The Importance of Follow-Up

The Importance of Follow-Up

Follow-up, as the term implies, means collecting information  or data about patients or making contact with them after the treatment or the research has been concluded.  Just what is treatment and what is research?  As Samuel Polsky, a distinguished professor of law and legal medicine at Temple University put it:  Treatment is research.  And, in the best sense of the word “treatment,” it is.  Or should be.   As providers of psychotherapy and analysis,  we should always be open to learning from our experience and changing the way in which we practice in order to bring it in line more completely with reality.  Follow-up provides an important way to do just that.

In my research training at Northwestern University, I was well schooled in the importance of follow-up by my doctoral dissertation mentor Donald T. Campbell.  Campbell in his landmark work on Experimental and Quasi-Experimental Designs for Research has pointed out the various ways that follow-up adds to and completes the research design.  For example, suppose that in a particular experiment or clinical trial the intervention had appeared to fail to provide the desired results or outcome, but that upon follow-up at a later time, the desired result had materialized unexpectedly.  Of course it could go the other way just as easily.  Or, in a more mundane example, suppose that the intervention had appeared to be very successful at the end of the treatment period, but that upon follow-up the success had faded over time into insignificance or failure.  The only way you would know these results is by conducting the follow-up.

I used to be a heavy  smoker of unfiltered cigarettes.  On occasion I would smoke cigars or a pipe.  I always inhaled.  My life revolved around smoking.  My fondest wish was that food too could be inhaled.  I had tried quitting numerous times but I was simply too addicted to the nicotine and the psychological gratification smoking provided.  In 1973, I enrolled in a behavior modification program at the University of Pennsylvania run by Ovide Pomerleau, a clinical psychologist, and Michael Pertschuk, a psychiatrist.  Along with five other members in the group, we were introduced to a variety of techniques for reducing our smoking with the aim of quitting completely.  The group met on a once-a-week-basis.  It provided guidance and social and emotional and moral support.  Just before Memorial Day, 1973, I was down to two cigarettes a day, which I had to smoke on a random schedule basis.  On Memorial Day, I engaged in “Satiation Therapy,” meaning that I smoked as many cigarettes as I could in a short period of time, poisoning myself in the process.  (Nicotine is a poison in high enough doses.)  I was so sick following this horrific experience that I now associate the smell of cigarette smoke with nausea, severe nausea.  On every Memorial Day I call or email Ovide to provide him with the follow-up that I am still a nonsmoker.  I also remind him that along with the behavioral techniques, my positive transference to him resulted in what Freud termed a transference cure.  Freud was very dubious about the lasting effects of a transference cure.  My transference cure has lasted almost 39 years.  Will I make it to 40?  My follow-up with Ovide is probably one of the longest follow-ups on record.

When I started as an assistant professor at the University of Pennsylvania in the Department of Community Medicine, I was very impressed by the Tumor Registry run quite effectively by Dr. Askenazi, trained originally as an opthamologist.  Along with a secretary and an assistant and a telephone and 80-column IBM cards, but no computer, he was able to reach a follow-up of more than 98% of the cancer patients in the UPenn Cancer Center.  His methods and personal characteristics, such as ingenuity and persistence, in place of high tech sophistication resulted in much better follow-up at five years than much more sophisticated research efforts that were lucky to reach 80% follow-up.  Sophisticated technology is no substitute for character and intelligence

In my clinical training at the University of Pennsylvania. these lessons were reinforced by the clinical instruction of Martin Orne, both a clinical psychologist and a psychiatrist.  Martin, after he completed his education and training at Harvard, repaired to Zurich, Switzerland where he gained an audience with C.G. Jung, after which he conducted the first published research in his illustrious career on the Rorschach Inkblot test with one of Jung’s associates.  Martin was supposed to be teaching us about hypnosis — he ran the Experimental Hypnosis Unit at UPenn — which he did, along with everything else under the sun!  And, one of the things he impressed upon us was the importance of conducting follow-up with our psychotherapy patients, for two reasons:  1. In order to learn whether or not our interventions worked over the long term, and 2.  In order to provide our patients with a sort of booster shot for our psychotherapy treatment interventions.  He also maintained that in this instance Freud had erred in his belief that at the end of an analysis, there should be no further contact whatsoever between the analyst and the analysand.  Furthermore, he believed that Jung was more oriented toward empirical science and research findings than Freud, very eye-opening opinions that in retrospect resonate intensely with my own experience of the fields of psychoanalysis and analytical psychology.

One last nugget from my clinical training.  A very famous psychoanalyst, who will go unnamed, regaled us about the book he was writing in which he described  several of his more successful cases of psychoanalysis.  Years after the analyses had ended, he had generated hypotheses about the turning points in each of the successful analyses before contacting his one-time analysands and asking them for their perspectives.  One in particular really surprised him.  His analysand pooh poohed the analyst’s theoretical formulations.  Instead,  he related that one day the analyst had arrived to the session wearing one blue sock and one brown sock, leading the analysand to realize that his analyst was human after all!  From his perspective, this was the turning point of the analysis.  Imagine asking the analysand for his or her opinion and taking it seriously!  This psychoanalyst had done just that.  And, it served his analysand well during the follow-up and thereafter.  And, it served us, the trainees, well, too.  Point taken.

Dr. Seth Isaiah Rubin, Ph.D.