[Winter 1998; Vol.25 No. 3]
Dr. Hershfield: In your role as Director of Hopkins’ AIDS Psychiatry Services, how are you able to work with people who are so ill?
Dr. Treisman: There is a short answer and a long answer. The short answer is that we are inspired because the patients get better. We get daily miracles in the clinic. That’s what keeps everybody going. The interpretation of people who work with difficult patients, including those who have been doing it for 10 and 20 years, has been that they can do that because of something about them, whereas my interpretation of people who do it for 20 years is that they know how to do it and that if you know how to do it, you generally get good results. Patients get better. At the time I got there, the AIDS clinic had recently undergone a dramatic change. When AIDS first started, as soon as you diagnosed the disease, they were going to die within three months. It was a death sentence. So we made those people comfortable. It’s a reasonable goal – to try to make someone comfortable when they are going to die. When I got there, people were living 5 and 10 years. Trying to make someone comfortable for 10 years when they are going to die is a terrible mistake. What you really want to do is to rehabilitate people who are going to live 5 to 10 years, even if they are really difficult to rehabilitate. As a result, my approach to HIV was very different than the rest of the people in the clinic when I arrived. My approach was to set limits and to make a diagnosis and to begin a treatment plan directed at the diagnosis. If someone had a personality disorder, I’d treat the personality disorder; if someone had a mood disorder, I’d treat him for that. If someone had a drug addiction, he’d get treatment for that. The patients had a different agenda. Patients came to the clinic and said, ‘Make me feel good.’ That’s how they got AIDS– by wanting to feel good, by not wanting to take the time to take precautions. At the time that I arrived, a lot of patients were getting HIV-infected without knowing what was causing the infection. Most people today know the risks. Most people in the high-risk groups have seen someone die of AIDS. People who continue high-risk behaviors, having seen someone die of AIDS, are members of a psychiatrically ill group.”
Dr. Hershfield: In what way have you changed since you started in this work?
Dr. Treisman: I am much better at limit setting than I was 10 years ago. I’ve learned about limit setting a lot and I’m more confident. Two things have changed. One is that I’m much more able to describe what I do and the second thing is that I’m more comfortable with doing the things that I think are right for patients that they don’t like. I was just at a meeting in New York and one of the people there said, ‘How do you set limits when somebody comes to you and says, ‘I don’t want this, I want that.’ How do you do that?’ I said, ‘Patients emotionally blackmail you only for things that are bad for them, they don’t have to emotionally blackmail you for things that are good for them. You’re glad to give them those things.’ So whenever there is emotional blackmail involved, whenever they say, ‘If you don’t do this, I will kill myself,’ you always, if you look at it, will see that it’s something bad for them. Otherwise, they wouldn’t have to threaten you. If you said, ‘If you don’t give me an antidepressant because I’m depressed, I’m going to have to kill myself...’ they don’t have to say that–you’re already going to give it to them. So, whenever emotional blackmail exists, they’re blackmailing you for something that is bad for them. If you can figure out what it is, you can say ‘I won’t do this because it’s bad for you this way,’ then the emotional blackmail is over.
Dr. Hershfield: What in your training and your background have proven to be particularly useful?
Dr .T.: I recently wrote an article about AIDS psychiatry and one of the things that the reviewer said was, ‘This article describes general psychiatry.’ and I agree. What I do in the AIDS clinic is really ABC, very basic. Every psychiatrist who is generally trained should be able to do it. I am probably more sophisticated about pharmacology than the average psychiatrist. I have a Ph.D. in pharmacology, but our whole group is very sophisticated about drug interactions, medical problems that go along with psychiatric problems, opportunistic infections, recognizing delirium, recognizing subtle medical symptoms mimicking psychiatric syndromes, that stuff we’re better at, because we’ve had a lot of experience. But any well-trained general psychiatrist could come join our group tomorrow and have no trouble because it’s wonderfully straightforward, what we do. Our patients are sicker. They usually have more than what walks into a psychiatrist’s office. They usually have a personality disorder and a mood disorder and a substance use disorder and horrendous life circumstances. So you have to do supportive psychotherapy, some insight psychotherapy, cognitive behavioral psychotherapy and give them antidepressant medicines. You have to do all of those things for almost every patient. But even so, it’s all very basic. It’s not that they have something different than other patients have, they just have more of it. In my training, the thing that prepared me best was being a careful diagnostician, being able to look at a patient and before starting a psychotherapeutic intervention, try to start my thinking at, ‘What’s wrong with the patient?’ As you know, one of the things Johns Hopkins stresses in its residency is, ‘You don’t start the treatment plan before you know the diagnosis.’
Can I go off on a tangent? Right now, psychiatry faces its largest challenge ever. We are being replaced, wholesale, with other professionals. We are not being supplemented, augmented, or enhanced with a team of other professionals. Other professionals are replacing us. That problem comes out because psychiatry hasn’t defined its role very well. If you are an infectious disease doctor, you can train in 10 different institutions and you’ll get roughly the same training. A psychiatrist training in 10 different institutions would receive radically different training.
Dr. Hershfield: What kind of training should psychiatric residents be getting now, so that they could best prepare to practice in 25 or 30 years?
Dr .T.: I think that what a psychiatrist brings to the table, as a mental health provider is the same thing that physicians in other disciplines of medicine bring to the table. We are the people who are trained in understanding the differential diagnosis that goes along with syndromal symptom sign sets. We think about putting together a series of complaints, symptoms, and signs of disorder into an historical, epidemiological/biological perspective that allows you to give a differential diagnosis list and therefore develop a treatment plan directed not at the complaint, but at what’s wrong with the patient that creates that complaint.
Dr. Hershfield: How do you address the fears of the residents that the field will radically change?
Dr. Treisman: By pointing out that schizophrenia costs more in terms of its treatment to society than virtually any other three to five illnesses that you could care to pick out that are common. Mental illness is vastly expensive, under-treated, under-recognized, and misunderstood. Our work is 25 to 50 years behind the rest of medicine, in pathophysiology and etiology of disorder. We have a vast playground of the mind and the brain in which to do research and in which to enrich our knowledge base and we have a huge population of victims of these disorders that desperately need our help. So psychiatry won’t go away because the illness won’t go away. The patients are out there. The thing that psychiatrists bring to the table that other mental health professionals don’t is our training in medicine, in differential diagnosis. Ultimately, treatment changes. Treatments are technical. They change. Psychotherapy can give way to a machine that shoots a wave into the brain that fixes the problem. You might be able to erase certain memories from people some day. I don’t know what’s coming. But understanding what’s wrong–that doesn’t change.
Dr. Hershfield: Do you see a change in the type of person who is going into psychiatry?
Dr. Treisman: I think the people coming in-- the residents-- are similar to the people who were interested in psychiatry when I applied. There is a large group of people who are incredibly fascinated by mental illness who want to be doctors and who see psychiatry as sort of the ultimate frontier in medicine. There is also a group of people who really don’t want to be doctors and who think that by getting into psychiatry they’ll have less medical stuff to think about and do. Those people are in for a huge disappointment in the future. Psychiatry, if it wants to survive, is going to have to be more of a discipline of medicine, not less, in the next 10 years. Psychotherapy is a very important part of psychiatry. But, it’s not psychiatry. Psychiatry is a discipline of medicine; the therapy is a technical practice. If you go into surgery because you want to be able to open people’s abdomens, and endoscopic surgery comes along, you have to learn to do endoscopic surgery. The techniques change. But the diagnosis of appendicitis hasn’t changed. You don’t care if the surgeon is the technically best surgeon in the world if he or she does the wrong operation. So what you pay a surgeon to do is not to be technically skilled at performing an operation, what you pay a surgeon to do is to be technically skilled at figuring out which operation to do and then to be an expert at the technique of doing the operation.
Dr. Hershfield: Do you find the work as Residency Training Director to be rewarding? Are you optimistic about it?
Dr. Treisman: I am very optimistic about it. This year, we have the best class of residents. In the last several years we have had phenomenal residents. All the residents whom we took this year could have gone anywhere, every one of them. They had an infinity of choices.
Dr. Hershfield: It’s no secret to me why they go to Hopkins.
Dr. Treisman: Yes, but when you think about Harvard, Yale, Columbia, and U.C.-San Francisco-Langley Porter, those are all great places, too. People say, ‘Is there really a difference in how we teach?’ There really is a difference in what Johns Hopkins teaches in its residency. There are three things, I think. The first is, some people, when they talk about a balanced program, mean that they have one of each kind of therapist. They have a cognitive behavioral therapist, a group therapist, a psychotherapist, a psychoanalyst, a brain research guy, and a brain neuroimaging guy, and that’s a balanced program. You have something representing personality and you have somebody who says that everything is borderline. Some other person who says that everything is a mental illness. Another person says that everything is a psychodynamic problem. Everybody is an incredible towering giant in each of those fields. That’s a balanced program. In this program, the balance is different. Each psychiatrist here is expected to approach a patient within the scope of his or her problems, where personality theory from classical psychology meets personality theory from psychodynamic theory and how we’re working on resolving those issues. Everybody here knows that, even people who do research on schizophrenia.
Dr. Hershfield: So where do you think psychiatry will be 30 years from now?
Dr. Treisman: I think that we will be, much more 30 years from now, a discipline of medicine. I think that 30 years from now, psychiatry will no longer rely on things like the DSM-IV for diagnosis, which will be much more like it is in Internal Medicine and Surgery. The little book that you carry in your pocket, instead of carrying a operationalized criteria for diagnosis, will tell you instead how to work up symptom and sign-sets into a differential diagnosis, the way the Washington Manual describes it for medical problems. People will be much more cognizant of the relationship between comorbidities like mood disorder and personality disorder and people will no longer try to fit everything under one umbrella of etiology. People will no longer fight. The war between biological psychiatry and dynamic psychiatry 30 years from now will be over. Biological psychiatry will be fascinated by the ideas of drive for alcohol and drive for illicit drugs and their reinforcing potential. But, the biological contribution to the problems will still be synthesized by people who come up with an initial diagnosis and who say, ‘This is a problem that emerges out of a person’s life and life experience and therefore needs re-scripting in psychotherapy. This is a problem that emerges out of a person’s neurochemistry–it needs adjustment with antidepressants.’ But, the role that psychotherapy plays in a person like that is supportive and encouraging and it provides hope.
Dr. Treisman is Director Residency Education and of the AIDS Psychiatry Services of the Johns Hopkins Dept. of Psychiatry and Behavioral Sciences
Dr. Hershfield is a member of The Maryland Psychiatrist Editorial Advisory Board