blog.stevenreidbordmd.comReidbord\'s Reflections

Reidbord’s Reflections thoughts & reflections on psychiatry by Steven P Reidbord MD Palliative psychiatry May 4th, 2024 The application of palliative care to intractable psychiatric disorders has been debated at least since 2010, when a journal article reported that a patient with severe anorexia nervosa died in hospice, after referral there by her psychiatrist. The New York Times published a thought-provoking article earlier this year on the same topic: whether we should ever deem severe, treatment-refractory anorexia incurable and terminal. Are there incurable psychiatric patients? Proponents argue that only hubris and false hope on the part of psychiatrists stand in the way. They say we should treat such patients as our colleagues treat medically incurable patients: with palliation and hospice. This question is vexing enough. But eating disorders are an exception in psychiatry: untreated, they can lead to death from medical causes. Other mental disorders are miserable but not terminal in the same way. Medical aid in dying For this reason, discussions of palliative psychiatry” lead directly to medical aid in dying (MAiD). Although MAiD solely for psychiatric conditions is not legal anywhere in the U.S., laws permitting it exist in Belgium and the Netherlands , and are pending in Canada . Accepting the framework of palliative psychiatry for incurable conditions appears to entail MAiD. However, arguments that advocate for palliative psychiatry are muddled in several ways, and do not in fact lead to that conclusion. Psychiatry is already palliative First, psychiatry is inherently palliative. All somatic psychiatric treatment (medication, ECT, TMS, and so on) treat signs and symptoms of psychiatric disorders, not their root causes. That’s because we don’t know these root causes, nor the mechanisms that connect them to the manifest signs and symptoms we observe. In essence, all such treatments aim to provide symptom relief, comfort, and support — the very definition of palliative care. It makes no sense to speak separately of palliative psychiatry when palliation is virtually the whole field. The only exception is psychotherapy. Psychotherapy aims to treat the root causes of emotional distress. Of course, this can succeed or fail, and in the case of failure we and our patients routinely resort to palliation. This is called supportive psychotherapy. It’s hardly a new concept that needs a new name. Treatment resistance is slippery Second, arguments for palliative psychiatry usually invoke treatment resistance,” or refer to treatment-refractory” disorders. Disorders so named are the putative targets of palliation, since we can’t treat” them. There are biases hidden in such language. Treatment resistance is a concept from biological psychiatry. It means a particular patient fails to improve in the face of somatic treatments that help most other patients. However, as David Mintz argues , adding psychotherapeutic elements to a medication treatment can overcome this kind of treatment resistance. From a psychotherapeutic standpoint, treatment resistance may say more about the treatment than the patient. Psychiatric disorders are not things” Psychiatric disorders sound misleadingly like reified things” we can treat with concrete interventions. In reality, our moods, thoughts, impulses, and actions result from a complex interplay of biology and psychology. Treatment resistance in that light is vague and abstract — not a sound basis for life and death decisions. Again in contrast, psychoanalytic psychotherapy is well-acquainted with treatment resistance. In fact, it’s expected. Not only is resistance not a reason to give up, it can be a signpost to insight and improvement. Personality change can take a long time. I saw a highly defended patient in weekly psychotherapy for several years before she allowed herself to be vulnerable and introspective. In the years before the change I often wondered if we were wasting time and money, if she was treatment refractory.” Now we both see that she isn’t. Conversely, I’ve seen another patient even longer with little to show for it. Is he incurable? There’s no way to know. Being present and bearing witness Third, sensitive psychiatrists (and other mental health professionals) stay with our patients whether they improve or not. The original idea behind palliative care was attending to the patient’stotal pain ,” which includes the physical, emotional, social, and spiritual dimensions of distress. Not listed but equally important is bearing witness to distress, and maintaining a caring therapeutic relationship come what may. Again, we offer palliation in nearly everything we do. MAiD is never inevitable in psychiatry Last but not least, given all of the above, MAiD cannot follow as a logical next step even after long-term hopelessness or failure to improve psychiatrically. Staying present isn’t hubris and it isn’t imparting false hope. If a patient chooses to forgo further treatment, whether somatic or psychotherapeutic, we will honor that choice and remain available. If local laws someday allow, and as a matter of personal conscience, some of us may choose to participate in MAiD. But that will be an individual matter quite separate from incurability, treatment resistance, or comparisons with terminal medical conditions. Tags: MAiD , medical practice , uncertainty | Category: Psychiatry in general, Psychotherapy | One comment Political advocacy and psychotherapy don’t mix December 31st, 2023 Two senses of psychotherapy is political” are often conflated. The first is the notion, popular lately, that psychotherapy either allows or demands political advocacy in the therapy room itself. The other is recognition that political factors influence the nature and practice of psychotherapy. It is a conceptual error to confuse the two, and a clinical error to justify the former by appeal to the latter. Yes, psychotherapy is political (like everything else) Viewing the practice of psychotherapy through a political lens, albeit one lens among many, can be valuable and revealing. Political analysis of this sort can be applied to nearly all human endeavors: war, housing, work, romantic relationships, childrearing, sports, nutrition, medical care, media, etc. There is no reason to imagine psychotherapy is an exception, and indeed it is not. To cite just a few of the most obvious areas where politics intersects with psychotherapy: third-party payment, public and private, and out-of-pocket cost the choice of psychotherapy versus other types of help social stigma, both of mental disorders and their treatments social inequities that lead to despair, anxiety, and anger controversies over what counts as a mental disorder lobbying and other activities of professional organizations allocation of research funds Note that none of these dictate how therapy itself should be conducted, aside from the value of understanding and appreciating what the patient is dealing with. In other words, for empathy. None of these political issues speak to what psychotherapy is, or realistically offers. Even issues such as gender and racial dynamics within psychotherapy itself, while important to be aware of, need not alter the way competent therapy is conducted. One political view that matters However, there’s a different kind of political position that does affect psychotherapy itself. It’s the degree to which one situates pathology in the sufferer, versus in his or her environment. Even Freud grappled with this. His earlyseduction theory ” held that childhood sexual abuse led to neurosis. Yet he was unable to believe such abuse was widespread. Thus, he soon revised his account to say that young children had sexual (or sexual-like) fantasies that led to inner conflict. This revision justified treatment of the individual who harbored the conflictual fantasies. Conversely, some therapists today hold that emotional distress and dysfunction are always...