Psychodynamic minimalism

Edwin Harari (2013) and I agree on many things: that a psychiatrist’s empathy and thoughtful reflection can deepen a patient’s understanding; that psychodynamic knowledge and skills are vital in general psychiatry; and that the currently dominant unexplanatory psychiatric paradigm neglects these issues to the disadvantage of patients and the profession. And even though he accuses me of neglecting ‘the psychodynamic paradigm of grief’’, we also seem to agree that recognising and facilitating the resolution of miscarried mourning is central to good psychiatric practice.

The substantial point of disagreement is over what might be termed my therapeutic minimalism in accepting what Harari regards as a superficial explanation for Zoe’s overdose that ‘ignores the psychodynamic foundations of the narrative frame’.

While he might agree that Zoe and her mother experienced an authentic increase in understanding, he worries that premature closure and a failure to apprehend that ‘a particular behaviour may have many meanings’ will result in a symptomatic recovery based on compliance rather than cure, with the risk of creating a false self. He demands more interest in why Zoe overdosed rather than manifest her distress in some other way; why her mother could not intervene without my help; and what was the narrative of the parental separation. These are legitimate concerns. Although such a catastrophic response to a relationship breakdown in adolescence often indicates some more profound predicament (in this case, paternal abandonment), the case as reported pays insufficient attention to the reality of Zoe’s loss of her boyfriend.

But the challenge for advocates of all psychotherapeutic approaches to suicide attempts is that they must work within the constraints of the emergency department/general hospital. Time is short and adherence to follow-up is poor, so that there may be but a single contact within which to act. Psychodynamic minimalism is a response to these circumstances, but it does not equate to accepting a mediocre compromise because of resource and time pressures or failure to appreciate the richness of the possible fields for exploration; that would simply be bad practice. Psychodynamic minimalism recognises both the limitations and the advantages of the opportunity provided by a crisis to briefly engage with a family.

Arguments that a minimalist approach to ‘leave it at that’ might be desirable include:

1. Optimism about patients’ and families’ capacity to continue to enrich their understanding without professional help, or to seek out help if needed later. Having engaged with the idea of explanation during the brief intervention, they might be expected to continue to create healthier narratives.

2. Lack of confidence in the superiority of long-term over short-term therapy. Harari (2013) correctly notes that patient or parental satisfaction is not the ultimate measure of the success of an intervention, and highlights the importance of considering long-term outcomes (missing from most psychiatric research, especially that related to medication). But we do not know whether Harari’s approach is associated with better long-term outcomes than therapeutic minimalism. We do know that longer-term therapy carries opportunity costs; that is, time spent in this activity is not available for others.

3. Concerns about potential loss of autonomy. Harari (2013) worries that Zoe will ultimately become powerless if the whole range of her psychodynamic issues is not addressed. But prolonging patient status undermines autonomy, and defining her as somebody who needs therapy might exacerbate her sense of powerlessness.

4. Recognition of a point of diminishing returns in pursuing detailed explanations. Some of the therapist’s ideas may be better left unsaid. There is no doubt that anger and aggression played a part in Zoe’s overdose, but little may be gained from saying so, when issues of sadness and loss seemed more relevant to her predicament. Sometimes the family is not yet amenable to reflecting on the particular issue. Sometimes there is no explanation at all (some things are just bad luck) or no explanation that is accessible to patient or therapist. Not knowing is preferable to glib unexplanations (Jureidini, 2012), and watchful tolerance of uncertainty may be better than ‘irritable reaching after fact and reason’ (Keats, 1899).

See Viewpoint by Harari, 2013, 47(7): 605–608