Allen Frances shows us how to adjust our therapeutic approach for problems that are simple and those a bit more complex.

Publication Date: 12/23/2024 

Duration: 16 minutes, 53 seconds 

KELLIE NEWSOME: You can give the right medicine the wrong way. Today, Allen Frances shows us how a strong therapeutic alliance improves outcomes from the emergency room to the therapy couch. 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 Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. When we left off last week Dr. Frances shared with us a remarkable statistic that has held true from Hippocrates to Carl Jung to modern antidepressant trials. In each case, the outcomes are similar: A third of patients recover; a third get somewhat better, and a third don’t change much at all.

CHRIS AIKEN: That is remarkable consistency considering how different each of these treatment approaches are, but they speak to a common ingredient that goes across all therapies. Some call that ingredient the placebo, but that makes it sound kind of like a parlor trick, the power of suggestion. This placebo effect is bigger than a sugar pill, and it includes the natural course of illness, the therapeutic relationship, and the patient's own inner resilience. Last August, a pivotal paper came out that ranked psychiatric disorders based on how they respond to the placebo. Here's what they found. 

KELLIE NEWSOME: At the top are Major Depression and Generalized Anxiety Disorder, and here the placebo effect is even higher for children and for mild cases. Next, in the middle, are panic disorder, ADHD, PTSD, social phobia, and bipolar mania. Yes, a lot of mania trials were done in the hospital, and mania responds to a structured environment with regular activity and wake times, not to mention PRN benzos that are often allowed in those trials. And the least responsive to placebo? That goes to OCD and schizophrenia.

CHRIS AIKEN: That's all intellectually interesting, but you may be wondering what to do with all that in practice. I mean, most of us aren't giving out placebos, right? Well, we are, and when psychopharmacologists neglect this delicate art of the placebo, their outcomes are pretty bad. In one large trial, the outcomes for depression depended more on who was prescribing the drug than on whether the patient got the placebo or the antidepressant. In that study, psychiatrists who built strong therapeutic alliances got better outcomes with the placebo, then did their colleagues who had poor bedside manner, but used an antidepressant. So, we asked Dr. Frances what we can do to brush up on those therapeutic skills that are partly responsible for these elusive placebo effects.

ALLEN FRANCES: It's an interesting question in terms of can you teach it. It is not difficult to develop manualized versions of the simple delivery of technical treatments for very simple problems. The problem with manuals is people worship them and they lose the patient. They start following the manual and they stop following the patient. It's much more difficult to teach people to be really good interpersonally. The experience I've had is that really great therapists are born, they're not taught. There's some people you meet in psych residency programs, or I met them when I was recruiting lay counselors for an addiction program, who are great therapists and maybe you can teach them a little bit, but they sort of know so much already that they don't need much training. Training can make good therapists much better, it probably can't make bad therapists into good therapists. So a very important part of developing an effective mental health program or mental health system is selection. It's important to try to get people who have those interpersonal skills that have been wired in or acquired through their previous lifetimes, 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, who can convey optimism even in the face of difficult problems in a realistic way, not in a false assurance way, that really good people are really good therapists. Can you improve that? I think that there have been a number of efforts to teach empathy, to have a systematic course in helping people to understand what other people are feeling, and I think that in addition to improved selection, I think it would be very useful in medical schools, not just psych residencies, to teach bedside manner, to teach the doctor-patient relationship. We spend a tremendous amount of time in medical schools, and residencies teaching specific facts, but maybe missing the main point that a tremendous part of the variance and outcome will depend on how well this person can form relationships. Instead of just filling the person with facts, we should be refining them as therapeutic instruments.

CHRIS AIKEN: I want to ask you about your own life, and what were some experiences that caused you to shut down your own empathy or to open it up? 

ALLEN FRANCES: One of the things I think I actually learned in the podcast, in our first podcast, Marvin quoted Sidney Blatt saying that he felt like a better person when he was doing psychotherapy than any other thing in his life. I believe in magic moments in psychotherapy. Psychotherapy isn't incremental. It's not like you keep building little blocks, and at the end of the day, the person is in much better shape, I think it's magic moments of corrective emotional experience that drive change in people's lives, where you suddenly realize something in a different way, experience something in a different way, do something you were afraid of doing before, and it works out okay; and I had a magic moment that I've been a much better person in my life than I ever was in any other role when I was doing psychotherapy, and I tried to figure out, after this insight, why? I came up with three things. One, that the psychotherapy relationship is the most unselfish of all relationships. I'm not inherently a selfish person, but even in my relationship with my wife, she'll say especially in my relationship with her, even in my relationship with 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. Occasionally, a sickness in the family or having children, where I pulled away some because I was preoccupied with other things in my life. By and large, as a therapist at my best and being unselfish. The second thing is the intimacy that you get to know your patients much better than you, almost anyone in your life, and maybe better than anyone in your life. You get very close to them. It's a tremendous privilege to be able to learn what people's innermost fears, and hopes, and disappointments, andembarrassments, and ways of looking at the world, and that makes you a better person. I've always been grateful to my patients, but I never realized how much it was because they were making me into a better person.

CHRIS AIKEN: By better, you mean more empathic? 

ALLEN FRANCES: More empathic, less selfish. It enriches your life in a way almost equivalent to getting married or having children, which is your life. 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, and I still have contacts with some people I've known for 50 years. I have contact with someone I first met in 1967, and we still exchange emails on a regular basis. And I treasure his relationship as much as I do almost any other relationship in my life.

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 a 2024 study, which disorders have the highest placebo response rate?

A. Major Depression and OCD

B. Panic Disorder and OCD

C. Major Depression and Generalized Anxiety Disorder

D. Generalized Anxiety Disorder and Panic Disorder

CHRIS AIKEN: On the other hand, I've seen studies from psychology and sociology showing that when people take on leadership positions or high status in society, their empathy tends to go down. 

ALLEN FRANCES: Over the years, I've been lucky enough to know a number of the leaders in psychotherapy, and one of the things that's amazing to me is first of all, how nice they are and how similar they are to one another. This is not universal to every person who's made a major contribution to psychotherapy, but most of them, regardless of their differences in theoretical orientation, when you see them working with a patient, they're remarkably similar. They form remarkably good bonds with the patient. Whether it's Marsha Linehan with DBT, or Tim Beck with CBT, or David Barlow with behavior therapy, when you hear them talk about their therapies in theory, they sound very different. When you see them with a patient, they seem remarkably alike, and they're all great at forming therapeutic relationships. 

CHRIS AIKEN: So these therapists have kept their ability to form strong bonds with patients, even as their own careers have risen in their fame, leadership, and research positions.

ALLEN FRANCES: Yeah, the person I send patients to the most now, including family members, is Judy Beck. She is the most empathic therapist I've ever met. 

CHRIS AIKEN: Yeah, she is great, and her father, Aaron Beck, developed CBT, which is seen as a very manual-driven therapy, but I was surprised to learn from you that Aaron Beck was skeptical of manuals.

ALLEN FRANCES: Oh, no, it's very interesting that Tim developed the manuals specifically because in our committee, the only way you could get funded was if you had a manualized treatment. So, when the NIMH was funding studies, it was a requirement that the treatment be amenable to manualization and standardization with frequent checks to see how closely the manual was being followed. The idea being, and again, it's a crazy disconnect between research and clinical practice. The idea being that you couldn't understand and interpret the results if the treatments weren't delivered in a standardized way. The trouble is that you would never want to do that standardized treatment in practice, and Tim and later Judy, when she took over the training at the Beck Institute, they never used the manual as a training tool, and never recommended it as a way of conducting therapy. 

CHRIS AIKEN: Allen you got to know a lot of the therapy leaders in the 1980s as you worked with the NIH to distribute funding for research projects to prove the efficacy of psychotherapy. So what do other therapy leaders think of these manuals? People like Marsha Linehan, who developed DBT.

ALLEN FRANCES: With Linehan, there was never the capacity to closely manualize DBT. The more difficult the patient, the harder it is to manualize; very interesting in light of the fact that some of the early studies found that the patients who were in treatments that were more closely following the manuals did better, and the dumb interpretation at the time was, aha, if you follow the manual you get better results. It's really a case of confusing correlation with causality. The causality is just the opposite. If you have easy patients they let you follow the manual. If a patient's difficult, you're going to have to be creative and flexible. They won't let you go rotely, we do this today and this tomorrow, they force you to respond to their current need, and I think that it's a great mistake to think that slavishly following manuals leads to better results. I think it may be useful to read the manual if you're a therapist to get a sense of the general idea of it, but never to follow the manual rather than the patient. You'll always be either a week behind or a week ahead of the patient if you're thinking in terms of what would the manual have me do. The best continuing education in psychotherapy is the next patient you get to see. 

CHRIS AIKEN: So if I hear you right, following the manual is best when you're treating a simple problem, like a simple phobia or PTSD from a single trauma, panic disorder, or like a single episode of depression.

ALLEN FRANCES: I think using the manual as a context to help you understand the general principles of the therapy is fine, but the idea that the manual can control the treatment, that it will allow you to be close to where your patient experientially needs you to be at any given moment in the session, that leads to really bad treatment, like originally my first patient where I was trying to think, what would the supervisor want me to say at this moment? You should never be thinking about what would the manual do? What would the supervisor say? You should always be thinking, what does the patient need at this moment? I would always tell the people I was supervising, don't take seriously what I say when you go into the next session.

CHRIS AIKEN: This is kind of a shock because we're often taught in residency programs that following the manual gives the best outcomes. Now, are you saying that this oft-repeated wisdom might just be an artifact of correlation and has never really been proven in a randomized manner? 

ALLEN FRANCES: I'd have to think about how you would randomize it. I'm not sure you could randomize it. Within a given study, they will take the different treatments and they will have process measures done by raters and how closely the manual is followed, and then at the end of the day, say, well, we got better outcomes when our measures indicated that the therapist was following the manual, but they're blind to the fact that the reason the therapist violates the manual is because he's attending to what the patient needs, and those types of manual violations will be much more necessary for the more difficult patient who have a worse outcome. Following the manual isn't what's making someone get better, it's because they have a good outcome to start with that allows you to follow the manual. Not following the manual may be the perfect thing to do with someone who has a worse outcome that improves the outcome, but it will never be as good as someone who started out being easy and likely to have a good outcome complicated way. I think you can say it better when you write it up. 

CHRIS AIKEN: I think you're right on this one Allen, I know it hasn't all been tested in a randomized manner, but I ran your idea by a group of therapists the other day and they were clear. Their take was that it's the more restricted, obsessive kind of therapists who stick to manuals and the more warm, flexible, adaptive, and connected therapists are the ones who tend to deviate from them.

ALLEN FRANCES: I'll just say one thing, the people who follow manuals, rather than patients, are not going to form that wonderful therapeutic relationship. 

CHRIS AIKEN: Thank you, Dr. Frances.

KELLIE NEWSOME: Allen Frances is a psychiatrist, psychoanalyst, and Chair Emeritus for the Department of Psychiatry at Duke. He chaired the fourth edition of the DSM and is 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’ll have more from Dr. Frances next week, and you can also find him in the Talking Therapy podcast with cohost Marvin Goldfried.

Do you like the Carlat Medication Fact Book? Well, there’s a new version out for inpatient psych, the Hospital Psychiatry Fact Book by Victoria Hendrick and Danny Carlat. It includes chapters on medication, therapeutic, and legal aspects for disorders commonly seen in the inpatient setting, as well as psychiatric emergencies, hospital safety protocols, and everyone’s favorite: navigating healthcare administration. Find it on Amazon or on the Carlat Website.