Psychiatric Times Vol 16 No 4

Rough Air

Marc Schuckit, M.D., professor of psychiatry at the University of California, San Diego, School of Medicine, examined recent developments in the treatments for alcohol and drug dependence, and examined important changes in DSM-IV's classification of substance use disorder at the 11th Annual U.S. Psychiatric & Mental Health Congress.

This article addresses several practical issues related to beginning psychotherapy: telephone contact, the initial session, referral to another therapist, discussion of arrangements, charging for missed sessions, guidelines for the patient and interactions outside the therapy hours. It takes a question-and-answer form, dealing with with questions a neophyte psychotherapist might ask. Although the article specifically relates to treatment that is dynamically oriented, it is also relevant to other forms of psychotherapy.

Myron Liptzin, M.D., is a respected psychiatrist who specialized in the treatment of university students. Liptzin retired last year as chief of psychiatry of student health at the University of North Carolina at Chapel Hill, where he had earned a reputation as a skillful clinician who was particularly adept at crisis intervention. If Liptzin had hoped to go on to a less hectic and stressful life, his expectations were shattered when he found himself accused of negligence in one of the most unusual cases of psychiatric malpractice of this century. A former patient went on a rampage-killing two people-and then blamed Liptzin. The verdict against the psychiatrist was front-page news, and CBS's "60 Minutes" went to North Carolina to do a story that aired mid-November 1998. Like a bolt out of the blue, Liptzin had gotten his 15 minutes of unwanted fame.

DeAndra's story: I came into the rooms and realized after a while that I had the attitudes and behaviors of an addict way before I ever picked up a drug. I remember growing up and being at my family's parties, [where] my aunts and uncles would give me and my brothers beer. There are pictures in our photo albums of us, all under 6 or 7, with cans of beer in our hands. At an early age I learned to manipulate to get what I wanted.

Psychiatrists, like the rest of America, continue to have trouble with alcoholic and other addicted patients. We are comfortable when patients want to get better, tell us the truth and come to treatment of their own free will, but alcoholics often don't fit this profile. We respond angrily when patients manipulate us. We are surprised when their sincere desire for help evaporates after we suggest a plan that will bring about real change.

Nearly 25 years ago, the National Institute on Alcohol Abuse and Alcoholism hailed couple and family therapy as "one of the most outstanding current advances in the area of psychotherapy of alcoholism" and called for controlled studies to test these promising methods. Currently behavioral couples therapy (BCT) is the family therapy method with the strongest research support for its effectiveness in substance abuse.

It is now customary psychiatric practice to think of a patient's illness as primarily biological in origin-so much so that, for many illnesses, published practice guidelines almost exclusively describe medication strategies.