Allen Frances shows us how to adjust our therapeutic approach for problems that are simple and those a bit more complex.
Publication Date: 12/16/2024
Duration: 21 minutes, 45 seconds
KELLIE NEWSOME: Lots of us treat simple, limited problems that benefit from brief psychotherapy, like insomnia or phobias. Today, Allen Frances, MD shows us how to adjust our approach for problems that are simple and those that are complex. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.CHRIS AIKEN: I'm Chris Aiken, the Editor-in-Chief of the Carlat Psychiatry Report.
KELLIE NEWSOME: And I'm Kelly Newsome, a psychiatric NP and a dedicated reader of every issue.
CHRIS AIKEN: Allen Frances wears many hats, but none of them quite capture who he is as a psychiatrist. He chaired the fourth edition of DSM, but he's also a vocal critic of the manual's diagnostic overreach. He is a biological psychiatrist who specializes in psychotherapy, and a trained psychoanalyst who advocates for CBT. In my own career, I was always a few steps behind him. I started training at Cornell, where Allen had recently left to become chair at Duke. Then I moved to Duke, where he had just stepped down as chair and left, and in both institutions, he left a strong legacy. He was one of the most talked about attendings even in his absence. At last, I caught up to him in this interview, but in no way can I say that I pinned down his ever-roving and creative mind. Thank you for joining us, Allen. A lot of people probably know you for your work on DSM IV, but tell us about your work as a psychotherapist.
ALLEN FRANCES: The way I see it, psychotherapy is part of every contact with the patient. So, I don't see psychotherapy as something you only do in 45-minute sessions. I see psychotherapy as something you're doing if you see someone for 15 minutes in the emergency room, that's psychotherapy. So, it's always a very big part of all my clinical practice and everything I did clinically, but also I spent a great deal of time and energy, and interest. In teaching psychotherapy, and also in trying to develop programs that would help to unify psychotherapy, so that people wouldn't come out saying I'm a psychodynamic psychotherapist, I'm a cognitive therapist, I'm a behavioral therapist, to teach it in a way that would be integrated and whole.
CHRIS AIKEN: How has your approach to psychotherapy changed over the years?
ALLEN FRANCES: I started out at a time when psychotherapy was the major thing you learned in training. The drugs were new—so I started my residency in 67'. The training I received was mostly psychodynamic, but we had an excellent behavior therapy training program, and shortly afterward, I discovered Tim Beck's work, and my job at Cornell in the 70s was running the outpatient department, and what we did was have each resident do a brief treatment according to each of the most popular models. So they would do a brief treatment that was primarily psychodynamic—and most of their long-term supervision was psychodynamic—but they would also do a brief treatment that was cognitive, another brief treatment that was behavioral, another that used family systems and paradoxical injunction, and the idea was to allow them to get a taste of a pretty pure culture of each type of treatment. And then to, in their own minds, in their own practices, to meld them together so that they wouldn't identify as they came out of the program as I'm just a psychoanalytically oriented or CBT oriented or a family systems person. But, I think that every competent clinician should have a toolkit that includes the techniques from the different schools, applied when suitable to patient need, rather than to therapist skill. So if you have a hammer, everything's a nail, but patients don't come in neat packages, and even a given patient may within the course of one session required different approaches from the therapist.
CHRIS AIKEN: What do we know about common healing factors across all therapies?
ALLEN FRANCES: Yeah. This is interesting, personally. So, my first outpatient psychotherapy experience was kind of a disaster. I had a supervisor who wanted me to take process notes—I had to take down every word—and every time I said something, it was always wrong, and it made me very constricted as a therapist. The treatment was not useful or fun for either of us—it was a mess. Luckily, I soon got another supervisor who couldn't care less about what the patient said or what I said and was interested in how I felt about the patient and what I thought the patient was feeling about me interested in the relationship. He was third-generation Harry Stack Sullivan (his supervisor had been supervised by Harry Stack Sullivan). That freed me up, and then I read the best single book that everyone should read about psychotherapy, written in 1961 by Jerome Frank, MD, called Persuasion and Healing. What Frank did was to look at psychotherapy as an anthropologist might, and to see in it common elements that extend back to the beginning of human prehistory, that the psychotherapist is a modern-day shaman, and the shaman was the first psychotherapist, maybe the first specialist in human society, and that he, or she (often it's a she, a woman) was someone who often had emotional experiences themselves, difficulties themselves, and had been cured of them, and developed a special skill in understanding and empathy for people with mental disorders and difficulties in behaving. In a small tribe, it's very important that everyone behave well and that everyone get along. So that is an important role to make sure that emotional difficulties and individual would not disrupt the movements of the group
KELLIE NEWSOME: Jerome Frank’s book is still in print, and the new edition has been updated by his daughter, psychiatrist Julia Frank, MD. If you haven’t read it, it’s worth the read. You’ll learn about the common healing factors in therapy and how to put them into action throughout your work, like empathy, warmth, genuineness, developing a shared understanding of the problem that instills hope and combats demoralization, and holding the patient in positive regard.
ALLEN FRANCES: So he compared modern-day psychotherapy to the shaman, having experienced the problem, having empathy for the people now experiencing it, having a special knowledge of the causes of the problems in the spirit world —the model then was a spirit world curse—bringing the person into a magic circle, negotiating with the spirits and the person what the problem was, coming up with a treatment plan, conducting a ritual, and the patient gets better. It required a strong relationship between the shaman and the person who was troubled. They both had to believe in the system they were working under. That the shaman had powers and understanding that would work to help the person. They had to know the rituals and accept them, and that would lead to cure, and the one-to-one showed how this would relate to a patient in psychotherapy today. That, again, was a tremendously liberating concept because it meant it wasn't so important about getting the wording just right in everything you said. What counted was establishing a very strong therapeutic alliance. If you and the patient could agree, both of you, to put your heart into what you were doing, and believe in it, and work well with each other to solve the problems. It was very likely that that would be, not necessarily sufficient, but a necessary condition for change, and then it focuses your thinking towards what's happening in the relationship. In the first session, you're thinking, how will I have a second session? You're not bringing in arcane theories or using jargon. You're working with the patient at their level. You're following them rather than trying to lead them, and you're trying to do what will, in any given moment, best further the relationship and best give them a chance to see the world in a way different than they have previously. Do you want me to go on a bit?
CHRIS AIKEN: Yeah, go on. So, the relationship and a common belief in the mode of healing are critical to all therapeutic work.
ALLEN FRANCES: I discovered a paper by Rosenzweig that he wrote in 1936 that was remarkably visionary. He based the concept on the dodo bird in Alice in Wonderland that all have run, all have won, and all deserve medals, and he predicted before there was psychiatric research, he predicted in 1936 that when psychiatric research emerged, that the different psychotherapies would mostly have high scores, that all will have run, all will have won, and all deserve medals, and they shouldn't be competing with each other, and his premise was that the common factors in psychotherapy, rather than the specific techniques, would be most powerful. So, having discovered Rosenzweig, having read the Frank book, and having several supervisors who encouraged the relational approach to understanding what psychotherapy was about, that led me in this direction.
CHRIS AIKEN: What are other common factors in therapy and healing?
ALLEN FRANCES: Well, first of all, it is interesting that there has been such an extensive confirmation of Rosenzweig's intuition over the last 40 years of psychotherapy, but we shouldn't assume that it's only the relationship and the technical factors have no role at all, so that different types of patients will have different specific needs. In effect, the simpler and more contained the problem, something like simple phobia, the more likely the technique is going to be helpful. You'll need the relationship in order for the technique to work, but the technique itself will be important, and I can't imagine treating someone with phobias without using cognitive behavioral technique. The more the problems are deeply ingrained in the individual's personality, the more important will be the repetitive patterns of behavior that can be traced through the person's life, particular styles of interrelating with other people that may show themselves in the sessions, in the form of transference, the more psychodynamic techniques become important. So, I don't think we should assume that the tie scores mean that different techniques don't have their place. But that place is embedded in the idea that it will only work if there's a strong therapeutic alliance.
CHRIS AIKEN: What you're saying here reminds me of PTSD. Most exposure-based therapies were tested in single trauma PTSD, but patients with multiple interpersonal traumas (ex. complex PTSD), they might require a different approach.
ALLEN FRANCES: Well, it is always easier to do research on simple problems, and the difficulty is translating that research to real life where people usually present with very complex problems, and that's one of the difficulties with all research and also with psychotherapy research.
CHRIS AIKEN: So, in your view, would a single trauma like a car accident be a good candidate for a focused technique-driven psychotherapy?
ALLEN FRANCES: It's simpler than if someone has had multiple traumas and they also present with substance abuse and taking nine different medications they've been prescribed, and they just lost their job and their wife is divorcing them, and the real-life tends to be ever so much more complex. People who would get into research studies rarely present in real life. People who present in real life might rarely get into research studies because they have complex problems.
CHRIS AIKEN: Okay. I want to make sure I understand what you consider to be simple problems here. I'm thinking of like a single episode of depression, social phobia without any comorbidities, would these be simple problems?
ALLEN FRANCES: Exactly. So if someone has a transient depression, say first depression, in response to a clear-cut stressor or loss of disappointment, it's going to be ever so much easier to devise a manual to treat that than it will be to devise a manual to treat someone who presents with a long history of depression with lots of co-morbid symptoms. Other psychiatric conditions have been thrown in, substance abuse added, medical side effect added, maybe medication side effect, medical problem added, pain syndrome or diabetes, plus the fact that they may be experiencing all sorts of life stressors. So, the more complex the problem and the context of the problem. The less likely you can develop a simple manual to deal with it.
CHRIS AIKEN: I'm thinking we can add primary insomnia in there as another simple problem. Any other simple, limited problems come to your mind, like panic disorder?
ALLEN FRANCES: Panic disorder is a beauty. I used to work in emergency rooms wherever I was, and the patients I'd love to see most throughout my career were panic disorder patients because if you get there early enough, just explaining what the mechanism of the physical symptoms are, how they relate to hyperventilation. If you can just be reassuring about the fact that they're certainly not going crazy, that we understand tons about panic disorder, and very often, especially in early days, I would guarantee they get better. I would say I've seen hundreds and hundreds of people with this problem, and we really can do a lot to make sure that you're going to get better, but just the reversal of demoralization, the solving of some of the uncertainty and fears that are associated with, helps to prevent the later development of avoidance and agoraphobic symptoms, helps to be reassuring. The simpler and earlier the problem, the more likely you can develop a simple solution to it.
CHRIS AIKEN: This is one area where I find the DSM helpful in a therapeutic sense because it says that panic attacks are not a codable diagnosis, they are normal. 70% of people have had panic attacks. I've had them, but panic disorder is totally different. It's a phobia of panic attacks in the way it's defined. So when a patient has a panic attack, we can actually help prevent it from turning into a full disorder, from turning into panic disorder, and then they're not going to have a psychiatric disorder.
ALLEN FRANCS: DSM has many deficiencies and creates many problems in life, but one of the things that can be very helpful is its psychoeducational sort of labeling a problem for many people makes it much less scary, knowing that you're not uniquely damned, I'm not the only person who has this. It's well described, it's well understood. There are very clear-cut treatment things I can do that will make a huge difference. And again, that's where special techniques have their value. Special behavioral techniques have enormous, and cognitive techniques, enormous value in panic disorder. I wouldn't be taking every person who comes in with a first panic attack and worrying about their childhood.
CHRIS AIKEN: Here's another one. What about classic bipolar disorder, like no co-morbidities, where they have a healthy personality outside of the episodes? Would that be a simple case where like you could focus on techniques around circadian rhythm regulation?
ALLEN FRANCES: Yeah, disease management and bipolar is the crucial thing. There will be many variables that go into the outcome, some of which will be inherent in their genetic in their family history), and then the severity and frequency of the episode. But a lot of the outcome of bipolar disorder is getting an understanding of the problem and doing the things you have to do to manage it well and so that those people who are able to realize that the importance of sleep, sleep hygiene, of not using substances, of not traveling around the world all the time, of not over-exciting the nervous system with constant stressors and constantly changed experiences, of taking the medicine as prescribed in a very regular kind of way, tend to have very good courses unless they're overwhelmingly genetically loaded. They tend to, and I see that psychotherapy would be crucial in the management of bipolar disorder. Psychotherapy is crucial in management of schizophrenia. It's crucial in management of diabetes. It's crucial in the management of all medical conditions. And I think that if we see psychotherapy as only something that's done one or two times a week for 45 minutes in a stereotyped psychodynamic way, we miss the fact that it's inherent in every contact every doctor has with every patient.
KELLIE NEWSOME: Let’s pause for a preview of the CME quiz for this episode. Earn CME for each episode through the link in the show notes.
1. According to Dr. Frances, which of these is a simple problem that would respond well to a structured therapy intervention?
A. Narcissistic personality disorder
B. Cyclothymic disorder
C. Chronic alcohol use disorder
D. Primary insomnia
ALLEN FRANCES: One way of looking at this is that most of medicine, going back to the shaman, has been psychotherapy. That the active treatments in medicine have been few, and most of them have been more harmful than helpful. Doctors killed more patients than they cured with their biological treatments over the course of the last 50,000 years. Hippocrates first Do No Harm was introduced because there was a competitive school in ancient Greece that was very aggressive in diagnosis and treatment, and he realized that the treatment was often more dangerous than the underlying problem. Many patients get better on their own, and he (Hippocrates) said it's more important to know the patient who has the disease than the disease the patient has. That he was advising doctors to form strong relationships with their patients and not to go in with heavy biological treatments, most of which were, some of which were useless and some of which were very harmful. Modern medicine has tended to ignore this wisdom and become excessively involved with, in general medicine, with technical procedures and with aggressive medical treatments, and in psychiatry, with just giving medicine. Patient comes in, has a problem, prescribe a script. In doing that, we lose the power of the relationship, the placebo response rate goes way down in whatever treatment we're delivering, and our overall effectiveness is much reduced. And so the reason I'm so involved now with psychotherapy is to try to highlight its importance across all mental health specialties.
CHRIS AIKEN: How much does the placebo effect account for the improvement we see when we give an antidepressant in depression? Can we put a number on that?
ALLEN FRANCES: There's a wonderful, again, vision that Hippocrates had. He said that one-third of patients get better on their own, one-third of patients won't get better no matter what we do as doctors, and one-third of patients will benefit from our treatment.
CHRIS AIKEN: It's remarkable. Carl Jung, MD said the same thing in his book Memories, Dreams, and Reflections. He wrote that 30% of his patients got cured, 30% got somewhat better, and 30% no change.
ALLEN FRANCES: Hippocrates said this 2,500 years ago, and it's not true for every type of patient. So, if you take the average patient in a depression study, it's remarkably accurate. About one-third don't respond much at all, one-third get a lot better, and one-third in the medium, and it's likely that the placebo response rate for the average depression seen clinically is about 30%. If you take very mild depression, placebo response rate is 50%. If you take the average run-of-the-mill depression, 30%. If you take severe depressions, it's probably below 10%. So, severity is a predictor of placebo response rate.
CHRIS AIKEN: Thank you for talking with us, Dr. Frances.
KELLIE NEWSOME: Allen Frances served as chair of the DSM-IV committee. He is Professor and Chairman Emeritus at Duke and the founding editor of the Journal of Personality Disorders and the Journal of Psychiatric Practice. His books include Saving Normal, Essentials of Psychiatric Diagnosis, and Twilight of American Sanity. We published an edited version of this interview in our October 2022 issue and are releasing the full audio now. To hear more from Dr. Frances, come back next week for part II of this podcast, or check out his Talking Therapy podcast with cohost Marvin Goldfried, PhD. Dr. Aiken is still posting one practice-changing study a day, and you can now follow him on the BlueSky app in addition to his usual feeds on LinkedIn, Twitter, and Facebook. Just search for Chris Aiken, MD. Thanks for tuning in and helping us stay free of industry support.
The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 CreditsTM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.