Efficacy Research and Psychodynamic Psychiatry

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].


  1. Stone AA: Law, science, and psychiatric malpractice: a response to Klerman's indictment of psychoanalytic psychiatry. Am J Psychiatry 1990; 147:419-427.
  2. Bursztajn HJ, Hamm RM: The clinical uses of utility assessment. Med Decision Making 1982; 2:162-165.
  3. 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.
  4. 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.
  5. 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.
  6. 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).