TCPR: Tell us about your interest in psychotherapy.
Dr. Frances: I always had a practice of 10 or 15 hours a week that included psychotherapy, but I also see it as part of every contact with the patient, even a brief encounter in the emergency room or inpatient unit. I taught at the Columbia Psychoanalytic School for 10 years, but I’ve also worked to unify the various schools of psychotherapy so that residents wouldn’t come out saying “I’m a psychodynamic psychotherapist,” “I’m a cognitive therapist,” or “I’m a behavioral therapist.” Now I’m working on a podcast along these lines with Marvin Goldfried, Talking Therapy. 

TCPR: Some of those psychotherapies bring unique techniques to the table. How important is that?
Dr. Frances: It’s the common factors in psychotherapy, rather than the specific techniques, that matter most, and these apply whether you are doing therapy or prescribing medication. The clinician has to build a trusting, healing relationship through qualities like empathy, warmth, genuineness, and positive regard for the patient. Clinicians must explain the problem and the treatment in a way that is jargon-free, engages the patient, instills hope, and combats demoralization (Wampold BE, World Psychiatry 2015;14(3):270–277). Technical factors still play a role, though, depending on the patient. The simpler and more contained the problem, the more likely that one or another technique is going to be helpful.

TCPR: What are “simple” problems?
Dr. Frances: Social or simple phobia or panic disorder. A single episode of major depressive disorder that was triggered by a clear-cut stressor. PTSD from a single trauma, like a car accident. Primary insomnia. All of these benefit from manualized therapies. The reality is that we don’t see simple problems too often in practice. The patients psychiatrists see tend to have multiple stressors, chronic medical disorders, and comorbidities like personality disorders or addictions. It’s easier to do research on simple problems, but real life is more complex.

TCPR: Does that mean manualized therapy is better suited to simple problems?
Dr. Frances: Yes. The more complex the problem, the less likely you can develop a simple manual to deal with it. Manuals still have a role in complex problems like schizophrenia and bipolar disorder, but here they largely provide guidance on disease management. In bipolar disorder, for example, that includes medication adherence, but also regular sleep, sleep hygiene, not using substances, not traveling the world all the time, not overexciting the nervous system with constant stressors and constantly changed experience.

TCPR: Can manuals cause harm?
Dr. Frances: They can lead people to follow the manual instead of following the patient. It’s easier to teach people technical procedures than it is to teach them to be really good interpersonally. The experience I’ve had is that really great therapists are born—they’re not taught—and they don’t become great by following a manual.

TCPR: I understand your point, but I’ve heard that outcomes are better when therapists follow a manual.
Dr. Frances: Some of the early studies found that patients did better when their therapist followed the manual more closely. The interpretation at the time was, “Aha, if you follow the manual, you get better results.” But it’s really a case of confusing correlation with causality, and the causality probably runs in just the opposite direction.

TCPR: How do you mean?
Dr. Frances: “Easy patients” let you follow the manual, and outcomes are better with easy patients. If a patient is difficult, you will need to be creative and flexible; they won’t let you say rotely, “We do this today and this tomorrow.” They force you to respond to their current need. As more studies came out, the supposed association faded, and a meta-analysis found no relationship between outcomes and manual adherence (Webb CA et al, J Consult Clin Psychol 2010;78(2):200–211). Manuals can give you the general principles of the therapy, but they won’t help you get close to where your patient experientially needs you to be at any given moment. The best continuing education in psychotherapy is learning from the next patient you get to see.

TCPR: Many of these manuals were written by psychotherapists who developed the field. Do they follow their own manuals?
Dr. Frances: I’ve been fortunate to see many of them in practice, and one thing I’ve noticed is how similar they are. They all form remarkably good bonds with the patient, whether it’s Marsha Linehan with dialectical behavior therapy, Aaron Beck with cognitive behavioral therapy (CBT), or David Barlow with behavior therapy. Psychotherapy manuals were developed originally because NIMH funding for psychotherapy studies required them. I worked on that committee for many years in the 1980s. Our thinking was that you couldn’t interpret the results of studies if the treatments weren’t delivered in a standardized way. But this is one of those odd disconnects between research and practice. Research required manuals, but slavish adherence to the manuals is bad for the clinical practice that research hopes to inform.

TCPR: It reminds me of fixed-dose studies, where they titrate everyone to the same dose. That is not what we do in practice.
Dr. Frances: Yes, and it’s even more true for psychotherapy. You would never want to issue standardized psychotherapy in practice. The Becks—Aaron and his daughter Judy—did not use the manual as a training tool and do not recommend it as a way of conducting therapy. Likewise with Marsha Linehan. Her therapy is for complex patients with borderline personality disorder, and rote adherence to a manual is not going to work very well there. Knowing the manual and using its principles flexibly can make a good therapist better, but rigidly following it can make a bad therapist worse.

Psychotherapy and Pharmacotherapy

TCPR: How do psychotherapy outcomes differ from medication outcomes?
Dr. Frances: For many mild to moderate conditions, the outcomes are similar, but one of the most powerful findings is that psychotherapy tends to have a more enduring effect for depression and anxiety. It may be slightly slower in producing gains, but the gains are more enduring (Spielmans GI et al, J Nerv Ment Dis 2011;199(3):142–149).

TCPR: What about severe depression?
Dr. Frances: For very severe depressions, the ones that require hospitalization or have melancholia or delusions, psychotherapy is less helpful because the person is too withdrawn and doesn’t have the energy to participate. Therapy might just feel like an added stressor. But for severe depressions that are just short of that, psychotherapy in a medically supportive way can be quite useful. But psychotherapy alone will rarely be sufficient in severe depressions.

TCPR: People can score high on self-rated scales even when they have adjustment disorder. How do you distinguish that from clinical depression?
Dr. Frances: Most patients who present with transient problems that result from stress and don’t have a long history of preexisting psychiatric problems are going to do just fine with time, normalization, watchful waiting, increasing supports, and reducing stress in their life. Many of them do a lot better without getting a diagnosis beyond adjustment disorder because once a diagnosis is made, it tends to haunt people for life.

TCPR: In our culture, many patients see medications as the only answer. How do you help them see other possibilities? 
Dr. Frances: It’s easy to help people without medications—but it takes more time. If the average PCP is seeing a patient for 10 minutes and that patient has been primed to want something concrete out of the too-brief contact, then writing a script is the quickest way to get them out of the office reasonably satisfied. This explains why 12% of the population is taking antidepressants. It’s not that way across the globe. In the UK, the NICE guidelines do not recommend antidepressants for mild depression. Instead, they recommend CBT, regular sleep, and exercise. If PCPs had enough time, they could get to know the person and say, “You’re up against a tough situation right now. Anyone would feel bad. It’s a tough thing for anyone to go through what you’re going through. These things tend to sort themselves out with time, and with changes you can make, and with help from the people around you. Let’s see what happens over the next few weeks. If things haven’t gotten better, we can try psychotherapy. Medication probably won’t be necessary, but we will have it in reserve.” That’s normalizing the patient’s distress and communicating that there are a number of options.

TCPR: Psychiatrists are also short on time. What can we do?
Dr. Frances: In Japan, psychiatrists often can’t spend more than 10–15 minutes with each patient, but they still see their contact as an important moment in the patient’s life, not to be taken trivially. It may be routine for us to see two to four patients an hour, but for the patient, that visit can be very meaningful. Those encounters are inherently psychotherapeutic, whether we know it or not. I think of patients I saw briefly in the emergency department who approached me years later in the hallway to say, “Doc, you probably don’t remember me, but you said something that stuck with me and helped change my life.” On the other hand, I worked with someone for 14 years twice a week with no real impact.

TCPR: What did you do in 10 minutes?
Dr. Frances: For example, I’ve seen many patients with acute panic attacks who were beginning to avoid trigger situations. In just a few minutes, it’s possible to explain the mechanism behind the physical symptoms—how they relate to hyperventilation—and to teach breathing hygiene, and to reassure them that they’re not “crazy.” This reverses their demoralization and all their fears and uncertainties that can otherwise lead to agoraphobia. In depression, I’ve seen surprising improvements result from advice that patients include more good minutes in their day, such as taking a walk, enjoying nature, listening to music, and speaking to friends. Good minutes help spark virtuous cycles to replace the vicious cycles of demoralization.

TCPR: You spoke about factors that are common across therapies. How much do they influence pharmacotherapy?
Dr. Frances: A strong therapist-patient relationship is a major factor in the medication response because it often includes a large dose of placebo response. Different disorders have different rates of placebo response, and the response also varies by severity. For very mild depressions, the placebo response rate is 50%. For the average run-of-the-mill depressions, it is 30%. For severe depressions, it is probably below 10%. Doctors with good people skills are likely to have better results with medication because they enhance the placebo response.

TCPR: Can these common factors like empathy be taught? 
Dr. Frances: Training can make good therapists much better, but it probably can’t turn bad therapists into good therapists. That is why selection is important. To develop a good mental health system, we need to identify people who have those interpersonal skills that have been wired in or acquired through their previous experiences so that they’re starting with a high baseline of empathy, of interpersonal comfort, with the capacity to not just understand what people are feeling but feel it with them in a way that conveys a sense of great concern on the part of the therapist. It is crucial that therapists convey realistic optimism even in the face of difficult problems—not false assurance. Really good people are usually really good therapists.

TCPR: Are there experiences in your own life that raised or lowered your capacity for empathy?
Dr. Frances: Practicing psychotherapy made me more empathic. I felt like a better person when I was doing psychotherapy than I did in any other role in my life. The psychotherapy relationship is the most unselfish of all relationships. I’m not an inherently selfish person, but even in my relationship with my wife and kids, there would be times when I would pick me rather than them. With patients, there have been very few moments when I ever did something because it was better for me than it was for them. Doing psychotherapy enriches your life in a way almost equivalent to getting married or having children. I think without having been a therapist I would have been a pretty shallow, feckless, good-time-Charlie kind of person, and I’ll always be grateful to my patients for making me a better person.

TCPR: Thank you for your time, Dr. Frances.