In this article, I present insights gleaned from over a decade of working in therapy with physicians in the trenches who practice at general hospitals located in an area afflicted by the community and political violence, and recently, by the COVID-19 pandemic. Psychotherapy with these physicians requires an integrative psychotherapeutic approach that heeds their changing needs. Espousing cognitive-existential psychodynamics (CEP), a theory-based psychotherapeutic perspective developed for complex cases, I show how cognitive, existential, and psychodynamic processes strongly converge during the treatment of physicians in the trenches. Such convergence is manifested in issues of mental representations (of death, medicine, and the hospital) and choice/meaning.
BaileyE.RobinsonJ.McGorryP. (2018). Depression and suicide among medical practitioners in Australia. Internal Medicine Journal, 48(3), 254–258. https://doi.org/10.1111/imj.13717
2.
BeckA. T. (1996). Beyond belief: A theory of modes, personality, and psychopathology. In SalkovskisP. M. (Ed.), Frontiers of cognitive therapy (pp. 1–25). Guilford Press.
3.
CamusA. (1965). The myth of Sisyphus, and other essays. H. Hamilton.
4.
CenterC.DavisM.DetreT.FordD. E.HansbroughW.HendinH.LaszloJ.LittsD. A.MannJ.ManskyP. A.MichelsR.MilesS. H.ProujanskyR.ReynoldsC. F.3rdSilvermanM. M. (2003). Confronting depression and suicide in physicians: A consensus statement. Journal of the American Medical Association, 289(23), 3161–3166. http://doi.org/10.1001/jama.289.23.3161
5.
CooperD. E. (1999). Existentialism: A reconstruction (2nd ed.). Wiley-Blackwell. https://philarchive.org/go.pl?id=COOEAR-4&proxyId=&u=http%3A%2F%2Fdx.doi.org%2F10.2307%2F2220043
6.
DanhauerS. C.FilesK.FreischlagJ. A. (2020). Physician suicide: Reflections on relevance and resilience. JAMA Surgery, 155(8), 721–722. https://doi.org/10.1001/jamasurg.2020.1345
FordE. W. (2019). Stress, burnout, and moral injury: The state of the healthcare workforce. Journal of Healthcare Management, 64(3), 125–127. https://doi.org/10.1097/JHM-D-19-00058
9.
GreenbergJ. R.MitchellS. A. (1983). Object relations in psychoanalytic theory. Harvard University Press.
10.
GreenbergN.DochertyM.GnanapragasamS.WessleyS. (2020). Managing mental health challenges faced by healthcare workers during COVID-19 pandemic. British Medical Journal, 368, Article m1211. https://doi.org/10.1136/bmj.m1211
11.
HorneyK. (1937). The neurotic personality of our time. W.W. Norton.
12.
HorowitzM. J. (1998). Cognitive psychodynamics: From conflict to character. Wiley.
13.
HorowitzM. J. (2014). Identity and the new psychoanalytic explorations of self-organization. Routledge.
14.
HoshmandL. T. (2005). Culture, psychotherapy, and counseling. SAGE.
15.
IsraeliH.ItamarS.ShaharG. (2018). The heroic self under stress: Prospective effects on anxious mood in Israeli adults exposed to missile attacks. Journal of Research in Personality, 75, 17–25.
16.
JackD. C. (1991). Silencing the self: Women and depression. Harvard University Press.
17.
KernbergO. F. (1984). Severe personality disorders: Psychotherapeutic strategies. Yale University Press.
18.
KleinM. (1928). Early stages of the Oedipus conflict. International Journal of Psychoanalysis, 9, 167–180.
19.
KoenigH. G.AmesD.NashW.BüssingA. (2019). Editorial: Screening for and treatment of moral injury in veterans/active duty military with PTSD. Frontiers of Psychiatry, 10, Article 596.
20.
KokN.HoedemaekersA.van der HoevenH.ZegersM.GurpJ. V. (2020). Recognizing and supporting morally injured ICU professionals during the COVID-19 pandemic. Intensive Care Medicine, 46(8), 1653–1654. https://doi.org/10.1007/s00134-020-06121-3
21.
KopaczM. S.AmesD.KoenigH. G. (2019). It’s time to talk about physician burnout and moral injury. Lancet Psychiatry, 6(11), Article e28. https://doi.org/10.1016/S2215-0366(19)30385-2
22.
KroenkeK.SpitzerR. L.WilliamsJ. B.LöweB. (2009). An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics, 50(6), 613–621. https://doi.org/10.1176/appi.psy.50.6.613
23.
LawrenceL. M.BishopA.CurranJ. (2019). Integrated knowledge translation with public health policy makers: A scoping review. Healthcare Policy, 14(3), 55–77. https://doi.org/10.12927/hcpol.2019.25792
24.
McFarlandD. C.HlubockyF.RibaM. (2019). Update on addressing mental health and burnout in physicians: What is the role of psychiatry. Current Psychiatry Reports, 21, Article 108. https://doi.org/10.1007/s11920-019-1100-6
25.
MelnykB. M.KellyS. A.StephensJ.DhakalK.McGovernC.TuckerS.HoyingJ.McRaeK.AultS.SpurlockE.BirdS. R. (2020). Interventions to improve mental health, well-being, physical health, and lifestyle behaviors in physicians in nurses: A systematic review. American Journal of Health Promotion, 34(8), 929–941. https://doi.org/10.1177/0890117120920451
26.
MischelW.ShodaY. (1995). A cognitive-affective system theory of personality: Reconceptualizing situations, dispositions, dynamics, and invariance in personality structure. Psychological Review, 102(2), 246–268. https://doi.org/10.1037/0033-295X.102.2.246
27.
MisiołekA.Gil-MonteP. R.MisiołekH. (2017). Prevalence of burnout in Polish anesthesiologists and anesthetist nursing professionals: A comparative non-randomized cross-sectional study. Journal of Health Psychology, 22(4), 465–474. https://doi.org/10.1177/1359105315604377
28.
OgdenT. H. (1993). The matrix of the mind: Object relations and the psychoanalytic dialogue. Jason Aronson.
29.
Peleg-SagyT.ShaharG. (2012). Depression and sexual satisfaction among female medical students: Surprising findings from a pilot study. Psychiatry: Interpersonal & Biological Processes, 75(2), 167–175. https://doi.org/10.1521/psyc.2012.75.2.167
30.
Peleg-SagyT.ShaharG. (2013). The prospective associations between depression and sexual satisfaction among female medical students. Journal of Sexual Medicine, 10, 1737–1743. https://doi.org/10.1111/jsm.12176
31.
Peleg-SagyT.ShaharG. (2015). Depression, sexual satisfaction, and dyadic adjustment in female medical students: The centrality of self-related processes. Self & Identity, 14(4), 420–440.
32.
Pereira-LimaK.LoureiroS. R. (2015). Burnout, anxiety, depression, and social skills in medical residents. Psychology, Health & Medicine, 20(3), 353–362. https://doi.org/10.1080/13548506.2014.936889
33.
PootC. C.van der KleijR. M.BrakemaE. A.VermondD.WilliamsS.CraggL.van den BroekJ. M.ChavannesN. H. (2018). From research to evidence-informed decision making: A systematic approach. Journal of Public Health, 40(suppl_1), i3–i12. https://doi.org/10.1093/pubmed/fdx153
34.
RadloffL. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. https://doi.org/10.1177/014662167700100306
35.
RandA. (1969). The romantic manifesto: A philosophy of literature. World Pub. & Co.
36.
RuudN.LøvsethL. T.RoK. I.TyssenR. (2020). Comparing mental distress and help-seeking behavior among first-year medical students in Norway: Results of two cross-sectional surveys 20 years apart. BMJ Open, 10, Article e036968. https://doi.org/10.1136/bmjopen-2020-036968
37.
SchwenkT. L. (2020). What does it mean to be a physician?Journal of the American Medical Association, 323(11), 1037–1038. https://doi.org/10.1001/jama.2020.0146
38.
SeligmanM. E. P.RailtonP.BaumeisterR. F.SripadaC. (2013). Navigating into the future or driven by the past. Perspectives in Psychological Science, 8, 119–141. https://doi.org/10.1177/1745691612474317
39.
ShaharG. (2013). An integrative psychotherapist’s account of his focus when treating self-critical patients. Psychotherapy, 50(3), 322–325. https://doi.org/10.1037/a0032033
40.
ShaharG. (2015a). Erosion: The psychopathology of self-criticism. Oxford University Press.
ShaharG. (2016). Criticism in the self, brain, social relations and social structure: Implications to psychodynamic psychiatry. Psychodynamic Psychiatry, 44(3), 395–421. https://doi.org/10.1521/pdps.2016.44.3.395
43.
ShaharG. (2018). The (suicidal-) depressive position. A novel, scientifically- informed reformulation. Psychodynamic Psychiatry, 46(2), 265–293. https://doi.org/10.1521/pdps.2018.46.2.265
44.
ShaharG. (2019). The nature of the beast: Commentary on “Can there be a recovery-oriented diagnostic practice?”Journal of Humanistic Psychology, 59, 346–355. https://doi.org/10.1177/0022167818777653
45.
ShaharG. (2021). Reformulated Object Relations Theory (RORT): A bridge between clinical psychoanalysis, psychotherapy integration, and the understanding and treatment of suicidal depression. Frontiers in Psychology, 12, 721746. https://doi.org/10.3389/fpsyg.2021.721746.
46.
ShaharG.DavidsonL. (2009). Participation-engagement: A philosophically-based heuristic for prioritizing interventions in the treatment of comorbid, complex, and chronic psychiatric conditions. Psychiatry: Interpersonal and Biological Processes, 72, 154–176. https://doi.org/10.1521/psyc.2009.72.2.154
47.
ShaharG.Elad-StrengerJ.HenrichC. C. (2012). Risky resilience and resilient risk: The key role of intentionality in an emerging dialectics. Journal of Social and Clinical Psychology, 31(6), 618–640. https://doi.org/10.1521/jscp.2012.31.6.618
48.
ShaharG.GovrinA. (2017). Psychodynamizing and existentializing active techniques: A focus on behavioral activation. Psychotherapy, 54(3), 267–272. https://doi.org/10.1037/pst0000115
49.
ShaharG.PorcerelliJ. H. (2006). The action formulation (TAF): A heuristic for clinical case formulation. Journal of Clinical Psychology, 29, 1115–1127. https://doi.org/10.1002/jclp.20291
50.
ShaharG.SchillerM. (2016). Treating the depressive self: A psychodynamic-integrative approach. In KyriosK.BharS.DoronG.MikulincerM.RouldingR.NedeljkovicM. (Eds.), The self in understanding and treating psychological disorders (pp. 29–39). Cambridge University Press.
51.
ShaharG.Ziv-BeimanS. (2020). Using termination as an intervention (UTAI): A view from an integrative, cognitive-existential psychodynamics perspective. Psychotherapy, 57(4), 515–520. https://doi.org/10.1037/pst0000337
52.
SimonsM.RapportF.ZurynskiY.CullisJ.DavidsonA. (2020). What are the links between evidence-based medicine and shared decision-making in training programs for junior doctors? A scoping review protocol. BMJ Open, 10, Article e037225. https://doi.org/10.1136/bmjopen-2020-037225
53.
StovallM.HansenL.RynM. V. (2020). A critical review: Moral injury in nurses in the aftermath of a patient safety incident. Journal of Nursing Scholarship, 52(3), 320–328. https://doi.org/10.1111/jnu.12551
TyssenR.RøvikJ. O.VaglumP.GrønvoldN. T.Ekebergø. (2004). Help-seeking for mental health problems among young physicians: Is it the most ill that seek help?Social Psychiatry and Psychiatric Epidemiology, 39, 989–993. https://doi.org/10.1007/s00127-004-0831-8
56.
WachtelP. L. (1977). Psychoanalysis and behavior therapy: Toward an integration. Basic Books.
57.
WachtelP. L. (2014). Cyclical psychodynamics and the contextual self: The inner world, the intimate world, and the world of culture and society. Routledge.
58.
YalomI. D. (1980). Existential psychotherapy. Guilford Press.
59.
Ziv-BeimanS.ShaharG. (2016). Therapeutic self-disclosure in integrative psychotherapy: When is it a clinical error?Psychotherapy, 53(3), 273–277. https://doi.org/10.1037/pst0000077
