TCPR: Can you give us an example?
Dr. Plakun: I once saw a woman who developed a bridge phobia after the death of her father. During our sessions, I learned that in childhood her relationship with her mother was distant, but she was closer to dad—who was more loving but could also be quite belittling and demeaning. In speaking about her phobia, she said that she had a terror of being swept over the side of a bridge while crossing it, and she felt a knot in her stomach when crossing bridges. When I asked if she’d ever felt that kind of knot in her stomach before, she recalled a childhood episode when she had climbed a steep and exposed fire tower with her father one windy day. It had been scary going up, but the prospect of descending was utterly terrifying. She asked father to hold her hand, but he refused, went down alone, and told her she would have to find her own way down. She had felt the same terrifying knot in her stomach as she descended very slowly. Father made fun of her timidity from the bottom. She had felt humiliated, enraged at “her father,” and abandoned by him.
TCPR: And what was the connection between her father’s death many years later and the onset of the bridge phobia?
Dr. Plakun: Her bridge phobia replicated the fire tower experience. She had felt abandoned by her father when she was descending the fire tower, and later her father’s death felt on some level like another abandonment, reawakening the old fears of vulnerability and of being swept away and falling.
TCPR: It is an interesting orientation to treating patients. In a more psychopharm-oriented practice, when a symptom is not responding, we tend to look for just the right combination of meds. But you’re saying we shouldn’t forget the value of digging a bit deeper into the meaning of symptoms.
While we often tend to view symptoms as problems, in the psychoanalytic view symptoms may look like problems, but they are also actually solutions.
~ Eric M. Plakun, MD
Dr. Plakun: Yes. For example, let’s take the issue of treatment resistant depression. We all have such patients, and the question is “why is this patient treatment resistant?” There are certainly those who don’t take the medication, and then there are those who do not respond to medication they are taking. It turns out that among these non-responders, a large number have a history of early adversity and a lot of comorbidity. In the one large study, Skodol and colleagues found that comorbid personality disorders, especially borderline personality disorder, “robustly predicts the persistence” of major depressive disorder (Skodol AE et al, American Journal of Psychiatry 2011;168(3):257–264). So the practical tip is that if you have a patient with treatment resistant depression, don’t think only about the next medication to try, think about the impact of early adversity, and think about the contributions of comorbidity, especially comorbid personality disorders.
TCPR: How do we sensitively assess for early adversity?
Dr. Plakun: You don’t do it with a DSM checklist of symptoms. You do it by listening to the patient’s life narrative in a way that follows the affect. Typically, I start by asking about the events leading up to the problem that brought the patient in, what is usually called the history of present illness. But then I go back to their early childhood. “How were things? What was your mother like? What was your father like? What were your siblings like? How were you treated? Did anything go wrong? Were you bullied? Were you harmed in any way?” But I don’t pepper them with questions; I try to hear the story and follow the affect. So if you hear that their mother died when they were young, you say, “That must have been awful,” and you hear more about it. This kind of engagement is also part of building the therapeutic alliance—it shows you are with the patient in their experience. And it is crucial in finding therapeutic stories, which can be very helpful.
TCPR: What do you mean by a therapeutic story?
Dr. Plakun: Therapeutic stories are episodes from a life history that illustrate a powerful, often recurrent theme in a patient’s life. They can be useful metaphors for a patient’s struggles. For example, I saw a patient in her forties who had been stuck in a pattern of treatment resistant depression for 10 years. In learning about her life, she told a moving story of having fallen into a cesspool as a young child, and nearly drowning in a difficult struggle to get out. Later, after a series of important relationship and work losses as an adult, she became depressed in a way that was refractory to treatment. It was quite useful for us to conceptualize her current plight in a way linked to the therapeutic story of the cesspool. She had once again fallen into one, and there was no one around who seemed able to help her get out—me included. We did a lot of work about her wish to be rescued, her anger at my limitations, and, ultimately, her own ability to find and use her own resources to reclaim her life.
TCPR: Thank you, Dr. Plakun.