Associate Professor of Clinical Psychiatry, Tufts Medical School, Boston MA
Dr. Robbins has no relationships with or financial interests in any commercial company pertaining to this educational activity.
Over 30 years of practicing and teaching psychotherapy with a range of patients, I’ve developed an integrated approach that can be individualized and is useful for my patients. Having received training and study in psychodynamic therapy and later cognitive behavioral therapy, as well as pharmacotherapy, I tend to combine these three techniques in what has traditionally been called the biopsychosocial approach (Gabbard G et al., Am J Psychiatry 2001;158:1956-1963).
Here’s how I do it.
The Biopsychosocial Evaluation
My initial visits with patients always last a full hour, and sometimes I need two hour-long visits to develop a good formulation. The formulation and diagnosis are further refined in subsequent visits.
When a patient comes in, I’ll greet them naturally, get some identifying data, and then ask, “What brings you here?” Patients will generally start with their chief complaint, and will describe symptoms that are troubling them, such as depression or anxiety.
I’ll then ask about onset, “When did this first start?” A patient might say, “I’ve had this all my life, but it got bad about three years ago.” There’s often a lot of information in a statement like that. I’m particularly interested in the precipitating event – and there is always a precipitating event – as well as the historical antecedents of the precipitants.
Let's assume the patient says, “I lost my boyfriend three years ago.” That is only the starting point, because 90% of people who report losing their boyfriends do not come into a psychiatrist’s office as a result. So my next task during the evaluation is to look for the developmental arrest in the patient’s early life that makes current events so difficult to cope with. The concept of a developmental arrest is a Freudian one, and while I do not agree with all of the psychoanalytic canon, I continue to find the notion of early conflict incredibly useful in my clinical work with many patients.
In order to search for the developmental issues, I’ll ask some open-ended questions like, “Tell me about your growing up years. What were they like?” Some patients will tend to gloss over this and say, “I had a good family, and there wasn’t much that happened that was out of the ordinary.” While this may be true for some people, these are generally not the ones who end up sitting across from me! So I’ll try to round it out a bit: “Color it in a little for me. What was it like being with your parents? Your siblings? Your home?” Then I sit back and listen for a while. Patients will often tell me something that relates to the precipitating event, for example, “Well, to tell you the truth, my mother was kind of cold to me most of the time.”
Then I’ll ask some more specific, yet open-ended questions, like, “Tell me about how you did in elementary school, and in high school.” I listen carefully to the answers and I’m constantly checking the story to construct my formulation. Am I on the right path? Is everything fitting together? For example, if I hear about a rejecting mother and an angry father, it would be unusual to hear about a great high school experience. If they seem to be skipping over relevant information, I might ask things like, “Did you have friends? Tell me about them.”
If my patient really has little to say about the past, then I may ask about a current relationship – almost all patients can provide detail on this. “What do you do with your boyfriend? Do you talk much? What do you talk about? How’s your physical relationship?” More generally, I’ll ask, “Does anything really bother you about yourself?”
Integrating Cognitive Behavioral Therapy
The psychiatrist and teacher Paul Meyerson once said as an aid to understanding patients: “There are blind spots and there are dumb spots.”
By “blind spots” he meant unconscious conflicts and developmental arrests of which the patient was totally unaware. By “dumb spots” he meant what would be termed “cognitive distortions” in the jargon of CBT. I try to look for both as I do my evaluations.
For example, I might point out to a patient, “Are you aware that you view males as authority figures?” If I felt the cause of this was a cognitive distortion I might help them work out a more reasonable attitude: “Actually, men aren’t necessarily any more authorities than anyone else. It depends on their level of knowledge and expertise.” And then, I’ll encourage them to self-observe: “Watch for the next time you are talking to someone at work, and it clicks in your mind that he is an ‘authority figure.’ Try to look at him in a different way. How can we find a more reasonable and realistic way of responding?" Once the patient agrees on this new way, persistent supervised practice is indicated.
I tend not to use all the jargon and specific techniques of CBT, like “automatic thoughts" and “thought records”; instead, I fold these techniques into my therapeutic practice.
Therapy and Medication Visits
In addition to therapy, I do quite a bit of psychopharmacology treatment, and these sessions are usually about 20 minutes. But even for these patients, I force myself to come up with a coherent formulation at the outset. I want to have some hypothesis about why this patient is stuck and what some of their overall psychological issues are. I also insist that most of my patients be in therapy (except for those with a clear biologically-based disorder), either with myself or someone else. If they say they don’t have time for therapy, I won’t accept them as a patients. In my view, that is analogous to someone coming to a surgeon to have their appendix removed but saying he has only 15 minutes!
During subsequent med visits, which I normally schedule monthly, I’ll start with a casual “How’s it going,” then review meds and side effects, etc. This generally takes about five minutes. Then I’ll ask about their therapy: “How are you doing with therapy? Are you working on your issues? Are you making progress? Are you understanding better what happened originally that made you come in to see a therapist?”
Unfortunately, I find that many patients say they don’t know what they are working on in therapy, saying, for example, “We just talk.” While simply talking can be supportive, I think it’s necessary for all therapy to have a specific focus. Otherwise, patients get in situations in which they are in endless therapy, or, just as bad, endless medication treatment. While this is heresy in some circles, one of my goals with psychopharm patients is to help them get to a point in therapy where they no longer need to take meds, to the extent possible.
Developing a rich, fully psychological and biopsychosocial understanding of a patient is just as crucial as developing a DSM-4 diagnosis. We need to integrate psychodynamic, cognitive, behavioral, and biological approaches in order to bring our patients relief from their symptoms and dysfunctional life patterns quickly.