Abstract
I read with interest the article by Berk and Parker and agree that it is important to be aware of both the beneficial and potentially harmful effects of psychotherapy [1].
In this response, I would like to discuss the complexity of the Osheroff case and make some recommendations for psychiatrist psychotherapists.
To begin, when Berk and Parker say that they take it as a ‘given’ that many psychotherapies are efficacious, it is important to remember that there is an evidence base for this ‘given’. For example, meta-analyses of psychotherapies collectively, and of types of psychotherapy individually, yield effect sizes of 0.75–0.85 [2].
Berk and Parker say that for drug-based therapeutic trials, adverse event monitoring is mandatory, while evaluation of psychotherapy has historically weighted the ‘benefit’ side of the equation. It must be remembered, however, that even in fields such as psychoanalysis, which tend to overlook aggregated data in favour of detailed descriptions of the course of individual cases, the literature is certainly not lacking in criticism. Freud's case of Dora is a good example, in that there has been substantial retrospective literature on the way Freud may have overlooked certain sexual abuse, adolescent and countertransference aspects of the case [3].
Berk and Parker describe an opportunity cost of, for example, giving psychotherapy when the patient may have improved faster using medication. In my opinion, this does not mean that psychotherapy should not be provided when it is indicated, just that the psychotherapist involved should also consider other treatment options as alternative or concurrent treatments. A point I would like to make here is that legally the onus may be higher on a psychiatrist than on other health professionals doing psychotherapy, because the psychiatrist is considered to have the training to make a full biopsychosocial assessment. The warnings for the psychiatrist doing psychotherapy are as follows: just because you are skilled in psychotherapy, make sure you make a full biopsychosocial assessment of all patients; and make sure consideration has been given to concurrent use of medication, or other treatment options where appropriate. Indeed, here we have hit upon one of the reasons why it is preferable for psychiatrists to provide psychotherapy to some difficult patients rather than other health professionals: the psychiatrist, presuming he or she has kept up their skills in both general psychiatry and psychotherapy, is in the best position to make ongoing judgments about the relative timing and nature of psychotherapy and medication and their interactions with the current state of the patient.
Berk and Parker mention the Osheroff case, but I think that they present only one side of that complex case. As Stone stated, a brief description of Osheroff may fail to reveal that this renal physician had a long history of relationship difficulties and sought treatment at Chestnut Lodge after the breakdown of his third marriage, at the same time as having serious disagreements with his professional colleagues in his practice [4]. As Stone stated, Osheroff's own autobiographical account of his illness would substantiate many, if not all, of the typical features of narcissistic personality disorder as described by Kern-berg. Osheroff had a long history of psychiatric treatment, including past marital therapy and personal psychotherapy. Before seeking treatment at Chestnut Lodge, Osheroff had seen at least three different psychiatrists, two of whom prescribed antidepressant medication, which was not successful. Stone refers to the likelihood of Osheroff developing a negative transference to his therapist at Chestnut Lodge and the hospital itself and the possibility of his amazing cure on tricyclics and phenothiazines at Silver Hill Foundation as having an element of narcissistic triumph over Chestnut Lodge and his therapist. Osheroff vs Chestnut Lodge ended in a settlement prior to ever going to court. This information about Osheroff, I might add, is all in the public domain.
The point I want to make here is that the Osheroff case, as much as anything else, illustrates how a patient with a personality disorder can seize upon biological psychiatry to try to triumph over their psychotherapist during a period of negative transference. Negative transference is a real phenomenon and if you took the patient's description of their therapist at face value at that time, the view could be damning. Ask them again in a few weeks, or sometimes even in a few hours, and the patient may give an entirely less damning appraisal. With successful psychoanalytic therapy, eventually the patient will begin to disentangle what belongs to them and what belongs to the therapist's shortcomings. Even the highly educated and otherwise rational patient, if they have a lot of anger about a relationship from their past, may re-experience this towards the therapist in a very real way. In my experience, working through a period of intense negative transference can be an opportunity for substantial therapeutic gain.
My advice to the psychiatrist psychotherapist would be: beware the potentially very angry patient like Osheroff; approach any psychotherapy patient with sharp biological and psychotherapeutic skills; and have the courage to keep working with transference.