Category: Therapy

What you see – descriptive psychopathology vs. what the patient tells you – phenomenology.

At first look you might say: objective vs. subjective. E.g.: appearance, behavior, speech, affect –  all accessible to an external (objective) observer vs. thought content and mood as (subjectively) reported by the subject. Now, these distinctions are not always as neatly clear-cut as one would like. As one can observe (as opposed to experience) his own process, i.e. one’s own thought content or process are the object of examination, an objective process. Or one can note someone’s else report of his internal experience, a report inherently filtered thorough the examiner’s preconceptions and predisposition, i.e. a subjective process. When it comes to a mental status examination the boundaries between objective:subjective are often times blurred.

The take home point: a comprehensive mental state exam necessarily includes an objective and a subjective examination of the external and internal attributes of one’s mental state.

For the objective component the examiner will aim to describe one’s mental state external manifestations (speech, behavior, affect) and ask the patient to describe his mental state internal manifestations (sensations, emotions, thoughts). Examples of questions aimed at internal experiences descriptions: “Please describe what you are feeling at this time.” “Describe your anxiety in terms of severity: mild, moderate, severe. Also frequency: you experience it once in a blue moon, weekly, a few times a week, daily, multiple times a day, all the time.” In other words the goal of the objective component of the examination is to quantitatively describe its objects regardless of their internal:external mental allegiance.

For the subjective component the examiner will aim to put himself in the patient shoes i.e. attempt to feel what the patient experiences. With regards to external manifestations of one’s mental state the examiner should carefully note his own feelings. E.g. an unaccounted for but palpable sadness in the room warrants a search for depressive symptoms even when the patient emphatically denies feeling depressed. With regards to internal manifestations the examiner should ask about the qualities of emotions, sensory experiences, or thoughts, “Describe your depression.” “What does hearing the voices feel like?” are good examples of how to inquire about the phenomenology of one’s internal experiences.

In summary:

A thorough mental status examination uses objective and subjective complementary approaches to assess external as well as internal attributes of one’s mental status exam.

The objective approach strives to produce quantitative data while the subjective approach aims to produce subjective data, regardless of the data’s provenance (external vs. internal).

In psychiatry we like to think along bio-psycho-social dimensions. Our current axial diagnosis is a reflection of this.

The reasons for our interest in things beyond the “biological” are straight forward. First, as it’s hard to draw a line in the sand separating where the brain ends and the mind begins and this mind that doesn’t separate clearly from the brain cares about our psychosocial environments. In other words, psychosocial events are, more times than not, an important cause for our thoughts, emotions, and behaviors. This does not mean biology does not matter. But it does mean that any examination of mind/brain continuum needs to include a psychosocial assessment to ensure that the collected data is non-biased and thus valid.

One of the unintended consequences of the DSM descriptive approach has been a shift in the focus of the mental health interview: from the broader themes of nature AND nurture and the implicit goal of attempting to establish cause and effect type of relationships between the different layers of one’s history, to a symptoms-focused, descriptive only approach. The gains in precision came at the price of slashing the context, which, as it turns out, is essential in understanding the deeper levels of pathology. And by “deeper level” I am not referring to the psycho-dynamic foundation of that out-of-consciousness conflict, but only to the fact the there are different levels of description. And chance is that the most superficial layer is, well, the most superficial one. Meaning, subject to much deformation and bias; as such, not nearly as accurate as the deeper levels.

Case and point: A case of chronic exhaustion

Mr. Tiredalot is a middle age gentleman complaining of no longer been able to enjoy things (including sex), feeling exhausted all the time, amotivated, dragging his feet, unable to concentrate, not sleeping for the last few weeks. There are no medical or substance abuse issues. Mr. Tiredalot denies any recent stressors. As he meets DSM criteria for depression he is started on an SSRI.

It turns out that Mr. Tiredalot’s sleep disturbance started after changing his mattress a few weeks back. A softer mattress was bought by his wife as she did not like the prior mattress that she found too hard.  Not only that Mr. Tiredalot does not find the new mattress as comfortable, but going to bed each night brings a lot of resentment about the fact that his wife decided to switch mattress without consulting  him. Going to bed turned into a “nightly” reminder of the fact that she rarely engages him in any decision making. Since the mattress switching conflict began Mr. Tiredalot wakes up in the morning with a slightly sore back and a terrible mood. Each time when he tried to breach the subject of the mattress the wife dismissed it as a “waste of time talking about it as it is a done deal”. Which only further escalated Mr. Tiredalot’s frustration. His troubles/stressors don’t reach the required threshold for an “adjustment disorder” and the patient himself does not identify any of the above as stressors.

This is an example of how an interview focusing exclusively on a description could actually miss the point.

Appearances are misleading and an antidepressant is clearly NOT recommended in this case. To see a couple’s therapist would be the best intervention for this patient at this time.

Understanding the psychosocial context – in this case the primary relationship issues with secondary sleep issues and tertiary mood issues – would not only save this patient from an antidepressant but likely many years of grief in a tense marriage.

“I am co-dependent on my therapist”,  says Mr. Intherapyalot. Is this even a possibility?

Think about it this way: the patient – therapist relationship (and by therapist I am psychiatrists, psychologists, etc.) is characterized by an immense power differential. The therapist is in many respects God-like in the eyes of his patient: omniscient (appearing as if he knows everything about the patient), omnipotent (with the ability of curing deep-seated or maybe even deeper-seeded conflicts), the subject of unfiltered transference (positive for the most part) and yet available.

Who wouldn’t like to have God like figure on the line? So when those always urgent phone calls start coming in the middle of the night, when the patient starts calling repeatedly about trivial matters, when tapering the visits results in increased symptoms, and the discussion of termination is pre-emptied by sudden exacerbations, consider “therapist dependence” in your diagnostic formulation.

Of course, “dependence” on the therapist is not always bad. In fact, during the initial stages of therapy, especially for patients who come from a background of poor object relations, “dependence” might in fact be a good thing. In such instances “dependence” might indicate that the patient is finally able to trust in the context of a safe relationship.

In later stages of therapy however, especially when dependence occurs after relative independence has already been established, chance is that the patient is experiencing a maladaptive regression.

What is the solution? First, as always, prophylaxis is gold. Rather than open-ended therapy decide when the discharge date/the final session will be scheduled from the beginning. There is a lot to be said – and good data as well – supporting the fact that time-limited therapy might be more effective that open-ended therapy.  If the patient manifests dependence do not “up the ante”, in other words, do not offer heroic and out of character solutions (such as special arrangements, rescheduling for more convenient times, changing your process by “doing more as the patient is doing less”). Any such responses can become a positive reinforcement for what in essence is a maladaptive behavior.

Instead, keep doing what you have done all along and do not change the termination date. Chance is that the patient will be able to mobilize enough internal resources to hold it together through termination if you would only give him your vote of confidence that he can do so. For the minority that cannot, a return/continuation of therapy might be recommended. If so, it’s usually better if you let another therapist take over. The rationale for switching therapists follows the idea that one needs to be consistent in preventing positive reinforcements for maladaptive traits or behaviors.

Not to mention that if the patient did not improve within the parameters that you initially discussed you might not be the best therapist (at least for that one patient) and they might really benefit from no longer seeing you.

On this day in 1904 Pavlov made his acceptance Nobel prize speech.

In his own words:

“Essentially only one thing in life interests us: our psychical constitution, the mechanism of which was and is wrapped in darkness. All human resources, art, religion, literature, philosophy and historical sciences, all of them join in bringing light in this darkness. But man has still another powerful resource: natural science with its strictly objective methods. This science, as we all know, is making huge progress every day.”

From Nobel Lectures, Physiology or Medicine 1901-1921, Elsevier Publishing Company, Amsterdam, 1967

107 years later we are still finding our way out of darkness. Pavlov’s theory remains as solid today as back then and over time came to ciment the foundation of experimental behaviorism. While no longer popular with philosophers, behaviorism remains strong in modern counseling, as seen in the evidence about the efficacy of cognitive-behavioral therapy in a variety of mind-brain conditions.

Using a CBT framework, you might think of symptoms, including Axis I symptoms or personality traits, as habits or, in pavlovian terms, conditioned reflexes. The treatment needs to extinguish undesirable behaviors, while creating “better” conditioned behaviors.

How do you do it?

Lack of practice results in extinction.

Lots of practice results in new habits.

Certainly true but easier said than done.

The essential ingredient that is missing in the above picture is will. Which the behavioralist can think of just another behavior that needs to be modified. However, how can this be done in a world that banishes behavior modification based on the preeminence of free will?

Solution: you need to find a way to convince your patient to go on your hand, i.e. abandon free will till recovery. Which is a risky proposal. Strong handed approaches or advice giving are unlikely to work. Alternatively, you need to find a way to engage, motivate, or persuade your patient about the right course of action.

In other words, if you are to be an effective behavioral therapist you need to first master the skills of motivational enhancement.

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