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Ways In Which Psychologists and Dentists Can Collaborate/Nadine A. Levinson |
| The Technological Base to Clinical Practice: Management & Marketing/David B. Adams | |
| When Hiring Another Psychologist/Michael J. Cuttler | |
| Book Review/Sex, Drugs, Gambling, & Chocolate, by A. Thomas Horvath/Reviewed by Michael Brickey | |
| Book Review/Men, Women and Prostate Cancer, by Barbara Rubin Wainrib and Sandra Haber/Reviewed by Dorothy Cantor |
| Nadine A. Levinson, DDS | Ways in Which Psychologists and Dentists Can Collaborate
You might as, what does psychology have to do with dentistry? Dentistry is a profession, like many other non-psychiatric medical specialties that can greatly benefit from consultation liaison. Dentists work in an area of the body, the mouth, which is developmentally significant and emotionally laden with much meaning. Psychologists who are trained to understand the development of personality, affects and emotions over the life cycle, are well suited to provide consultation to the dentist about all aspects of dental practice. Dentistry and Psychology have a great deal more in common than is often considered. Each professional works with patients in a similar area of the body, the mouth and the mind, respectively. It is the mouth and the face that hides and expresses human feelings and emotion; it is the mind that processes feelings and emotion. Dentists and psychologists are usually high achievers, work alone, and practice in quiet and controlled settings. Both professionals work with physical and mental structures that evolve over time and continue to change. Each practitioner works with patients in a way to try and make their lives better, very often starting from a state of pain and anxiety. This sincere wish to be a healing caretaker can often be painful for either care provider when the patient (for a variety of reasons) does not get better or even needs to unconsciously sabotages treatment. Although each field is seen as a unitary whole, both fields have many subspecialties and evolving schools. My entire professional career has been practicing first as a dentist and then as a psychoanalyst. In this capacity as both psychoanalyst and dentist, I have had the unique opportunity to meet with patients referred to me by dentists and to provide consultation liaison between dentistry and psychiatry. These referrals have come from a diversity of specialties and subspecialties of dentistry including, oral surgery and oral and maxillofacial surgery, orthodontics, restorative dentistry, prosthetics, and pediatric dentistry. As well I have provided consultation for TMJ Disorders, esthetic dentistry, facial pain, oral trauma, the phobic dental patient, the stressed dentist, legal issues, and anytime there may be a breakdown in the patient/doctor relationship. Many of these referrals stemmed from a perception by the dentist that my being originally trained as a dentist, accorded me some special knowledge that would allow me to help. I do not feel however, that having a double degree is a necessary prerequisite for understanding and communicating a psychologically-informed view related to the dental situation. In the remainder of this article, I will briefly outline what I will be discussing in greater detail at the Millennium 2000 Psychology Conference “Psychologist/Dentist Collaboration,” March 4-5, 2000 held in Los Angeles. My topics will include: an outline of a psychodynamic approach, transference and countertransference, clinical areas in which psychologists can be especially helpful to dentists, and guidelines for providing consultation for the dentist. What do I mean by a psychodynamic perspective and why do I think such an approach is essential? Not only dentists but also some psychologists are resistant to a psychodynamically-informed perspective, misunderstanding it as a theory that reduces human behavior to simply motivated by sex and aggression, alone. Modern psychodynamic psychiatry owes a great debt to Sigmund Freud. He explained all mental phenomenon as the outcome of unconscious forces in the mind seeking expression (Freud, 1953a). Freud also emphasized the importance of a developmental perspective for an understanding of human behavior (Freud, 1953b). Relationship and body experiences over the life cycle impact personality development and help maintain a psychological homeostasis. In the specific case of orality, the mouth takes on new and different functions and meanings over time and influences the personality as well as the quality of relationships. The mouth becomes a symbol for the total self. Expressions such as “don’t bite the hand that feeds you,” or “she set her jaw in determination” characterize how the mouth becomes a metaphor for the self. Most dental advertisements featuring a big, beautiful smile illustrate how the mouth has become a representation of an ideal of psychological, social and physical adequacy (Levinson, 1990, 1990). A contemporary psychodynamic model also conceptualizes personality difficulties related to developmental deficits, or deficiencies or weaknesses of psychic structure. These deficits manifest as negative feelings of self or self-esteem, insecurity, inability to feel complete or whole and thus require inordinate feedback to feel good about themselves (to make up for the deficit), from those they come into contract with in the world, including the psychologist or the dentist. It also involves, not only an informed view about our patients, but about ourselves in the field between patient and treater or for that matter, between treater and consultant. Patterns of relating to others, such as the dentist are determined by these internal self and object representations and can impact the patient/dentist interpersonal relationship. In summary, conflict, deficits, and internal object relations, and their development over the lifecycle are the key elements of a psychodynamic approach. A psychodynamically-informed view assumes that all behavior has meaning, even if that meaning is not conscious. Experiences from childhood and childhood are crucial determinants of adult personality and the meanings people give to a situation. This approach constitutes a way of thinking about a wide range of human behavior as well as thinking about the essence and meaning of any number of different treatment modalities. It seeks to determine what is unique for each patient with his or her own life story (Glabbard, 1990). Case 1: Micrognathia, its successful surgical repair, its consequent psychological decompensation A seventeen-year-old female patient was referred to a psychoanalyst for psychological consultation following a surgical repair for micrognathia. After extensive orthognathic surgery of the maxilla and mandible, she became depressed, more asocial, withdrawn, and generally dissatisfied with the surgical results despite realistic assurances from everyone about how much better she actually looked. Over the next seven months, the patient gained 30 pounds in spite of being in intermaxillary fixation for eight weeks and then developing a bulimic disorder. The surgeon was devastated, having felt like he had done a great job and was beside himself, not knowing what to do to fix the situation. From a three-hour psychological evaluation, it was learned that she was the younger of two children born into a solid, upwardly mobile middle class family. She looked like her father, who was also micrognathic, and felt she could never be as pretty as her mother or two-year older sister. She saw both her mother and sister as well-liked and social, whereas she in contrast, was withdrawn, although an excellent student. Her mother and sister always seemed to enjoy doing things together, while she was closer to her father, who was often gone on business trips. Because of her poor facial appearance, she never felt she could match up to her mother or sister and so gave up trying, becoming more reclusive. At 16 years of age, her mother, feeling that all of her daughter’s problems were caused by her undesirable facial appearance requested orthognathic surgery. The patient was reluctant to have the surgery, but everyone attributed this to the normal fears of adolescence. No psychological evaluation was considered and the patient complied with the wishes of her mother. After orthognathic surgery, as in other areas of esthetic dentistry, there was an immediate transformation from ugly duckling status to being a beautiful young lady. Young men were attracted to her, but she was frightened of their overtures. Some even considered her more attractive than her sister. It seemed inconceivable that she would become more depressed, withdrawn, and obese. She could no longer use her poor facial appearance as an excuse and a protection to avoid competing with her sister or to distance herself from others. Because of her inhibitions, she was ill-prepared for the normal adolescent developmental demands and strain. Because her body image had changed by her becoming more attractive, her conflicts were only intensified. These conflicts concerned her angry and guilt-ridden feelings about her position in the family, her sexuality, and other aspects of her identity. She warded off her conflicts about femininity with new symptoms, which safeguarded her by making her less attractive. The patient became a fat, cherubic child, rather than an attractive young woman. The eating disorder was a symptom that caused the patient to feel ashamed, but also punished her for some of her angry feelings toward her beloved family. The oral surgeon learned that despite his best intentions and care, unwittingly he was drawn into a family drama where untreated psychological factors prevail and can spoil excellent surgical technique. He now requests psychological consultation pre-operatively for extensive maxillo-facial surgery. What is Transference and Countertransference and how can these concepts be useful to the dentist? Two clinical phenomena derive from psychodynamic theories discussed above that have crucial relevance to the dental situation: transference and countertransference. Transference occurs when the patient experiences the dentist and other caretakers as a significant figure from the patient’s past (Greenson, 1967). Transference is characterized by an exaggerated, repetitive, or inappropriate reaction by the patient toward the dentist. Just as patients may respond to their dentists as important people from the past, the dentist does the same in relation to patients. In most cases, transference facilitates a positive patient-doctor relationship as most people have had “good enough” caretaking experiences and expect that their dentist, like their parents will make them feel better and look better. In a negative transference situation, the patient may view the dentist as an authority figure or tyrant, with whom they might comply and then eventually rebel. A transference of power and authority to the professional (dentist or psychologist) can be the basis for a positive treatment experience, but also a negative one. Much of this “potential” negative transference toward both the dentist and mental health professional is similarly represented in devaluing and denigrating images seen in the cinema. Often the dentist is viewed as the sadistic torturer, as in Marathon Man, while the mental health professional is seen as the crazy sex pervert in Dressed to Kill. For a dentist who does not know about the dynamics of transference it can be devastating to self-esteem and feelings about being a dental health care provider. Countertransference can also be a powerful diagnostic and therapeutic tool, used to understand the patient’s feeling state. Case 2: A sexual invitation A dentist called me quite upset as he did not know how to handle the overt sexual invitations of a very seductive 40-year-old woman. She had been his patient for several years and this behavior was unusual. He mentioned that he curiously did not feel seduced, but instead, felt motherly (an unusual feeling for him). He was afraid of hurting her further by rejecting her advances. In our discussion, I helped him formulate what he could say to her at their next appointment, but suggested he needed to talk to her and find out what had changed? Since he did not really feel sexually seduced, I said those feelings may be indicative of something else occurring in her life. I suggested he say something like although her advances flattered him, he was her dentist, and felt he could help her best in that role. He sensed something was quite wrong? Had something changed? By asking and being willing to listen, he learned that recently the patient’s mother had become terminally ill. In response, her husband was also quite distant. The listening seemed quite helpful-enough. The patient broke down into tears and soon spoke of her fear of being unlovable and alone. This empathic exchange led to a referral by the dentist to a psychologist who could help this woman deal with these issues around death and dying. The sex of each patient-dentist pair may also influence the transference, especially in the dental situation where there is a potential for regression and passivity, as the patient is asked to assume a non-talkative, recumbent position at the hands of the dentist. In the male dentist-male patient dyads, powerful transference feelings and enactments can be stirred up if the male patient feels dominated and controlled. These issues can be acted-out in the dental situation by the patient not following instructions or not paying the bill. As reflecting changes in our society, more women are seeking female treaters (Person, 1983). In normal female development, the early mother/daughter relationship is psychologically meaningful with both positive and negative feelings. All girls struggle with the powerful and close relationship with their mother. This struggle can create a conflict between their need for connection and closeness and their need to be independent. Sometimes these early conflicts can be enacted in the dental situation. For female patients, typical female fantasies may be agreeable to being passive or compliant to male dentists, but some women may respond negatively to either gendered dentist who may take on the unconscious role of the bad and controlling mother. Parenthetically, it is important to note that patients of either sex may unrealistically chose a female dentist seeking a maternal, gentle approach (mother’s milk versus anesthesia) only to become disillusioned when they realize that their female dentist can potentially cause discomfort or even pain like their male dentist counterpart. The primary lesson to be learned with each case is that every patient has a unique and individual story determined by past and present relationships with significant others and by previous and current experiences of the body and mind. For the majority of patients, the psychological dimension falls within normal limits, but like with all mental phenomenon, there is a continuum that exists from health to symptom formation. Limitless Topics in Dentistry for providing Psychological Consultation to Dentists How does the psychologist provide useful collaboration for the dental practitioner and for what conditions? The psychologist has an infinite number of topics with which to provide psychological insight to dentists. Generally, I have found dentists to be open and receptive to learning about psychological issues, especially as it relates to dental care. Courses about how to conduct a psychologically-oriented dental interview can easily show how a little time spent in the beginning of dental treatment can save hours of time and frustration, later, especially if a difficult patient can be identified early. Further, you will find that most dentists are interested in the quality of their own professional life and are concerned about minimizing stress in the dental setting for both themselves and their patients. “Stress in the dentist and how to minimize it” would be a sell-out attraction at any local dental meeting or dental school. In 1985, I was asked by the American Dental Association to write a paper on “The Psychology of Dental Health” (Levinson, 1986). This paper was about the idea that dental health in a major way could contribute to a normal narcissistic sense of well being and how dental and mental health are intertwined over the life cycle. In it, my own dental profession was interested to learn about the emotional, psychological and social significance of the mouth from in utero existence throughout the life cycle. Psychologists could teach courses at dental schools about the intertwining of psychological factors and dental health care. The psychologist has much to contribute here with regard to the emotional and developmental aspects of thumbsucking, breast vs. bottle feeding: what are the concerns?; the meaning of loss of baby teeth as well as the multiple symbolic meanings of loss of teeth at any other time in the life cycle as just a few examples. Psychologists can be especially helpful in teaching dentists why a psychologically-informed dental interview is important and how to conduct one. These lectures can be modified slightly to accommodate interviewing the chronic facial pain patient, the TMJ patient, or an evaluation of a patient for maxillofacial surgery. A lecture on “the difficult dental patient” could shed much light on the origins of a non-compliant patient, a hypochondriac, a narcissistic personality disorder or a highly anxious patient. In doing so, I would emphasize to dentists, how a little time in the beginning can save much time later as well as help to develop a more optimal therapeutic relationship between patient and dentist. These interviews would stress finding out about the developmental past of the patient so as to determine how it might influence current treatment needs and satisfaction. As psychologists know: Sometimes a patient’s conscious wishes may not mirror his or her unconscious needs. Case 3: Unneeded braces and larger teeth A 48-year-old man requested braces for his front teeth, after first wanting them whitened. When he was told she did not need braces, he requested full anterior porcelain crowns as he wanted his front teeth to look “larger.” His occlusion was very good and the esthetics was pleasing. The dentist did not know what to do. No matter what he suggested, nothing was good enough. The patient had a 25-year-old son who was quite attractive and dating. Upon consultation with a psychologist, it was determined that this 42 year old newly divorced man was struggling with issues around aging, a lost relationship and a desperate need to compete with his own son in order to restore his sense of masculinity and virility. If she could make his teeth perfect and “stronger looking,” he could feel better about himself and create an allusion that his life was more perfect. Working with this man to help him deal with his narcissistic concerns about aging, his masculinity, and competitive issues as well as working with the dentist to help him see his own limitations with this patient was useful for all concerned. Sometimes, patients such as these are unfortunately have some kind of surgery that is not needed and moreover, will never be good-enough as the real problem does not get addressed. Here the psychologist can be very helpful. Without a psychologist’s help, these problems may show up later as a lawsuit against the dentist for lack of satisfaction with the dental procedure. Dentists are relieved to know psychologists who are willing and available to collaborate with dentists around any range of dental problems in the dental situation. In practice, it can be helpful for the psychologist to get to know the dentists in their community by phoning, taking them out for lunch or offering to give a lecture at a dental school, dental study club, or dental meeting. Guidelines for Providing Consultation Liaison with the Dentist Once the psychologist has established a dialogue with a group of dentists who might refer, there are some helpful hints about consultation with dentists that can help to build a dental referral resource further. The first task at hand is to help the dentist make an empathic referral to the psychologist. This is not always easy because of common myths and biases against mental health needs. I begin by explaining to dentists that if they have a patient they are considering for consultation, it would be best to first call me to discuss the case. In this way, we can collaborate in order to find an optimal way to relate to this individual dental patient. When the dentist calls, I promptly return the call. I listen to the problem the dentist is having with the patient and try and ascertain a way to help the dentist make the referral to me. I teach the dentist how to listen for intense or inappropriate affective responses by the patient. For example, a woman was complaining that her facial pain was “destroying” her entire life. After our collaboration, the dentist was able to tell his patient that he would be happy to treat the pain as best he could. However, since it had taken on a life of its own, it might be also helpful to see a psychologist for a consultation to find other ways to also help. The patient felt understood and was not threatened by abandonment from her dentist. Another key point about the dentist’s referral: it must be for consultation, not treatment. I believe if the dentist makes a referral for psychological “treatment,” the patient is more likely to pejoratively misconstrue the referral. The idea of consultation keeps the interaction open and gives the dental patient a sense of active control in deciding to seek help. If the dentist says, “I think you need to see a psychologist, I can’t find anything wrong!” the dentist may be unwittingly setting up a situation in which the patient will have to prove the dentist wrong. In the case of chronic pain, all pain is real. The dentist needs to communicate a sense of genuine belief about the pain, and the patient is imagining or hallucinating it. It is very helpful to communicate in a nonjudgmental, nonconfrontative manner, which helps assuage patient’s anxiety. Here is an example of a dialogue I might use to instruct the dentist on how to speak to the patient about a referral, using simple language about what they may observe. “You’ve had this pain a long time. It is getting you down, interfering with important relationships, work and your sleep. We know that emotional factors can often intensify or perpetuate the dental problems you are still having, so why don’t we get an assessment of what is happening in your life?” “I would like you to call Dr. X for a consultation.” Dentists need to be reminded to not have their receptionist call for the patient. I explain to the dentist that having patients call is an important part of assuring the patient is an active collaborator in the treatment process. Dentists are also helped to know that they can’t always “cure.” Perfectionistic expectations put the patient at risk for iatrogenic treatment failure, when the treatment employed is not the one needed. I have seen several TMJ patients with dentists who kept utilizing escalating and invasive dental treatments in order to treat symptoms that in these particular cases would have responded better to talking. The psychologist can help the dentist differentiate what can and cannot be done as well as to recognize the limitations of the procedure in relation to the patient’s unconscious needs. Sometimes a psychological consultation about a patient can be useful for the dentist who may be feeling frustrated and angry, which becomes even more intense given the isolation of dental practice. Another function of the psychologist can be to offer a group session to the entire dental team on coping with the stresses of dental practice and the difficult dental patient. Here dentist and staff can learn about dental team goals for managing a psycholgically-oriented patient. Goals include:
In summary, I have discussed how important the psychologist can be in working in a psychodynamically informed way collaboratively with the dentist. A psychodynamic view is one that seeks to determine what is unique for each patient with his or her own life story. This collaboration extends into all aspects of dental health care of the patients and the dentist as well. Within this dental collaboration, there is a myriad of situations where psychological consultation is useful and even essential. The psychologist can develop another source of great patients by educational outreach to the dental profession. References Freud S. (1953a). Introductory lectures on psycho-analysis 1916-1917 in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vols. 15 and 16. Translated and edited by Strachey J. London: Hogarth Press. Freud S. (1953b). Three essays on the theory of sexuality in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol 7:125-243. Translated and edited by Strachey J. London: Hogarth Press. Glabbard G. (1990). Psychodynamic psychiatry in clinical practice. Washington, DC: American Psychiatric Press, p. 5. Greenson, R.R. (1967). The technique and practice of psychoanalysis. New York: International Universities Press. Levinson N. A. (1990). Psychological facets of esthetic dental health care: A developmental perspective, J Prost Dent, 64, 486-491. Levinson N. A. (1986). Our smiles, ourselves: The psychology of dental health. Published by the American Dental Association in conjunction with National Children’s Dental Health Month. Person, E. S. (1983). Women in therapy: Therapist gender as a variable. Int Rev Psycho-Anal, 10, 193-204.
Nadine A. Levinson, DDS, is a Clinical Professor of Psychiatry at University of California, Irvine and a Training and Supervising Psychoanalyst at the San Diego Psychoanalytic Society and Institute. In private practice as a psychotherapist and psychoanalyst she is a consultant and liaison to dentists. Her address is: 30131 Town Center Drive, Suite 216, Laguna Niguel, California 92677, Phone: (949) 495-3332 Email: levinson@compuserve.com |
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