation calls attention to the, "...patient’s verbal and nonverbal communications that are in contradiction with each other and that represent internal states that are segregated from each other." An example would be pointing out her own aggressive behavior to a patient who frequently feels mistreated by others.

As for interpretation, itself, "In the advanced phases of the interpretive process, the TFP
therapist continues to support reflection, while calling attention to the dissociation of positively and negatively colored aspects of affective experience and ultimately exploring the patient’s motivations
for keeping them apart. In the process of interpretation, TFP emphasizes a persistent focus on the here-and-now and an empathy with the total internal experience of the patient, which is to say, with the patient’s identifications with both the persecutory as well as the persecuted object, and with the idealized as well as idealizing object." Much of this work takes place in the transference, i.e. in the therapist's interpretation of the patient's reactions to the therapist, whether idealizing or demeaning.

Empirical studies of TFP have shown decreased suicide attempts, ER visits, and hospitalizations, as well as increases in global functioning. (all significant, see this summary)

One study comparing TFP with DBT and supportive treatment found significant improvements in depression, anxiety, global functioning, and social adjustment in all three groups, at one year. TFP and DBT showed significant improvement in suicidality. TFP and supportive treatment were associated with improvements in anger and impulsivity. Only TFP was significantly predictive of change in irritability and verbal/direct assault.

The difference in approach of TFP vs. DBT seems to be that DBT is good at getting Borderline patients to function, despite their affective and cognitive tendencies, while TFP tries to shift those tendencies.

Panic Focused Psychodynamic Psychotherapy (PFPP):

I actually wrote a post about PFPP a couple years ago, Panic Disorder Study. Unfortunately, the link I used to the article doesn't seem to work anymore, so here's a new link, with the full text.

As a quick recap, PFPP is a manualized treatment for Panic Disorder that runs for 24 sessions over the course of 12 weeks (2/week). It assumes that panic symptoms have psychological meaning, often related to conflicts surrounding separation, autonomy, and anger. There are three phases of treatment.

In phase 1, the meanings behind the panic symptoms are explored, with the goal of some initial symptom relief. Phase II involves addressing transference to examine the way the conflicts causing the panic can play out in real time. Phase III addresses termination, including the reliving of central separation and anger themes in the transference.

One of the impressive things about PFPP is that it managed to develop a manual for doing psychoanalytic psychotherapy. I haven't seen the actual manual, but presumably, it was able, "... to maintain the essential features of a psychoanalytic treatment (free association, elucidating unconscious meanings and conflict, developmental exploration, interpretation, use of the transference) with adequate flexibility, while focusing on the specific underlying meanings of symptoms of panic disorder." (Discussed Here).

I couldn't find a trial testing PFPP against CBT, since the original, 2007 study, which tested PFPP against something called, Applied Relaxation Training. There does seem to be a trial in progress, as well as one about PFPP in adolescents. I guess they were satisfied enough with the results of the original trial that they continue to offer training in PFPP.

That's about it for my return post. Hope to post again soon.

Published on Psych Practice March 13, 2017