Efficacy Research and Psychodynamic Psychiatry
HAROLD J. BURSZTAJN, M.D.
Cambridge, Mass.
Am J Psychiatry 148:817-818, June 1991
© 2000 American Psychiatric Association
SIR: Alan A. Stone, M.D. [1] raised wise doubts about
whether efficacy research is sufficiently advanced that it can be used
to decide between the competing clinical paradigms of the science of
mind, and perhaps even world views, implicit in the Osheroff v.
Chestnut Lodge case. At the risk of redundancy, I wish to amplify
these doubts with the following reflections.
More than a decade of engaging in a dialogue about utility assessment
does not leave me with any clearer understanding of the commensurability
of such values as 1) autonomy achieved through insight and 2) the kind
of freedom from depression that can be psychopharmacologically induced.
Moreover, there is good reason to believe that how much we value such
functions in a given case is profoundly dependent on the method and context
of measurement as well as the person whose values are being measured
[2].
It is understandable that outcome studies tend to be primarily concerned
with assessing easily measurable, relatively short-term outcomes such
as improvement in sleep and neglect longer-term, less easily quantifiable
outcomes such as autonomy. However, even if methods of measurement for
these latter variables come to be developed, there is no reason to believe
that methods for measuring how much we value such "soft" variables can
be as easily developed. In fact, what constitutes validity for such utility
measures is open to debate. Shifting the debate about efficacy from courtroom
trials to clinical trials is not likely to mend the rifts in clinical
understanding that are at the heart of Osheroff v. Chestnut Lodge.
Elsewhere my colleagues and I have argued that there is ample reason
to consider that psychodynamic psychiatry can itself contribute to perfecting
these very methods of utility assessment [3]. Before
the clinical trial becomes the court of first resort for settling these
clinical controversies, perhaps psychodynamically informed research will
have to make a much-needed contribution to the still infant science of
utility assessment.
On another note, I do not believe that the different psychological capacities,
such as memory, concentration, and autonomy, are so selectively or exclusively
enhanced by one form of treatment as to preclude the integration of psychodynamic
insight with psychopharmacological intervention. Whether either or both
are used, a psychodynamically informed approach to informed consent as
a process can help to increase the patient's sense of autonomy [4].
As for turning to the courts as a first resort, Dr. Stone suggested the
sensible alternative of a clinical consultation. Depending on the clinical
issues, two other consultations may be in order. 1) A forensic psychiatric
consultation to assess a patient's capacity to engage in the risk-benefit
dialogue regarding treatment alternatives can take the burden of competency
assessment off the treatment alliance [5]. 2) A consultation
with a psychiatrically informed ethicist can bring to light covert value
investments that too often drive the dialogue about treatment choices.
Such consultations can prevent those misunderstandings of a patient's
capacities or values which often lead to regret, recrimination, and even
a malpractice suit in the event of a tragic outcome [6].
References
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Stone AA: Law, science, and psychiatric malpractice:
a response to Klerman's indictment of psychoanalytic psychiatry.
Am J Psychiatry 1990; 147:419-427.
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Bursztajn HJ, Hamm RM: The
clinical uses of utility assessment. Med Decision Making 1982;
2:162-165.
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Bursztajn HJ, Feinbloom RI, Hamm RM, et al: Medical
Choices, Medical Chances: How Patients, Families, and Physicians
Can Cope With Uncertainty. New York, Routledge, Chapman, & Hall,
1990.
-
Bursztajn HJ, Gutheil TG, Cummins B: Conflict
and synthesis: the comparative anatomy of ethical and clinical decision
making, in Divided Staffs, Divided Selves: A Case Approach to Mental
Health Ethics. Edited by Reiser SJ, Bursztajn HJ, Gutheil TG, et
al. Cambridge, Cambridge University Press, 1987.
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Gutheil
TG, Bursztajn H: Clinicians' guidelines for assessing and presenting
subtle forms of patient incompetence in legal settings. Am J
Psychiatry 1986; 143:1020-1023.
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Illingworth P: Foreword, in Decision Making
in Psychiatry and the Law. Edited by Gutheil TG, Bursztajn HJ, Alexander
V, et al. Baltimore, Williams & Wilkins (in press).