Victor Bloom MD
A half century ago psychoanalysis was at the center of psychiatry. For the most part, heads of departments were psychoanalysts or psychoanalytically trained or at the very least, psychodynamically-oriented. Most of them had had some personal analysis or psychotherapy. Supervisors of psychiatric residents were largely psychoanalysts and many residents started a personal analysis or psychotherapy during or after their residency training.
The word “therapy” meant psychotherapy. Drugs were a last resort for most patients, except for those with serious mental illnesses, such as schizophrenia and manic-depression. Before the phenothiazines, sedatives were used for severe behavioral problems, such as acute psychoses and catatonic excitement. These sedatives included barbiturates and chloral hydrate. In the most extreme cases, electroshock therapy was used, usually without the benefit of skeletal muscle relaxants and anesthesia.
A SHORT HISTORY
With the advent of Thorazine, a congener of anti-histamines, a true anti-psychotic was found which interfered greatly with hallucinations, delusions and fragmentation of thought processes. Hospital stays were shortened, the revolving door was initiated and ultimately the closing of many state hospitals, with the fantasy that the family and community could absorb them. Sadly, many of our severely mentally ill are now in jails or on the street. But in addition, many of the severely mentally ill have been greatly helped and have been restored to functioning. Study after study show that a combination of psychotropic medication and psychotherapy works better in most conditions than either medication or psychotherapy alone.
In spite of this fact, most psychiatrists favor either psychotherapy or psychopharmacology, as if one must take sides or make a choice. As time has gone by, market forces have pushed everyday practice to short term therapy and pill-pushing. Polypharmacy and shotgun medication have become rampant, to the detriment of many patients who would do better with longterm psychotherapy assisted as necessary with one or two medications of choice. Longterm therapy means followup by one psychiatrist who gets to know the patient very well, and who is therefore able to adjust medication according to clinical response, and at the same time take into account personal dynamics, family dynamics and the patient’s work environment and subculture. This is really what is meant by ‘biopsychosocial.’
HMO’s and managed care have swept longterm followup under the rug as not ‘cost-effective.’ Employers have been induced to offer employees less and less coverage to maximize their profits or stay in business. Drug companies have succeeded in swaying gullible young psychiatrists into convictions that all mental illnesses are biologic and that there’s an appropriate drug for each condition or symptom. For example, Luvox is advertised as good for obsessive thinking, and I have heard psychiatric residents repeat this mantra.
Drug companies have succeeded in producing ‘research studies’ which prove the effectiveness of their product over placebo and over their competitors, but in many cases the research is sloppy, the data is ‘doctored’ and researchers are beholden to their benefactors, with a resulting loss of scientific objectivity. Practicing psychiatrists are often swayed by detail men and women and elaborate dinners in fancy hotels with experts extolling the virtues of the latest drug.
In the last fifty years, the psychiatric pendulum has swung from one extreme to the other, from psychoanalysis to polypharmacy.
The fact is that Thorazine, Stelazine, Prolixin, Mellaril and Haldol did much to rehabilitate many schizophrenic patients. And it is true that Lithium was not only helpful, but became the drug of choice for mania. But Lithium had its dangers and side effects and the phenothiazines caused drowsiness and Parkinson-like (extrapyramidal) side effects, including irreversible Tardive Dyskinesia. Further research by the drug companies came up with the newer antipsychotics such as Clozaril and Zyprexa and mood stabilizers, such as Depakote and other anti-convulsants.
The facts also include our knowledge that in the last half century medications for depression have become more and more effective. At first there was only Dexedrine and shock therapy, but along came the tricyclics, such as Tofranil and Elavil, and the MAO inhibitors, such as Nardil and Parnate. Sometimes, in refractory cases, and with care, they were used in combination, with occasional effectiveness in otherwise refractory depressions.
More recently came the SSRI’s, which had an even greater therapeutic ratio, a higher incidence of improvement in symptomatology and a lower incidence of untoward side effects. Still, the anti-depressants sometimes induced weight gain and loss or reduced sexual desire and performance, which became another source of psychological depression. Presently psychiatrists have available to them a large spectrum of psychotropic medications, actually a huge pharmacopeia, and it is common practice to use trial-and-error, much like the shoe salesman, to see what fits the client or ‘consumer’. (Somehow, in many circles it has become more politically-correct to refer to patients as clients, much to the detriment of the therapeutic and traditional doctor-patient relationship.)
A NEED FOR INTEGRATION AND SYNTHESIS
For those psychiatrists on either end of the spectrum of ‘biologic’ and ‘psychologic,’ I would propose a great degree of integration of these two, fundamentally valid positions. Our knowledge of psychoanalysis and the unconscious, of the importance of early development, defense mechanisms, character structure, transference and resistance, tells us that psychotherapy is of invaluable importance and should never be disregarded. But our knowledge of genetics and neurochemical imbalance also tells us that without some cohesion of the personality or control of wildly swinging and extreme moods, insight psychotherapy is impossible.
THE LIMITATIONS OF PSYCHOANALYSIS
The Osheroff case at Chestnut Lodge revealed the shortcomings of psychoanalysis in the treatment of Major Depression, which used to be called Involutional Melancholia and ‘endogenous’ depression. Osheroff was treated with psychoanalysis in an inpatient setting for six months with no improvement, and soon thereafter he was given Prozac and had prompt amelioration of his condition. Another embarrassment for psychoanalysis was the treatment of George Gershwin for headaches. The composer did not benefit by an attempted analysis of his supposedly psychosomatic condition, and eventually died of a brain tumor.
THE LIMITATIONS OF POLYPHARMACY
Most psychiatric clinicians have observed and experienced longterm cases that have deteriorated and regressed over time if both the psychotherapy and psychopharmacology have been minimal and/or inadequate. With regression over time without some symptomatic benefit, the positive transference turns negative, hope and trust are lost, disillusionment and despair set in and there is no establishment of a working alliance. This condition prevails when the patient is not seen often enough and/or drug doses are minimal and inadequate. Usually patients need to be seen more often than once a week with talk that is deeper than just symptoms. And medication has to be increased to effective levels short of toxicity.
THE BENEFITS OF PSYCHOANALYSIS
For many years psychoanalysis or psychoanalytically-oriented psychotherapy was used with chronic schizophrenics and manic-depressives, which were thought to be psychogenic conditions. We all remember the concepts of ‘double-bind,’ ‘schizophrenigenic,’ ‘primary narcissism and ‘oral fixation,’ but for the most part these theories have not passed the test of time. And yet at the time they were strongly advocated by their adherents, who were largely pedantic and spoke with great authority and conviction. With due respect they meant well, but the basic psychotherapeutic ingredients, according to Jerome Frank and Heinz Kohut were longterm personal involvement, rapport, a caring, supportive and optimistic attitude, and empathy.
PERSONAL EXPERIENCE (LONGTERM CASES)
My own experience in the past 42 years started with inheriting an infamous ‘case’ of a young woman who was uncontrollably self-mutilatory and suicidal. She was involuntarily committed, and as a first year resident I used the theory and technique of Harry Stack Sullivan and Frieda Fromm-Reichmann. I did this for two solid years and eventually the consensus was chronic undifferenitated schizophrenia, but in retrospect I think she was ‘schizo-affective,’ in which the final common pathways of both schizophrenia and manic-depression came together, and there were aspects of not only a thought-disorder, but wildly swinging emotions and impulsive, dramatic and dangerous behaviors.
To make a long story short, she was involuntarily committed to state hospitals for five years after two years intensive psychoanalytically-oriented therapy with me. During this time phenothiazines and anti-depressives were necessary for her to be sufficiently comfortable and stable to sit down and talk with me for 50 minutes at a time, during which time I was able to generate a working alliance and a positive transference. The patient was extremely intelligent and a talented poet and communicated a lot via poetry, art and music. According to Federn, I had found ‘an island of intact ego’ and had worked to enlarge it.
I had read Freud to the effect that it was impossible to establish a transference relationship with a schizophrenic because of their primary narcissism, but the relationship I developed flew in the face of this conviction. I could see that Sullivan, Fromm-Reichmann and others had much to say beyond Freud about psychotherapy with psychotics. My proof was that five years after the termination of my therapy with her, when she was finally discharged from the state hospital, she called me up saying she needed to talk.
After another ten years of outpatient psychotherapy, during which time she continued to have psychotic episodes and periods of serious self-cutting, she eventually improved to the point where she obtained a master’s degree in human development, which included a stressful experiential group, became a social worker, worked effectively, kept her job, was self-sufficient and developed a social life and enjoyed cultural events.
The psychotherapy was extremely eclectic, but psychoanalytically-based, which included group psychotherapy, bioenergetic analysis, regression therapy (reparenting), music therapy and still utilizing poetry and artistic expression. At no time could she function without stabilizing medication, which she has accepted as a lifelong necessity.
In contrast, my next major psychotherapy case started in my second year of residency lasted on and off over twenty years, also with dramatic improvement over time. In this case, the young woman had neurotic and characterologic problems and never needed any psychotropic medication. She was seriously damaged in her early development, but at her core was a solid ego with a structure that never disorganized. Although she suffered severe depressions and was sometimes suicidally inclined, they were always related to interpersonal problems and were amenable to interpretations. As time went on, despite many doubts and negative feelings in the transference, her positive transference grew and the working alliance solidified.
The above two cases both required decades of psychotherapy, but one required medication and the other did not. It is important for the clinician to make a distinction between those patients who have a true neurochemical imbalance and those who do not. It is a mistake to deny medication to those who need it, and to give medication to those who do not. Sometimes it is difficult to make the distinction, and sometimes a trial of medication and/or psychotherapy is indicated, but usually over a relatively short time, it becomes clear whether medication is a help or a hindrance.
PERSONAL EXPERIENCE (SHORTER TERM CASES)
When I first heard about Peter Kramer’s “Talking to Prozac,” I didn’t like what he was saying and I didn’t believe it. I had been indoctinated with the credo that personality change could only come about with traditional (couch) psychoanalysis. However, my own clinical experience proved that he was right. I had a middle-aged male attorney who was functionally successful but miserable because of incessant marital conflicts. He developed the realization that he was the cause of most of it, his wife being reasonable, stable, kind and empathic, despite endless provocations by my patient. Psychotherapy with him was not making any headway, and I felt confronted with inordinate characterologic resistance. The man was chronically angry and irritable. In desperation, he suggested we try Prozac, because he heard that sometimes it was very effective. At the time I was dubious, but it was worth a try.
One week after taking 20 mg a day, he felt amazingly calm. He no longer felt angry or irritated. He had a dramatic sense of relief from a lifelong condition. He thought his angry and irritable state was caused by external circumstances, but now the same circumstances did not bother him. I wondered if he might have an unusual strong placebo response, but his calm state remained and he began to enjoy life, including all the little things like smelling the roses. His wife and the rest of his family were extremely gratified. I was convinced that Prozac was responsible for this dramatic change. This experience correlated with many similar reports by word of mouth and in the growing literature.
Interestingly, he referred his mother, who he said was also always angry and irritable, a known grouch. She was 70 and refused to be retired from her job of 30 years because she reached retirement age. Her job was her whole life and she had no friends because she was so negative and angry. She was retained on the job because she threatened a suit for age discrimination. She was good at her work, but alienated everyone around her with her constant complaining, blaming and criticism. She resisted her son’s admonitions to come and see me to try some Prozac, calling it nonsense, and saying she was satisfied with herself as she was. She could not imagine being any other way. Over time her son reminded her that she was always dissatisfied and had no friends, leading a lonely life, and being a thoughtful person, gradually accepted the idea of seeing a shrink and trying out this miracle drug.
Sure enough, in a week she responded like her son, probably having genetically a similar neurochemical imbalance, and learned to get used to the feeling of not being irritable or angry. In time she got lots of positive feedback at work, which she enjoyed, and she started to redevelop a few old friendships, especially one in which her friend had Alzheimer’s disease, and she assumed the burden of being an attentive caretaker. Her son was delighted with the change in his mother, and they developed a closer and more enjoyable relationship. She came back religiously for renewals to her prescription.
This was indeed personality change, and there were no significant explorations into the unconscious or early development, no significant transference was developed, and there was no great resistance to the use of medication.
In following years, there were some patients with whom I had tried an SSRI, without benefit, but in others, there were similar dramatic changes.
One was with a bright young CFO of a major corporation, married with two young children, who was a workaholic and distant from his wife and children, depressed and worried about his job. His boss was an irrational tyrant, but the patient put up with him, even though he was highly employable, because he wanted a resumé that showed some longterm employability. What brought him to my office was a seemingly trivial incident in which he caught the gaze of a newly hired African-American secretary, and could not remember her name. After that he obsessed about being accused of sexual harrassment, of contributing to a hostile work environment, and being prejudiced against blacks because he couldn’t remember her name. Although cognitively he reasoned that his concerns were irrational and overblown, he could not get his mind off them, and his worry escalated. He could not stop thinking about it and it was driving him crazy. He could not afford to break down or act inappropriately. He saw my article in the local newspaper about the incidence of untreated and unrecognized depression, so he made an appointment. By this time I was a lot more experienced about making the diagnosis of Major Depression, so after taking a complete history, which included a strong family history of manic-depression, I put him on Prozac and he responded dramatically in one week, with further improvement as time went by.
More recently another young married man with four children came in complaining of obsessive thinking. The history revealed that he had been previously verbally abusive and had attended classes on anger control. He was a victim of ‘road rage,’ erupting violently within when somebody changing lanes cut in in front of him. He knew his reactions were excessive and he tried every which way to control them by will power, but he was not successful. There was a problem at work in which he could have been held accountable and responsible, which might cost his employer a lot of money, depending on how the pending litigation would be resolved, but it was clear from the description that the situation was complex, with many variables, and it was not likely that he would be singled out or fired. Nevertheless this eventuality frightened him, even though he knew he could get another job pretty easily.
He also had a strong family history of bipolar disorder, and he actually had a teenage daughter with depression who was stabilized for two years with a large dose of Prozac. So of course I prescribed Prozac and he rapidly experienced dramatic relief. In fact he said he never felt so good in his life, and didn’t think it was possible that he would be without obsessive thoughts or catastrophizing worries. He had previously thought that’s just the way he was and that the world as it is, with problems, challenges and disappointments, would always make him irritable and angry. He is now facing his pending deposition calmly and assuredly, knowing he is in good shape and not likely to be blamed or fired.
A more complicated case, showing the value of continued experimentation was the case of a 40 year old chronically depressed woman I treated with psychotherapy for eight years. She felt she was being picked on at work, and responded in a way to invite criticism. She couldn’t stand it, but didn’t want to quit her job, which had great promise for her if she could only persist and handle her paperwork in a timely manner. In her depression she had trouble concentrating and procrastinated a lot as she approached her accumulating pile with feelings of dread. It seemed her depression was related to a chaotic and traumatic childhood, and interpretations seemed to help, but the work problems continued to mount and became repetitive.
A complicating factor was a serious on-and-off relationship with a respected and admired colleague at work, a divorced man who kept her at a distance. There were numerous reconciliations and devastating rejections, until she decided she had no choice but to give up having the man of her dreams. As time went on it became clear that intensifications of their intimate relationship were associated with heavy drinking, and in addition she was a chain-smoker. She was obviously self-medicating with alcohol, nicotine and caffeine. We could see that psychotherapy alone was not helping and so she consented to try various anti-depressants. Over a period of years, some medications elicited minimal and temporary improvement, but there were side effects and none were longlasting. Finally, in desperation, she asked wasn’t there another medication she could try? I reluctantly prescribed Wellbutrin, which had been reported as having a unique mechanism of action, but which contained some dangerous side-effects. She was willing to take the risk, and it turned out that Wellbutrin did the trick! She became calm and her depression and irritability were largely gone. She was able to finally break off the relationship for good, realizing that she had been obsessing about it. And she was able to get her work done, get commendations, raises and promotions. And taking Wellbutrin, for the first time she was able to stop smoking. Interestingly, I found out later that the detail men for Wellbutrin promote it for people who have trouble stopping smoking.
Presently I have a case of a man who is taking 20mg daily of Prozac which was prescribed by a different psychiatrist. He is now in intensive psychotherapy because of marital difficulties and wanting to decide whether he should leave his marriage of 23 years. He had read Kramer’s book, “Listening to Prozac,” as well as his next publication, “Should You Leave?” which explores several examples of similar dilemmas and suggests ways of deciding whether to stay or leave. The book was interesting but of no help, but he says of his taking Prozac, that it puts a solid floor under him. He used to suffer terrible depressions and feelings of utter loneliness and fear, despite years of relatively superficial and supportive therapy by another psychiatrist, who offered him no medication. He sought consultation and another psychiatrist prescribed Prozac, which made him feel a lot better, but there was no psychotherapy. When he came to me he said he didn’t think he could bear the pain of deeper and more intensive psychotherapy, which he was experiencing now, without the Prozac, but that remains to be seen.
However it has been my experience that some patients cannot face reliving the pain of their childhood. In patients with an affective disorder, and others who have not had the benefit of internalizing a consoling good mother, the re-experience of their childhood pain has an intensity we can hardly imagine. In these cases it is impossible to work through early deprivation and trauma without some medication. For some patients, intensive uncovering psychoanalytic therapy is like brain surgery without anesthesia. Usually the psychological ‘anesthesia’ of uncovering is the positive transference, the ‘safe’ environment and the empathic skill of the psychotherapist.
But I have found from the revelations from some patients and the suicide of others, that the average mentally healthy psychiatrist, who has never experienced a thought disorder or the depths of depression, has no idea what he or she is dealing with. I have learned, in such cases, in order to be appropriately empathic, to realize at certain times of hardening resistance to increased openness and vulnerability, that if I think of the worst mental anguish I have ever felt, I must multiply that by an order of 10 or a 100, to understand what they might be feeling, knowing something of their past and their neurochemical imbalance, in which emotions are not automatically moderated or modulated.
A POSSIBLE MECHANISM OF AFFECTIVE DISORDER
We who do not have a neurochemical imbalance, have a functioning reticular activating system, a system that screens out painful stimuli, from within or without. For example this system is dysfunctional in ADD (attention deficit disorder) with extreme distractibility and hyper-reactivity to external stimuli. And there must be internal inhibitory mechanisms which modulate subjective emotional experience in normal persons, which are deficient in affective disorders.
THE MAGNITUDE OF THE PROBLEM AND FINAL RECOMMENDATIONS
The conditions in which there is not sufficient screening of external stimuli, nor sufficient modulation of internal, subjective affective states are many. These include many depressives, subclinical bipolar conditions previously called, ‘cyclothymic,’ borderline states and personalities and alcoholics and other substance abusers. These conditions add up to a large proportion of psychiatric cases, and require neither psychoanalysis nor psychopharmacology, but a combination of dynamic psychotherapy and judicious use of appropriate psychiatric medications. In practice, this combined therapy is most helpful when there is longterm followup by one psychiatrist who is knowledgeable and experienced in both psychodynamic psychotherapy and psychopharmacology.
Clinical Associate Professor
Department of Psychiatry and Behavioral Neuroscience
Wayne State University
School of Medicine
Victor Bloom MD phone: 313.882.8640
1007 Three Mile Drive fax: 313.882.8641
Grosse Pointe MI 48230 email: firstname.lastname@example.org