Learning Objectives

After reading this article, you should be able to...

1. Recognize the importance of a differential diagnosis and how to implement one before starting psychotherapy

2. Consider neurological and general medical factors for each patient before beginning psychotherapy

3. Understand the need to tailor psychotherapy to different mental health issues

Allen Frances, MD. Chair of the DSM-IV Task Force; Professor and Chairman Emeritus of the Duke University Department of Psychiatry; founding editor of the Journal of Personality Disorders and the Journal of Psychiatric Practice; and co-host of the podcast Talking Therapy.

Dr. Frances has no financial relationships with companies related to this material.

CPTR: In your view, how important is psychiatric diagnosis to the everyday practice of psychotherapy?
Dr. Frances: There are three reasons I don't trust psychotherapists who fail to do a careful differential diagnosis before beginning every therapy:

1) It's crucial to determine if the person's psychiatric symptoms are caused by substance use or withdrawal. In older people, most often a prescribed medication or alcohol; in younger people, street drugs. It is surprising how frequently substance use or withdrawal causes or exacerbates psychiatric symptoms—and worrying how often this is missed (Smith MJ et al, Compr Psychiatry 2009;50(3)245-250; Substance Abuse and Mental Health Services Administration. (June 2023). Identification and Management of Mental Health Symptoms and Conditions Associated With Long Covid. Retrieved from https://store.samhsa.gov/sites/default/files/pep23-06-05-007.pdf).

2) Clinicians must always consider the possibility that symptoms are caused by a neurological disorder or a general illness. Nowadays, for instance, long-COVID has to be part of every differential (Davis HE et al, Nat Rev Microbiol 2023;21(3):133-146).

3) Different psychiatric disorders imply very different treatment plans—eg, whether psychotherapy is indicated at all and if so which type of therapy and with what goals. For example, behavioral exposure is often most useful for anxiety disorders; CBT for depressive disorders; DBT for borderline personality; dynamic approaches for many of the other personality disorders; and supportive therapy for people with schizophrenia or severe bipolar disorder (Kaplan JS and Tolin DF, Psychiatr Times 2011;28(9); Cuijpers Pim et al, Can J Psychiatry 2013;58(7):376-385; May JM et al, Ment Health Clin 2016;6(2):62-67; McWilliams N. Psychoanalytic Diagnosis 2nd Ed, Guilford Press 2011; Markowitz JC, Focus (Am Psychiatr Publ) Published Online:1 Jul 2014 https://doi.org/10.1176/appi.focus.12.3.285). Ignoring a psychiatric diagnosis is possible only for clinicians who restrict their practice to treating pretty healthy, high-functioning people for whom a specific psychiatric diagnosis is often less relevant.

CPTR: Can you tell us a little about your evolution as a psychotherapist from someone who was psychoanalytically trained (and taught Freudian theory) to someone who, now, has much broader appreciation for the various schools of psychotherapy?
Dr. Frances: I was lucky that my training in psychotherapy was broad based, flexible, and eclectic. My program was psychodynamically oriented, but also had great supervisors in family therapy, group therapy, behavior therapy, and supportive therapy. I later learned cognitive therapy reading books and through contacts with Aaron Beck. I also learned a lot serving for eight years in the 1980s as a member the NIMH committee that funded psychotherapy research. Helping to support the early research on DBT and CBT was probably the most useful thing I ever did in my career.

CPTR: What do you think is the single most important thing you’ve learned in all of your years doing psychotherapy?
Dr. Frances: Having a strong relationship with the patient is much more important to successful psychotherapy than the power of any specific technique, and the therapists who are most flexible in integrating the right mix of techniques for each patient are usually also the best at developing healing relationships (Frank JD and Frank JB. Persuasion and Healing: A Comparative Study of Psychotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University Press; 1993). It’s remarkable that the best therapists from the seemingly very different schools of psychotherapy are very similar in their clinical approach to work with any given patient—however seemingly different the jargon of their theories. 

CPTR: What is your sense of the future of psychotherapy within psychiatry?
Dr. Frances: In one way pessimistic, in one way optimistic. Pessimistic because psychiatrists now get to spend much less time with their patients and also receive much less training in psychotherapy. Optimistic because I regard every clinical encounter, however brief, as a great opportunity to say something that may have a dramatic impact on a person's life. I have helped many people a great deal after one 20-minute meeting; I have also failed to help many people after many years of treatment. 

CPTR: You trained with many great psychotherapists in New York City. Which of them served as your greatest inspiration, or taught you the greatest lesson?
Dr. Frances: 

• Silvano Arieti taught me that people suffering from schizophrenia are more simply human than otherwise—when they treated with humanity and understanding, their schizophrenic symptoms improve; when neglected or misunderstood their symptoms usually get much worse.
• Sherv Frazier taught me to focus on the patient's interpersonal relationships—with me and with other people in their lives.
• Nathan Ackerman taught me that psychiatric problems are always family problems, that families should usually be involved in evaluations, and often involved in treatment.
• Larry Kolb taught me the importance of common sense, decency, and humility. 
• John Talbott taught me the value of community psychiatry, systems theory, and treating difficult patients.
• Leon Salzman taught me it was often useful to share humorous moments with patients and to provide advice on occasions when they really needed it and I had good advice to give.
• Howard Hunt taught me the basics of behavior therapy and the importance of context in triggering and reducing symptoms.
• Harold Searles taught me to study my feelings and fantasies about patients as way of understanding their feelings and fantasies.
• Security guards in the emergency room taught me that the best psychotherapy to help calm an agitated patient is to offer orange juice and a meal and to switch the conversation to neutral conflict-free areas.
• And I am also grateful to the several supervisors who were arrogant, ignorant, and inflexible jerks—for teaching me how not to be as a person, as a supervisor, and as a therapist. 

CPTR: Any closing words of wisdom to the next generation of psychotherapists?

Dr. Frances: Yes, here are some:

1) Your patients are your best teachers—doing psychotherapy will not only help them, but also help you become a much better person.

2) Resist the temptation to treat only easy patients who would likely do fine on their own; treating people with more severe problems stretches your skills and provides the deep satisfaction that you made a real difference.

3) Learn, integrate, and master all the various techniques of psychotherapy—never be a worshipful slave to anyone.

4) Get lots of supervision with greatly varied supervisors—but don't be so obedient to your supervisor's suggestions about last week that you lose track of what your patient needs now.

5) Learn a lot about the indications for psychiatric meds; dosing strategies; side effects and withdrawal symptoms; and deprescribing strategies and risks. Psych meds are overused for the many; but essential for the few—and every psychotherapist of whatever discipline should know when meds are needed/when they are not needed/how they should be started/when and how they should be gradually deprescribed.

6) Your life experiences will make you a better therapist—fall in love; develop a wide and varied circle of friends; read a lot of books and see a lot of movies; travel, try new things that you are not good at. 

7) Personal therapy is useful to increase your self-understanding, round off your rough edges, and teach you what it's like to be a patient.

8) Always do your best, but don't always expect to succeed. Learn from your mistakes and failures, but don't be demoralized by them.

9) Be genuine and close to your patients, but don't cross boundaries.

10) Don't take your work home with you and don't act like a therapist with loved ones, friends, and coworkers.

11) Listen to or watch the Talking Therapy podcast I do most weeks with master therapist Marvin Goldfried, PhD.

CPTR: Thank you very much for taking the time to share your wisdom with us, Dr. Frances.

Citations in order of appearance in this article:

Smith MJ, Thirthalli J, Abdallah AB, Murray RM, Cottler LB. Prevalence of psychotic symptoms in substance users: a comparison across substances. Compr Psychiatry. 2009 May-Jun;50(3):245-50. doi: 10.1016/j.comppsych.2008.07.009. Epub 2008 Sep 23. PMID: 19374969; PMCID: PMC2743957. 

Davis, H. E., McCorkell, L., Vogel, J. M., & Topol, E. J. (2023). Long COVID: major findings, mechanisms and recommendations. Nature reviews. Microbiology, 21(3), 133–146. https://doi.org/10.1038/s41579-022-00846-2 

Kaplan, J. S., & Tolin, D. F. (2011). Exposure Therapy for Anxiety Disorders. Psychiatric Times, 28(9), Volume 28, Issue 9. https://www.psychiatrictimes.com/view/exposure-therapy-anxiety-disorders 

Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Kleiboer, A., & Dobson, K. S. (2013). A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 58(7), 376–385. https://doi.org/10.1177/070674371305800702 

May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The mental health clinician, 6(2), 62–67. https://doi.org/10.9740/mhc.2016.03.62 

McWilliams, N. (2011). Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd ed.). Guilford Press. Markowitz, J. C. (2014). What is Supportive Psychotherapy? Focus (American Psychiatric Publishing). Published Online: July 1, 2014. https://doi.org/10.1176/appi.focus.12.3.285 

Frank, J. D., & Frank, J. B. (1993). Persuasion and Healing: A Comparative Study of Psychotherapy (3rd ed.). Johns Hopkins University Press. Goldfried M & Frances A (Hosts). (2022– present). Talking therapy [Audio podcast]. https://www.youtube.com/@talkingtherapy.