Dr. Esplen is a scientist at the National Cancer Institute of Canada. She is also head of the Program of Psychosocial and Psychotherapy Research in Cancer Genetics in the Department of Psychiatry at Mount Sinai Hospital in Toronto, Canada, and assistant professor in the Departments of Psychiatry and Nursing at the University of Toronto.

Dr. Hunter is head of the Psychosomatics Program in the Department of Psychiatry and director of psychosocial oncology in the Marvelle Koffler Breast Centre, both at Mount Sinai Hospital.

Acknowledgments: The authors wish to thank to Ms. Kate Butler, the project coordinator of this study and all the women who participated in the study groups. This work was supported by Canadian Breast Cancer Research Initiative grant #9684 and by a career scientist award from the National Cancer Institute of Canada granted to Dr. Esplen.


 

Abstract

The literature suggests that women with a family history of breast cancer have high perceptions of their personal risk for breast cancer, which can often promote emotional distress such as anxiety, depression, and grief.

Objective: This paper reports on loss and grief in  31 women who participated in a study of a supportive-expressive group intervention for women with a family history of breast cancer (at least one first-degree relative with breast cancer). The literature on grief is reviewed.

Method: The women participated in a pilot study of a 12-session, 6-month supportive-expressive group intervention designed for this population. Pre- and post-group psychological measures were given, including a standardized measure of grief.

Results: The amount of loss that these women had experienced was significant: 30 out of 31 women described losing a loved one, this loss was due to breast cancer in 21 cases. In 19 cases the loss was of a mother. A baseline measure of grief prior to the group intervention demonstrated an intensity and pattern congruent with unresolved or acute grief. There was a statistically significant reduction in grief from pre- to post-intervention.

Conclusions: The findings described in this paper support the theoretical and clinical observations reported in the literature on loss and grief in women with a family history of breast cancer and have relevance for future interventions for this population of women.

 

Introduction

Breast cancer has an impact on the whole family. The descriptions in the literature of first-degree relatives of women with breast cancer1-7 indicate increased levels of perceived risk for breast cancer, anxiety, depression, and grief. High levels of intrusion and distress have been found to impede counseling interventions geared toward improving accurate risk perceptions for breast cancer,3-5 which may be associated with both lack of compliance with screening recommendations such as mammography or with excessive breast self-examination (BSE) or other screening activities.4

During the risk counseling process a woman observes patterns in her family through the presentation of a genogram, which includes the number of diagnoses, the closeness of the diagnosed relatives to herself, and the number of deaths due to cancer in her family.8 A woman receives an “estimate” of her personal risk of breast cancer based on family history and, in some cases where patterns indicate a possible genetic mutation of BRCA1 or BRCA2, may be offered genetic testing.8

It is often the case that a woman feels very aware of her own risk for breast cancer due to her experience of close family members dealing with the disease. Many women in this circumstance have lost family members to cancer and participated in caring for the female relative with breast cancer. Such events can result in the loss of normal childhood or adolescent experiences.1,2 Furthermore, the literature suggests that the risk counseling process generates an additional sense of loss, underlining an “impaired invulnerability” as women observe and contemplate their own family history. This may be experienced as a loss of confidence around their present and future health.6,9,10

This paper reviews the relevant literature on grief, presents a clinical example relating the impact of loss and grief for women with a family history of breast cancer, and reports on the quantitative grief data from a study9,10 investigating the impact of a group support intervention.

 

Literature Review

Although there is little empirical evidence for grief amongst women with a family history of breast cancer, some studies have looked at the broader psychological impact on women who have experienced breast cancer in their families. Wellisch and colleagues1,2,11 studied daughters of women diagnosed with breast cancer and found that daughters who were adults at the time of their mothers’ diagnoses had the least adjustment problems, those who were children at that time had moderate adjustment problems, and those who were adolescents had the greatest overall general adjustment difficulties. In addition, the subgroup of daughters with deceased mothers had greater adjustment problems. Furthermore, Wellisch and colleagues found that the only independent variable (from a potential pool of fourteen independent predictor variables) that predicted nonresolution of feelings about the mother’s breast cancer was the alteration of long-range life plans due to the mother’s illness.1,2,11 These included such changes as altering school or marriage plans, or not moving because of the mother’s illness.11,12
 

Wellisch and colleagues1,11 have speculated that difficulties associated with the insufficient resolution of the premature loss of a mother at an early life stage contributes to the later problems encountered by women with a family history of breast cancer. Thus the presence of grief as a significant factor seems likely in this population. The long-term consequences of maternal loss are difficult to ascertain because they are contingent on several mediating variables.13 However, multiple ramifications such as additional domestic responsibilities, the temporary psychological loss of the surviving parent, the permanent loss of the family unit, and the potential financial burdens, are possible.2,14 Consequences such as these are reported by women who have experienced the death of their mother from breast cancer, as shown by the case example discussed later in this article.
 

Other historical writings also address the issue of grief and loss. The phenomenon of grief was first described psychologically by Freud,15,16 who referred to the process of reviewing the internal world after bereavement as “the work of mourning,” or “grief work.” This provided an explanation for the phenomenon termed “obsessional review,” a well-documented component of grief.17,18 Others19,20 have since introduced the notion of grief work being in “stages.”
 

There are many descriptions of abnormal grief classified by terms such as “delayed,” “chronic,” “pathological,” and “morbid.”21-27 Grief has been described as being normal, exaggerated, abbreviated, inhibited, and anticipatory,21,22 and time-limited,28-30 or as a dynamic process “changing over time.”31
 

Individuals can experience aspects of grief and feel as if they have resolved certain issues, such as anger or guilt, only to have them resurface at a later point in time.31,32 Grief is also pervasive in that it can affect every aspect (physical, emotional, spiritual, and social) of the lives of people who experience significant loss.25 For example, characteristics of bereavement such as fatigue, loneliness, anxiety, somatization, guilt, anger, denial, social desirability, and depression have all been investigated in the literature.25-27 Both the “resurfacing” aspect of grief, and its pervasiveness, are pertinent to the experience of women with a family history of breast cancer, who are continually exposed to breast cancer-related activities such as the genetic risk counseling process and breast screening examinations.
 

Studies of life events suggest that the most difficult life-change events are those that require people to undertake a major revision of their assumptions about the world. Such events are lasting in their implications rather than transient and take place over a relatively short period of time, leaving little opportunity for preparation.31 These attributes are also frequently relevant to the experiences of women with a family history of breast cancer.
 

Lerner and Lerner33 suggest that the impact of loss covaries with the extent to which the psychic structures have been internalized and are autonomous from the sustaining object. Given that the lost object served a function for the person, the loss must be resisted (ie, denied) until the function has been replaced. The person may deny the loss in the hope of completing the developmental process of separation and autonomy with the now introjected object. Similarly, Horowitz and colleagues34 suggested that incomplete early separation from the mother figure rendered a person especially prone to pathological grief. Clearly this suggestion is pertinent to women with a family history who lose a mother to breast cancer at a young age.
 

One theoretical model that has been extremely influential is the attachment model of grief originally developed by Bowlby.28,35,36 Bowlby maintained that when close affectional bonds are threatened, powerful attachment behaviors, such as clinging, crying, and angry protest, are activated. The effective mastery of bereavement involves passing through phases of mourning, which include periods of depression. Eventually, individuals enter the final phase in which they are able to break down their attachment to the lost loved one and start to establish new ties to others and a gradual return of former interests.
 

Bowlby28 suggested that the inability to accept and express anger can lead the bereaved individual to remain preoccupied with thought and action directed at the lost object. Striving for the return of the lost object becomes repressed and unconscious. The unconscious yearning and displacement of anger are both understood as attempts at reunion with the lost object.13 Such preoccupation and anger are characteristic of some women with a family history of breast cancer who have sustained distress and anger.
 

The bereaved woman may also identify with the lost object and her family function. Sometimes social or familial pressures determine this proxy response. For example, following the death of a mother, the oldest female child may assume the caretaking role with the younger siblings—a type of event frequently described by women with a family history of breast cancer.
 

 

Indicators of Pathologic Grief

Indicators of a pathologic grief reaction may be characterized by excessive anger, guilt, self-blame, or depression.31 Changes in behavior may include avoiding reminders of the loss event or avoiding/forbidding references to the death within their family or social network.13,31,37,38 Additionally, when an individual cannot speak of the deceased without experiencing intense and immediate grief, even if many years have passed since the loss, pathological grief should be considered.37,38
 

Risk factors associated with loss and difficulties in adjustment or unresolved grief include the nature of the loss (ie, parental loss versus extended family member or child loss), availability of social support, developmental level of the surviving individual, open permission to mourn, and personality style (eg, being the “strong one” in the family).13,31,38
 

 

Method

The study was designed to develop, describe, and complete pilot testing of a supportive-expressive group therapy for women with a family history of breast cancer. This article reports on pre- and post-intervention results of the grief measure. All women were recruited from two risk-counseling clinics for breast cancer and met the following inclusion criteria: age 18–65 years, having an “inaccurate” personal risk perception for breast cancer that was, on average, double that of the objective risk estimate given in the counseling session, at least one first-degree relative with breast cancer, and fluency in English.
 

Following a description of study procedures, written informed consent was obtained and the women attended a supportive-expressive group intervention. A battery of standardized psychosocial measures, which included a measure of grief, were given pregroup at 8 weeks, at 6 months (postintervention), and at 1 year.
 

 

The Supportive-Expressive Group-Therapy Intervention

The grief literature suggests that factors such as emotional support, protection through the period of helplessness, and assistance in discovering new models of the world appropriate to the emergent situation, are required for successful change around grief processes.31 Supportive-expressive group therapy originated from an existential therapy background39-41 and incorporates many of these features.
 

The intervention consisted of eight weekly sessions (intensive phase), followed by four monthly booster sessions for a total of 12 group sessions (90 minutes each) over 6 months. The group incorporated supportive-expressive principles outlined by Spiegel and colleagues39-41 and was adapted for women with a family history of breast cancer.9,10 Supportive expressive group therapy uses techniques to encourage individuals to directly and openly express their thoughts and feelings in a nonthreatening, nonjudgmental and safe environment. The goals of supportive-expressive group therapy include the facilitation of mutual support, emotional expressiveness, improving family and social support, expanding the repertoire of coping skills, and detoxifying the threat of developing breast cancer.39-41 These components are described in detail elsewhere.9,10,39-41 On two occasions an “expert,” such as a genetics counselor or a medical oncologist, attended the group to answer the questions of the group participants. An active component of the intervention involved having two women included in the group who had been diagnosed with breast cancer at least 1 year ago. This feature of the intervention was planned to facilitate an opportunity for women at risk to explore any fears or questions with those women who had experienced and survived breast cancer.
 

Study Sample

A sample of 31 women with at least one first-degree relative with breast cancer attended the group sessions. Demographics are presented in the Table.

 

Reports of Loss

In addition to the general demographics, information on prior losses was obtained through self-reports and as part of the Texas Revised Inventory of Grief (TRIG). Of the 31 women, 30 reported “losing someone close to them” (97%), 21 (70%) reported having lost a close relative to breast cancer, 19 reported having lost a mother, and two indicated the loss of a sister. Of the total sample, 66% reported that the loss they indicated as the focus to complete the TRIG was a “relationship closer than any or most relationships they have had with other people either before or since.” In addition, 59% of the deaths associated with the reported losses occurred more than 10 years ago. Of those women who lost mothers, the mean age of the mothers at the time of death was 51.7 years of age (standard deviation [SD]=16.2) with a range of 32-–91 years of age. The mean age of the daughters at the time of death of a mother was 25.6 years (SD=14.6), ranging from 9–58 years of age. Thus, in this sample, 65% of the mothers died prior to reaching age 50 years and 71% of the daughters were under 25 years of age at the time of their mothers’ deaths.
 

Instrumentation

To measure grief, the TRIG, a standardized measure of grief with good psychometric properties such as α coefficients of 0.87 and 0.89 for past and present factors, respectively, was utilized.42 The tool is used to measure grief as a “present emotion of longing, as an adjustment to a past life event with several stages, as a medical psychology outcome, and as a personal experience.”42 The TRIG was developed using factor analysis and consists of a two-factor Likert-type measure of grief following bereavement. It is an easily administered self-report assessment and permits evaluation of the extent and nature of an individual’s personal reaction to bereavement. Intensity of individual or group means of grief reactions can be compared to normative means and ranges at each of four time intervals following the loss: within the first year, at 1–5 years, at 5–10 years, and after more than 10 years. In addition, the TRIG contains a set of clinical demographic questions such as, “How close were you to the person who died?”
 

The two grief factors are part I: Past Behavior and part II: Present Feelings. The Past Behavior subscale contains eight items which ask the subject to “think back to the time the person died,” provides content on a variety of life events that might have been disrupted by grief, and summarizes one’s initial adjustment to the death of a loved one. The Present Feelings subscale includes 13 items focusing on current feelings associated with the deceased, such as “I still want to cry when I think about the person who died.”42
 

Analysis

Descriptive statistics were calculated on the demographic variables and for the TRIG. In addition, paired t-tests were completed on the TRIG between pre- and post-intervention time points.
 

Results

The intervention had a significant impact on a battery of measures which included instruments of risk comprehension, psychosocial functioning, breast cancer risk factors knowledge level, and promoted screening adherence. These results are provided in detail in a previous report.9,10
 

The results of the TRIG are presented in the Figure. The “Past Behavior” mean of 22.9 (SD=7.2) at baseline is significantly higher than published norms, indicating considerable grief and significant disruption at the time of the prior loss.42 As one would expect, this subscale did not change over the course of the intervention because the subscale aims to capture the amount of disruption “at the time of the loss.” The “Present Feelings” pre-group mean of 36.3 (SD=11.9) represents a significant amount of grief and is in the upper quarter percentile for norms, (taking into consideration the amount of time since the losses occurred). In addition, the pattern of the two subscales measured before the intervention is congruent with a pattern of unresolved or acute grief.42

 

At 6 months following the complete intervention (intensive and booster phase) there was a statistically significant decrease in the “Present Feelings” mean score (P=.034). In examining the change in grief scores, for those who lost a close relative to breast cancer, the majority, (11 out of 19, SD=57.9%) of the study participants scored an average reduction of 5.7 points (or half an SD) on the Present Feelings subscale, indicating a moderate effect size in reducing the intensity of grief. The following case example will illuminate the clinically significant grief processing that occurred for many women in the program.
 

Case Example

“Ms. B” is in her mid-forties and came to the group expressing marked fear and anger, particularly towards the medical system. She had participated in caring for her mother until she died when Ms. B was 19 years of age. She became tearful particularly when describing her mother’s surgery, suggesting that her mother had been “butchered” and left with “horrible scarring.” She was immensely afraid of breast cancer and felt she would not accept chemotherapy or radiation treatment if she were herself diagnosed with breast cancer. She had chosen not to marry and had not had children. She was driven to obtain any information on diet and exercise or genetics that could assist in reducing her sense of risk. She was fearful to even identify a risk level for herself, stating that “it is just a number… and anything can come along and boost the risk up.” She also believed that if she stated what she felt her true risk was, “It may cause breast cancer to happen.” She was interested in genetic testing, but frequently inquired about whether or not there was some psychological test that could indicate whether or not she could handle the news.
 

Ms. B was amazed at the level of grief that she expressed in the group, believing that she had finished grieving more than 20 years ago. In the group she heard stories with themes of anger at the medical profession that echoed her own experience of her mother’s death. In particular, she had fearful images involving surgical procedures and treatments associated with breast cancer; she also suffered intense memories of concerning caring for her very ill mother. The women in the group shared their own losses with Ms. B and she was able over time to express her emotional reactions as well as gain a more accurate and balanced view concerning her own life, medical options, and health behaviors. Through the support, vicarious learning, and modeling in the group, she became able to relate to the loss of her mother in a less intense manner. In particular, she expressed feeling grateful for the closeness and caregiving experience she had experienced through the time of her mother’s illness. She was able to integrate the loss in a fashion that permitted her to separate her mother’s experience from her own.
 

By the end of the group, Ms. B was also able to identify differences in the medical system, such as treatment options and health preventive measures that could allow her to live her life currently with less hypervigilance. She developed the view that even if diagnosed with breast cancer, she could survive. In addition, she also discussed the loss of her mother more openly with her sister—her main link to her family—and developed a greater understanding of their unique and different reactions to their loss, which had been a factor in her experiencing a sense of isolation.
 

 

Discussion

These interesting pilot data add to the theoretical and clinical literature describing women with a family history of breast cancer who have experienced the loss of a significant other. The baseline demographic items suggest that the women who participated in the group intervention had undergone significant loss, particularly in relation to cancer, and in many cases at a young age. The baseline TRIG scores suggest that the losses occurred frequently during childhood or adolescence and indicates that there was considerable disruption and emotional impact during the acute bereavement period. These women experienced the loss of their mothers at a time when they were highly active in family roles. The fact that the mothers were young, on average, at the time of their deaths may have contributed to the sense of injustice and the notion, held by many group participants, that the death was highly premature. The women in this study may be similar to the sample described in Wellisch’s earlier study on daughters of mothers with breast cancer.1,2,11
 

The “Present Feelings” level further supports the hypothesis that women in this population have to contend with significant bereavement as the mean indicates a high level of grief. The elevated “Present Feelings” scores are remarkable, given that the average time since the occurrence of the loss was more than 10 years prior to measurement. The other baseline psychosocial measures (10) indicate that there was also a significant amount of other kinds of distress among these women, which is consistent with previous reports.43 For example, 37% of the women in the study exhibited depression in a clinical range for the CES-D and there were elevated levels of Intrusion and Avoidance as measured by the Impact of Event Scale.9,10
 

The “Present Feelings” mean and average change scores demonstrated a statistically and clinically significant reduction in current grief intensity following completion of the intervention, for the majority of participants. This finding is clinically significant given the magnitude of change and the fact that the grief processing and resolution occurred more than 10 years after the actual loss. It is also in contrast with an earlier report of a 6-week structured group intervention that failed to significantly alter a measure of grief in a similar sample of women.44 The grief experience, specifically when combined with high levels of intrusion or depression, may play a role in the inability of short-term or information-oriented interventions to modify inaccurate risk perceptions as has been noted in the literature.3,10
 

These findings suggest that women who have undergone significant prior losses may require intervention beyond individual risk counseling or a short-term psychoeducational intervention. Optimal interventions should aim to address the expression of grief and the emotions associated with earlier (and in some cases an ongoing) sense of loss.13,37,38 The supportive-expressive group is an ideal intervention in this regard, given its focus on emotional expression over a period of time with therapists skilled in eliciting and managing affect and through the facilitation of mutual support and the examination of existential themes.9,10 The vicarious learning and modeling that occurs throughout the group experience addresses these themes optimally. In fact, the group did “feel,” in many ways, like a bereavement or grief group to the therapists, particularly during the early sessions.
 

In considering the case, Ms. B was seeking risk counseling and the exploration, expression, and resulting discharge of affect that occurred in the group therapy may have permitted her to resolve her loss issues and allow for a more direct examination of information. By the end of the group intervention she was able to more readily integrate and process the complex risk information. She also exhibited more optimal coping in dealing with her breast cancer risk and even demonstrated a sense that she may not develop breast cancer or at least could survive it.
 

Limitations

This pilot study utilized a small sample and self-report measures, and therefore, these findings must be interpreted with caution. In addition, all the women were recruited through risk counseling clinics and this may limit the generalizability of the study. Despite these limitations, the data contribute to the empirical literature of women who have suffered losses to breast cancer and who present at risk clinics. These women may require additional intervention beyond that of standard care in order to address their concerns, modify risk comprehension, and facilitate coping. More definitive conclusions could be drawn from a prospective randomized controlled trial that is currently being conducted by our group.
 

Conclusion

This article reports on grief data from a pilot study of women with a family history of breast cancer, participating in a supportive-expressive group intervention. The sample suffered a significant amount of loss and exhibited high levels of grief, supporting theoretical and clinical observations in the literature. The supportive-expressive intervention appeared to alter the experience of grief, in a direction congruent with the resolution of acute grief. Supportive-expressive group therapy may be particularly relevant for women who have suffered severe loss due to breast cancer. These findings have implications for future descriptive research and intervention studies for women with a family history of breast cancer.   PP
 

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2.    Wellisch DK, Gritz ER, Schain W, Wang HJ, Siau J. Psychological functioning of daughters of breast cancer patients: Part II: characterizing the distressed daughter of the breast cancer patient. Psychosomatics. 1992;33:171-179.
3.    Lerman C, Lustbader E, Rimer B, et al. Effects of individualized breast cancer risk counseling: a randomized trial. J Natl Cancer Inst. 1995;87:286-292.
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7.     Kash KM, Holland JC, Halper MS, et al. Psychological distress and surveillance behaviors of women with a family history of breast cancer. J Natl Cancer Inst. 1992;84:24-30.
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12. Wellisch DK, Hoffman A, Goldman S, Hammerstein J, Klein K, Bell M. Depression and anxiety symptoms in women at high risk for breast cancer: pilot study of a group intervention. Am J Psychiatry. 1999;156:1644-1645.
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Ms. Kohlmann is genetic counselor in the Division of Medical Genetics at the University of Michigan Medical Center in Ann Arbor.

Dr. Peterson is assistant professor in the Department of Behavioral Science at the University of Texas MD Anderson Cancer Center in Houston.

Acknowledgments:The authors report no financial, academic, or other support of this work. 


 

Abstract

Hereditary nonpolyposis colorectal cancer (HNPCC) and familial adenomatous polyposis (FAP) are the most common forms of hereditary colon cancer. Due to the increased cancer risks associated with these conditions, the need for intensive cancer screening and management programs, and disease implications for patients and families, both affected individuals and their family members have unique needs for medical information and psychosocial support. To address their medical and psychosocial needs, genetic counseling should be offered to persons who are concerned about a possible inherited risk for HNPCC or FAP, and who may be considering genetic testing for these conditions. The purpose of this article is to provide an overview of the HNPCC and FAP syndromes and relevant psychosocial issues. The need to address complex medical and psychosocial issues related to these syndromes also will be illustrated through the presentation of two genetic counseling case scenarios.

 

Introduction

Colorectal cancer (CRC) is the third most common form of cancer and the second leading cause of cancer-related deaths in the United States.1 Approximately 20% of CRC cases occur in individuals who have a family history of the disease. Hereditary nonpolyposis colorectal cancer (HNPCC) and familial adenomatous polyposis (FAP) are the two most common forms of hereditary colon cancer as well as the most studied. Both conditions are associated with an increased lifetime risk for CRC and other cancers. At-risk individuals are advised to follow rigorous cancer screening and management regimens because of the increased likelihood that they may develop polyps or colon cancer at a younger age than the general population. Lack of information and poor adjustment to an HNPCC or FAP diagnosis may interfere with adherence to management recommendations and limit communication about these conditions amongst other at-risk family members.

It is important for healthcare providers in primary care settings to have an understanding of the medical, social, and psychological implications of hereditary colon cancer syndromes so that they can effectively and responsibly integrate this information into their current practice.

This article will provide an overview of HNPCC and FAP as well as psychological and behavioral issues associated with genetic counseling and testing for these hereditary cancer syndromes. Genetic counseling case studies are used to illustrate psychosocial issues experienced by individuals and families at risk for these syndromes, and how such issues may influence adjustment and cancer risk-management decisions.

 

Overview of Hereditary Nonpolyposis Colon Cancer and Familial Polyposis

Two well-characterized hereditary CRC syndromes account for 5% to 10% of all CRC cases: HNPCC, associated with germline mutations in mismatch repair genes (hMSH1, hMLH2, hMSH6, PMS1, PMS2) and FAP, caused by germline mutations in the APC gene.2 An inherited mutation in one of these genes is suspected in a family when CRC (or other syndrome-related cancers) is present in successive generations and at earlier ages compared with the general population, and when individuals have more than one primary cancer associated with these syndromes. Children of mutation carriers have a 50% chance of inheriting the mutation themselves, and both genders can inherit these conditions equally. A distinct feature of FAP is the development of multiple colorectal polyps, often beginning in puberty, and the disease can be diagnosed clinically on this basis.

HNPCC confers a 70% to 80% lifetime risk for developing colon cancer, with an average onset at 44 years of age.3-6 Women with HNPCC have a 40% to 60% lifetime risk for endometrial cancer and a 6% to 13% risk for ovarian cancer.7-10 HNPCC is also associated with an increased risk for biliary tract, small bowel, upper urinary tract, and gastric cancers.9,10

If polyps are not removed in persons with FAP, the lifetime risk of colon cancer approaches 100%, with an average onset of 42 years of age. FAP also is associated with benign features outside of the digestive system including epidermal cysts, osteomas, congenital hypertrophy of retinal pigmented epithelium (CHRPE), dental abnormalities, and desmoid tumors. FAP also confers an increased risk for upper gastrointestinal cancers, hepatoblastoma, brain tumors, and thyroid cancers. Some families have a milder expression of FAP with few polyps and later age of onset.11,12 Although this attenuated form of FAP is associated with increased cancer risks, its diagnosis may be missed due to the lack of classic presentation. It has been reported that 22% of FAP cases have no family history of the disease and result from a spontaneous APC gene mutation.13

When genetic testing is offered to a group of persons with family histories suggestive of HNPCC or FAP, it is optimal to begin testing in a person who has been diagnosed with a syndrome-associated cancer or who has a clinical diagnosis of FAP. Doing so increases the likelihood of finding a disease-predisposing mutation if one is present in the family. If a mutation is found in the index case, then genetic testing for the presence of this specific mutation can be offered to other at-risk family members. It is possible that a known deleterious mutation may not be detected in an index case with a family history suggestive of HNPCC, or in an index case with multiple polyps characteristic of FAP, because of limitations in current technology. When this occurs, families are still considered to be at high risk for a hereditary CRC syndrome and are recommended to follow high-risk screening and prevention recommendations. A negative test result is considered conclusive only if the deleterious mutation has been previously identified in an affected member.

Genetic testing for hereditary cancers can identify persons who would benefit from increased screening and surveillance because they carry a disease-predisposing mutation. Conversely, genetic testing can identify persons who are not genetically at high risk for developing cancer, and as such are recommended to follow screening guidelines for the general population. Recommended screening and prevention options for HNPCC and FAP are presented in the accompanying table.14-16 Recent evidence indicates that chemopreventive agents may play a role in the management of FAP. However, at this time these medications are not a replacement for screening and prophylactic surgery.17

 

Genetic testing for adult-onset disorders such as HNPCC is discouraged for persons under 18 years of age, because the medical and psychosocial benefits of testing are not realized until adulthood. Ethical concerns about testing children include the inability of minors to give informed consent, as well as the possibilities that children found to be carriers may be stigmatized, may be given fewer opportunities, and may not receive appropriate counseling about their results.18 On the other hand, genetic testing is offered to families with children at risk of FAP, generally beginning at 10 years of age, because surveillance for this condition is warranted at an early age.19

 

Genetic Counseling for Hereditary Colon Cancer

Professional organizations have issued statements to guide the implementation of genetic counseling and testing for hereditary cancers in clinical and research settings to assure that individuals seeking these services receive sufficient information to make an informed decision about testing, screening, and prevention options.20-22 Genetic counseling should be conducted with persons who are concerned about a possible inherited risk for cancer and/or who may be considering cancer genetic testing, because the interpretation of genetic test results is complex.22 A study of persons undergoing commercial genetic testing for FAP found that less than 20% of them were offered genetic counseling prior to testing.23 Only 17% of persons in that study gave written informed consent prior to testing and results were misinterpreted by the physician in 32% of cases.23

The process of genetic counseling is ideally carried out in a manner that combines education about genetic concepts with counseling techniques.24 Genetic counselors gather detailed information about individuals’ personal and family history of cancer in order to accurately assess their inherited cancer risk, and to educate them about options for early detection and prevention, which may include genetic testing. An initial genetic counseling visit may include discussion of the family history, providing information about personal and familial cancer risks, and the option of genetic testing, assessment of the client’s motives, coping strategies, and family strategies.

Although there are potential medical and psychological benefits to defining one’s inherited cancer risk through genetic testing, there also are significant risks and limitations to the process. Genetic counselors generally discuss the option of genetic testing in a nondirective manner, and encourage individuals to make a decision about testing based on the risks and benefits relevant to their personal and family situation. The importance of adhering to age- and risk-appropriate screening guidelines is emphasized to all individuals regardless of their eligibility or decision regarding genetic testing.

If a client decides to pursue genetic testing, results are given during a follow-up genetic counseling session. Clients at risk for hereditary CRC may benefit from ongoing interactions with a genetic counselor to reassess changes in the family history and to stay informed about new early detection and prevention developments. Continued support also may help assure that information about the diagnosis is shared with other at-risk relatives, and can help families cope with medical and psychosocial issues that may develop over time (eg, a new cancer diagnosis in the family, reproductive considerations, screening for children).

 

Psychosocial Impact of Genetic Testing for Hereditary Colon Cancer

Studies that have evaluated interest and participation in hereditary CRC genetic testing have found that individuals are motivated by recommendations from their doctor or genetic counselor, beliefs in the benefits of testing, and a desire to gain information that may reduce uncertainty about their condition, help their children, reduce the need for frequent screening, and facilitate lifestyle or health-habit decisions.25-28 Few studies have evaluated psychological or behavioral outcomes of testing for HNPCC or FAP. Based on validated distress measures, the limited evidence suggests that undergoing genetic counseling and testing for other hereditary cancers does not cause significant psychological morbidity for most individuals.29-32

Notification that one does not carry a hereditary cancer mutation has been associated with a reduction in distress from the pre- to post-test time periods, suggesting that receipt of true negative test results confers a psychological benefit.31,32 However, subgroups of individuals may be at higher risk for experiencing adverse emotional outcomes from testing, and may benefit from increased support. Individuals who have higher levels of distress, lower quality of life and social support, and concerns about their ability to cope with their mutation carrier status prior to testing may be at greatest risk for experiencing distress after disclosure of positive genetic test results.33-35 Carriers of cancer-predisposing mutations reported higher levels of psychological distress compared with noncarriers,31,32,36 and one study37 suggested that mutation carriers who did not expect to receive positive genetic test results experienced higher distress after disclosure. Additional research is needed to evaluate the impact of carrier status notification on psychological adjustment as well as adherence to screening and surveillance recommendations.

Psychological adjustment to the genetic counseling and testing process may be influenced by family members’ experiences as well. A study of children who had undergone FAP genetic testing found that mutation carriers and noncarriers scored within normal ranges on measures of distress and behavioral problems. However, children with an FAP-affected mother were more distressed compared with children of unaffected mothers.38 Persons seem generally willing to share test results with other family members and follow through in doing so,28,39 although cancer patients have expressed concern about having the responsibility of passing on this information to others in their family.39 A limitation of studies to date is that they have focused on outcomes of the genetic counseling and testing process, and have not evaluated the impact of hereditary cancers on persons who have not come forward for counseling and testing. Future research should attempt to close this gap and further assess the impact of hereditary cancer on the family as well as the individual level.

 

Case Studies in Genetic Counseling for Hereditary Colon Cancer

The following cases illustrate psychosocial issues and counseling decisions faced by families with HNPCC and FAP. These cases represent two families who have participated in research studies for HNPCC and FAP. Pedigrees were modified to maintain confidentiality.

 

Case 1

Anna was diagnosed with CRC at age 35 years, and underwent HNPCC genetic counseling and testing as part of a research study. During a genetic counseling session to disclose results indicating that she was a mutation carrier, the genetic counselor began by reviewing the family history (Figure 1). Anna reported that the family had no contact with her sister, Nancy, and that she had “heard through the grapevine” that Nancy had been diagnosed with CRC. This information cued the genetic counselor to further explore issues about family communication during the session. Anna indicated that she planned to share the test results with her brothers and her mother, but not with Nancy. She stated that since Nancy had excluded herself from the family it would be Nancy’s own responsibility to seek out information about her cancer risk.

 

The genetic counselor further explored implications of Anna’s estrangement from her sister by role-playing scenarios focusing on possible outcomes from sharing or not sharing her test results with Nancy. Through this exercise, Anna expressed concern about her at-risk niece, Erica, regardless of her feelings about her relationship with Nancy. Anna stated that knowledge of her own test results could benefit Erica, who was approaching the age when high-risk screening options would be recommended. Although Anna still did not feel comfortable contacting her sister, a plan was developed to have her brother, who still had some contact with Nancy, share the information from genetic testing with her.

This case illustrates the important issue that Anna’s genetic test results also had medical implications for her family. In cases such as this the genetic counselor is faced with the issue of one’s duty to warn other at-risk family members. This matter has been addressed through case law, which has indicated that the clinician does have a duty to inform patients of familial risks.40 However, whether solely warning the patient fulfills this duty or whether and how family members can be notified without breaking patient confidentiality has not been clarified. Thus, genetic counselors and other healthcare providers face challenges regarding their roles and boundaries in disseminating genetic information to at-risk family members.

In families who express communication barriers due to estrangement, distance, or other reasons, simply informing the client about genetic risks for family members may not assure that the information is conveyed. Dissemination of genetic information in families may be limited, even in the absence of identified communication barriers, because of concerns about arousing relatives’ anxiety or other reasons.41 As a result, family members may not convey hereditary cancer risk information in a manner that emphasizes the importance of this information for one’s health or that prompts action among relatives. Any discomfort with communicating genetic information may be magnified when there are other problems with family relationships. Genetic counseling strategies that may facilitate the dissemination of risk information within families include role-playing to increase clients’ comfort in explaining information, providing written information to share with other relatives, identifying relatives who can help communicate the information, and preparing clients to cope with possible reactions from family members.

This case also illustrates the potential risk to Anna’s own emotional well-being if she chooses not to share genetic information with her sister because of their prior conflicts. One goal of genetic counseling is to help clients cope with immediate issues resulting from a genetic diagnosis and to help them anticipate feelings that they may experience in the future as a result of the genetic condition in their family, including the potential impact on future generations.42 Anna was disturbed by the thought of her niece developing cancer. Through genetic counseling, Anna better understood the possible decisional outcomes if she withheld or shared her test results with her sister and identified factors important to that decision.

 

Case 2

Lisa was diagnosed with FAP when she was 18 years of age. She underwent prophylactic colectomy at 25 years of age and subsequently developed a desmoid tumor, which required several additional surgeries and chemotherapy (Figure 2). Lisa requested genetic counseling to discuss the option of genetic testing for her children, and canceled several counseling appointments before she was finally seen. During the session, she appeared very apprehensive about having genetic testing for her daughters when they reached 10 years of age, and the genetic counselor explored reasons for her reluctance. The counselor discussed common concerns expressed by parents with FAP, including feelings of guilt about passing on a genetic condition, worries about the impact of testing on their relationship with their children, and worries about children’s ability to cope with an FAP diagnosis. Lisa acknowledged her fear that an FAP diagnosis might negatively affect her relationship with her daughters. The counselor asked Lisa to describe her feelings toward her mother, Maria, for passing this condition on to her. Lisa indicated that she understood that her mother could not control the path of inheritance. However, she stated that she had blamed Maria for her health problems when she was a child and young adult, and did not think that she could cope with her daughters having similar feelings towards her. Lisa suggested that having more information about the cause of her disease and talking with other teenagers who had FAP may have helped her cope better with her condition. Lisa and the counselor discussed how such strategies could be implemented for her children as they undergo screening and genetic testing.

 

In addition to her worries about her children, it became clear during the session that Lisa was having difficulties coping with her own disease. Her desmoid tumor was not responding well to treatment and Lisa expressed bitterness because she was the only person in the family to have developed this FAP-related complication. She and the counselor discussed reestablishing her relationship with her mother as another source of support as her daughters approached ages when genetic testing is recommended. Through counseling, Lisa identified how her difficulties in coping with her own disease may affect how she would be able to cope with the additional stress of learning her children were positive. This issue was important to explore because the early onset of FAP requires that parents take an active role in their children’s care.

An educational approach in genetic counseling can convey information, but it may not truly facilitate understanding of the personal implications of a genetic diagnosis.21 In addition to educating Lisa about her children’s risk of inheriting an FAP-predisposing mutation, it was important for the genetic counselor to address her feelings of guilt, anger, and fear related to her own experience with this condition as well as the experiences she anticipated for her children. Parents may avoid having their children evaluated at an appropriate age because of an underlying fear that their children might blame them for having passed on a genetic condition. Indeed, Lisa’s worries about her children’s reaction may have been part of the reason she missed several genetic counseling appointments prior to being seen by the counselor.

This case also illustrates the importance of evaluating clients’ personal experiences with genetic conditions as part of the genetic counseling process. Both FAP and HNPCC can exhibit different phenotypes among family members who carry the same disease-predisposing mutation, which in turn may carry different psychosocial implications for those affected. Lisa’s other mutation-positive family members underwent colectomy for FAP and had no further complications, in contrast to her own experience with desmoid tumors and additional treatment. Perception of one’s own disease also may be affected by whether other affected family members survived their cancers or whether they had a caregiver role for an affected family member.

Lisa’s distress regarding her disease and her children was not resolved through genetic counseling alone, and further psychological counseling was recommended. Follow-up genetic counseling visits were recommended to reassess Lisa’s feelings about having her children evaluated, and to establish a medical management plan to assure that her children receive the care they need.

 

Conclusion

Families affected by HNPCC and FAP face a challenging array of medical, psychological, and social issues. It is important for primary healthcare providers to be aware of these issues and to integrate knowledge about hereditary cancer syndromes into their current practice and care of families who may potentially be at risk for HNPCC or FAP. In addition to assuring that at-risk individuals receive appropriate referrals for genetic counseling and medical care related to the management of these conditions, primary care providers also could provide encouragement for adherence to screening recommendations and support for medical decisions that may impact both patients and their families.

This article emphasizes the importance of utilizing genetic counselors and other genetics professionals to educate families about their hereditary CRC risks and risk management options. As illustrated by the cases presented here, it is crucial to address the psychosocial issues that may arise during these discussions to facilitate ability in both individuals and families to effectively cope with and successfully manage their disease. Ongoing support from genetic counselors and other healthcare providers can be instrumental in helping persons adjust to new developments that may affect their own or their family members’ risks.   PP

 

References

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2.    Giardiello F, Brensinger J, Petersen G. AGA technical review on hereditary colorectal cancer and genetic testing. Gastroenterology. 2001;121:198-213.
3.    Ad Hoc Committee on Genetic Counseling. Genetic counseling. Am J Hum Genet. 1975;27:240-242.
4.    Lynch HT, Smyrk TC, Watson P et al. Genetics, natural history, tumor spectrum, and pathology of hereditary nonpolyposis colorectal cancer; an updated review. Gastroenterology. 1993;104:1535-1549.
5.    Scapoli C, Ponz De Leon M, Sassatelli R, et al. Genetic epidemiology of hereditary nonpolyposis colorectal cancer syndromes in Modena, Italy: results of a complex segregation analysis. Ann Hum Genet. 1994;58:275-295.
6.    Vasen H, Wijnen J, Menko FH, et al. Cancer risk in families with hereditary nonpolyposis colorectal cancer diagnosed by mutation analysis. Gastroenterology. 1996;110:1020-1027.
7.    Watson P, Lynch HT. Extracolonic cancer in hereditary nonpolyposis colorectal cancer. Cancer. 1993;71:677-685.
8.    Watson P, Vasen HF, Mecklin JP, Jarvinen H, Lynch HT. The risk of endometrial cancer in hereditary nonpolyposis colorectal cancer. Am J Med. 1994;96:516-520.
9.    Dunlop M, Farrington SM, Carothers AD, et al. Cancer risk associated with genermline DNA mismatch repair gene mutations. Hum Mol Genet. 1997;6:105-110.
10.    Aarnio M, Sankila R, Pukkala E, et al. Cancer risk in mutation carriers of DNA-mismatch-repair genes. Int J Cancer. 1999;81:214-218.
11.    Lynch HT, Smyrk T, Lanspa SJ, et al. Flat adenomas in a colon cancer-prone family. J Natl Cancer Inst. 1988;80:278-282.
12.    Lynch HT, Smyrk T, McGinn T, et al. Attenuated familial adenomatous polyposis (AFAP). A phenotypically and genotypically distinctive variant of FAP. Cancer. 1995;76:2427-2433.
13.    Rustin RB, Jagelman DG, McGannon E, et al. Spontaneous mutations in familial adenomatous polyposis. Dis Colon Rectum. 1990;33:52-55.
14.    Burke W, Petersen G, Lynch P, et al. Recommendations for follow-up care of individuals with an inherited predisposition to cancer. I. Hereditary nonpolyposis colon cancer. JAMA. 1997;19:915-919.
15.    Terdiman JP, Conrad PG, Sleisenger MH. Genetic testing in hereditary colorectal cancer: indications and procedures. Am J Gastroenterol. 1999;94:2344-2356.
16.    Rex DK. Johnson DA. Lieberman DA. Burt RW. Sonnenberg A. Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology. Am J Gastroenterol. 2000;95:868-877.
17.    Steinbach G, Lynch PM, Phillips RK, et al. The effect of celecoxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis. New Engl J Med. 2000;342:1946-1952.
18.    American Society of Human Genetics Board of Director, American College of Medical Genetics Board of Directors. Points to consider: ethical, legal, and psychosocial implications of genetic testing in children and adolescents. Am J Hum Genet. 1995;57:1233-1241.
19.    Peters JA, Stopfer JE. Role of the genetic counselor in familial cancer. Oncology (Huntingt).1996;10:159-166.
20.    American Society of Clinical Oncology. Statement of the American Society of Clinical Oncology: genetic testing for cancer susceptibility. J Clin Oncol. 1996;14:1730-1736.
21.    American College of Medical Genetics Foundation. Genetic susceptibility to breast and ovarian cancer: assessment, counseling and testing guidelines. Available at: www.health.state.ny.us/nysdoh/cancer /obcancer/contents.htm. Accessed April 11, 2000.
22.    McKinnon WC, Baty BJ, Bennett RL, et al. Predisposition genetic testing for late-onset disorders in adults. A position paper of the National Society of Genetic Counselors. JAMA. 1997;278:1217-1220.
23.    Giardiello FM, Brensinger JD, Petersen GM, et al. The use and interpretation of commercial APC gene testing for familial adenomatous polyposis. New Engl J Med. 1997;336:823-827.
24.    Kessler S. Psychological aspects of genetic counseling: IX. Teaching and counseling. J Genet Couns. 1997;6:287-295.
25.    Croyle RT, Lerman C. Interest in genetic testing for colon cancer susceptibility: cognitive and emotional correlates. Prev Med. 1993;22:284-292.
26.    Lerman C, Marshall J, Audrain J, et al. Genetic testing for colon cancer susceptibility: Anticipated reactions of patients and challenges to providers. Int J Cancer. 1996;69:58-61.
27.    Vernon SW, Gritz ER, Peterson SK, et al. Intention to learn results of genetic testing for hereditary colon cancer. Cancer Epidemiol Biomarkers Prev. 1999;8:353-360.
28.    Esplen MJ, Madlensky L, Butler K, et al. Motivations and psychosocial impact of genetic testing for HNPCC. Am J Med Genet. 2001;103:9-15.
29.    Lerman C, Narod S, Schulman K, et al. BRCA1 testing in families with hereditary breast-ovarian cancer A prospective study of patient decision making and outcomes. JAMA. 1996;275:1885-1892.
30.    Croyle RT, Smith KR, Botkin JR, Baty B, Nash J. Psychological responses to BRCA1 mutation testing: preliminary findings. Health Psychol. 1997;16:63-72.
31.    Lodder L, Frets PG, Trijsburg RW, et al. Psychological impact of receiving a BRCA1/BRCA2 test result. Am J Med Genet. 2001;98:15-24.
32.    Schwartz MD, Peshkin BN, Hughes C, Main D, Isaacs C, Lerman C. Impact of BRCA1/BRCA2 mutation testing on psychologic distress in a clinic-based sample. J Clin Oncol. 2002;20:514-520.
33.    Vernon SW, Gritz ER, Peterson SK, et al. Correlates of psychologic distress in colorectal cancer patients undergoing genetic testing for hereditary colon cancer. Health Psychol. 1997;16:73-86.
34.    Gritz ER, Vernon SW, Peterson SK, et al. Distress in the cancer patient and its association with genetic testing and counseling for hereditary non-polyposis colon cancer. Cancer Res Ther Contr. 1999;8:35-49.
35.    Dudokde Wit AC, Tibben A, Duivenvoorden HJ, Niermeijer MF, Passchier J. Predicting adaptation to presymptomatic DNA testing for late onset disorders: who will experience distress? J Med Genet. 1998;35:745-754.
36.    Michie S, Bobrow M, Marteau TM. Predictive genetic testing in children and adults: a study of emotional impact. J Med Genet. 2001;38:519-526.
37.    Dorval M, Patenaude AF, Schneider KA, et al. Anticipated versus actual emotional reactions to disclosure of results of genetic tests for cancer susceptibility: findings from p53 and BRCA1 testing programs. J Clin Oncol. 2000;18:2135-2142.
38.    Codori AM, Petersen GM, Boyd PA, Brandt J, Giardiello FM. Genetic testing for cancer in children. Short-term psychological effect. Arch Pediatr Adolesc Med. 1996;150:1131-1138.
39.    Bonadona V, Saltel P, Desseigne F, et al. Cancer patients who experienced diagnostic genetic testing for cancer susceptibility: reactions and behavior after the disclosure of a positive test result. Cancer Epidemiol Biomarkers Prev. 2002;11:97-104.
40.    McAbee GN, Sherman J, Davidoff-Feldman B. Physician’s duty to warn third parties about the risk of genetic diseases. Pediatrics. 1998;102(1 Pt 1):140-142.
41.    Green JM, Richards MP, Murton F, Statham H, Hallowell N. Family communication and genetic counseling: the case of hereditary breast and ovarian cancer. J Genet Counsel. 1997;6:45-60.
42.    Bernhardt BA, Biesecker BB, Mastromarino CL. Goals, benefits, and outcomes of genetic counseling: client and genetic counselor assessment. Am J Med Genet. 2000;94:189-197.

Dr. Wellisch is professor-in-residence in the Department of Psychiatry at the UCLA School of Medicine in California.

Acknowledgments: The author reports no financial, academic, or other support of this work. 


 

Abstract

Most woman who have experienced breast cancer in a beloved first-degree relative (eg, mother, sister) are profoundly impacted by the experience. This article attempts to deal with three basic questions regarding the family experience of the woman at high risk for breast cancer. These include: 1) What are the known predictors of increased difficulties in adaptation/coping in this population? 2) What are some important clinical manifestations of problems in this population? and 3) What are reasonable interventions to be considered and attempted in this population? Although homogenous in their experience of having a first-degree family member with breast cancer, this is also a heterogeneous population in important issues such as the age of the woman at the time of the family member’s breast cancer diagnosis, the survival or death of the family member(s), the number of afflicted relatives, and the pre-cancer coping, support, and communication capacities of the family system, all of which serve to differentiate and subdivide this population.

 

Introduction

The women on whom this article is based can be daughters, sisters, nieces, granddaughters, or even mothers of women with breast cancer. They bear a genetic legacy of trauma, past visions of suffering, and some degree of resolution of grief over their past family experiences with breast cancer. These women must learn to live with the conflict of loving, empathizing with, and/or missing the one who confers upon them increased risk in regard to their own physical vulnerability. This population must also learn to live with a vulnerability for which there is currently no 100% definitive medical intervention to eradicate their increased risk. Further complicating their family legacy is the reality that this threat/risk will never end and, in fact, increases and becomes co-mingled with age, forming a composite risk factor for breast cancer.

Since 1993, a multidisciplinary group has formed a working team/clinic at the Revlon-Breast Center at the University of California at Los Angeles (UCLA) School of Medicine. This is the High Risk Clinic of the Revlon-UCLA Breast Center. Since its inception, we have seen approximately 1,200 high-risk women, and are actively following and studying a matrix of 600 such women at the present time. A more complete description of the High Risk Clinic has been previously published.1

 

Predictors of Problems Stemming From the Family Experience

To date, somewhat limited data and clues exist on how to predict which women are likely to experience increased difficulty with adaptation and coping in adulthood as a result of their family experiences with cancer.

The data that exists suggest that the following factors can predict poorer adjustment. A constellation of factors from the family experience predict poorer (adult) adjustment in daughters of breast cancer patients. These include being an adolescent at the time of mother’s diagnosis (versus being preadolescent or an adult), and having a mother die from breast cancer (versus surviving).2 This developmental stage issue was confirmed by another group who showed that adolescent girls whose mothers had breast cancer displayed more symptoms of anxiety and depression than either preadolescents or young adult women in the same circumstance.3

A second constellation of factors also predicts poorer adult adjustment in the daughters. These include: poorer prognosis in the patient (eg, mother with breast cancer), poorer adjustment to the cancer (by the patient with cancer), and more severe surgery (mastectomy versus lumpectomy).4

A third constellation of factors correlates with women above the cutting score of 16 on the Center for Epidemiologic Studies Depression Scale (CES-D) in our clinic, having the increased likelihood of clinical depression. Some variables that significantly correlated with CES-D scores above 16 included: having had significantly more relatives with breast cancer (P=.04), having been significantly younger at the diagnosis time of the relatives (P=.05), and never having viewed the site of the relatives’ breast surgery (P=.03).5

 

Current Clinical Manifestation of Issues Stemming From Earlier Family Experiences:

Several clinical symptom patterns have been presented to us by this population which reflect current coping/adjustment problems, appear to reflect past and unresolved family issues, and appear to embody mandates for interventions. Six such patterns1 will be described, including:

(1) The woman who either cannot speak about the family experience of breast cancer at all, or cannot speak about the experience without overt painful, tearful grief. For the staff of the High Risk Clinic, this is a major clue that grief remains largely or totally unresolved. In clinic experience this is more often true for women whose mothers had breast cancer (and died from it) in the 1950’s and early 1960’s when families often lived in silence about the experience of cancer. However, we also see women who are younger and have more recently been confronted with familial breast cancer who sometimes are hard pressed to talk about the experience. Interestingly, and to our surprise, some of these women are even engaged in ongoing psychotherapy when visiting our clinic and report never discussing their familial experience of breast cancer in psychotherapy.

(2) The woman who presents the relatively common theme of “I have decided not to have children.” We often feel such decisions can be based on traumatic memories of their experiences as children of breast cancer patients and fears of perpetuating such genetic legacies on future generations. Sometimes embedded and coexisting with this is a lack of participating in any meaningful or intimate relationship with a man. This leads us to explore the woman’s memories of her father’s participation, or lack thereof, in the familial breast cancer experience. We have found instances of unresolved disappointment and rage at these fathers for their behavior and the position their behavior has put their daughters in during their mother’s illness. Sometimes these daughters are so angry and disappointed in their fathers, especially if the mother died and their fathers further mismanaged the father-daughter relationship, that their relationships with men are paralyzed and foreclosed without intervention.

(3) The woman who acknowledges sexual conflicts secondary to a fear of breast cancer, potential loss of breasts, or generalized dysphoria or more major depression. Of the first 161 patients in the High Risk Clinic, 36 (22%) were above the cutting score of 16 on the CES-D, indicating a probable presence of a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition6 diagnosis of depression. In this context, we are often presented with the notion “Why should I get pleasure from something (ie, my breasts) which I will almost certainly lose?” This is a complex, multilayered area, with guilt over sexual pleasure in the context of a depressed, traumatized mother who lost her ability to have sexual pleasure in the wake of breast cancer and treatments therein. In addition, the daughter who was an adolescent when her mother was diagnosed may have been developing breasts simultaneously to her mother losing hers. Thus, developmental issues resurface in this area of symptomatology.

(4) The woman who cannot touch her breasts, much less perform breast self-examination (BSE). This is not an unusual problem in this population. In a study of BSEs among high-risk women, only 27% performed a monthly BSE.7 Those who performed a BSE less than monthly, or never, were found to be significantly more anxious than those who performed a monthly BSE (P<.007).7 Thus, we view such women as having anxiety that has a somatic component and wonder about these women identifying with an ill relative who was phobically anxious about BSE and was also unable to deal with breast cancer as a life challenge.

(5) The woman who, by description, has identified with the mother’s maladaptive style of coping with her breast cancer. Two prominent styles we hear about in the mothers and see in the daughters is that of the anxious one in denial and that of the angry isolate, respectively. The issue of disentangling the daughter’s anxious identification with her mother is psychodynamically complex in that her agency of self and femininity are also wrapped up in this process.8

(6) The woman who presents as (chronically) dysphoric. The question we ask is whether this is unresolved (now internalized) anger in the daughter about her forced participation in the mother’s (or other relative’s) illness, or how much this is a pre-cancer aspect of the woman’s personality structure unrelated to the family experience of illness.

 

Reasonable Interventions Based on Earlier Family Experiences

Almost no data exists in the literature regarding interventions specifically for the population of women at high risk for breast cancer. The limited published data suggests that group therapy of a combined supportive/educative nature with this population can be successfully conducted, may lower symptoms of anxiety and depression, and may lead to increased knowledge about breast cancer and decreased personal risk perceptions.9,10 Given this reality, interventions will be described that fit the symptom patterns described previously based on the assumption that data does exist to link interventions with such symptom patterns.

(1) For the woman who cannot speak about the experience of familial breast cancer at all or with fresh and obviously unresolved grief, we tend to recommend supportive individual therapy which can be of a relatively brief duration. Just the experience of speaking about the occurence the context of our brief clinic interviews is cathartic to such women. We always recommend that women who have not spoken about familial breast cancer during ongoing psychotherapy should redouble their efforts to do so.

(2) For the woman who has decided not to have children, we start with intensive education from our clinical geneticist about the vulnerability to breast cancer. For those who also lack any intimacy with men (or women who are gay), we recommend more intensive, dynamic therapy. Anger and disappointment at fathers is often, or usually, entangled in this web of conflicts. We have seen women who are even further into such conflicts who have not really been able to begin living adult lives because they are preoccupied with the idea they will die when they reach the age their mothers were diagnosed or died. Often these women come to our clinic at an age that is shortly before the anniversary of their mother’s illness or death.

(3) For the woman who acknowledges sexual conflicts/phobic fears about her breasts, we carefully assess underlying etiology of an anxiety disorder and/or depressive disorder with vegetative symptoms such as anhedonia. We then try to facilitate psychopharmacologic intervention and supportive psychotherapy.

(4) For the woman who cannot examine or touch her breasts, we have her begin intensive work with our clinic nurse practitioner in systematic desensitization around breast touching and examining. The first step is with a breast model, the second is with the woman’s own breasts. We realize this can take many clinic visits and are willing to have the nurse do the breast exams for a series of visits while this desensitization process unfolds. The nurse is a highly skilled listener and often-repressed anxiety and memories emerge during this most sensitive process.

(5) For the woman who is trapped in a complex, fearful, and unproductive identification with her mother, we suggest dynamic individual therapy and group therapy where she can identify with other, different styles of coping.

(6) For the woman who is chronically dysphoric, often angry, and often at odds with our clinic staff, we try to first create a safe “holding” environment in our clinic itself. We try to deal with the potential for staff splitting and pitting created by such a patient. Slowly, we explore the possibilities for referral to a therapy that will be psychodynamic, ventilative, and/or grief resolving, and offer the possibility of adjunctive use of medications such as antidepressants. We do not feel rejected or disillusioned when such patients refuse these referrals. They have been dysphoric and angry as a way of life, and we have learned to view change in them as a gradual process.

 

Conclusion

Women at high risk for breast cancer are a psychologically heterogeneous population with a similar background of a familial history experience with breast cancer. Interventions are in the process of being developed and tested for this population and modest data exists to suggest or guide these interventions. Styles of problems in these women may stem from identifications with family members who struggled maladaptively to cope with breast cancer or from unresolved grief or anger about such familial experiences.   PP

 

References

1.    Wellisch DK, Hoffman A. Daughters of breast cancer patients: Genetic legacies and traumas. In: Daneli Y, ed. International Handbook of Multigenerational Legacies of Trauma. New York, NY: Plenum Press; 1998:603-619.
2.    Wellisch DK, Gritz ER, Schain WS, Wang HJ, Siau J. Psychological functioning of daughters of breast cancer patients: Part II. Characterizing the distressed daughter of the breast cancer patient. Psychosomatics. 1992;33:171-179.
3.    Compas BE, Worsham NL, Epping-Jordon G, et al. When mom or dad has cancer: markers of psychological distress in cancer patients, spouses, and children. Health Psychol. 1994;13:507-515.
4.    Lichtman RR, Taylor SE, Wood JV, et al. Relations with children after breast cancer. The mother-daughter relationship at risk. J Pyschosoci Onc. 1985;2:1-19.
5.    Wellisch DK, Lindberg NM. A psychological profile of depressed and non-depressed women at high risk for breast cancer. Psychosomatics. 2001;42:330-336.
6.    Radloff L. The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychol Meas. 1977;1:385-401.
7.    Kash, KM, Holland JG, Halper, MS, Miller DG. Psychological distress and surveillance behaviors of women with a family history of breast cancer. J Natl Cancer Inst. 1992;84:24-30.
8.    Stern DN. The representation of relationship patterns. In: Sameroff, AJ, Emde RN, eds. Relationships and Relation Disorders. New York, NY: Basic Books; 1989:52-69.
9.    Kash KM, Holland JC, Osborne MP, et al. Psychological counseling strategies for women at risk for breast cancer. J Natl Cancer Inst. 1995;17:73-79.
10.    Wellisch DK, Hoffman A, Goldman S, Hammerstein J, Klein K, Bell M. Depression and anxiety symptoms in women at high risk for breast cancer: Pilot study of a group intervention. Am J Psychiatry. 1999;156:1644-1645.

Dr. Simon is clinical professor of psychiatry and director of the Program in Psychiatry and Law at Georgetown University School of Medicine in Washington, DC.

Acknowledgments: The author reports no financial, academic, or other support of this work.


 

Abstract

The standard of care requires that psychiatrists adequately assess patients at suicidal risk. An exception to the standard of care for performing adequate suicide risk assessments does not exist for the clinician practicing in managed care settings. However, it is often more difficult for the clinician to perform systematic suicide risk assessments due to a high volume of patients and limited time and treatment resources. Data-based adequacy of the clinician’s evaluation of suicide risk in the managed care setting depends on a number of factors. These include completing a formal suicide risk assessment, weighing suicide risk factors, obtaining information from collateral sources, assessing the working alliance between the patient and the clinician, and close collaboration with the treatment team in inpatient settings.

 

Introduction

In managed care settings, only the sickest patients are admitted to inpatient psychiatric units. These patients usually have a primary diagnosis of schizophrenia, major affective disorder, or a severe personality disorder with prior hospital admissions. Many of these patients have comorbid substance-related disorders. Most of the patients are at heightened risk of suicide. In outpatient settings, patients at suicide risk may be seen by clinicians in split treatment situations or for a few brief, authorized visits. In the managed care era, all but those patients at highest risk of suicide are treated as outpatients.

Predicting which patients will commit suicide is an impossible task.1 No professional standard of care exists for the prediction of who will commit suicide. Nevertheless, the clinician has a professional and legal duty to perform an adequate assessment of the patient at risk for suicide.2 A variety of suicide risk assessment methods are available.3-7 No model of suicide risk assessment has been empirically tested for reliability and validity.8 Clinicians are free to construct and use their own comprehensive risk assessment methods based on their training, clinical experience, and the pertinent psychiatric literature.

Clinicians’ suicide risk assessments range on a continuum from merely asking patients if they are suicidal to performing formal, systematic suicide risk assessments. Especially in managed care settings, the former is much more common because of the large volume of patients treated. Nonetheless, clinicians continue to have a professional, ethical, and legal duty to provide adequate care to their patients regardless of managed care restrictions and protocols.9 In managed care settings, clinicians need to gather information about patients quickly and accurately. By accessing multiple informational sources, the clinician can be confident that suicide risk assessment rests upon a firm factual foundation.

 

The Adequacy of Suicide Risk Assessment

In managed care settings, clinicians often practice under conditions of too little time and too little information. The liability risk of the clinician is high if insufficient information is gathered and the patient subsequently attempts or commits suicide. Errors of fact, rather than errors of judgment, greatly increase a clinician’s liability exposure. The clinician cannot make sound judgments in the absence of essential facts. If the clinician gathers sufficient information upon which to base an adequate suicide risk assessment but makes an error in judgment that harms the patient, it is less likely that a lawsuit will succeed against the clinician. Errors alone do not constitute malpractice. The clinician is not held legally responsible for mistakes provided due care was used in making clinical decisions.10

Since the standard of care is the assessment of suicide risk rather than prediction, the clinician’s confidence in the adequacy of the suicide risk assessment is paramount. Systematic suicide risk assessment is ultimately a data-informed clinical judgment. There is a direct correlation between the database upon which the risk assessment is conducted and the level of adequacy to which it can be ascribed. A convergence of confirmatory data from a number of sources acts as an adequacy indicator. The adequacy level of the clinician’s suicide risk assessment is dependent upon whether sufficient, reliable information has been gathered to support a systematic analysis of suicide risk.

Suicide risk assessment has been analogized to weather forecasting.11,12 Weather forecasters make probability predictions based on available data and computer models. For example, a weather forecast may predict “a chance of rain tomorrow.” Forecasters try to achieve additional accuracy by expressing the chance of rain as a percentage, such as 30% or 70%. Forecasters may add a numerical confidence factor to their predictions expressed on a scale of 1–10, 10 being the most confident. The confidence in any weather forecast is diminished by time. For example, the forecaster’s confidence is much greater for 24-hour predictions than for 3–5 day forecasts.

Though lacking probability and computer models, the clinician’s confidence in suicide risk assessment similarly depends upon the timeliness, sufficiency, and reliability of the data obtained and evaluated. If the clinician only asks a patient if he or she has suicidal ideation, intent, or a plan, the confidence in such an assessment must be necessarily low. When the clinician performs a systematic suicide risk assessment that accesses multiple data sources, confidence should be greater that the assessment identifies the patient’s level of risk. Like weather forecasts, frequent updates keep the suicide risk assessment current and maintain confidence in the assessment.

 

Suicide Risk Assessment—A Medical Necessity

Formal Suicide Risk Assessment

The purpose of suicide risk assessment is to identify modifiable suicide risk factors and to inform the clinician about the patient’s safety and treatment needs. Especially in managed care settings, the rapid identification of a patient’s treatable suicide risk factors and safety requirements is of critical importance. Suicide risk assessment is first an essential clinical tool that informs treatment, and only secondarily a risk management technique.

As noted previously, suicide risk assessments range from the clinically naive to the clinically sophisticated. On one end of the spectrum, just getting a perfunctory “yes” or “no” answer to the question, “Are you suicidal?” is an inadequate assessment. A layman can just as easily ask that question. On the other end, a systematic suicide risk assessment provides a higher degree of confidence that important sources of clinical information are not overlooked in the overall evaluation of the patient. The formal suicide risk assessment can be thought of as a data-gathering engine. Both risk and protective factors are considered in the overall determination of suicide risk. An adequate suicide risk assessment reliably informs treatment and management.

In a formal suicide risk assessment, clinical, interpersonal, situational, statistical, and individual risk and protective factors are assessed.8 Careful weighing of risk and protective factors as low, moderate, or high according to the patient’s clinical presentation provides additional confidence in the adequacy of the suicide risk assessment. Evaluating suicide risk factors without also considering protective factors diminishes clinical confidence, since that is only half of the suicide risk assessment. Further, differentiating overall suicide risk as low, moderate, or high provides for more clinical precision in determining the patient’s safety needs (eg, suicide precautions: 5-, 10-, or 15-minute check-ups or one-on-one supervision). In addition, a formal suicide risk assessment permits the clinician and utilization reviewer to provide managed care organizations (MCOs) with credible data needed for the decision to admit a patient and to determine the length of stay and appropriateness of discharge.

Risk factors can also be evaluated using a variety of data parameters that enhance suicide risk assessment.13 As noted, the patient at suicide risk can be assessed on a facilitating-protective axis. A patient who is assessed at moderate risk when considering only suicide risk factors may have an overall low suicide risk assessment when protective factors such as positive interpersonal relationships and work satisfaction are present.

Other parameters that enhance suicide risk assessment include necessary and sufficient (individual and situational) and acute and chronic risk factors. Suicides generally occur when both necessary (depression) and sufficient (perturbation) factors are present.14,15 For example, a patient with major depression who also experiences an important personal or occupational loss has both necessary and sufficient suicide risk factors. Short-term and long-term risk factors are frequently observed in patients with comorbid Axis I and Axis II disorders. Discerning acute from chronic suicide risk factors focuses clinical attention on treating and modifying acute suicide risk factors, especially with limited outpatient visits or brief hospital stays.

A major resistance to performing formal suicide risk assessment is the perception that it is an onerous and time-consuming task—it is neither. A formal suicide risk assessment is an integral part of the mental status examination performed at admission or initial intake in outpatient settings. Documentation of the suicide risk assessment takes just a few minutes. The initial suicide risk assessment needs to be systematic. Subsequent suicide risk assessments can focus primarily on the patient’s acute risk factors that have required hospitalization or outpatient treatment. Current protective factors are also assessed. Chronic suicide risk factors such as prior attempts, family history of suicide, and demographic factors are identified during the initial suicide risk assessment. Given brief lengths of stay and limited outpatient visits, the ongoing systematic assessment of acute suicide risk factors and the patient’s response to treatment and management become the center of clinical attention.

In managed care settings, much reliance is placed on no-harm or “suicide prevention” contracts because of the volume and rapid turnover of patients. A no-harm contract is inherently unreliable with a new and unknown patient. Even with known patients, no-harm contracts should not be allowed to create a false sense of confidence. There is no evidence that no-harm contracts diminish the risk of suicide; they merely create an illusion of safety. No-harm contracts often diminish the perception of suicide risk without changing the reality of risk. No-harm contracts are actually most useful when patients reject them; the clinician is not deceived by disingenuous assent. No-harm contracts that take the place of performing a systematic suicide risk assessment prematurely cut off the essential task of data gathering.16

The usefulness of the suicide risk assessment is further strengthened when it is conducted as a process rather than as an event. Suicide risk assessment is a “here and now” assessment that time rapidly attenuates.8 Suicide risk assessment as a process continues to incorporate changing clinical data about the patient as well as additional information obtained from the patient’s family or other sources. Suicide risk assessments should always be documented.

MCOs, of necessity, require that suicide risk assessment be a process. In inpatient settings, the hospital utilization reviewer is queried by MCOs regularly about a patient’s level of suicide risk. Hospital length-of-stay determinations are based on the clinician’s assessment of the patient’s suicide risk. Some MCOs contact the utilization reviewer daily. The absence of continuing suicide risk assessments leaves the utilization reviewer unable to respond to the MCO’s questions about a patient’s level of suicide risk. Premature termination of the patient’s insurance benefits may result.

 

Suicide Risk Factors

Suicide risk factors can be divided into three groups: long-term, short- term, and individual. Long-term suicide risk factors are derived from community-based psychological autopsies and the retrospective study of completed suicide by psychiatric patients.17 Long-term suicide risk factors for patients with major affective disorder are significantly associated with completed suicides 2–10 years following assessment.18

Short-term suicide risk factors are derived from prospective studies of completed suicides in patients with major affective disorders.18 Short-term suicide risk factors are statistically significant within 1 year of assessment. They are predominantly anxiety based, usually severe, and often treatable.19 Short-term risk factors include panic attacks, psychic anxiety, loss of pleasure and interest, alcohol abuse, depressive turmoil, diminished concentration, and global insomnia.18 Identification of modifiable risk factors that can quickly lower suicide risk provides important data for patient care in all managed care settings. Many patients admitted to psychiatric units experience acute, severe anxiety that drives suicidal impulses. Recognition and treatment of anxiety symptoms often diminishes suicide risk and promotes rapid stabilization of the patient.

Patient availability and accessibility to guns significantly increases near-term suicide risk. The clinician must determine if guns are accessible to the patient. The patient may deny that availability and access to guns exists. Family members or others who live with the patient should be asked if guns are present in the home. Locking up or hiding guns is insufficient. Patients who are intent on killing themselves manage to find ways of gaining access to guns that are hidden or locked away. Guns must be removed from the home and stored in a safe place. The recent purchase of a handgun, especially by a female patient, should alert the clinician that the patient is at very high risk for suicide.

General suicide risk factors derived from retrospective studies have a high base rate of occurrence in depressed patients who do not commit suicide (high sensitivity, low specificity).20 Suicide risk factors unique to the individual are often the most reliable in suicide risk assessment. Clinicians who have treated patients over an extended period of time usually are able to recognize the recurrence of suicidal patterns. Patients vary greatly in the way that they manifest their suicidal patterns. Some patients display unique, even idiosyncratic symptoms not described in the professional literature, such as sleepwalking, stuttering, or compulsive whistling that presage suicidal behavior. Other patients may experience more conventional patterns, such as suicidal ideation, within a few hours or days following the onset of early morning awakening.

In the managed care era, due to split-treatments, brief outpatient and partial hospitalization visits, short hospital lengths of stay, and rapid patient turnovers, the emergence of unique, individual suicide risk factors are not usually recognized by clinicians. Collateral sources of information from family or friends may provide this vital data.

 

Collateral Sources of Information

Given the short length of hospital stays for patients (often 3–5 days), the psychiatrist may have insufficient patient information to conduct an initial, systematic suicide risk assessment. Information from other sources must be obtained quickly and reliably. Prior hospitalization records should be obtained and reviewed. A faxed discharge summary should be obtained or a phone call made to prior treaters after proper authorization by the patient or substitute decision-maker. Sending an authorization by mail and waiting for the records to arrive is futile. The patient will have been discharged long before the records arrive.

Prior records are usually very informative. For example, the psychiatrist may learn that during prior hospitalizations the patient secreted potentially lethal instruments or cheeked medication. The psychiatrist may discover that the patient accepted voluntary hospitalization after being confronted with the prospect of involuntary hospitalization, only to sign out against medical advice shortly thereafter. This kind of information is especially important when the patient is being treated by the clinician for the first time.

Family members are often a very important source of information for suicide risk assessment. Fawcett and colleagues18 discovered that approximately 25% of patients at suicide risk do not admit to being suicidal. However, in most cases the patient had communicated suicidal ideation or intent to family members. Some patients will admit suicidal thoughts or intentions in the emergency room and be certified by an MCO for admission but deny suicidal ideation once in the psychiatric unit. Patients who deny suicide risk usually do not meet managed care criteria for hospital admission. Regrettably, clinicians may exaggerate suicide risk to ensure admission.

The confidence that the clinician places on information from family members is contingent. Information from family members or friends may be unreliable due to denial, shame, or ambivalence toward the patient, or due to mental illness in family informants. Social workers are valuable members of the treatment team who can provide in-depth family evaluations and access collateral sources of important information about the patient.

A patient’s family or friends may provide vital information that the patient will not or cannot give. For example, the patient may deny or minimize their abuse of alcohol or street drugs. However, the family may reveal that the patient has an extensive history of abuse related to depression and suicide attempts. Obtaining information about the patient’s truthfulness and impulsivity provides additional important data. However, family or friends may not be available immediately or at all. When suicide risk assessment is a process rather than an event, new information that becomes available both clinically and from other sources can be incorporated into ongoing suicide risk assessments. Although the patient may not consent, the clinician may need to talk with the patient’s family members if a suicide crisis develops.2

 

The Therapeutic Alliance

The therapeutic alliance between the clinician and the patient affirms the willingness of each party to work together for the benefit of the patient’s treatment.21 If a solid working alliance exists, the patient usually cooperates with the clinician in disclosing suicide risk. However, the therapeutic alliance may vary considerably between outpatient visits or during inpatient treatment sessions because of instability and volatility of the patient’s condition. There are patients who have maintained a solid therapeutic alliance only to kill themselves between outpatient visits or inpatient sessions. A sustaining therapeutic alliance was present during the last session but was overcome by a downturn in the patient’s clinical condition.

In managed care settings, the time spent by the clinician with the patient is often insufficient to develop and sustain a therapeutic alliance. The frustration and distraction felt by both the therapist and the patient over managed care limitations on treatment and administrative “red tape” can disrupt the working alliance. The clinician’s confidence that the patient has provided reliable information about suicide risk is uncertain. On the inpatient unit, the psychiatrist can obtain information about patients at suicide risk by working closely with the treatment team. The treatment team has “a thousand eyes.” Members of the team are continually observing and working with the patient. The psychiatrist’s visits with the patient are often relatively brief. Daily careful review of the patient’s chart invariably provides a treasure trove of clinical information recorded by the treatment team.

 

Miraculous Cures and Other Fictions

Certain anomalous clinical practices arise when clinicians attempt to “game” managed care policies and procedures. For example, additional hospital days are authorized by MCOs based on the clinician’s assessment of a continuing high level of patient suicide risk. Nonetheless, if the MCO determines that the patient can be treated in a partial hospitalization program or as an outpatient, authorization for additional hospital stay is denied. Faced with denial of patient insurance coverage, the patient may be declared “miraculously cured” by the clinician and discharged.

In the managed care era, a heightened risk of patient suicide arises from premature discharge.8 Uncertainty about the number of additional outpatient treatment or hospital days that the MCO may approve often destabilizes patients by disrupting a therapeutic termination and discharge process. Suicide risk assessment may help prevent a premature discharge that is likely doomed to fail. Formal suicide risk assessment provides a solid basis for appealing denial of benefits when patients remain at high suicide risk. If the appeal fails, the patient may still require additional hospital treatment. Although the quality of care may be negatively influenced by the MCO’s restriction of services, clinicians continue to have a professional and legal duty to provide competent care to their patients while still in crisis.13

Formal suicide risk assessment gives the clinician confidence that a realistic evaluation of a patient’s suicide risk has been performed. “Gaming” the MCO becomes unnecessary. Exaggerating the severity of the patient’s condition to qualify for MCO approval exposes the clinician to increased liability risk when the “miraculously cured” patient is prematurely discharged and then attempts or commits suicide.

A related conundrum arises if a psychiatrist issues a therapeutic pass to assess the patient’s ability to function outside the hospital.22 Writing an order for any kind of pass raises a red flag for MCOs. MCOs have greatly restricted the use of this important assessment and treatment intervention. Once a therapeutic pass is issued, the MCO may deny further hospital benefits based on the presumption that the patient is ready for discharge. Careful suicide risk assessment before issuing a pass and upon the patient’s return from the pass is essential in preventing a premature discharge. The patient may return from a pass in worse clinical condition than when he or she left the hospital.

By the time the patient appears ready for a pass, the clinician usually knows more about him or her. The clinician has had time to collect sufficient information from a variety of sources upon which to conduct an adequate suicide risk assessment. Unfortunately, psychiatrists are very reluctant to issue patient passes that may lead to the MCO denying further benefits. If the pass does not go well, a formal suicide risk assessment can support both the clinician and utilization reviewer’s attempts to obtain authorization for additional hospital days.

Finally, upon inpatient admission patients at suicide risk usually are placed on safety precautions. Most of these patients want to smoke. In some psychiatric units patients must leave the unit to smoke, which requires that they be taken off suicide precautions in order to receive a staff-accompanied off-unit pass. They may refuse nicotine gum, patches, or inhalers. In order to smoke, patients frequently deny suicidal ideation even though they remain at heightened risk. Patients can mount considerable pressure on the clinical staff to be allowed to smoke, even threatening to leave if their requests are denied. If not in the unit, the psychiatrist is contacted, informed of the patient’s demand to smoke, and told that the patient denies suicidal thoughts. Based on that phone call, the patient may be allowed to leave the unit to smoke. A suicide risk assessment should be performed by the clinician before such changes are made in a patient’s safety requirements. When safety precautions are prematurely discontinued, the MCO may determine that the patient is not at suicide risk and deny further benefits.

Patients who manipulatively declare that they are “suicidal” can test a clinician’s equanimity. This situation frequently arises in emergency rooms with individuals who want to gain admission to the hospital but are not felt to be at substantial suicide risk. Similarly, at the time of discharge, patients may claim that they are suicidal in order to avoid discharge. Some manipulative individuals have learned that the magic words, “I am suicidal” can lead to hospital admission or a forestalling of discharge. Clinicians frequently feel helpless, manipulated, and frustrated by this declaration, but nevertheless may passively acquiesce. Confronted with this situation, some clinicians feel that they cannot confidently assess a patient’s potential for self-harm, and the patient is admitted. Also, the ever-present fear of being sued if the patient is not admitted and commits suicide induces feelings of helplessness that can make the clinician yield to the patient’s manipulation.

Clinicians need not be held hostage by questionable threats of suicide. A data-based formal suicide risk assessment is the best antidote. Suicide risk assessment can provide the clinical confidence that replaces paralyzing doubt. Clinicians will not be held legally responsible for adverse outcomes such as patient suicide if reasonable suicide risk assessments are conducted and documented. However, psychiatrists will be held liable for malpractice if they breach the duty to exercise that degree of skill and care ordinarily employed in similar circumstances by other psychiatrists.23 Failure to adequately assess patients at risk of suicide is a deviation from the standard of care.

 

Avoiding Inadequate Assessment

As with weather forecasting, the clinician can determine the confidence he or she should place on the adequacy of the suicide risk assessment based on the data-gathering process that forms the foundation for the patient evaluation. Determining the clinician’s level of confidence in the patient data is essential for the treatment and management of those at suicide risk. The accompanying Table contains a suicide risk assessment data checklist that can be used by clinicians. The standard of care requires that the clinician gather sufficient information upon which to base an adequate suicide risk assessment. The checklist can alert the clinician to deficiencies in the data collection.

 

A formal assessment itself is the impetus to gather information about a patient’s level of suicide risk. The therapeutic alliance, though extremely important as a conduit of information about the patient’s mental state, can be absent, limited, or variable. The formal checklist reminds the clinician to consider multiple data sources that create the foundational basis for the overall evaluation of the patient’s suicide risk and the continuing suicide risk assessment process.

 

Clinical Vignette

A 42-year-old single man is admitted to a psychiatric unit from the hospital emergency room after threatening to jump off a building. The patient is extremely depressed and suspicious. He seems to be responding to auditory hallucinations. The patient provides minimal history. He is a first-time admission who is unknown to the psychiatrist and the hospital staff. Next of kin live in another state. The patient says he has not seen his parents and sister for over 5 years. The psychiatrist makes a preliminary diagnosis of major depression with psychotic features. The patient denies suicidal ideation, intent, plan, or prior attempts. A formal suicide risk assessment is not performed. He is placed on 15-minute suicide precautions. The treatment team notes that the patient is seclusive. He is found positioning himself by the exit door. Staff considers the patient to be an elopement risk. Agitation manifested by constant pacing is observed. The patient is prescribed a benzodiazepine with marked decrease in pacing.

The vignette is illustrative of a typical first-time admission from the emergency room of a general hospital to a psychiatric inpatient unit. Although a rudimentary suicide risk assessment is performed, considerable data are available for a more thorough suicide risk assessment, such as diagnosis and behavioral information including agitation, seclusiveness, auditory hallucinations, and an absent therapeutic alliance with staff.

A quick glance at the suicide risk assessment data checklist can remind the staff that much more information is needed. In the vignette, little confidence should be placed on the initial suicide risk assessment. As a result, suicide risk precautions must remain high. The first 24 hours following admission are critical for evaluation of suicide risk and safety management. As hospitalization continues, the treatment team learns more about the patient. The social worker usually contacts collateral information sources. More clinical data about the patient become available for a formal suicide risk assessment, especially when considering discharge.

In the vignette, the initial denial of suicidal ideation, intent, or plan by a seriously depressed, suspicious patient provides an inadequate and misleading suicide risk assessment. In the managed care era, the suicide risk assessment data checklist may help clinicians counteract this data deficiency.

 

Conclusion

Professional standards do not exist for the prediction of suicide. The standard of care does require that psychiatrists adequately assess patients at risk. An exception to the standard of care does not exist for the clinician practicing in a managed care setting. However, it is often more difficult for the clinician to perform systematic suicide risk assessments due to limited time and treatment resources. Also, with shortened hospital lengths of stay, the responsibility for treating an acutely ill patient shifts to partial hospitalization programs and other outpatient settings, where adequate suicide risk assessment continues to be just as important.

The adequate assessment of the patient at suicide risk requires the presence of reliable, timely information. A suicide risk assessment is only as useful as the information it is based upon. Data-based adequacy of the clinician’s evaluation in the managed care setting depends on a number of factors. These include weighing suicide risk factors, obtaining information from collateral sources, assessing the working alliance between the patient and the clinician, and close collaboration with the treatment team in inpatient settings. Data-based suicide risk assessment increases the clinician’s confidence in both treatment interventions and the safety management of patients at risk.   PP

 

References

1.    Pokorny AD. Prediction of suicide in psychiatric patients: report of a prospective study. Arch Gen Psychiatry. 1983;40:249-257.
2.    Simon RI. The suicidal patient: accepting patient risk and therapist anxiety. In: Lifson LE, Simo RI, eds. The Mental Health Practitioner and the Law: A Comprehensive Handbook. Cambridge, MA: Harvard University Press; 1998.
3.    Simon RI. Concise Guide to Psychiatry and Law for Clinicians. 3rd ed. Washington, DC: American Psychiatric Press; 2001.
4.    Jacobs DG, Brewer M, Klein-Benheim M. Suicide assessment: an overview and recommended protocol. In: Jacobs DG, ed. Guide to Suicide Assessment and Intervention. San Francisco, CA: Jossey-Bass; 1999.
5.    Maris RW, Berman AL, Maltsberger JT, et al. Assessment and Prediction of Suicide. New York, NY: Guilford Press; 1992.
6.    Chiles JH, Strohsall K. The Suicidal Patient: Principles of Assessment, Treatment and Case Management. Washington, DC: American Psychiatric Association; 1995.
7.    Clark DC, Fawcett J. An empirically-based model of suicide risk assessment of patients with affective disorders. In: Jacobs DG, ed. Suicide and Clinical Practice. Washington, DC: American Psychiatric Association; 1993.
8.    Simon RI. Psychiatrists awake! Suicide risk assessments are all about a good night’s sleep. Psychiatr Ann. 1998;28:479-485.
9.    Simon RI. Psychiatrists’ duties in discharging sicker and potentially violent inpatients in the managed care era. Psychiatr Serv. 1998;49:62-67.
10.    Macbeth JE, Wheeler AM, Sither JW, et al. Legal and Risk Management Issues in the Practice of Psychiatry. Washington, DC: Psychiatrist’s Publishing Group; 1994.
11.    Simon RI. Clinical Psychiatry and the Law. 2nd ed. Washington, DC: American Psychiatric Press; 1992.
12.    Monahan J, Steadman HJ. Violent storms and violent people: how meteorology can inform risk communication in mental health law. Am J Psychol. 1996;51:931-938.
13.    Simon RI: Taking the “sue” out of suicide: a forensic psychiatrist’s perspective. Psychiatr Ann. 2000;30:399-407.
14.    Schneidman ES. Definition of Suicide. New York, NY: Wiley; 1985.
15.    Goodwin FK, Runck BL. Suicide intervention: integration of psychosocial, clinical, and biomedical traditions. In: Jacobs DG, ed. Suicide and Clinical Practice. Washington, DC: American Psychiatric Association; 1992.
16.    Simon RI. The suicide prevention contract: clinical, legal and risk management issues. J Am Acad Psychiatry Law. 1999;27:445-450.
17.    Fawcett J, Clark DC, Busch K. Assessing and treating the patient at risk for suicide. Psychiatr Ann. 1993;23:244-255.
18.    Fawcett J, Scheftner WA, Fogg L, et al. Time-related predictors of suicide in major affective disorder. Am J Psychiatry. 1990;147:1189-1194.
19.    Fawcett J. Profiles of completed suicides. In: Jacobs DG, ed. Guide to Suicide Assessment and Intervention. San Francisco, CA: Jossey-Bass; 1999.
20.    Murphy GE. On suicide prediction and prevention. Arch Gen Psychiatry. 1983;40:343-344.
21.    Karasu TB. Psychoanalysis and psychoanalytic psychotherapy. In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry. Vol 2. Baltimore, MD: Williams & Wilkins; 1989:1442-1461.
22.    Simon RI. Discharging sicker, potentially violent psychiatric inpatients in the managed care era: standard of care and risk management. Psychiatr Ann. 1997;27:726-733.
23.  Stepakoff v Kantar, 473 NE2d 1131, 1134 (Mass 1985).

Dr. Strasburger is assistant clinical professor of psychiatry at Harvard Medical School in Boston, MA, and attending psychiatrist at McLean Hospital in Belmont, MA.

Acknowledgments: The author reports no financial, academic, or other support of this work.


 

Abstract

Boundaries are defined as the structures and limits of psychiatric treatment which enable treatment to proceed. Boundary keeping is an essential aspect of medical and psychiatric treatment—a process which protects the patient and informs the clinician. Boundary crossings occur from time to time and, if properly attended to, can further the treatment. However, if not dealt with effectively, boundary crossings can become boundary violations—a destructive form of unethical behavior on the part of the clinician. This article will discuss various forms of boundary crossings and violations and offer suggestions for risk management through preventive measures.

 

Introduction

The concepts of boundaries and boundary keeping have attracted attention in recent years, partly as a result of media focus and partly as the result of a series of malpractice awards for purely emotional damages.1 Yet, this awareness needs to be renewed and deepened with respect to training about boundary issues (D Norris, MD, TG Gutheil, MD, LH Strasburger, MD, unpublished data, 2002).2 The clinical concept of boundaries makes possible the professional work of medical practice and psychotherapy, permitting them to flourish. The handling of boundary issues is as important to therapeutic technique as it is to risk management.

Understanding the concepts of boundaries and boundary keeping is central for medical practice, psychotherapeutic technique, and risk management.

 

Boundaries Defined

One can think of a treatment boundary as a spatial metaphor describing the interpersonal frame defining the edge of appropriate behavior in the therapeutic relationship. The metaphor “Good fences make good neighbors,” expressed in Robert Frost’s poem “Mending Wall,”3 is a good example.

In our work as psychiatrists, boundaries constrain the doctor in order to enable treatment. This constraint on the clinician imposed by boundaries contains and protects the patient, the clinician, and the therapeutic frame. Once the structure of treatment is established and the limits are formed, the process of human interaction can carry the treatment forward. Boundaries outline the stage on which the drama of clinical interaction can be played out. However, where the boundaries are breached or nonexistent there is no theater because the patient does not experience the safety and freedom to conduct an inner exploration.

The conscious application of a clear sense of boundaries should be thought of as a technique to enable and enhance treatment rather than merely as ethical protection for the patient or legal protection for the treating clinician. Keeping boundaries thoughtfully and carefully allows the clinician to experience situations redolent with the patient’s issues in the immediate present of the consulting room. These encounters can be discussed in therapy in terms of their meaning to the patient; it is just this discussion that preserves the therapeutic force of the doctor-patient relationship.

The issue of boundary keeping is a significant one whether the treating clinician is engaged in dynamic psychotherapy, general medicine, behavioral treatment, or psychopharmacology. All areas of medicine will be involved in a power imbalance with the patient and may be the object of magical wishes and attributions. Any doctor or clinician has an ethical responsibility to act in the patient’s interest and not to exploit a vulnerable patient for personal gain.

Although not every physician practices Freudian psychotherapy, Freud’s ethical principle of abstinence is the paradigm case for the theory and analysis presented here, and the ethical principles apply to all. According to Freud’s principle of abstinence, the clinician must refrain from improper gratification of himself from the medical relationship. No matter how “creative” his approach, the doctor must stick to business, remaining in role and at task.

Patients who are trusting (sometimes excessively) and frequently regressed often do not act self-protectively. Expecting to receive help, these patients assume they can let their guard down, creating vulnerability. Compounding this is an immediate power imbalance in the relationship in which the treating clinician has education, experience, status, and authority. For example, doctors in our society can ask almost any imaginable question, no matter how personal, to a patient. To someone who is unhappy or in trouble, the treating clinician appears to be a strong, successful person who has all the answers. The asymmetry exists even when one is treating a peer (ie, a fellow clinician).

Medical treatment is a system in which mere knowledge of the process confers power. Through experience, the clinician knows what to expect and has the power to influence the patient’s development in many ways. He can confer a sense of personal value simply through his paying attention, inspire emotional attachments, persuade the patient to do what is best for himself, and, alternatively, create confusion and conflict.4

Intimacy and the intensity of strong feelings in the clinical relationship may foster regressive longings, needs, and fantasies for both clinician and patient while weakening the good judgment required for self-control. When a patient’s infantile yearnings are revived, they often take the form of sexualized dependent striving. If the patient or treating clinician confuses these with adult sexuality, “familiarity breeds attempt” (SJ Welpton, MSW, oral communication, 1982). Patients more likely to exhibit this dynamic are those with borderline personality disorder5 or those who may have been previously abused “sitting ducks.”

 

Boundary Crossings

A lot of concern about professional boundaries has emerged because of the wish to prevent mild, nonsexual transgressions leading to frank sexual exploitation of patients. Sex with patients is a boundary violation; one would think that this hardly needs saying, yet it continues to occur and typically begins with minor boundary crossings.4

Boundary crossings are benign interactions which vary from traditional medical interactions but do not harm the patient. When doctor and patient are able to discuss these interactions and they are not part of a repetitive pattern, they may improve the relationship and advance the treatment. What seems to be a minor boundary crossing might be therapeutically beneficial (if properly handled), neutral (innocuous), or a boundary violation (improper, possibly dangerous in itself and possibly leading to more serious violations). Of course, a crossing that is not itself an unethical boundary violation may still be harmful to both the patient and treatment depending on the patient’s sensitivities and the doctor’s skill in handling them.

Answering two important questions can determine whether an interaction is a boundary crossing or a boundary violation: (A) Is this action a part of the professional role? and (B) Can the interaction be discussed? Consider some examples: a patient is unavoidably late after tending to a sick child and the doctor allows the appointment to extend beyond its usual limit; a patient stumbles upon leaving the office, falls to the floor, and the doctor helps the patient up making sure he/she is not hurt; a patient announces that his/her son has just died and the doctor accepts the patient’s tearful embrace. Each of these interactions represents a boundary crossing but probably not a boundary violation. Flexibility, human responsiveness, and warmth are still professional.

Other situations that rub the edge of boundaries include chance encounters, use of first names, and a variety of contact possibilities. It is a small world, and one may easily encounter a patient at the movies, in a museum, or at a party. It would be rude not to say hello, but ill-advised to get into an extended conversation. The significant risk of boundary violation here would be breaking confidentiality through openly acknowledging treatment. For chance encounters, a humane response is indicated.

The use of first names can become a boundary issue. How should the patient be addressed? To many patients, the use of first names is a familiarity that is expected because we live in an informal society. To some, the use of first names by a doctor feels condescending and infantilizing or overly familiar. Asking how someone wants to be addressed turns the issue into one of proper respect, though explicit permission does not always resolve the issue. The doctor must always use clinical judgment. A patient may beg to be called by a first name yet be unable to handle the intimacy which is engendered. A similar issue forms around what the patient calls the doctor.

Context frequently determines whether behavior is a boundary crossing or a boundary violation. For example, a doctor who gives a patient a ride home in a blizzard might be judged differently depending on whether public transportation was still running, whether the patient felt coerced by the doctor to accept the ride, and whether the doctor also gave the patient rides in mild weather. Assessment of the propriety and therapeutic appropriateness of this gesture also depends on the doctor’s conduct in the course of the ride (maintaining professional bearing, avoiding undue familiarity, not conducting therapy in the car) and whether the doctor explored the unusual encounter with the patient in a subsequent session. The latter brings the encounter into the context and boundaries of treatment, restoring the boundaries that have been breached.

Physicians almost always see their patients when hospitalized, but a psychotherapist deciding whether to call or visit an ill patient in a general hospital has to use careful clinical judgment. The benefits would have to be weighed against the patient feeling exposed or intruded upon. The context might depend on the patient’s history, the seriousness of the illness, the nature of the therapeutic alliance, and the patient’s preferences. Frank discussion clarifying the issue with the patient would be of considerable assistance.

The type of treatment is a factor in considering the appropriateness of professional behavior. Case management and most medical treatments are more (figuratively) hands-on than traditional psychodynamic psychotherapy. It might be entirely appropriate outreach for a case manager to render practical assistance to patients, arrange appointments, encourage socialization, set up transportation, or engage with families. For example, drug and alcohol counselors may attend Alcoholics Anonymous meetings with their counselees, a game of catch with a latency boy might be an important approach to forming an engagement and therapeutic alliance, a behavioral doctor might assist an agoraphobic patient in going to a shopping mall to overcome his fear, or a child custody evaluation might involve a home meeting. Each of these situations could be regarded either as a boundary violation or acceptable behavior depending on context or type of treatment. Different kinds of treatment have different boundaries, so that what might be a boundary violation in psychodynamic therapy would not even be a crossing in another context.

Self-disclosure, albeit a common precursor in cases of therapist-patient sexual exploitation, can be a means of adapting the frame to connect with the patient.6 With some patients who have difficulty talking, and particularly with adolescents, one might want to discuss sports or movies as a way of engaging the patient in the treatment process. In the course of this discussion a doctor may reveal a great deal about personal interests and activities. The boundary issue is not whether the treating clinician self-discloses, since people self-disclose whenever they open their mouths. The vital question is what is disclosed and for what purpose? When a doctor burdens a patient with his own problems, self-disclosure has gone too far. To establish alliance, what does the patient need? What withholding will the patient tolerate? Whether a clinician’s self-disclosure is a boundary crossing or a boundary violation may be subjectively determined by the patient’s needs. 

It is important that the clinician not misinterpret the concept of boundaries as prohibiting frank clinical inquiry about emotionally charged issues. One must take a sexual history from a patient, explore a patient’s fantasy life, and understand erotic or sexual transference feelings that can attach to any doctor. Anxiety about sexual boundary violations should not lead to avoiding discussions of a sexual nature with patients. In the clinical setting, open discussion should be the rule of thumb. Context and type of treatment are crucial determinates.

 

Boundary Violations

Boundary violations represent a failure to define and carry out the interaction as professional, not personal, social, or sexual. Boundary violations that stop far short of sex can still compromise treatment; they comprise many of the problematic interactions which precede frank sexual encounters.7 While boundary violations do not, in and of themselves, prove sexual misconduct, it is worth noting that juries give more credence to allegations of sexual misconduct where other boundary violations have occurred. The argument has been that where there is smoke, there must be fire.

The following examples of nonsexual boundary violations are taken from consultations with a series of over 125 clinician-patient sexual abuse cases: the patient runs seemingly inconsequential errands for the doctor which include mailing letters, returning library books, picking up the clinician’s laundry and groceries, doing household chores, and picking up the doctor’s children after school. In other cases, patients have been engaged to do the doctor’s professional billing, secretarial work, and to write academic papers for publication under the doctor’s name.

The list of inappropriate behaviors include going to lunch, dinner, movies, or family parties with patients and escorting patient to professional functions. In one case, a patient was made head secretary for the Department of Psychiatry which her doctor chaired. Dubious financial transactions have included charging purchases on a patient’s credit card, selling a boat to the patient, borrowing money from a patient’s retirement funds, and using “insider” investment information gained from the patient.

Sexual exploitation of patients does not usually begin de novo. The usual pattern is a gradual blurring of boundaries. In a typical scenario, the action begins with small and seemingly inconsequential behaviors such as extending sessions beyond scheduled time, excessive telephone conversations, or inappropriate self-disclosure leading to role reversal where the sessions begin to serve as “therapy for the therapist.” Perhaps gifts are exchanged or the doctor begins to direct work or life choices for the patient. In an early court case of “undue familiarity,” the patient was invited to the therapist’s home and asked to participate in parties, skating, and nude swimming. The judge ruled that the behavior would have been equally egregious if it had consisted of ballroom dancing and swimming with suits on.8

 

Patient Consequences

Harms to the patient, although common and (both clinically and legally) reasonably foreseeable, are not universal and vary in severity depending on the patient as well as the nature of the offense. The damage does not necessarily take the form of dramatic personal trauma. That happens in some cases of sexual transgression, but in a larger set of cases, sexual or nonsexual, there is first an undermining of treatment. If the relationship is sufficiently compromised by inappropriate personal and social communications, meetings, gifts, and the like, the doctor will no longer be able to serve in a professional role and minister to the patient’s health. These are substantial losses. Even where transgressions are nonsexual and relatively innocuous, they set up a “special” role for the patient. The “special” relationship may be initially gratifying, feeding the patient’s self-esteem. However, when it accelerates and finally crashes, the “cessation trauma”9,10 can be devastating.

Patients may not immediately recognize when they have been abused and exploited, especially when there has been no overt sexual relationship.  When there has been a sexual relationship, the effects have been well documented.11 The patient is caught in a deep ambivalence toward the doctor, wishing to escape from a destructive process but fearing separation. The patient’s guilt and sense of having caused the doctor’s behavior is similar to that experienced by incest victims. Often, patients develop a sense of pervasive isolation and feelings of emptiness and confusion which affect their ability to relate to others. Their ability to trust is severely compromised.

Victims fluctuate between rage and despair but are often unable to talk about the source of their rage.  Suicidal risk increases and cognitive deficits such as inattention, intrusive thoughts, flashbacks, and nightmares are common. Simple daily tasks may seem impossible to perform. A variety of diagnoses afflict these victims, including posttraumatic stress disorder, major depression, anxiety states and panic disorder, eating disorders, and drug and alcohol abuse. Also, personality disorders which had lain dormant may become aggravated. It is abundantly clear that no inappropriate bodily violation can be called “treatment.”

 

Liability

The clinician who has committed serious boundary violations faces real trouble in terms of liability. The professional damage often falls under five major areas of concern: 
(1) Civil lawsuits may be filed against the doctor and the institution in which the boundary violations occurred. Allegations may include negligent hiring, negligent supervision, and negligent retention; 
(2) Complaints may be registered with the clinician’s licensing board, resulting in suspension or revocation of professional license;
(3) In many states there are criminal penalties for sexual boundary violations;
(4) The clinician’s professional society may sanction him for ethics violations; 
(5) The lingering pain of bad judgment and the loss of professional respect endures long beyond the incidents and sanctions themselves.

 

Warning Signs

How can physicians help themselves and their colleagues manage the boundary risks inherent in interactions with patients? Monitoring one’s own behavior and reviewing the slippages with colleagues and supervisors is an ongoing task which is essential for treating clinicians. The following self-examination indices are behaviors which should raise red flags and trigger self-reflection:12,13 
• Recurrent erotic feelings about patients;
• Being lax about late-fee payment;
• Attempting to impress a patient;
• Tardiness in starting appointments;
• Allowing appointments to run overtime;
• Gossiping about a patient with colleagues;
• Frequent drowsiness during appoint-ments
• Encouraging overdependence;
• Excessive fear about a patient’s leaving treatment;
• Asking patients to do favors;
• A need to argue a point with a patient;
• Unnecessary or intrusive self-disclosures;
• Having appointments outside the office.

Epstein and Simon’s Exploitation Index13 also contains valuable questions that clinicians can ask themselves in order to forewarn against incipient boundary violations. The index includes searching questions such as:
• Do you find the chronic silence or tardiness of a patient a satisfying way of getting paid for doing
nothing?
• Do you accept gifts or bequests from patients?
• Do you disclose sensational aspects of your patient’s life to others?
• Do you recommend treatment procedures or referrals that you do not believe to be necessarily in your patient’s best interests, but that may be to your direct or indirect financial benefit?
• Do you find yourself trying to influence your patients to support political causes or positions in which you have a personal interest?
 • Do you find it painfully difficult to agree to a patient’s desire to cut down on the frequency of appointments, or to work on termination?

Similar self-examination questions can be found in Pilette, Berck, and Achber’s Nursing Boundary Index.14
 

Prevention

The best prevention against boundary violations are (1) having a satisfying personal life and (2) remaining in role and at task. Anyone who works with others in a helping capacity needs to be able to distinguish between normal human feelings and unethical acts. Are you ever attracted to clients? Of course you are.  The problem arises when one either acts on the feelings or allows too much energy to be drained by the feelings so that professional effectiveness declines.
 

Responses to Provocation

Provocative gestures, overtures, and leading questions from patients require a response. First, acknowledge your feelings to yourself. If needed, get supervision aimed at helping to understand your feelings evoked by the provocation. Confide in your peers, supervisor, or a professional consultant. One can deal with these feelings with help from colleagues or a therapist, learn to set them aside, and formulate strategies to deal with the provocative behavior. Such confidences to peers effectively remove the option to act out one’s impulses.  Establish a record of your having addressed the situation in an ethical, professional manner. Above all, never worry alone. Do not make the client’s problems your own; overidentification impairs judgment. Do not make your problems the clients’ problems; they have all they need. Do not share your sexual interests with patients. Nothing should be done when alone with a patient that could not be reported to a colleague or supervisor.
 

Seductive patients are testing limits. Recognize the line between compassion and passion. Set limits but do not be rejecting. Do express nonsexual caring, the basis of empathy. The patient should not have to act out to obtain warmth and caring, but one need not answer personal questions. Become adept with boundary-keeping responses. For example the patient’s question, “Are you married?” may be answered with a response such as, “What if I am and what if I am not?” Explore whether the question is related to treatment or an invasion of privacy. Clarify and emphasize that a personal relationship cannot be negotiated. “What is going on here?” and “That is not what we are here for” can be appropriate responses.
 

Try not to refer out—the patient does not need abandonment added to other problems. When the trainee or doctor says, “I am falling in love with the client” rather than referring the patient out, the supervisor should explore what is interfering with professional performance. Where referring the patient out is inevitable, accept responsibility for being unable to provide support and allow time to process the termination.  With regard to follow-up care of former clients, the client should be able to return to a professional relationship. 
 

Building Awareness

Trainees, staff, and patients all need education about maintaining boundaries. Staff meetings that focus on personal feelings and issues of boundary violations combat isolation. An open sharing of feelings about patients among staff is helpful. Personal feelings about patients are normal and inevitable and need not be repressed, denied, or explained away. Staff must learn to experience, identify, tolerate, and use their responsive feelings toward patients.
 

Educating patients is an important step that should not be forgotten.  Patients need to know that strong feelings are likely to develop toward clinical staff, that these feelings are normal and natural, and that discussing them is likely to be helpful. Teaching about the limits of acceptable behavior can be done by example, like responding to patient invitations or gifts with, “Let us discuss it.”
 

Supervisors must recognize that when staff is having difficulty or not having needs met, guidance is essential.  Reaching out for help is a healthy sign, and staff seeking supervision should be praised, not pathologized. Clinical supervisors should be good role models who offer examples of appropriate behavior. Supervision should not just take place during a crisis when there is a suspicion of wrongdoing, but on an ongoing basis. Everyday vigilance keeps individuals and organizations out of trouble.  
 

Conclusion

To come full circle, recall that a boundary is a protective, containing structure that enables clinical work.  Boundary crossings may be beneficial if dealt with properly. Boundary violations are destructive because they do direct harm to patients, and they divert and prevent good treatment. In Frost’s poem “Mending Wall,”4 he and his neighbor go out and pile stones to build a wall. In our work, the maintenance of boundaries is a one-person job—it is always and solely the responsibility of the professional. Still, the ultimate principle is clear: good boundaries make good treatment.   PP

References

1.    Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice. Am J Psychiatry. 1993;150:188-196.
2.    Gutheil TG, Gabbard GO. Misuses and misunderstandings of boundary theory in clinical and regulatory settings. Am J Psychiatry. 1998:155;409-414.
3.    Robert Frost. Complete Poems of Robert Frost. New York, NY: Henry Holt Co.; 1949:47.
4.    Simon RI. Sexual exploitation of patients: how it begins before it happens. Psychiatric Annals. 1989;19:104-112.
5. Gutheil TG. Borderline personality disorder, boundary violations and patient-therapist sex: medicolegal pitfalls. Am J Psychiatry. 1989;146:511-602.
6.    Psychopathology Committee of the Group for the Advancement of Psychiatry. Reexamination of therapist self-disclosure. Psychiatr Serv. 2001;52:1489-1493.
7.    Strasburger LH, Jorgenson L, Sutherland P. The prevention of psychotherapist sexual misconduct: avoiding the slippery slope. Am J Psychotherapy. 1992;46:544-555.
8.    Landau v. Werner. 105 Sol. J. 527 (Cal 1961).
9.    Gutheil TG, Gabbard GO. Obstacles to the dynamic understanding of therapist-patient sexual relations. Am J Psychotherapy. 1992;46:515-667.
10. Gutheil TG. Patients involved in sexual misconduct with therapists: is a victim profile possible? Psychiatric Annals. 1991;21:661-667.
11. Epstein RS. Keeping Boundaries. Washington DC: American Psychiatric Press; 1994.
12.    Menninger K, Holzman P. Theory of Psychoanalytic Technique. 2nd ed. New York, NY: Basic Books; 1973.
13. Epstein RS, Simon RI. The Exploitation Index: An early warning indicator of boundary violations in psychotherapy. Bull Menninger Clin. 1990;54:450-465.
14. Pilette PC, Berck CB, Achber LC. Therapeutic Management of Helping Boundaries. J Psychosoc Nurs Ment Health Serv. 1995;33:40-47.

Dr. Bursztajn is associate clinical professor of psychiatry and Mr. Brodsky is senior research associate, both in the Department of Psychiatry at Harvard Medical School in Boston, MA.

Acknowledgments: The authors thank A. Stone Freedberg, MD, Patricia M.L. Illingworth, PhD, JD, and members of the Program in Psychiatry and the Law at Harvard Medical School, Massachusetts Mental Health Center, for their helpful dialogue. The authors report no financial, academic, or other support of this work.


 

Abstract

How does managed care contribute to the psychiatric hazards of medical illness? How can primary care physicians and psychiatrists (as treaters or consultants) recognize and manage the clinical dynamics that result, together with their liability implications? For patients in managed healthcare settings, a latent subjective sense of captivity triggered by care restrictions can exacerbate feelings of helplessness and hopelessness brought on by the threat of serious illness. This sense of captivity can also intensify the patient’s feelings of alienation and betrayal when managed care constrains patient-physician decision making. These emotional dynamics, together with the rigid, defensive reactions to which physicians sometimes fall prey in the face of managed care’s restrictions on professional autonomy, can compromise the patient-physician relationship and the quality of clinical care while heightening liability risk. In the extreme, some patients will experience the escalating distress characteristic of posttraumatic stress disorder. Clinicians can prevent this emerging form of iatrogenesis by using such strategies as crisis anticipation and preparedness, intervention, and damage control, with the goals of enhancing the patient’s decision-making capacity and recovering a sense of choice in the patient-physician relationship. The introductory, ongoing, and termination phases of the treatment alliance are analyzed as focal points for particular clinical interventions.

 

Introduction

There has been a growing recognition of the influence of managed health care on the doctor-patient relationship,1 including the forcing of primary care physicians into an alienating, ethically ambiguous, and clinically conflicting “gatekeeper” role.2,3 While financial constraints have always been a factor in clinical cases, one major consequence of managed care practices has been a concern as to the lack of meaningful healthcare choices for both doctors and patients. In this atmosphere, patients and their physicians—who face the threat or actuality of a major illness—may experience heightened feelings of helplessness and hopelessness, especially when healthcare benefits are denied. More dangerous still, some patients and physicians come to distrust each other, as when patients feel that physicians are not advocating for them, and when physicians feel that patients are “shooting the messenger” (ie, blaming the physician for managed care-initiated restrictions). In this atmosphere, physicians often avoid consideration of treatment alternatives they view as likely to be denied by a managed care reviewer, or feel compelled to focus on the catastrophic possibility in the differential diagnosis to obtain otherwise denied benefits.4 The final stage of this downward spiral of the physician-patient relationship can be a kind of mutual resignation, where the patient leaves with silent resentment while the physician acquiesces in the silence of a de facto gag clause.

The sense of virtual clinical captivity that patients and physicians can experience in the face of benefit denial need not be taken as a fait accompli. By becoming aware of the dynamics and dilemmas of the physician-patient relationship under managed care, treating physicians can create greater freedom for their patients and themselves to work together effectively. Useful clinical interventions can be implemented to recover a sense of choice in the doctor-patient relationship, while decreasing liability risk, by effectively anticipating, preparing for, identifying, and responding to the distress that is likely to accompany managed care restriction of clinical care.

There are compelling clinical and ethical considerations favoring a proactive stance by physicians who are aware of potential negative managed care influences on their patients. Given that helplessness and hopelessness have been documented to be predictors of negative patient outcomes (eg, in breast cancer),5 the undermining of the clinical process and the resulting loss of trust also undermine the potential for healing relationships and, in turn, the likelihood of positive health outcomes. Physicians who work to reverse this process are not just protecting themselves from liability, but also providing quality care by protecting patients from the consequences of helplessness, hopelessness, and distrust.

Although specialized consultation (eg, psychiatric) can be helpful in the face of a denial of healthcare benefits, it is important that primary care physicians have the tools and perspectives needed both to advocate for the patient and to support the patient when individually indicated benefits are deemed not “medically necessary.”6 An understanding of the dynamics of the physician-patient relationship in the managed care context can be helpful in adapting one’s clinical skills to the task of supporting the patient’s capacity for choice, hope, and trust.

 

Patient Dynamics: “Virtual Captivity”

Even as the prevalence of mental health problems such as mood and anxiety symptoms in primary care settings has come to be recognized,7 the cost containment strategies of managed health care have been found to inhibit the recognition and treatment of psychiatric disorders in medical treatment settings.8 Not only has a diagnosis of depression been found to be associated with patient dissatisfaction with medical care,9 but patients with high levels of depressive symptoms are less likely than the general population to act on their dissatisfaction by switching health plans.10 At the same time, the inability to choose one’s personal physician has been found to be a major determinant of patient dissatisfaction with their healthcare plan.11 The existing pool of trapped, frustrated, disillusioned patients also represents a potential tinderbox of litigation in the wake of tragic outcomes associated with managed care-influenced restrictions on effective treatment—in particular, restrictions on the building of therapeutic alliances in the doctor-patient relationship.

Serious illness that threatens an individual’s bodily or psychological integrity already poses a threat to a person’s sense of autonomy and control. Serious illness can heighten dependency while bringing with it feelings of helplessness, hopelessness, and distrust associated with depression. When faced first with a lack of choice of a provider, and then with restriction or even denial of care, the vulnerable patient, already feeling like a prisoner of the threat of serious illness, may now also begin to feel like a lonely captive of the healthcare system. This trapped, “nowhere to turn” feeling may persist after the illness is treated or even cured, as the patient, once burned by the denial of anticipated care or by worry over the prospect of such a denial, may come to think, “What if I get sick again? What care will I receive?” At the extreme, the patient may begin to experience, subtly but significantly, the emotional traumas associated with abandonment12 and captivity.13

Clinically, such experiences can generate cognitive distortions driven by anxiety—and depression—that may impair the patient’s capacity to temper realism with the hope necessary to tolerate uncertainty and to choose wisely from available alternatives.4,14 Moreover, the prospects for a supportive patient-physician alliance are undermined when the physician is seen by the patient as either untrustworthy or largely powerless to implement his or her own clinical recommendations and protect patient choices due to managed care pressure. The patient’s perception of physician trustworthiness may suffer, for example, when managed care drug formularies restrict the physician from prescribing a medication of choice. Even a trusting relationship, especially when it is founded on blind optimism,  can be destroyed by adversity together with perceived abandonment. As the patient’s distrust increases, responses can include such modes as “fight” (litigate), “flight” (drop out of treatment), or “freeze” (become numb, passive, demoralized, and unable to act effectively in the interest of one’s own health care). The resulting anxiety and depression can lead to a greater likelihood of dissatisfaction with medical care9 and to an impaired capacity to act on that dissatisfaction by changing health plans.10

 

Physician Dynamics: “False Necessity”

The human tendency toward resignation or self-deception and denial of what is too painful to see is not limited to patients. Often, the treating physician may not have freely chosen to be part of a particular managed care organization (MCO) nor to treat a particular patient, except as the best of a set of undesirable choices or the lesser of necessary evils. The physician is also likely to have experienced a substantial reduction of economic and professional autonomy in the shift to managed care. Like the patient, the physician may have few options and insufficient time to recognize, reflect upon, process, and put into perspective the feelings engendered by the managed healthcare context. Under any circumstances physicians are likely to react to a patient’s rejection by withdrawing emotionally from the patient. This reaction is especially likely, however, if the physician faces one frustrated, recalcitrant patient after another in a time-pressured managed care setting. At the same time, from the patient’s perspective, emotional withdrawal by a hurried and frustrated physician can easily be experienced as indifference to the patient’s suffering and a perceived abandonment.

Physicians are far from immune to the contagion of pessimism that can sweep through an institutional atmosphere, as in end-of-life care. Physicians who risk being penalized for caring for patients when, in the judgment of an anonymous third-party reviewer, there is no medical necessity to do so, are more likely to succumb to institutional pressures. Careful “not to raise the patient’s expectations” by effectively disclosing all possible options and advocating for the patient’s right to the best available care, they “hang crepe”15 as a prelude to premature discharge. In the extreme, some clinicians will automatically advise the patient and their family that only low-cost palliative measures be taken, not mentioning the more costly, intensive alternatives that may hold out a slim but real hope for the patient.

Such an atmosphere increases the risk that patients and families will give up prematurely while clinicians who are too distracted or time-squeezed to do the hard work of eliciting the patient’s and family’s deeper intentions go through the motions of obtaining informed consent.16,17 At the same time, some physicians react to their loss of autonomy and choice by making a premature cognitive commitment to diagnostic and treatment decision strategies designed to avoid punitive profiling practices. For example, a physician who is concerned about being identified as readily willing to hospitalize a patient for observation and evaluation will tend to avoid the risk of being deselected by the MCO. This avoidance can manifest itself in the doctor-patient encounter as a fixed, overly rigid stance or a reluctance to present alternatives to the patient other than the treatment least likely to engender MCO scrutiny. Such an attitude interferes with the informed-consent process vital to clinical care, and is often a pivot point in liability.

Of course, some denials of benefits by MCOs do represent a genuine effort to weed out unnecessary treatments and excessive costs. Nonetheless, other treatments that are medically appropriate (in that they are effective relative to individual patient values) come to be discounted as medically unnecessary by reference to an interpretation of “medical necessity” that is insensitive to individual patient values18 as well as to broader health-related social values.19

Medically appropriate care is care that is indicated based on the doctor-patient dialogue as informed by scientific research and accepted practice. Ideally, medically appropriate care considers the whole patient.20 By contrast, the term “medically necessary,” as used by third-party reviewers, is a misapplication of triage principles from military and disaster medicine to individual patients.21 Even treating physicians, when compelled to be time-pressured and hyper cost-conscious (as in many fixed-fee per subscriber capitated systems), tend to narrow their focus to overly concrete, readily measurable “necessary” benefits. Easily overlooked in such calculations are the costs of incomplete treatment22 to a patient’s freedom to live in the least restricted manner, as well as the biopsychosocial benefits of treatment that considers the patient’s overall well-being and level of independent and interdependent functioning.

Excessive reliance on managed care-driven “practice guidelines,” in the guise of being evidence-based, is also used to justify a denial of care. Such guidelines are often very selective as to the evidence they cite, as in the paucity of studies with outcome measures that reflect quality-of-life issues or the widespread neglect of many well-grounded outcome studies showing the efficacy of mental health treatment for patients with many medical and surgical conditions. In any case, decision making for patients in the aggregate is no substitute for individualized clinical decision making.

 

Prevention and Management of “Managed Care Side Effects”

Whether or not in conjunction with specialized consultation, a variety of clinical tools are available for prevention and management of the increasing iatrogenic harms experienced as side effects of managed care. To begin with, it is helpful for the treating clinician to keep in mind the complex interactions between medical and psychiatric disorders that are often obscured by various managed care influences, such as the lack of time to take a careful history that is objective and empathic. Although psychiatric consultation or referral is helpful in cases that present special difficulties, it is now less accessible than ever given the restrictions of managed health care.7

Thus, diagnostically, it is now more important than ever for treating physicians to be aware of psychiatric comorbidity within both acute and chronic physical illness. Patient suffering accompanying physical illness can present as depression, “sick role” adaptation, chronic pain, exacerbation of substance abuse or dependence, obsessive or dissociative reactions, and conversion reactions. In a person who has had a life-threatening illness, such suffering can sometimes rise to the level of disorders in the posttraumatic stress disorder (PTSD) spectrum.23

The flip side of the tendency to overlook psychiatric disorders exacerbated by managed care is the tendency to use psychiatric disorders as convenient labels to rationalize the denial of medical care and to neglect the existential dimensions of the patient’s suffering. Thus, it is important not to write off patients in panic as simply hypochondriacal because of time pressure associated with managed care. If a person presents with symptoms similar to those that marked a previous life-threatening illness, the physician first rules out a recurrence of that illness. When there has been a recurrence, any posttraumatic sequelae need to be attended to, even in the face of managed care constraints. These sequelae may include symptoms of depression, demoralization, dissociation, flashbacks (eg, “Oh my God, it is happening again!”), and an increased risk of panic and suicide. It is helpful for physicians to keep in mind that a patient who suffers from PTSD (or other emotional vulnerabilities) is especially susceptible to an exacerbation or recurrence of symptoms.

Even if a recurrence of the illness has been ruled out, the illness may have left a vulnerability in that the emotional memory of its painful and frightening initial presentation may be reactivated simply by the recurrence of general symptoms. There is the possibility of life-threatening complications for the patient, such as depression, panic disorder, and suicide or “suicide equivalents.” The latter may include self-medication of panic by excessive drinking or medication overdoses, or counterphobic risk-taking such as driving under the influence of alcohol. With the threat of illness recurrence, the feeling of being alone and the lack of choice in the managed care situation can increase the likelihood of such self-destructive reactions. The patient’s anxiety may also be amplified by acute somatic symptoms associated with vulnerable body image areas.24

Even when practicing in a time- and resource-restricted environment, with access to psychiatric consultation severely limited for patient and physician alike, treating physicians can be alert to make emotional contact with patients. Physicians can create provisional alliances even when they do not have the usual time and ongoing involvement required for sustained alliance building or for providing psychotherapy per se.25 In creating such alliances, it is important to convey certain understandings and attitudes, as delineated here, in whatever wording comes naturally to the individual physician.

 

Remedies for Each Phase of an Evolving Relationship

In the introductory phase of the relationship, the physician can make contact with the patient while observing the patient for indications of a potential (or hidden) but deep sense of helplessness and hopelessness which accompanies the experience of captivity.13 At the same time, it is helpful to initiate a meaningful dialogue as a first step toward creating a therapeutic alliance and detoxifying feelings of aloneness and abandonment. This step can include engaging in an informed-consent process (not merely a pro forma litany of risks and benefits).4,14 Such a process needs to address clinical and economic risks and potential ethical and role conflicts that might be engendered when a clinician is a dual agent (eg, both a “gatekeeper” and the primary care treating clinician in a capitated system).26 By the same token, the clinician can tactfully but effectively disclose all substantial treatment alternatives, including those not covered by the patient’s health plan.

These disclosures can enable the patient and physician to decide together how to respond to economic restrictions on treatment without the patient being overwhelmed by anxiety and pessimism. Likewise, if it is reasonably foreseeable at the outset that continuity of care will be interrupted by changes in the patient’s insurance coverage, then reminding the patient of how helpful it can be to keep abreast of possible insurance changes will be part of the economic informed-consent process. In our experience, patients can sometimes influence employers’ choice of insurance providers and managed healthcare packages. Subsequently, if a change in coverage is threatened, the physician can support the patient by actively inquiring about how any prospective benefit changes might affect continuity of care.

Given the distrust of physicians engendered by managed care policies,27,28 it is important to sensitively inform the patient of economic considerations such as provider profiling, managed care guidelines, and capitation contracts that may affect the quality of care that the patient receives. Openly acknowledging such dilemmas can enhance the possibilities for a therapeutic alliance. To provide for continuity in sharing uncertainty, it is helpful to articulate questions left open to be addressed in future visits, and to anticipate which questions may arise before the next visit. Such open communication is vital despite the fact that the “gag clauses”29 eliminated as explicit provisions in physician contracts with MCOs may still be implicitly enforced through healthcare provider profiling, economic deselection, and other often hidden rules and procedures.

In the ongoing care phase, the physician can implement treatment with as much continuity and mutual planning as possible while continuing to respond to managed care treatment restrictions in light of the patient’s evolving attitudes and preferences and changing clinical status. Treatment can proceed in a manner that respects the patient’s best interests, including autonomy interests, without being overwhelmed by considerations such as how this will affect the physician’s profile. The physician who needs or wants to apply practice guidelines, as noted above, is also faced with translating what any diagnostic or therapeutic option actually means for this particular patient given the patient’s life history and individual values.

In the event of a denial of benefits, every effort must be made to continue the relationship and avoid abandonment. While the denial of some benefits can reduce the quality of other benefits and the clinical care that the patient receives, it need not result in a catastrophic end to the doctor-patient relationship. For example, even when indicated hospitalization is denied, the physician can work with the patient on an appeal and remain available to help the patient consider the life choices that chronic illness periodically poses.

By working throughout the benefit denial and appeal processes to maintain as much patient confidentiality as possible under the circumstances, the physician can avoid feeling pressured into establishing “secret” manipulative agreements with the patient. An example of such an agreement is selecting, for billing purposes, differential diagnoses that increase the likelihood of receiving managed care benefits. Physicians who feel that their only recourse is to “spin”30 or lie for their patients31 are often expressing the underlying helplessness and hopelessness that they themselves feel. Such secrecy and misalliance based on deceiving the MCO can all too readily undermine the trust necessary for the doctor-patient relationship to be open and healing. The patient may ask, “If my doctor is willing to lie for me, might he/she also be willing to lie to me?” Moreover, a relationship built around secrecy and deception rather than confidentiality and open commitment is vulnerable to a sudden, panicked withdrawal by a guilt-ridden physician, culminating in abandonment.

The termination phase is critically important in any clinical relationship in which an emotional bond has been formed. Prior to the patient’s transferring to another care provider, it is helpful to consider what choices the physician and patient have made together, what other choices they might have made, and how managed care pressures may have influenced those decisions. The physician whose contract is terminated by an MCO can inform the patient of the MCO’s action and coordinate the transfer of care while supporting a patient’s choice to take steps to oppose involuntary termination. If involuntary termination is brought about because the patient’s employer has changed its health plan, the physician can attend actively to both the practical and emotional aspects of termination. The physician need not allow his or her own feelings of anger and frustration toward the MCO to become displaced onto the patient, leading to abandonment via failure to inform patients of the foreseeable consequences of “involuntary” abrupt termination. When the process of saying goodbye is properly attended to, even an involuntary termination can be borne without sliding into an abyss of abandonment and paralysis.

 

Conclusion

We have offered guidelines for prevention and management of observable clinical harms resulting from managed care’s control of choices made by patients and physicians, including anticipated and actual benefit denial and restrictions on care. Medical outcomes are affected not only by the quality of technical care given, but also by the process of care, including patient participation in decision making.32 Denial of choice reduces quality of care in that the patient loses both the psychological benefits of exercising choice and the medical benefits of individualized treatment. Moreover, irrespective of the structure of healthcare delivery, the physician retains a primary duty to advocate for the patient’s interests, including the right to make informed choices based on effective disclosure of treatment options.3 A considered clinical response to managed care constraints can help physicians fulfill this ethical duty to provide effective and compassionate care.

As risk management, attention to the clinical process can also help prevent malpractice liability in the event of a tragic outcome. Both bad medical outcomes, reasonably attributable to MCO-initiated distractions from a clinical focus on the patient’s best interests, and bad feelings arising from managed care restrictions on patient autonomy tend to feed malpractice risk.1 Moreover, attention to the clinical process allows physicians and patients to initiate, proceed with, and terminate relationships appropriately even when each phase of the relationship is subject to substantial external control.

Although clinical intervention is no substitute for instituting fundamental changes in healthcare financing and regulation of third-party control, even today the ethically sensitive primary care physician or psychiatrist practicing in a marketplace dominated by managed care need not feel too overwhelmed to practice effectively on the individual doctor-patient level. By identifying and then preventing or alleviating the negative biopsychosocial side effects of the restriction of available patient choices, a substantial reduction in the clinical complications and liability risks of MCO control and denial of patient choice and care can be achieved.   PP

 

References

1.    Bursztajn HJ, Brodsky A. A new resource for managing malpractice risks in managed care. Arch Intern Med. 1996;156:2057-2063.
2.    Bodenheimer T, Lo B, Casalino L. Primary care physicians should be coordinators, not gatekeepers. JAMA. 1999;281:2045-2049.
3.    Council on Ethical and Judicial Affairs, American Medical Association. Ethical issues in managed care. JAMA. 1995;273:330-335.
4.    Bursztajn HJ, Feinbloom RI, Hamm RM, Brodsky A. Medical Choices, Medical Chances: How Patients, Families, and Physicians Can Cope With Uncertainty. New York, NY: Routledge, Chapman, Hall; 1990.
5.    Watson M, Haviland JS, Greer S, Davidson J, Bliss JM. Influence of psychological response on survival in breast cancer: a population-based cohort study. Lancet. 1999;354:1331-1336.
6.    Levinson W, Gorawara-Bhat R, Dueck R, et al. Resolving disagreements in the patient-physician relationship: tools for improving communication in managed care. JAMA. 1999;282:1477-1483.
7.    Nease DE Jr., Volk RJ, Cass AR. Investigation of a severity-based classification of mood and anxiety symptoms in primary care patients. J Am Board Fam Pract. 1999;12(1):21-31.
8.    Horn SD. Overcoming obstacles to effective treatment: use of clinical practice improvement methodology. J Clin Psychiatry. 1997;58(suppl 1):15-19.
9.    Wyshak G, Barsky A. Satisfaction with and effectiveness of medical care in relation to anxiety and depression: patient and physician ratings compared. Gen Hosp Psychiatry. 1995;17:108-114.
10.    Druss B, Schlesinger M, Thomas T, Allen H. Depressive symptoms and plan switching under managed care. Am J Psychiatry. 1999;156:697-701.
11.    Schmittdiel J, Selby JV, Grumbach K, Quesenberry CP Jr. Choice of a personal physician and patient satisfaction in a health maintenance organization. JAMA. 1997;278:1596-1599.
12.    Pollock GH. Abandonment. In: Rothstein A, ed. The Reconstruction of Trauma: Its Significance in Clinical Work. Madison, Conn: International Universities Press; 1986:105-120.
13.    Bursztajn HJ, Brodsky A. Captive patients, captive doctors: clinical dilemmas and interventions in caring for patients in managed health care. Gen Hosp Psychiatry. 1999;21:239-248.
14.    Gutheil TG, Bursztajn HJ, Brodsky A. Malpractice prevention through the sharing of uncertainty: informed consent and the therapeutic alliance. N Engl J Med. 1984;311:49-51.
15.    Siegler M. Pascal’s wager and the hanging of crepe. N Engl J Med. 1975;293:853-857.
16.    Curtis JR, Rubenfeld GD. Aggressive medical care at the end of life: does capitated reimbursement encourage the right care for the wrong reason? JAMA. 1997;278:1025-1026.
17.    Bursztajn HJ, Brodsky A. Authenticity and autonomy in the managed-care era: forensic psychiatric perspectives. J Clin Ethics. 1994;5:237-242.
18.    Rosenbaum S, Frankford DM, Moore B, Borzi P. Who should determine when health care is medically necessary? N Engl J Med. 1999;340:229-232.
19.    Emanuel EJ, Emanuel LL. Four models of
the physician-patient relationship. JAMA. 1992;267:2221-2226.
20.    Tucker JB. Modification of attitudes to influence survival from breast cancer. Lancet. 1999;354:1320.
21.    Bursztajn HJ, Gutheil TG, Brodsky A. Ethics and the triage model in managed care hospital psychiatry. Psychiatr Times. 1998;15(9):33-40.
22.    Simon G, Ormel J, VonKorff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry. 1995;152:352-357.
23.    Green BL, Epstein SA, Krupnick JL, Rowland JH. Trauma and medical illness: assessing trauma-related disorders in medical settings. In: Wilson JP, Keane TM, eds. Assessing Psychological Trauma and PTSD. New York, NY: Guilford Press; 1997:160-191.
24.    Meissner WW. The self and the body. I. The body self and the body image. Psychoanalysis and Contemporary Thought. 1997;20:419-448.
25.    Meissner WW. The Therapeutic Alliance. New Haven, CT: Yale University Press; 1996.
26.    Miller TE, Sage WM. Disclosing physician financial incentives. JAMA. 1999;281:1424-1430.
27.    Hillman AL. Mediators of patient trust. JAMA. 1998;280:1703-1704.
28.    Grumbach K, Selby JV, Damberg C, et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA. 1999;282:261-266.
29.    Brody H, Bonham VL Jr. Gag rules and trade secrets in managed care contracts. Arch Intern Med. 1997;157:2037-2043.
30.    Illingworth PML. Bluffing, puffing and spinning in managed care. J Med Philosophy. 2000;25(1):62-76.
31.    Freeman VG, Rathore SS, Weinfurt KP, Schulman KA, Sulmasy DP. Lying for patients: physician deception of third-party payers. Arch Intern Med. 1999;159:2263-2270.
32.    Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213-220.

Dr. Meyer is associate in psychiatry at both Beth Israel Deaconess Medical Center and the Program in Psychiatry and the Law at Massachusetts Mental Health Center, and assistant clinical professor of psychiatry at Harvard Medical School, all in Boston, MA.

Acknowledgments: The author would like to thank Dr. Robert Simon for his comments and encouragement and Noreen O’Connor for her editorial assistance. The author reports no financial, academic, or other
support of this work.


 

Abstract

Neither mental illness nor its treatment is clearly separable into either medical and nonmedical components or on the basis of the different mental health disciplines.  Mental health care with multiple clinicians requires the resolution of inherent clinical and professional ambiguities.  Effective clinical care and risk management requires clarification of the individual and interprofessional duties and effective communication between clinicians.  Patient assessment for anticipatable therapeutic problems with multiclinician therapies can help assure therapeutic efficacy and lower clinician liability risks.

 

Introduction

In the current psychiatric world, split treatment has become a fixed part of the landscape. Whether the treatment is termed “split,” “collaborative,” “combined,” “coordinated,” “divided,” or simply “med backup,” the names for this mental healthcare paradigm underscore the ambivalence with which it is often viewed by clinicians.1 At the heart of this ambivalence are the clinical and professional conflicts that pose potential impediments both for quality clinical care and effective risk management. Split treatment is a part of the wider concept of mental health care provided by more than one clinician and across professional divides. Clinicians who practice split treatment must decide how the general conflicts inherent in this treatment paradigm apply to the mental health care of the individual patient under consideration. Only then can the clinician determine whether split treatment is an acceptable clinical option.

 

Potential Benefits and Problems Associated With Split Treatment

In communities that have a shortage of psychiatrists, split treatment increases patient access to psychopharmacology. For patients with mental disorders that call for multimodal treatment unavailable through a single clinician, split treatment may be the only pragmatic method. Furthermore, some patients feel that split treatment maximizes their choices as healthcare consumers by providing access to the greatest range of mental health treatments and treatment providers.

Physicians are familiar with the concept of delegating a portion of medical care and responsibility to another professional colleague.2,3 Practitioners are expected to confine their practice and responsibility to their individual area of expertise. In most medical settings this concept is supported by the separability of the patient’s illness into component parts that roughly correspond to the expertise of the clinician. In the diabetic patient, the endocrinologist attends to the patient’s insulin levels, the neurologist to the patient’s neuropathy, the ophthalmologist to the patient’s retina, and the nephrologist to the patient’s renal function. The primary care physician has the job of holding the clinical center.

However, mental illness is not similarly divisible. Neither mental illness nor its treatment is clearly separable into medical and nonmedical components or on the basis of the different mental health disciplines.4 While prescription refills are clearly medical, drug compliance is not. Though many drug side effects may be purely medical, a patient with mania secondary to antidepressant treatment requires both medical and psychotherapeutic intervention. Also, a depressed patient whose depression has worsened or who has become actively suicidal requires both medical and therapeutic intervention. Added to the difficulty of parsing out which clinician should be responsible for which aspect of the patient’s care is the fact that the split treatment fraction of the mental health treatment population is the sickest.

We know that a team of two or more clinicians requires more administration and communication than a single-clinician practice. Clinicians comprising a treatment team have less authority individually than if each were to conduct the therapy alone. The question of authority is further complicated by the frequent absence of an internal hierarchy or reporting relationship for the split-treatment team.

Psychiatrists and their mental health colleagues who practice split treatment are faced with clarifying their respective and shared clinical duties with the most severely mentally ill, with an illness that does not lend itself to being divisible along professional lines, and within a team that may lack a formal hierarchy and reporting structure. Another level of complexity may be introduced by the presence or absence of formal policies from a clinic or hospital.

Added to the clinical and professional ambiguities of split treatment is the concern that split treatment may increase liability exposure for the psychiatrist.5 Psychiatrists who participate in split treatment have the potential to see greater numbers of more severely ill patients than they could if they were singly responsible for all facets of the patient’s psychiatric care. Patients in split treatment often have more serious or treatment-resistant mental illnesses.  These two factors taken together would seem to confer a greater exposure to negative clinical outcomes compared to a psychiatrist who does not deal with split treatment.

 

Clinical and Risk Management With Multiple Mental Health Clinicians

Mental illness and treatment are not separable into respective professional specialties. Therefore, a psychiatrist and psychotherapist must create a treatment plan in which each clinician can answer the following questions:
• What is my clinical competence and duty to the patient?
• What is my relative clinical autonomy?
• What are the areas of clinician interdependence?
• Is there any specific agency or legal statute that has bearing on the treatment being offered to the patient?

Answers to these questions should incorporate available guidance from published reviews,4,6-8 professional ethical standards,2 and, where available, legal decisions or statutes pertaining to psychiatric practice.

Psychiatrists are always responsible for determining the scope of the psychiatric examinations that they perform. Patients, collaborating clinicians, and healthcare agencies may each have their own reasons to circumscribe initial clinical contacts. However, a psychiatrist cannot delegate the responsibility for that decision to anyone.2 It is unethical to medicate a patient whom the psychiatrist has not directly examined.9,10 There may be patients with whom a more circumscribed examination is clinically justified; a psychiatrist can weigh the immediate clinical benefits against the risks of not discovering what he/she may never have the opportunity to know or ask.

The clinical agency within which a mental health treatment has occurred, such as a hospital or clinic, can also have enormous impact on the liability risks for clinicians who are collaboratively providing mental health treatment. Agencies typically have policies that affect the professional credentialing, supervision, quality assurance, standard clinical assessment, and emergency clinical assessment for the care of patients. Violation of the agency’s accepted protocol is disastrous for risk management. In view of this, policies should not set unrealistically high standards that in practice cannot be followed.11

 

The Consultation

Perhaps the most narrowly delimited request for interprofessional collaboration is a psychiatric consultation. In this case, the patient is being treated by a therapist who is qualified through training, experience, and independent licensure. The psychiatrist is responsible for making a clinical assessment, collecting an adequate clinical database, and forming and communicating a professional opinion to both therapist and patient.

The psychiatrist should believe that the therapist is capable of handling the patient’s treatment. Psychiatrists should not perform consultations for therapists who do not have the necessary training, experience, and license, even if this conflicts with a patient’s choice of provider (eg, alternative therapy). It is unethical for any physician to participate in treatment with a clinician whom he or she believes to be unfit to manage a patient.12

Importantly, the psychiatric consultant does not assume any ongoing care for the patient or supervision of the treatment. The consultant’s only authority is over the opinion offered, and not whether its recommendations are followed. Both patient and therapist need to understand that the consultation does not represent continuing participation in the patient’s care. A consultation is the least ambiguous collaboration between clinicians because there are no shared clinical duties. A consultation is a time-limited event, not an indeterminate clinical process.

 

Ongoing Collaboration Between Independently-Licensed Clinicians

The most common form of split treatment is a collaboration involving “a mutually shared responsibility for the patient’s care.”2 As in a consultation, the psychiatrist should have a basis to believe that the nonphysician therapist is qualified by training, experience, and licensor to make the anticipated clinical judgments and interventions. Both clinicians have a responsibility to ask for and provide this professional information. It is also advisable for both clinicians to verify that each has adequate malpractice insurance. In the event of a bad clinical outcome and one underinsured or uninsured colleague, a liability action will seek the deeper pocket.

The two clinicians must agree upon the basics of the patient’s diagnosis, the anticipated therapies, and the risks that derive from the patient’s diagnosis and treatment. The major sources of clinical risk—suicide, violence, other types of impulsivity, worsening of the patient’s clinical condition, diagnostic uncertainty, and deterioration of the relationship with the patient—should be discussed to anticipate what response, if necessary, would be initiated and by whom.

Several of these issues have been the subject of excellent reviews.13-15 It is important to remember that risk assessment is an ongoing process concurrent with clinical care. It is not a one-time event. Most patients in split treatment have diagnostic factors that increase their statistical risk of suicide. Some of these patients have multiple risk factors such as a diagnosis of an affective or psychotic disorder and concurrent chronic pain, substance abuse, or history of (self) destructive behavior. Feelings of paranoia, humiliation, anxiety, or agitation are emotional springboards to behavioral enactment for patients already at risk.

Assessment of psychological and environmental mitigators of risk are equally important. Patients can be asked to articulate what events or relationships they view as important positive factors or attachments in their future. These factors can help a patient persevere through a serious illness. They can also be reassessed during the progress of  the treatment to clarify whether they still retain the same positive meaning for the patient.

Many clinicians will indicate that their patient has “contracted for safety”; sometimes the patient has already signed an actual document. Contracting for safety evokes the concept of a legally-binding agreement or promise between patient and clinician, and offers a false sense of security to both individuals. A patient may have believed what he/she signed, only to not believe it after leaving the doctor’s office. A patient’s belief that he/she is safe is simply one factor of, and not a substitute for, risk assessment.

Risk assessment involves a judgment of the patient’s vulnerability at the time of the examination and a hypothesis about the patient’s anticipated level of function in the immediate and intermediate future. In formulating the hypothesis, the clinician needs to evaluate the patient’s capacity to self-monitor and  communicate information to treating clinicians. Initiating this discussion can begin with asking the patient, “How would you know if things were getting worse?”

Most worrisome are historically impulsive patients with little capacity to notice whether they are deteriorating and those who are psychologically inhibited or unmotivated to collaborate with others about their distress. Risk management for these patients involves helping them foster conscious awareness of high-risk situations, premonitory signs of deterioration, and potential ameliorating responses. As an interim measure, clinicians may find it helpful to articulate concretized potential indicators of psychological deterioration and then construct a series of predetermined responses for the patient.

Certain issues of risk management are unique to split treatment. Both clinicians need to be aware that they have independent and interdependent duties for ongoing risk assessment. Psychotherapists will have more frequent opportunities. Psychiatrists and psychotherapists will be privy to different types of information from the same patient, partly based on the different relationships and partly on the different focus of inquiry for psychopharmacology and psychotherapy. Both therapists have the responsibility for sufficient direct examination of the patient consistent with the patient’s clinical status. Both therapists have a responsibility to let the other clinician know about any substantive change in the patient and/or treatment.

Clinicians should verify with each other their customary practices for emergency coverage during and after office hours and on weekends, holidays, and vacations. Both clinicians can increase their clinical efficacy and risk management by clearly showing the other clinician that they are easily accessible and want to be contacted for significant developments. Successful split treatment involves the development of a responsive system for sharing information. Clarity is the best counterweight to destabilizing clinical and interprofessional ambiguities.

 

When Split Treatment May Not Be Appropriate

Split treatment is not for every patient. Methods of clinical risk management notwithstanding, part of good clinical practice and good clinical risk management involves patient selection. Therapists who participate in split treatment can review the kinds of clinical issues that may make an alternative treatment modality preferable for a particular patient’s care. Some patients with severe character pathology are especially intolerant of strong or ambivalent emotions. Their capacity for projection, splitting, and projective identification may be unwittingly fostered by having two therapists between whom they can parse out polarized but unintegrated pieces of their experience. Patients with this sort of character problem will be better served with a single individual who possesses the right composite of therapeutic skills. The same can be said of patients who have had a history of strong negative transference reactions.

Rapid-cycling bipolar patients may pose a particular strain for split treatment due to the expectable reassessments and interventions that the two therapists will need to discuss and implement. The split-treatment team may find itself unduly burdened having to allocate large amounts of unreimbursed time for interprofessional communication. Split treatment of bipolar depression may pose some of the same risks because many of the drug treatments involve the risk of the patient switching over into mania.

Other clinical issues can increase the amount of patient oversight and discussion, thereby increasing the burden to the split-treatment clinicians. Treatment resistance, dual diagnosis, multiple or off-label drug regimens, or a history of impulse disorder could be relative contraindications to split treatment.

All psychopharmacology involves psychotherapy. A patient’s feelings of transference do not observe the professional division of duties that a psychiatrist and psychotherapist may have constructed in a split treatment. Psychiatrists who are acting as psychopharmacologists can anticipate that their short sessions with a patient will be sufficient for the development, but not the analysis of transferential feelings. The short sessions can also be an unintended problematic repository for a patient’s splitting off a part of the polarized ambivalent feelings that have developed in a psychotherapy relationship.

The psychiatrist in a split treatment team can be prepared to make comments that can identify and clarify the appearance of transference as a segue to referring the material to the psychotherapist, where it can be more fully explored. Patients who have a history of intensely ambivalent or mercurial transference relationships may not be appropriate for split treatment. These patients, in the midst of experiencing intensely positive or negative feelings toward a healthcare provider, may unwittingly play one clinician against the other to the detriment of their own care.

Psychiatrists may find it useful to ask patients about their experiences in other treatment relationships to anticipate some psychological responses to the current treatment. Patients who have felt shame or anger in response to feeling dependent may view taking medication and having a medication doctor as a similar narcissistic wound. Patients who have a history of idealizing important relationships may bring that same capacity to their experience of psychotropic drugs and having a psychopharmacologist.

Managed care organizations regulate access to treatment benefits. Treatment authorization and appeals processes represent additional unreimbursed administrative requirements for clinicians in a split treatment team who may already feel overextended by the time required for interprofessional collaboration about the patient. Notwithstanding these burdens, clinicians continue to have a duty to the patient’s welfare independent of the actions of a managed care organization.16 In the face of treatment authorization denials and in the absence of being able to make alternative fee arrangements, the clinician must make a good faith effort to arrange for other affordable mental health care for the patient.

 

When Split Treatment Does Not Work

Sometimes a split treatment proves unworkable. For example, the match between the two clinicians is poor, the patient’s illness is too thorny, the two clinicians have diagnostic or therapeutic differences that cause strategic conflicts in patient management, or the patient’s relationship with one of the clinicians has deteriorated.17,18

Clinicians should not be bound to a treatment that no longer meets their own standard of care regardless of whether or not the treatment conforms to the standards of some practitioners in the community. A clinician should respectfully resign from the treatment in a time frame that allows the patient and the other clinician to make appropriate arrangements. The patient’s best interests should guide which clinical misgivings or disagreements between clinicians are disclosed directly to the patient.8

Patients may want to change their therapist or psychopharmacologist during the course of their treatment. While the patient has that right, patients may be unaware that the remaining treating clinician cannot automatically agree to work with whomever the patient has chosen. The remaining clinician has the right and the responsibility to make an informed choice regarding whether or not the successor clinician will be acceptable in the newly configured split-treatment team.

 

Supervisory Collaboration Between Clinicians With Dependent Licensure

In some settings a psychiatrist may collaborate with another mental health professional who is licensed to work only with concurrent psychiatric supervision. A psychiatrist who supervises a psychiatric resident, medical student, or a psychology or social work trainee is working with a colleague whose license for clinical activity legally requires the participation of the psychiatrist. For some clinicians with dependent licensure (eg, a clinical nurse specialist), the type and frequency of psychiatric supervision may be specified by law.

In the case of concurrent care of a patient with a mental health professional trainee, the psychiatrist delegates and supervises in accordance with the abilities of the trainee. The psychiatrist retains some responsibility for the patient’s care, including that portion that was delegated. In one of the most famous malpractice suits in psychiatry, Tarasoff v Regents of California,19 the attorney for Tarasoff commented thus:

It is my view that if (the supervisor of the clinic) had personally examined the patient Poddar and made an independent decision that the patient Poddar was not dangerous to himself or his victim—Titiana Tarasoff—there would be no cause of action based upon foreseeability. However, (the supervisor) never saw the patient Poddar and ignored the medical records developed by his staff.

A similar sentiment was articulated in the sentinel case Cohen v New York,20 in which an inpatient under the care of a psychiatric resident left the unit and committed suicide. The court commented:

The treating physician did not, at this point in his medical career, possess the requisite skill or trained psychiatric judgment to, essentially unsupervised, provide ordinary and reasonable care to this decedent. There was not one but many errors of judgment made by a doctor not qualified in an unsupervised status to make a judgment; made by those in a supervisory capacity; and all made without careful examination.

Psychiatrists who supervise mental health clinicians with dependent licenses can assign their colleague a clinical task in the patient’s treatment, but they cannot assign the responsibility for the supervisory decisions. Those supervisory decisions should be informed by the training, experience, and individual competence of the trainee and by the clinical difficulties of the patient and the treatment.

 

Educational Supervision of Independently Licensed Clinicians

Psychiatrists who supervise the work of clinicians who are licensed for independent clinical activity have a reduced responsibility for the clinical work they are supervising. Often in mental health, the term “supervision” indicates an educational activity that does not include managerial authority for oversight, direction, and control of those being supervised. A psychiatrist who educationally supervises an adequately trained, independently-licensed clinician can reasonably expect that the therapist, not the educational supervisor, is the ultimate decision maker regarding the patient’s treatment.

In reviewing a complaint of negligent supervision in a claim brought by a patient against her therapist’s supervisor (Schrader v Kohout),21 the court focused on whether a doctor-patient relationship legally existed, commenting, “There could be no liability of malpractice in the absence of physician-patient relationship.” The court noted the following facts about the treatment and its supervision:  the patient and supervisor had never met; the supervisor had been paid by the therapist and not by the patient; the therapist testified that she had made all the treatment decisions; the supervisor had no access to the patient or the patient’s records; and the therapist controlled the flow of clinical information to the supervisor. The court found that there was no physician-patient relationship between the patient and the therapist’s supervisor and thus decided for the supervisor and against the patient.21

The court’s view of this legal question might not have been the same in a somewhat different clinical setting. The supervisor and therapist in Schrader v Kohout were in private practice. Had they both worked for the same outpatient clinic, the supervisor might have had authority to direct the therapy and access to both the patient and her records. Furthermore, if the supervisor were reimbursed by the clinic from funds the patient had paid for her treatment, the supervision might be legally viewed as a part of the treatment. Psychiatrists who supervise should consider these factors as they assess their liability exposure for activities that they may view as educational rather than clinical.

 

Promoting Interprofessional Clarity and Cooperation

Mental health treatments involving more than one clinician present enormous opportunities for clinical ambiguity and professional misalignment. Comprehensive assessment at the initiation of a split treatment can protect against many downstream clinical and liability risks. The depth of assessment of a colleague’s skills depends on the type of treatment collaboration, the responsibility that one clinician has for the other’s activities, and on the patient. Assessment can be difficult in the absence of reviewing a colleague’s actual work. However, some easily accessible information can aid in the assessment of a colleague’s skills:
• Is the colleague able to clearly represent the clinical data?
• Is the history coherent?
• Can the colleague reconstruct what was directly heard and observed in the office?
• Having been able to represent the clinical data, can the colleague make interpretive hypotheses based on that information?
• Has a phenomenologic diagnosis been made?
• Has a psychodynamic formulation been made?
• Can the colleague identify and understand transference and countertransference as it may manifest itself with the individual patient?
• Has the patient’s treatment and an overview of therapeutic interventions been formulated?

The answers to these questions can often be derived from initial discussions about the patient and can help guide any type of interprofessional collaboration.

Once the initial evaluation of a patient is complete, the greatest enemies of effective interprofessional collaboration may be clinician anxiety and shame and the resultant chilling of effective comminution. All clinicians worry that clinical uncertainty may lead to a loss of clinical authority and professional reputation. Discussion between colleagues of a patient’s negative transference or a therapist’s countertransference frequently raises concerns of revealing too much about one’s own psyche and of being pathologized by the collaborating clinician.22 Members of a split-treatment team can help counter these risks by making themselves easily available to colleagues and creating a climate where clinical uncertainty can be disclosed and discussed.

Clinicians who communicate an attitude of interest and shame-free tolerance toward their colleague’s uncertainty will foster the kind of open communication of new clinical data that is essential to a good working relationship. Clinicians should actively resolve clinical uncertainty or developing interprofessional conflicts. These conflicts are sometimes mistakenly deferred to a later time when it is hoped that the colleagues might have more of a professional working alliance. True alliances may evolve over time if founded on a working relationship that  can contain and resolve interprofessional clinical conflicts rather than avoid them.

 

Conclusion

In 2002, mental health clinicians have increasingly sophisticated interventions to treat mental illness. Mental health care that requires coordination of multiple clinicians is being promoted by a variety of forces: consumer choice advocates, public health services, and managed care organizations. Such coordinated care may offer more treatment combinations. Whether or not these combinations ultimately provide clinical and financial benefits, mental health care with more than one clinician has inherent clinical and administrative ambiguities. Those ambiguities need to be considered in light of the individual patient’s needs to clarify whether coordinated mental health care with multiple clinicians will pose insurmountable or soluble clinical and risk management dilemmas.   PP

 

References

1.    Goldberg RS, Riba M, Tasman A. Psychiatrist’s attitudes towards prescribing medication for patients treated by nonmedical psychotherapists. Hosp Community Psychiatry. 1991;42:276-280.
2.    Guidelines for psychiatrists in consultative, supervisory or collaborative relationships with nonmedical therapists. Am J Psychiatry. 1980;137:1489-1491.
3.    American College of Physicians. Ethics manual. Fourth edition. Ann Intern Med. 1998;128:576-594.
4.    Meyer DJ, Simon RI. Split treatment: clarity between psychiatrists and psychotherapists. Part 1. Psychiatr Ann. 1999;29:241-245.
5.    Macbeth JE. Legal aspects of split treatment: how to audit and manage risk. Psychiatr Ann. 2001;31:605-610.
6.    Appelbaum PS. General guidelines for psychiatrists who prescribe medication for patients treated by nonmedical psychotherapists. Hosp Community Psychiatry. 1991;42:281-282.
7.    Sederer LI, Ellison J, Keyes C. Guidelines for prescribing psychiatrists in consultative, collaborative and supervisory relationships. Psychiatr  Serv. 1998;49:1197-1202.
8.    Meyer DJ, Simon RI. Split treatment: clarity between psychiatrists and psychotherapists. Part 2. Psychiatr Ann. 1999;29:327-332.
9.    American Psychiatric Association. The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Washington DC: American Psychiatric Association Press; 1998.
10.    APA condemns Kaiser prescribing policy. APA Press Release No. 0012. April 14, 2000.
11. Meyer, D. The psychiatrist as supervisor: risk management issues. Rx for Risk. 1997;3:1-8.
12. Council on Ethical and Judicial Affairs. Code of Medical Ethics. 1998-1999 ed. Chicago, Ill: American Medical Association; 1999.
13. Simon, RI. Taking the “sue” out of suicide: a forensic psychiatrist’s perspective. Psychiatr Ann. 2000;30:399-407.
14.    Jacobs DG, Brewer M, Klein-Benheim M. Guide to Suicide Assessment and Intervention. San Francisco, CA: Josey-Bass; 1999.
15. Miller MC. A model for the assessment of violence. Harvard Rev Psychiatry. 2000;7:299-304.
16. Wickline v State, 192 Cal App3d 1630, 239 Cal Rptr 810 323 (1986).
17.    Ellison J, Smith J. Intertherapist conflict in combined treatment. In: Ellison J, ed. The Psychotherapist’s Guide to Pharmacotherapy. Chicago, Ill: Year Book Medical Publishers; 1989:96-115.
18. Busch FN, Gould E. Treatment by a psychotherapist and a psychopharmacologist: transference and countertransference issues. Hosp Community Psychiatry. 1993;44:772-774.
19.    Slovenko R. Legal issues in psychotherapy supervision. In: Hess AK, ed. Psychotherapy Supervision: Theory Research and Practice. New York, NY: John Wiley & Sons; 1980:468.
20. Cohen v State, 51 AD2d 494, 382 NYS2d 128 (1976).
21. Schrader v Kohout, 522 Ga App 134, SE2d 19 (1999).
22. Jacobs D, David P, Meyer D. The Supervisory Encounter. New Haven, Conn: Yale University Press; 1995.

Dr. Goldwater is a psychiatrist in private practice in Boston, MA.

Acknowledgments: The author reports no financial, academic, or other support of this work.


 

Abstract

In the managed care era, the physician-patient relationship is clearly under distorting economic pressures. Greater awareness of relational factors can aid physicians in forming solid relationships despite those constraints and can provide compassion as well as achieve liability prevention through understanding the broader dynamics of intimate relationships.

 

Introduction

The ancient and honorable doctor-patient dyad has by now thoroughly dissolved into algorithms of medical economic data. Washed away as well in the data stream is the distinction between the two complementary elements of health “care”: treatment and healing.

Treatment refers to the application of technique; healing refers to a body’s reparative responses to illness or injury. Many assume and a lot of evidence supports the notion that patient-physician psychology affects healing, at least indirectly, by fostering a patient’s willing cooperation with treatment. However, managed medicine allots precious few moments in which to establish a physician-patient alliance sufficient to support healing. Therefore, the medical new world order may be said to manage “health” or “health treatment” rather than health “care.”

The physician-patient alliance is also, and not coincidentally, the best protection for conscientious practitioners against the frivolous perception of malpractice. Patients may easily feel alienated from physicians who seem uninterested in them and unmoved by their plights. Some of these patients may be moved to file lawsuits in order to reclaim the human recognition of which they feel deprived by managed medicine. As Alan Stone1 wrote:

By bringing competitive market forces into medicine, managed care has demonstrated that the right financial incentives can reverse a century of rising professional standards and make health care just another mean and lean downsizing industry…. Market forces have inevitably had a devastating impact on traditional medical ethics, which is rooted in the doctor-patient relationship…. Patients cannot sue a [managed care] plan for damages even if its protocols, restrictions, and incentives clearly caused them harm. They can still sue doctors and hospitals, but not the [managed care] organizations….

Economists think this is just fine. A healthcare economist, while a psychotherapy patient, reminded a colleague several years ago of the conventional wisdom that underlies managed medicine: “The traditional physician does not really treat patients. We can show statistically that what physicians do is determined more by the effect of treatment on physician income than by what might actually treat an illness. Anyway, in general, it is the prevention of illness in the population, and not the medical treatment of individuals, which mostly improves overall life expectancy.”

To reconcile our sense of physician role with the forces of medical economics and to protect ourselves as best we can from the impatient, litigating mind, we must face a conceptual as well as a practical problem. Economic models cannot account for or describe an alliance such as that between the physician and the patient, because economic transactions are at best zero-sum. As a result, economic transactions are intrinsically adversarial.

Newtonian laws describe the dynamics of motion as actions and reactions, or equal and opposite exchanges. These actions and reactions balance each other so that overall there is no net change. In perfectly Newtonian style, microeconomics describes fair exchanges of goods and services for money. Just as in the interaction of bodies in motion, in an economic transaction there can be no net change. One gains only as the other loses. Hence, economic modeling, inherently, can only promote adversary psychology and not alliance psychology. In zero-sum transactions, therefore, there can be no “alliance” in which both parties may gain or conspire together against an outside force, such as an illness.

When physicians are employees of “macro” economic corporations, the situation is worse for alliance psychology than is “zero-sum.” Working for a corporation, a physician employee’s duty is first fiscal—to create “surplus value” that may pass along the corporate, alimentary canal toward the coupon clips of shareholders. The ethics of personal treatment must yield to the necessity of profitability.

To promote the physician-patient alliance as necessary for both proper care and litigation prevention, we must encourage new thinking.

First, we shall briefly recount the foundational mythology of the physician as healer. Then, we shall present a model of the stages of identification between physician and patient, which are the same as may describe the development of any intimate relationship. These stages will imply steps physicians may take to enhance their perception as compassionate healers. Finally, we shall consider how the mathematical abstractions of medical economics may be transformed, at least metaphorically, so that they may take the need for healing into account.

 

The Physician as Healer

The association of treatment and healing appears in the relationship between Asclepius and Chiron, which represents the mythic basis of Western medicine.2

In Greek myth, Asclepius was the first physician. His familiar symbol is the caduceus, an insignia in which a snake coils around a staff. Asclepius was a son of the god Apollo; Apollo rescued Asclepius from his unfaithful mother’s womb as she lay on her funeral pyre and gave the infant to the centaur Chiron, who taught Asclepius the skills of medicine. These skills included the ability to revive the dead—an art which Asclepius practiced with notable success. Hades, god of the underworld, complained to the chief god, Zeus, about this feat. Zeus, fearing that the practice of resurrection would upset world order (Asclepius was acting without managed care authorization), killed Asclepius with a lightning bolt.

A rarity among the nasty lot of centaurs, Chiron was a compassionate and loving individual; a veritable male mothering figure. Among the immortal Chiron’s other wards were the classic heroes Achilles and Jason.

Herakles (Hercules), in a battle with centaurs, accidentally but painfully and incurably wounded Chiron with an arrow. To end his eternal pain, Chiron gave away his immortality and exchanged places in the underworld with Prometheus, the divine, prime benefactor of humanity in Greek myth.

The story of Chiron and Asclepius leads us meaningfully to the story of Prometheus, a son of Zeus but a representation of human individuality.

Prometheus, as mentioned, was the chief benefactor of humanity in Greek mythology. In some stories, Prometheus actually creates humanity. He was a trickster who outwitted Zeus and stole fire from the gods to bestow upon humans. In response, Zeus punished Prometheus horribly. Eventually, Herakles rescued Prometheus from Hades by offering the suffering Chiron to Zeus in his place.

Taking Prometheus as one punished for the “original sin” of individuality, which means using one’s wits against authority, the stories of Chiron, Asclepius, and Prometheus prefigure the founding story of Christianity. The suffering Chiron redeems humanity from death by giving up his immortality in favor of Prometheus. Chiron suffered and died for our sins, redeeming humanity from hell.

These stories also hint at a modern psychology of medical healing consistent with our larger culture, as if to suggest that every physician needs to be like what some would call “Doctor Jesus.” Without the sense that a physician, to some extent, can share one’s suffering, even the ability to raise the dead is insufficient health care.

However, a culture of compassion cannot easily arise in a managed treatment environment. The managed care organization cannot represent itself as the wounded healer, despite any advertising campaign. Most concretely, and especially because patients cannot sue them, managed care corporations cannot be vulnerable to patients.

The following sections present a brief course in psychology as it applies to the physician-patient relationship.

 

The Developmental Psychology of Physician-Patient Relationships

The single characteristic word without which there is no such thing as psychology is identification. Most fundamentally, identification refers to the assignment of what one perceives to a category or type. Thus, one may identify a flying object as a bird, or an antique chair as a Louis XIVth. In psychology, one identifies types of other people as distinct from oneself by the roles they play in one’s mind—starting with “mother,” and moving on to “father,” “sibling,” and “physician”—and maybe also on to such prejudicial types as “villain,” “terrorist,” “blond,” or “queer.” As one matures, one moves from “identifying others as,” to “identifying with others as.” A sense of mature, healthy self arises from the sum of the roles one plays for those others with whom one identifies.

However, in social terms, “self and other” are often indistinguishable from “innocent versus guilty,” as though some people may be guilty simply of being different from oneself or of not being “like us.” It is interesting to note that to “categorize” derives from the Greek root word “kategoria,” meaning “accuse”; the Hebrew root “KTG” also means “accuse.”

The identification of others as types of people different from oneself thus likely precedes the development of identification with others as fellow members of the same category or type. Eventually, one may grow to realize that one is a person, and that one’s parents are also people, but likely not more quickly than parents may realize that their children are distinct and separate people from themselves.

 

“Stages” of Healing

I propose that there are four developmental stages of psychological identification leading to the separation of a child from his or her family as a whole, intact being, as which one may identify with others as beings very much like oneself. I find these stages more or less in operation over the course of any intimate or loving relationship, and I refer to them as I explain marital difficulties to couples whom I treat in psychotherapy. The four stages are:
Idealization (how an infant perceives a mothering parent, and the parent’s total power to gratify or destroy);
Mirroring (by age 2 years, how a small child must perceive his or her parents, as they may actually relate and respond to the child with compassionate understanding);
Internalization (by age 3 years, as a child starts to retrieve the idealized and mirroring attributions from one’s parents and works to internalize them to be able to perform these functions for oneself);
Separation (by age 6 years, as a child goes off to school, beginning to function as oneself).

The four stages repeat themselves with the onset of puberty and adolescence, and several times subsequently over the life cycle. Healing seems to develop within the physician-patient dyad in just this sequence.

First, just as a small infant must idealize parents, a patient must have “faith in” or otherwise “idealize” his or her caretakers. Physicians may “idealize” themselves in simple ways—for example, by wearing white coats, hanging credentials discretely on their office walls, and perhaps by occasionally clucking wisely. Regardless of such made-for-television role playing, a physician must attract confidence in and respect for his or her competence and good intentions. Sufficiently idealized figures may impart a mighty placebo effect: they can make one “feel better” simply by being present at the bedside.

Mirroring exists when a subject sees him or herself reflected back in another’s understanding; mirroring makes one feel that he/she exists within the consciousness of the “mirroring object.” By age 2 years, every child requires such mirroring because of the newly discovered power to displease parents during potty training. The subjective patient develops in the dyadic relationship with the idealized physician only as the physician “object” can “mirror” the patient, which means the physician must deal well with what the patient may feel upset about.

Thus, in the second stage of healing, patients and their families will need physicians to help them comprehend and accept what is happening. A physician must not fail to communicate a sympathetic understanding of the patient’s condition and experience.

In wholesome childhood development, a child internalizes both the idealized and mirroring images of the parents in the creation of an “ego,” or stable point of view. By internalizing functions formerly attributed to the parents, a child comes to be able to idealize, understand, and accept oneself.

In the third stage of identification as it applies to “healing,” a patient must be able to “internalize” his or her caretakers as ideal (providing treatment) and mirroring (providing compassion) so that the fourth stage of psychological “separation” from treatment may occur. The fourth stage implies the developing capacity to survive both the illness and the treatment, with minimal posttraumatic disruption.

In the first idealized stage of identification, caretakers are perceived as omnipotent, as “above” oneself. In the second stage, caretakers are perceived as suffering servants, as “below” oneself. This distinction exists in traditional societies as the difference between “fathering” and “mothering,” and in traditional medicine as the rank distinction between physician and nurse. In today’s medicine, the functions of various practitioners are more ambiguous. In the absence of the traditional reassurance of clear roles as related to clear ranks, especially with the reduction of “physician” to “provider,” careful attention must be paid to how one interacts with the patient, less the patient be reduced to merely a “client” or a “customer.”

In developmental psychodynamic psychology, the inability to unify “idealized” and “mirroring” figures accounts for a multitude of sins, including the psychopathology of many mental and personality disorders.

However, it is the failure to mirror which most of all accounts for the psychology of many malpractice suits, and not so much the disappointment in idealization one would expect as a consequence of presumed incompetence. The natural history of any intimate relationship (including marriage) will pass through the four stages of identification. It is predictable that any important relationship will begin with idealization and pass on to the need for mirroring once the “honeymoon” of idealization is over. Unless the relationship with a patient includes adequate mirroring, the inevitable fall of the physician from the pedestal due to his or her crumbling feet of clay will be truly shattering.

For internalization to take place in the healing process, and for separation to take place from the healing process, physicians and other caretakers must be able to play the compassionate “healing” role. The patient must not simply imagine or infer a physician’s compassion. The physician must feel it and know how to convey that feeling to the patient.

 

Conveying Identification

How can the physician convey his/her “identification” to the patient? What can one do with moments to spend? The four stages of identification may suggest specific salutary actions.

The physician must be able to be idealized, meaning that he or she must appear prepared, calm, organized, methodical, and knowledgeable.

At the risk of being simplistic, I suggest first that a physician review a patient’s chart—and pause long enough to allow the chart information to settle in the brain—before entering the examining room. One must not appear rushed. By not needing to refer to the chart during the examination to recall information such as the patient’s name, a physician will demonstrate simple courtesy and, more importantly, will model internalization. The physician will have “internalized” the patient sufficiently for him/her to be perceived as mirroring the patient; the physician will appear “to care.”

The physician must actively demonstrate mirroring; the physician must convey interest in the patient’s fears and hopes. One must ask the patient what he or she may fear, and demonstrate foreknowledge of what the patient may expect. A physician must provide reasonable access to follow-up conversations (eg, via telephone or e-mail).

Avoid relying on general questions such as, “Anything else I should know?” Be sure to find something important about which to ask follow-up questions. Ask the patient to refine or go deeper into a matter that he/she has brought up. Running down a list of symptoms does not necessarily demonstrate interest in the patient.

The physician must support internalization, which includes taking the time to discuss how a patient may follow his/her treatment instructions. Leave nothing about treatment to the patient’s imagination. Follow-up appointments during which the physician exhibits recollection of the patient are very important. Signs of internalization predict a wholesome separation from treatment, rather than a resentful and disappointed abandonment.

Among the signs of internalization leading to a successful separation from treatment is sticking to a regimen. Are prescriptions filled? Is diet improved? What are a patient’s supports? Does the course of illness threaten the well-being of a spouse?

 

Conclusion: A Lesson in Compassion From Modern Physics

I offer these stages of identification in the healing relationship specifically to argue for attention to patient care in a manner not to be dismissed as sentimentality. Were there time and space, I would continue this argument into the very nature of scientific perception.

I can say no more than this. It is widely understood that the quantum physicists of the early 20th century revised the notion of scientific objectivity, which previously theorized an absolute distinction between an observer and what could be observed. The new physicists realized the importance of the fact that nothing can be measured without affecting what is measured. While the amount of air released from a tire to measure its pressure does not importantly alter the remaining pressure in the tire, observing an object on an atomic scale or smaller does radically affect it. As a result, for example, one cannot measure both the position and the momentum of an atomic object at the same instant. Insofar as an object has position, it is a discrete particle fixed in time and space at the instant of its observation. However, insofar as an object has momentum, it is in motion, and so cannot have any specific position—as though it were a wave.

So, objects on the atomic scale as “wholes” must be perceived not as made up of objective properties existing all at the same moment, but as made up of complementary properties impossible to measure simultaneously. The resulting picture at any given moment of any atomic or subatomic object as a whole resolves only into a blur of uncertainty.

This 20th century “Uncertainty Principle” explains the world as we must participate in it producing paradoxes as we go, rather than as we may “objectively” observe it. The statistical mathematics of the Uncertainty Principle measures exactly how uncertain one may be in a given situation.

Observations on the atomic scale, therefore, reveal the wave-particle duality of matter and energy, in which entities sometimes seem to behave as discontinuous particles, and at other times as continuous waves. However, the larger the scale of the observation, the more the behavior of objects of matter is particle-like, and the less such behavior is wave-like. By the time an object reaches the size of a golf ball, there are no discernible wave properties, except as a ball may seem to move out of the way as one swings at it with a club.

Physical and social scientists mostly perform macroscopic, objective studies, summing the interactions of hosts of presumptive particles, which may just as well be either molecules of air, or human voters or consumers. We physicians work more as molecules within the population balloon than as social scientists measuring overall effects from outside of the balloon. Operating as we do at the atomic scale of human intimacy, as far as the economists looking at us are concerned, we physicians and patients exist in the difficult to imagine domain of wave-particle complementarity.

Healing and treatment are the complementary aspects of health care at the physician-patient micro level.  Treatment phenomena, all of which may be described as provider-consumer interactions, may very well add up to follow macroscopic, economic laws. In such interactions, there is no qualitative difference between the parties—provider and consumer are simply interchangeable particles. However, in our roles of physician and patient, we constitute wave phenomena—which amount to nothing that is measurable as they fold into the big picture.

It is only the failure of these relations as they come back to haunt us quantitatively in malpractice suits which directs our attention to these issues. It is as though our collective “wave phenomena” are offended because they are ignored, and strike back with a vengeance.

Understanding healing and treatment as a kind of wave and particle duality, perhaps we “can get some respect” from those economic scientists who would relegate our human relations to the dust bin of mythology, as well as from those business people who are alarmed at malpractice costs. Shame on us for needing to attend to elementary human relations only because “it costs us.”  Nevertheless, I hope that presenting a picture of the “stages of identification” may assist the discussion of these relations in an “objective” manner.   PP

 

References

1.    Stone AA. Managed care: the iceberg and Titanic. Harv Ment Health Lett. 1998;15(1):4-6.
2.    Greece: Myth and Logic. In: Grimal P, ed; Beadsworth P, trans. Larousse World Mythology. Secaucus, NJ: Chartwell Books, Inc; 1965:124-141.

Dr. Zayfert is assistant professor of psychiatry and director of the Anxiety and Posttraumatic Stress Disorder Treatment Program in the Department of Psychiatry at Dartmouth Medical School in Hanover, NH.

Dr. Gillock is clinical associate in the Department of Psychiatry at Dartmouth Medical School.

Dr. Mellman is associate professor of psychiatry and director of the Psychopharmacology Program in the Department of Psychiatry at Dartmouth Medical School.

Acknowledgments: The authors would like to thank Carolyn Black Becker for her helpful comments. The authors report no financial, academic, or other support of this work.


 

Abstract

Why is it important to detect posttraumatic stress disorder (PTSD) in medical settings and how can physicians help these patients obtain effective treatment? PTSD often manifests through physical symptoms and might be associated with a variety of medical problems. Unaware that such symptoms may be related to PTSD, many patients seek medical care only. This article discusses the critical role of medical professionals in ameliorating the deleterious effects of PTSD on physical and emotional well-being. Patients who present in medical settings often do not readily comprehend the complex role posttraumatic stress reactions can play in their health problems and are often reluctant to discuss their traumatic experiences. Thus, physician identification and management of PTSD is crucial for many patients. However, addressing PTSD presents unique challenges even for physicians skilled in addressing other mental health concerns. These challenges include recognizing signs of PTSD and developing effective strategies for communicating with patients about the role of PTSD in their overall health.

 

Introduction

Recent epidemiologic data indicate that a substantial majority of Americans have experienced traumatic events.1 Posttraumatic stress disorder (PTSD) is a potentially debilitating anxiety disorder that affects many who are exposed to trauma. The current prevalence of PTSD in the general United States population is estimated to be 5%,2 and approximately 8% of the population meet criteria for PTSD at some point in their lives.3 However, the prevalence of PTSD among medical populations is substantially higher.4,5

The high rates of PTSD observed in medical populations are not surprising given that PTSD has been linked to poor health outcomes and functioning in a variety of domains. Studies have shown an association between PTSD, increased physical complaints, and poor overall health.6,7 PTSD has also been associated with an increased risk for medical conditions affecting the circulatory, digestive, musculoskeletal, nervous, respiratory, and immunological systems.8 Finally, available evidence suggests that individuals suffering from PTSD seek medical treatment more often than those without PTSD.7,9

Researchers have developed a variety of models to explain the association between PTSD and poor physical health. However, it is likely that a complex interaction of biological, behavioral, and psychosocial mechanisms leads to seeking of medical treatment among individuals with PTSD. For example, many traumatic events result in physical injury, some with lasting medical sequelae that require ongoing care.7,10 In addition, biologic dysregulation associated with PTSD, principally in the adrenergic and hypothalamic-pituitary-adrenal systems, has been implicated in the development of a variety of medical conditions for which patients seek care.11 PTSD has also been linked to behavioral risk factors (eg, smoking, substance use, poor diet, lack of exercise) for poor health.3,11 Finally, because PTSD involves avoidance of thinking about traumatic experiences, patients may selectively attend to physical symptoms that often accompany PTSD.7,12

In addition to the more straightforward medical presentations, PTSD is also associated with complex syndromes such as irritable bowel syndrome,13 fibromyalgia,14 and chronic fatigue syndrome.15 The primary care provider is in the optimal position to coordinate referrals for the multidisciplinary services that will best serve the needs of these patients. Thus, identification in the primary care setting has a pivotal role in meeting the treatment needs of individuals with PTSD. Even so, PTSD eludes detection in primary care in many cases. Thus, patients frequently present to specialized clinics such as those treating chronic pain, headaches, or epilepsy. Because these patients may be among those least likely to comply with recommendations to seek psychological services, it is important that clinicians become adept at drawing connections between PTSD and other disorders in a persuasive yet nonthreatening manner.

A variety of factors can interfere with identification of PTSD in clinical practice. Unfamiliarity and/or discomfort with the disorder and time constraints on clinicians may impede detection. Detection is also hindered by overlap between PTSD symptoms, diagnosable physical conditions, and the ambiguity in symptom presentation. Because there is often a gap of months or years between traumatic events and the onset of physical symptoms, individuals with physical complaints often do not link them to prior trauma. Many patients are reluctant to disclose traumatic events and discuss psychological symptoms. Avoidance of thoughts or reminders about the traumatic event is a core aspect of PTSD. Cultural influences, such as the belief that psychological symptoms are indicative of weakness, may dissuade some patients from revealing relevant diagnostic information.

Despite obstacles, enhancing detection of PTSD in medical settings is a worthy goal. Identification of PTSD offers physicians the opportunity to refer patients for effective intervention16 and alleviate suffering of those who might otherwise never seek mental health treatment. Thus, the remainder of this article will offer guidance to healthcare providers in meeting the needs of patients suffering from PTSD who present in medical settings.

 

Recognizing PTSD

The criteria for PTSD include the experience of a traumatic event, reexperiencing symptoms, avoidance symptoms, and hyperarousal.17 Events that may lead to PTSD typically involve a threat of serious harm to the individual or someone close to them and produce a sense of intense fear, helplessness, or horror. Clues from the patient’s history, behavior, and self-report are helpful for recognizing PTSD (Table). A diagnosis of PTSD is given when traumatic memories remain disturbing for 1 month or longer and persistently provoke fear, arousal, and avoidance behavior that is very distressing or that greatly interferes with a person’s life. PTSD is often accompanied by physical health complaints and feelings of depression, guilt, or shame.

 

Interviewing Strategies With Traumatized Patients

While there are a number of reasons why providers might be reluctant to ask about trauma, patients often welcome provider’s inquiries about their trauma experiences.18 When providers do not ask about abuse and assault, they can inadvertently send the message that this information is not important. Providers may be more inclined to assess patients’ exposure to trauma if they feel equipped to intervene effectively.

Once trauma has been identified as a significant concern, specialized psychiatric services are often indicated. Guiding patients with PTSD to seek appropriate services is typically a gradual process that takes place over multiple visits. The following strategies may facilitate identification and management of PTSD.
Ask about trauma directly and specifically. Taking the initiative shows that the clinician recognizes that trauma is a health issue. Using behaviorally specific and nonjudgmental questions maximizes the likelihood that the patient will disclose potentially embarrassing experiences such as abuse and assault.18
Interview the patient alone. Disclosure of trauma is sometimes more difficult or embarrassing in the presence of significant others. In addition, providers should alert themselves to the possibility of current abuse and avoid questioning in the presence of a possible perpetrator.
Summarize observations. Describing observations in simple and objective terminology can help the patient draw connections between experiences that previously appeared unrelated. Often, it is helpful to present this to the patient in a tentative manner (eg, “I’ve begun to wonder if what you are experiencing lately might be related to things that happened in your past”).
Normalize and validate posttraumatic reactions. Many patients with PTSD are aware that something is “not right,” but are fearful that their symptoms mean that they are abnormal, losing control, or “going crazy.” Communicating that the symptoms are understandable reactions experienced by many trauma survivors is a powerful method of managing traumatized patients. Validation can smooth subsequent steps, including medical procedures and referrals. Validation may include statements such as, “It’s not unusual to be bothered by stressful experiences long after they are over” and “It makes sense that you feel overwhelmed.”
Link to the presenting complaint. Patients with PTSD who present in medical settings are often concerned that the physician will not take their medical complaints seriously. For a variety of reasons, some patients are not ready to directly address their condition. Establishing a connection to the presenting complaint may enhance willingness to address psychological issues that affect the presenting problem. For example, the physician can make a statement such as, “It might be frightening to think about, yet the stress of ‘unfinished business’ can make it harder to deal with your back pain.”
Emphasize stress reduction. In making a referral for psychological services, it is important to communicate to patients that you take their symptoms seriously and to dispel the impression that you think the symptoms are “in their head.” Emphasize that stress can affect physical health and that a multidisciplinary approach may offer strategies to reduce stress and thereby alleviate suffering related to health concerns.
Offer optimism. PTSD patients often feel they have little control over many areas of their lives. Hopelessness interferes with taking steps to get help. Thus, an important goal of early intervention is to establish a sense of optimism by communicating to the patient that he or she can learn more effective ways of coping with stress. For example, the physician might say, “You can learn other ways to cope with your distress about the past. While we can’t change the awful things that have happened to you, I am hopeful that we will be able to help you feel less stressed by them.”
Enhance control. Using specific strategies to enhance the patient’s feeling of control can increase his or her willingness to adhere to recommendations. In addition to open and collaborative communication, this includes more extensive education about reproductive functioning, medical procedures, and offering choices whenever possible.

 

Screening Instruments

Given the high costs and burden on resources associated with undetected PTSD,19 formal screening processes may have utility in some settings. Several brief screening instruments for PTSD have recently been developed. Breslau and colleagues20 devised a seven-symptom screening tool based on a widely used diagnostic interview. Breslau and colleagues found that interview endorsement of four of the seven symptoms accurately detected 80% of cases classified as lifetime PTSD, based on the full diagnostic interview. However, follow-up assessment is recommended since the rate of false positives with this screening is 29%.

Meltzer-Brody and colleagues21 offered a four-item self-rating scale to screen for current PTSD diagnosis. The Startle, Physiologic arousal, Anger, and Numbness (SPAN) Test correctly identifies 84% of PTSD cases, and has a false positive rate of 11%. The use of these screening tools has the potential to enhance detection of PTSD when used in a population where the prevalence rate is 10% or higher.

 

Detection and Initial Management of PTSD in Populations With Increased Risk

As noted above, PTSD is overrepresented in medical populations and is associated with a higher rate of service utilization. This section reviews considerations relevant to the detection and initial management of PTSD in three populations for which it may be of particular significance: acute injury, obstetrics/gynecology (OB/GYN), and chronic pain clinics.

 

Acute Injury

Settings in which acute injury is treated are unique in that identification and management is aimed at prevention of PTSD soon after a trauma. Traumatic injury is a relatively common antecedent of PTSD.1 Psychiatric sequelae of traumatic injury often take the form of “subthreshold PTSD,” ie, posttraumatic symptoms that cause distress and impairment but fail to meet full PTSD diagnostic criteria.22,23

The significance of psychiatric complications of traumatic injury is underscored by findings that PTSD and depression significantly predict functional status and satisfaction with recovery after controlling for injury severity.24

Although serious injury is highly prevalent, only a minority of injury survivors will develop PTSD.25,26 Therefore, determining who is at future risk based on acute signs and symptoms is an important consideration for targeting interventions. The recently introduced diagnostic category of acute stress disorder emphasizes dissociation and the presence of PTSD symptoms as demarcating early risk for continuing PTSD. However, the data regarding the significance of dissociation for predicting PTSD in the aftermath of severe injury are mixed.23,26 Other factors that have been associated with increased risk for development of PTSD after injury include elevated heart rate within hours of the trauma,27 severity of early PTSD symptoms,26 and avoidant and maladaptive coping styles.22,23

Since it is not feasible for all injured patients at risk for PTSD to receive mental health interventions, it is important that providers in acute trauma settings have a general awareness of issues related to the disorder. Educating injured patients about possible PTSD symptoms is potentially a useful and cost-effective first-line intervention. Patients who begin to experience nightmares or flashbacks are often confused and frightened by their symptoms and can benefit from having a frame of reference for understanding them. The brief screening tools discussed above and patient information materials can provide this framework.

Injured patients who manifest intense reexperiencing, anxiety, sleep disturbance, dissociation, or appear to be trying hard to avoid thinking about what happened warrant the highest priority for mental health intervention. Research on interventions for preventing PTSD soon after trauma is in preliminary stages. Some of the most promising data support a modification of cognitive-behavioral therapy (CBT) for injury survivors.28 This suggests that some of the key components of CBT, such as educating the patient about the nature of PTSD and facilitating expression of trauma-related memories, thoughts, and feelings, are potential strategies for prevention of PTSD.

 

OB/GYN

Women are at high risk for exposure to assaultive violence. Approximately 35% of those assaulted have experienced PTSD during their lifetime,29 warranting a skillful approach to detecting and managing PTSD in the OB/GYN setting. Abuse/assault and subsequent PTSD put women at greater risk for reproductive health problems, including sexual dysfunction, genital or nongenital physical injuries, sexually transmitted diseases,30 chronic pelvic pain (CPP),31 and complications during pregnancy and/or childbirth.32

OB/GYN providers should be especially cognizant of abuse/assault and PTSD because pelvic exams, labor, and delivery procedures can evoke feelings of loss of control and violation. In addition, both pregnancy and childbirth can trigger memories of past abuses, and childbirth itself is a potentially traumatic event.32 Being aware of a woman’s abuse history enables OB/GYN providers to adjust their interactions with the patient to enhance her sense of control and reduce her anxiety and posttraumatic symptoms during medical procedures.

 

Chronic Pain

Traumatic events, particularly sexual and physical abuse, are common experiences of patients seeking help for chronic pain problems. Such events have been implicated in the development and maintenance of chronic pain syndromes.33 Estimates of the prevalence of any form of abuse among patients with chronic pain have been as high as 65%.34,35 Despite the attention to trauma in the development and maintenance of chronic pain, the role of PTSD in chronic pain has only recently been investigated. However, available data suggests that the prevalence of PTSD among patients with chronic pain problems approximates 35%.5 Moreover, the presence of PTSD appears to adversely affect the adaptation to chronic pain.12,36

CPP, in particular, is a complex problem with multiple contributing factors. Approximately 58% of women who present with CPP report a history of assault or abuse,37 yet there is no conclusive evidence that psychological factors have a causative role.38 It is important to identify possible psychological contributions such as PTSD. However, CPP is a multifaceted problem, and communicating to the patient that physical complaints are to be taken seriously regardless of identifiable organic pathology promotes effective management.

 

Conclusion

PTSD is a highly prevalent disorder with pervasive effects on emotional and physical health. Despite this, many individuals do not seek appropriate interventions that can attenuate the aftereffects of trauma. Patients with PTSD present in medical settings with a wide range of physical health concerns, yet show little awareness of the role of their traumatic experiences in their presenting complaints. Attention to the detection of PTSD and the use of strategies suggested above would facilitate effective intervention for PTSD as an important adjunct to the patient’s medical care.  PP

 

References

1.    Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma. Arch Gen Psychiatry. 1998;55:626-631.
2.    Norris FH. Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psychol. 1992;60:409-418.
3.    Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry. 1995;52:1048-1060.
4.    Stein MB, McQuaid JR, Pedrelli P, Lenox R, McCahill ME. Posttraumatic stress disorder in the primary care medical setting. Gen Hosp Psychiatry. 2000;22:261-269.
5.    Asmundson G, Norton GR, Allerdings MD, Norton PJ, Larsen DK. Posttraumatic stress disorder and work-related injury. J Anxiety Disord. 1998;12:57-69.
6.    Clum GA, Calhoun KS, Kimerling R. Associations among symptoms of depression and posttraumatic stress disorder and self-reported health in sexually assaulted women. J Nerv Ment Dis. 2000;188:671-678.
7.    McFarlane AC, Atchison M, Rafalowicz E, Papay P. Physical symptoms in post-traumatic stress disorder. J Psychosom Res. 1994;38:715-726.
8.    Schnurr PP, Spiro A 3rd, Paris AH. Physician-diagnosed medical disorders in relation to PTSD symptoms in older military veterans. Health Psychol. 2000;19:91-97.
9.    Schnurr PP, Friedman MJ, Sengupta A, Jankowski MK, Holmes T. PTSD and utilization of medical treatment services among male Vietnam veterans. J Nerv Ment Dis. 2000;188:496-504.
10.    Beckham JC, Crawford AL, Feldman ME, et al. Chronic posttraumatic stress disorder and chronic pain in Vietnam combat veterans. J Psychosom Res. 1997;43:379-389.
11.    Schnurr PP, Jankowski MK. Physical health and post-traumatic stress disorder: Review and synthesis. Semin Clin Neuropsychiatry. 1999;4:1-11.
12.    Bryant RA, Marosszeky JE, Crooks J, Baguley IJ, Gurka JA. Interaction of posttraumatic stress disorder and chronic pain following traumatic brain injury. J Head Trauma Rehabil. 1999;14:588-594.
13.    Irwin C, Falsetti SA, Lydiard RB, Ballenger JC, Brock CD, Brener W. Comorbidity of posttraumatic stress disorder and irritable bowel syndrome. J Clin Psychiatry. 1996;57:576-578.
14.    Amir M, Kaplan Z, Neumann L, Sharabani R, Shani N, Buskila D. Posttraumatic stress disorder, tenderness, and fibromyalgia. J Psychosom Res. 1997;42:607-613.
15.    Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med. 2001;134:917-925.
16.    Foa EB, Keane TM, Friedman MJ, eds. Practice Guidelines From the International Society for Traumatic Stress Studies: Effective Treatments for PTSD. New York, NY: The Guilford Press; 2000.
17.    Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.
18.    Acierno R, Resnick HS, Kilpatrick DG. Health impact of interpersonal violence. 1: Prevalence rates, case identification, and risk factors for sexual assault, physical assault, and domestic violence in men and women. Behav Med. 1997;23:53-64.
19.    Greenberg PE, Sisitsky T, Kessler RC, et al. The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry. 1999;60:427-435.
20.    Breslau N, Peterson EL, Kessler RC, Schultz LR. Short screening scale for DSM-IV posttraumatic stress disorder. Am J Psychiatry. 1999;156:908-911.
21.    Meltzer-Brody S, Churchill E, Davidson JRT. Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder. Psychiatric Res. 1999;88:63-70.
22.    Schnyder U, Moergeli H, Klaghofer R, Buddeberg C. Incidence and prediction of posttraumatic stress disorder in severely injured accident victims. Am J Psychiatry. 2001;158:594-599.
23.    Mellman TA, David D, Bustamante V, Fins A, Esposito K. Predictors of PTSD following severe injury. J Anxiety and Depression. 2001;14:226-231.
24.    Michels AJ, Michaels CE, Moon CH, Zimmerman MA, Peterson C, Rodriguez JL. Psychosocial factors limit outcomes after trauma. J Trauma. 1998;44:644-648.
25.    Ursano RJ, Fullerton CS, Epstein RS, et al. Acute and chronic posttraumatic stress disorder in motor vehicle accident victims. Am J Psychiatry. 1999;156:589-595.
26.    Harvey A, Bryant RA. The relationship between acute stress disorder and posttraumatic stress disorder: a 2-year prospective evaluation. J Consult Clin Psychol. 1999;67:985-988.
27.    Shalev AY, Sahar T, Freedman S, et al. A prospective study of heart rate response following trauma and the subsequent development of posttraumatic stress disorder. Arch Gen Psychiatry. 1998;55:553-559.
28.    Bryant RA, Harvey AG, Dang ST, Sackville T, Basten C. Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol. 1998;66:862-866.
29.    Breslau N, Chilcoat H, Kessler R, Peterson E, Lucia V. Vulnerability to assaultive violence: further specification of the sex difference in posttraumatic stress disorder. Psychol Med. 1999;29:813-821.
30.    Resnick HS, Acierno R, Kilpatrick DG. Health impact of interpersonal violence 2: medical and mental health outcomes. Behav Med. 1997;23:65-78.
31.    Savidge CJ, Slade P. Psychological aspects of chronic pelvic pain. J Psychosom Res. 1997;42:433-444.
32.    Allen S. A qualitative analysis of the process, mediating variables and impact of traumatic childbirth. J Reproductive & Infant Psychol. 1998;16:107-131.
33.    Rapkin AJ, Kames LD, Darke LL, Stampler FM, Naliboff BD. History of physical and sexual abuse in women with chronic pelvic pain. Obstet Gynecol. 1990;76:92-96.
34.    Taylor ML, Trotter DR, Csuka ME. The prevalence of sexual abuse in women with fibromyalgia. Arthritis Rheum. 1995;38:229-334.
35.    Haber J, Roos C. Effects on spouse abuse and/or sexual abuse in the development and maintenance of chronic pelvic pain in women. In: Fields HL, Dubner R, Cervero F, eds. Advances in Pain Research and Treatment. New York, NY: Raven Press; 1985.
36.    Hickling EJ, Blanchard EB, Schwarz SP, Silverman DJ. Headaches and motor vehicle accidents: results of the psychological treatment of post-traumatic headache. Headache Quarterly. 1992;3:285-289.
37.    Walker EA, Gelfand AN, Gelfand MD, Koss MP, Katon WJ. Medical and psychiatric symptoms in female gastroenterology clinic patients with histories of sexual victimization. Gen Hosp Psychiatry. 1995;17:85-92.
38.    Steege JF, Stout A. Chronic gynecologic pain. In: Stewart DE, Stotland NL, eds. Psychological Aspects of Women’s Health Care: The Interface Between Psychiatry and Obstetrics and Gynecology. Washington, DC: American Psychiatric Press; 1993.

Dr. Marshall is director of trauma studies and services at the New York State Psychiatric Institute and associate professor of clinical psychiatry at Columbia University College of Physicians and Surgeons, both in New York City.

Dr. Sinha is research fellow in the Department of Psychiatry at Columbia University College of Physicians and Surgeons.

Acknowledgments: This work was supported in part by National Institute of Mental Health Grant#MH01412. 


 

Abstract

The history of the recognition of psychological impairment after severe trauma is, in many ways, a microcosm of the history of clinical psychiatry and psychology. Until recently, etiological assumptions about clinical manifestations have confounded the field. However, current research regarding the central nervous system’s plasticity in both the developing and adult human links severe psychological trauma with enduring alterations in brain function. These recent studies offer a rationale for administering medication to patients with posttraumatic stress disorder (PTSD). More importantly, adults diagnosed with PTSD can receive a number of different medications that have demonstrated efficacy. However, the real priority is to achieve full remission in patients rather than merely improvement in symptoms. Hence, further study of new compounds as well as longer and combined treatments will be necessary and will likely improve our management of patients with this often refractory disorder.

 

Introduction

There is … no a priori reason why drugs should not be discovered which have a wholly beneficial effect. I have never myself observed any but good effects to flow from the drinking of tea, at any rate if it is China tea.


Bertrand Russell1

For several centuries, medical literature has documented the relationship between traumatic experiences and enduring, debilitating psychological suffering. However, only recently has this association been incorporated in the psychiatric literature (Diagnostic and Statistical Manual of Mental Disorders, Third Edition2 [DSM-III]). The history of this phenomenon is revealing in itself and pertinent to contemporary debate in the field.3 The structure of arguments proposing a connection between trauma and psychological stress seem consistent with the Hegelian model of the evolution of “thesis, antithesis, synthesis.” Initial theoretical explanations focused on the biological perspective in the 18th and 19th centuries. The early 20th century witnessed the psychoanalysis debate with psychological explanations brought to the forefront.
 

In the past 10 years, proof of both somatic and psychological approaches have emerged, along with evidence of biological vulnerabilities and a genetic predisposition to posttraumatic stress disorder (PTSD). Once all the data are synthesized, we suspect that a true biopsychosocial model of PTSD will emerge as the most accurate and clinically useful model.
 

Throughout this debate, propositions about the etiology of PTSD symptoms have often polarized between two models.4 A more biologically based model posits that vulnerability factors explain why some individuals develop PTSD while other persons, despite the same severity of trauma, spontaneously recover. A psychologically based model driven by stigmatization proposes that all individuals with PTSD possess a universal vulnerability to severe trauma and objects to the medicalization of posttraumatic reactions as “symptoms” rather than normal reactions to abnormal events.
 

In the 19th and early 20th centuries, a common belief was maintained that PTSD-like syndromes resulted from neurological damage (eg, minimal brain damage during an accident, damaged heart tissue, or concussion-like effects of explosive shells leading to “shell shock”).5 The alternative viewpoint—that clinical symptomatology might be better explained as a psychological consequence of trauma—came to the forefront during the psychoanalytic era, in which all mental illness was reconceptualized as having a psychological and developmentally rooted etiology. However, even this perspective presumed the existence of constitutional vulnerabilities. We now know that both biological alterations and vulnerability factors are associated with PTSD. For example, in a large study of United States Vietnam veterans, genetic models accounted for about one third of symptom liability.6
 

After World War II, psychoanalysis was the dominant paradigm. In 1947, after treating many war veterans, Kardiner and Spiegel7 noticed striking physiologic symptoms in patients who seemed to suffer from damage and/or dysregulation of the autonomic nervous system. They termed this condition “physioneurosis.”
 

During this era, physicians primarily treated psychiatric illness by analyzing neurotic conflicts that were rooted in the patients’ early development; physicians assumed that the patients’ symptoms represented regression under stress.
 

Pharmacotherapy for Physioneurosis

After World War II, experts advocated the use of sedatives in patients with chronic conditions to facilitate the psychotherapeutic process of dealing with memories of trauma. Only barbiturates were available then, and their disadvantages often outweighed their usefulness. Dr. Kardiner8 explained it thus:

Barbiturates have the advantage of being simultaneously an anesthetic and a device to render the subject accessible. It has however the disadvantage of blunting the sensorium, so that, although it is possible to dissolve a good many peripheral defenses, the chances of complete integration of the reconstructive efforts are diminished.

Although researchers recognized that biological factors played a role in physioneurosis, they did not believe that medications contributed toward recovery, which was presumably a psychological process.
 

Empirical Findings to Date

Pharmacotherapy for patients with PTSD has demonstrated direct usefulness over the past 10–15 years, despite the fact that the mechanism of action for most psychiatric medications remains unknown. Although medications are categorized by their pharmacodynamic properties (eg, selective serotonin reuptake inhibitor [SSRI]) and molecular structure (eg, heterocyclic antidepressants), none of these designations explain the mechanism of action. This is a very important research issue because premature closure regarding the relationship between the psychobiology of PTSD and the putative mechanisms of pharmacotherapy can be damaging to scientific progress in this area.
 

Early medication trials were conducted exclusively with war veterans who usually demonstrated modest results with the exception of a single trial of phenelzine.9 Tricyclic agents also seemed to have modest effectiveness in this population.9,10
 

Since the discovery of the SSRIs, the study of PTSD caused by combat or other types of trauma has shifted to progressively larger, more rigorous trials. Five large multicenter trials using the SSRIs sertraline, paroxetine, and fluoxetine have demonstrated efficacy compared with placebo in adults who had chronic PTSD due to a wide range of traumas.10-14 These findings replicated and extended the results of two previous single-site studies with fluoxetine.15,16
 

Negative trials with SSRIs have also been reported.17-19 Three of the four negative trials were conducted primarily using US war veterans as subjects. To date, the only multinational trial conducted in Africa and Europe showed efficacy for war veterans. This suggests that recruitment patterns in US studies probably differ from those abroad and may be biased toward enrolling treatment-refractory individuals who have failed several prior treatment attempts.14
 

Three earlier pioneering trials demonstrated superiority over placebo for the tricyclic antidepressants amitriptyline9 and imipramine,9 and the monoamine oxidase inhibitor phenelzine.9 Smaller early trials conducted with phenelzine20 and similar drugs (alprazolam21 and inositol22) produced negative results, although the studies were probably inadequately powered.
 

A large number of case reports have reported therapeutic efficacy for other drug categories including mood stabilizers such as valproate, topiramate, carbamazepine, gabapentin, and lithium, and α-agonists (eg, clonidine).23 Of course, double-blind, placebo-controlled trials must be conducted before a drug can be considered effective. The history of medicine is replete with humbling examples of the post hoc fallacy. The scientific literature is biased toward positive reports because negative trials are less likely to be submitted for publication.
 

Treatment-Response Patterns

Many clinically relevant observations have emerged from the new large-scale SSRI trials that answer longstanding questions, sometimes overturn previously held assumptions, and often point investigators toward important and new directions such as the following:
 

• Medication is effective for PTSD. Although this point may seem obvious to many readers, only a decade ago this controversial assertion was maintained by only a minority of experts in the field. The Food and Drug Administration (FDA) has approved sertraline and paroxetine for PTSD. The largest paroxetine trials to date have now demonstrated efficacy for all three symptom clusters analyzed.13,14 It was initially surprising that a medication could help to reverse entrenched behavioral avoidance patterns that had often been maintained for years.
• Medication is effective for PTSD arising from a wide range of trauma types. Early literature focused largely on the type of trauma, rather than the universal features that most trauma survivors shared. Thus, there was a railway spine syndrome, a rape trauma syndrome, battle fatigue, irritable heart syndrome, and so forth. A major contribution of the DSM was the focus on defining universal features of syndromes, such as longitudinal course.3 Thereafter, clinical trials demonstrated that drugs were effective for treating individuals with PTSD resulting from all types of traumas ranging from car accidents to domestic violence.
• SSRIs appear to be equally effective for men and women. A major controversy in the literature has been the question of whether there are gender differences in treatment response. Approximately twice as many women as men report a lifetime history of PTSD.24 However, until recently, the literature was confounded by the fact that most of the negative trials with SSRIs were conducted in US war veterans, who were almost entirely males. A recent trial13 with paroxetine demonstrated equal treatment efficacy in both genders, the majority of whom had experienced nonwar-related trauma.
For most individuals, medication alone will not lead to remission, at least in the short-term. On the whole, the mean reduction in symptoms in large SSRI trials is approximately 50% compared with a 30% reduction in symptoms observed in patients who received a placebo. Similar findings are seen in time-limited psychotherapy trials that use the same methodology for outcome analysis (ie, intent-to-treat analysis). This deserves emphasis because the psychological literature has traditionally published more complete analyses which tend to be more favorable than intent-to-treat analyses. These results suggest that additional treatment will be needed for most individuals. In double-blind, placebo-controlled trials, the response pattern suggests a flattening of the response curve at 6–8 weeks of treatment with adequate doses of an SSRI (in the higher range).
 

However, a recent report by Londborg and colleagues25 suggested that therapeutic benefits can continue for more than 12 weeks in at least a subgroup of individuals. Patients were offered the opportunity to receive open treatment with sertraline in a continuation phase (24 weeks) after completing a double-blind, placebo-controlled trial. The authors included in the analysis only those patients who had been randomized to receive the active medication. Of those patients who received sertraline during the trial and opted to receive open treatment (n=128), about half of those who had been rated as nonresponders (28/52) became responders during this phase over the next 24 weeks.
 

This response pattern stands in contrast to those observed in all acute controlled trials to date—a clear plateau in treatment response seen in patients who received medication alone after 6–8 weeks. It is possible that individuals who could not tolerate sertraline or had a minimal response did not enter the open trial, thereby altering the sample composition. Nevertheless, this study25 provides the first evidence that at least some patients can show ongoing improvement over 6 months, and that partial responders should probably continue medication beyond the usual 12 weeks if other treatments that might accelerate recovery are unavailable or are refused.
The clinical need for additional treatments exceeds our empirical knowledge. Case reports and open trials document the fact that many patients do not achieve full recovery after treatment with medications of established efficacy. This finding is apparent to most clinicians who manage and treat PTSD patients. Until further research is available, the recommended strategy is to target specific symptom clusters or problems that may be responsive to certain types of medications. For example, patients who have problems with affect dysregulation, irritability, and aggressive impulses and who have not responded to SSRIs might experience symptom reduction by taking a mood stabilizer. Patients with persistent reexperiencing in the form of nightmares and/or vivid imagery might respond to α-agonists. Patients with depressive symptoms that have only partially responded to the first antidepressant agent might improve with the addition of a second medication of complementary antidepressant action. In all clinical situations, the combination of medication with supportive psychotherapy has been recommended.26
 

Treatment Versus Referral

Most experts working with PTSD patients, including those involved in research in primary care settings, have stated that the primary care provider’s preferred role is identification, provision of education, and referral to a specialist.27
 

The most efficient and successful way to detect PTSD is to assess for lifetime traumatic experiences. Brief questionnaires such as the Life Events Questionnaire28 or Short PTSD Rating Interview (SPRINT)29 offer a natural lead into questions about the consequences of the traumatic experience. The physician’s assessment might include questions about reexperiencing (eg, “Was it on your mind a lot afterward?” or “Did you keep seeing it in your mind and dreaming about it?”), avoidance (eg, “Did you find yourself withdrawing from other people afterward?” or “Do you feel less interested in things you enjoyed before?”), and arousal (eg, “Were you very jumpy or jittery afterward?”, “Are you more cautious or fearful in general?”, “Are you having trouble sleeping?”, or “Do you startle easily?”). Relationship problems are also common (eg, “Did you find you were more irritable, having trouble getting along with others? If so, did this affect your sex life?”).
 

If the diagnosis of PTSD is made, it is crucial to mention that there are safe and effective treatments, in order to give the patient hope and motivation for seeking help. Referral to a specialist is preferable for patients who are willing. If patients are reluctant to meet with a mental health practitioner or if none are available, providing information about treatment options is still important because a subsequent partial response to medication may require revisiting the option of psychotherapy.
 

A number of typical questions can arise during medication treatment. Because trauma patients have a heightened sense of caution, they may have exaggerated fears about side effects of medications. Reviewing research findings with these patients may provide reassurance. Patients may misperceive the offer of medication treatment as an expression of unwillingness to talk about their traumatic experience.
 

On the other hand, many patients seek help based on the assumption that the medical model is most appropriate when they feel severely ill. In nonwestern countries, depression and anxiety primarily present with somatic symptoms. The fact that there is a biological model for PTSD can be experienced as legitimizing their suffering. Patients may experience the biological model as a positive connection to their physicians  and, hopefully, as a way of taking positive action to improve their lives. However, patients may sometimes rely heavily on the medication based on an idealized wish to erase the trauma from their memory. We believe it is important to present the medication as an adjunct to the patients’ efforts toward recovery.
 

If a first medication is only partially effective, the physician can again recommend the option of psychotherapy. Although guidelines have been recently published26 concerning the next steps in a treatment algorithm, a psychiatrist’s assistance is highly advisable at this point, if possible.
 

Conclusion

The history of treatment for chronic PTSD reflects the vicissitudes of our field. Although we still have no coherent and validated theory to explain PTSD symptoms, emerging ethological and clinical research strongly supports the power of pharmacotherapy to correct alterations in multiple systems that modulate affect and perception. The SSRIs offer the most optimal and validated empirical treatments to date. The FDA has approved both sertraline and paroxetine in the US.
 

Acute treatment trials of medication or psychotherapy demonstrate that a substantial proportion of patients remain symptomatic at the conclusion of the trial. Unfortunately, most individuals with trauma-related symptoms or problems never seek and/or receive effective treatment. Public health efforts and clinical trials are equally important in diminishing the suffering of trauma survivors.   PP
 

References

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13.    Marshall RD, Beebe KL, Oldham M, Zaninelli R. Efficacy and safety of paroxetine treatment of chronic PTSD: a fixed-dosage, multi-center, placebo-controlled study. Am J Psychiatry. 2001;158:1982-1988.
14.    Martenyi F, Brown E, Zhang H, Prakash A, Koke S. Fluoxetine vs placebo in posttraumatic stress disorder. Poster presented at: Annual Meeting of the American Psychiatric Association; May 2001; New Orleans, La.
15.    Connor KM, Sutherland SM, Tupler LA, Malik ML, Davidson JR. Fluoxetine in post-traumatic stress disorder. Randomised, double-blind study. Brit J Psychiatry. 1999;175:17-22.
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