Tuesday, August 15, 2006

Talk Therapy

[posted by dinah]

I began this venture with a pre-existing belief about psychotherapy. I thought of it then (when? not sure, Med School or even before) as a Process that evolves over time whereby the patient talks about meaningful ideas and events, often from his past, and the psychiatrist makes insightful interpretations that help the patient to change and modify his feelings about himself and how he interacts with the world. It was, I believed, a process which both cures mental illness, and helps people change in ways that are not necessarily about illness, but perhaps about growth. A goal and an end were essential to this line of thought. If my conception of psychotherapy sounded both vague and grandiose, well it was both vague and grandiose.

Years later, I have very different ideas about what psychotherapy is, more about what it is not, and it's taken me a while to realize how clueless I remain.

Over time, my ideas modified. I like science, I love the concrete, I want there to be a bit of predictability to how the world works and what actions effect what kind of changes. In that sense, I chose the wrong career, so it's really good that I love what I do.

I was trained to see mental illness as reasonably (though not perfectly) discrete diagnoses with clusters of symptoms defining any given illness. So, for example, Major Depression required either a persistent low mood or anhedonia, along with some combo of sleep/appetite/libido/vital sense change and guilt...etc.: this was an illness, probably with some degree of genetic etiology, and medications treat the disorder. Psychotherapy also helps, and the Cognitive Behavioral folks (Beck in particular, from my undergraduate days at Penn) say it works as well as medication, maybe better. But why does psychotherapy work? And what components of psychotherapy are necessary for it to work? Does it work differently if you're using it to treat an Axis I illness versus personality pathology or what about if someone without a diagnosis wants to change their patterns of relating (eg "I pick men who are bad for me") or is simply overwhelmed when stressful life events strike? Does the patient need to talk about specific things? What if the patient just comes and sits?

In my ideal world, medications would completely treat the symptoms of Axis I (oy!) diagnoses, and psychotherapy would be a tool which helps people gain insight into their patterns of behaving-- or perhaps more reasonably, their patterns of feeling or relating to others-- and by understanding these patterns they would be better able to modify or control them. Occasionally that actually happens.

So a patient walks in the door with an illness, I prescribe a medication and we begin psychotherapy. I meet with new patients weekly (if the situation is extreme or dangerous, more) and we see how it goes. After a number of session, a fair percentage of people announce they are better: the medications worked, their symptoms are gone, they are back to their old selves, thanks and I'd like to come less often. Some patients even wander in the door cured: a previous psychiatrist moved or died and they just need someone to prescribe the medications and be available in case they relapse (which can happen even when the meds work).

So what's the problem and why am I writing a post about this?

A fair number of patients get better (meaning their symptoms abate) and yet keep coming. I like to have a goal in my head, something we're working towards, and usually I can find some goal to justify treatment. Patients, however, don't always. It's not uncommon for people to come to therapy and simply talk about the events in their week in a way that remains very close to the surface: what movies they saw, which grocery store has a special on chopped beef, who said what to whom in a minor disagreement, dealing with the painters, not to mention endless numbers of sessions on crashed computers and broken cars....you get the idea. And yet, these same patients are the ones who will describe psychotherapy as "lifesaving" or "a safety net" and who may be troubled by a need to miss appointments. I've been left to conclude that it's not about the endpoint, it's not about symptom reduction, and sometimes it's not even about personal growth. Sometimes it's about the comfort the relationship conveys. Hard to quite articulate on an insurance company treatment plan.

My favorite vignette about this, one that I tell the residents I supervise:
When I was a resident, I rotated through a counseling center for 3 months; the care I gave had a pre-determined time-limit, unless I chose to offer the patients further care if they came to see me at the hospital. My first patient on my first day was a young man distressed because his girlfriend had cheated on him. The relationship ended; in a matter of a couple of weeks, he felt better and had moved on. This was an intact man whose life was otherwise progressing smoothly, he had no history of psychiatric illness, had never been in therapy, and no evidence of any personality disorder. He continued to show up on time for subsequent sessions, would rattle off to me the events of his week with an update of how everything was going. Everything was going smoothly. Unfortunately, he had no desire to give details such as the price of beef or he-said-she-said descriptions of conversations (I like those), so it would take him approximately 5 minutes for him to tell me that all was well. This left 45 minutes to the session. I'd ask questions, he'd answer, I tried to find something to say, tell him what type of things it might be useful to talk about, would sometimes engage him in discussions of books or movies, anything to pass the time and make some head way (into what?). He was fine; I was dying.

One week, I got sick. I called him and offered to see him at the regular time next week, or we could reschedule sooner. He chose to reschedule, and again came in to report that all was well.

At the time, I was reading Irvin Yalom's Everyday Gets A Little Closer: A Twice Told Psychotherapy, in which Dr. Yalom has his patient take process notes and he publishes both his and her notes on the same therapy: I found the idea fascinating and started asking patients to take notes on their sessions.

My time with the silent gentleman was winding down. I asked him to write something about the therapy. For the last, nearly silent session, he arrived with a paper listing items 1 to 12 of what he had gotten out of psychotherapy. I wish I'd saved that list, mostly what I recall was that it was right on target and began with, "1. I didn't realize how difficult it was for me to discuss my feelings...." It went on and on, all with useful insights he'd gained from our silent sessions.

Did making the list help him? I think so. It certainly helped me.

This may be the first of a multi-part series on psychotherapy.


Anonymous said...

Most of the people that I have worked with in psychotherapy over the last 34 years have been what we used to call "the worried well" -- they do not really fit the DSM IV model and medication is not for what ails them. I do not have any magic in my bag of tricks. I listen; I offer comment as seems appropriate. I show up. I reflect what I see. Almost all of them find the process invaluable, as have I in my personal life. And often what they have found most helpful has not been what I would have thought -- funny about that.

Jessica said...

From the patient perspective…

I've only just began psychotherapy and treatment for major depression.

It scares me quite a bit to think of what happens when I'm deemed well and my therapy is ended or not as frequent, perhaps it will not be so scary when I'm actually doing better.

I have found that psychotherapy helps me look at myself and the way I perceived situations from a different point of view. Which is very helpful.

I have in the short amount of time been treated seen 3 different psychologists, each which was different, one challenged me and our sessions were like debates, but they really helped me… after I took the time to reflect, when I would write. Another was one of the ones who repeated everything you said, but eventually it helped as well, the other just knew me so well… she could almost and sometimes did finish my thought for me.

I have seen 5 psychiatrists… all except for one I was able to get along with and they helped, eventually.

I think I’m going to try writing right after the session certain things that stood out to me, because try as I may I do forget things that I wanted to remember from the sessions.

Good post.


Shiny Happy Person said...

I've always fought tooth and nail against having any kind of psychotherapy, and probably will contine to do so. From what I can work out about psychiatric practice on the other side of the pond, hings work pretty differently. I am not a qualified psychotherapist, nor never likely to be (although a certain amount is an obligatory part of my training), and if I feel a patient needs that, I refer them for it. Doesn't apply to all patients. I suppose the payment factor plays a art too. Patients can' just come along and see a psychiatrist in the NHS every week just because they feel like it, but I imagine the private sector can verymuch mirror these sorts of situations.

I appreciate the reasons why people might think psychotherapy (specifically CBT) might be useful for me (relapse prevention), but the idea just turns my stomach. I don't want to become that involved in my illness. I don't want it to be something I have to TALK to someone about every damn week. I LIVE it, for god's sake. That's enough for me. I don't want to become so involved in thinking about it and talking about it that it begins to define me. That terrifies me. Psychotherapy would feel self-indulgent and navel-gazing.

Isn't it odd, the different views we hold for ourselves and our patients? Of course, none of this applies when I treat patients. I fully advocate psychotherapy where necessary (though I most certainly don't think it's for everyone with or without a mental illness), and the rules I apply to myself don't come near those I apply in my practice.

Sarebear said...

This might inspire a post or series of posts on this from the other side of the . . . . . what, chair? couch? in my case, ottoman? (that's what's between my ologist and I that I put my MP3 player on to record the session).

I had many thoughts on this this am but had to go to therapy. I love therapy! Well, sometimes it's painfully sucky hard, and sometimes I'm just pissed off and pouty not wanting to go, but given all the stuff that comes out there, I think that's understandable.

Anyhoo, was just reflecting on my one year anniversary of starting therapy, with him today . . . some posts from me on this too, maybe more comments. Off to Pirates O the Carob Bean, ARR!

Anonymous said...

I've been on the receiving end of a variety of therapy for a number of years ranging from basic counselling to brief CBT to protracted Jungian stuff. Some of it I've found very helpful indeed and some of it I've found very damaging.

My experience of it was that the attitude of the person delivering it mattered rather more than any other factor. Maybe that's partly because I rile at any therapist who appears to think they know better than me who and what I am or what matters to me in life. They're there to help me to deal with myself and life, not to dictate to me or convert me.

If clients feel they're gaining from the experience, well they're the ones who have to live with the outcomes and if they pay privately, they're the ones who have to make the cost-benefit analysis.

Mother Jones RN said...

I think psychotherapy is useful when used in combination with medications. Medications work to help the brain think more clearly, while talking helps the patient reflect on his or her life.

Too bad HMOs continue to place
more restrictions on psychotherapy sessions, thereby blocking access to care.

NeoNurseChic said...
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Sarebear said...

Carrie, I find that's true of my once a week appt's as well. Sometimes I schedule a second one, but since that's on a generous person's dime, and I'm loathe to go to far, I don't do that often. We imminently have insurance, but THAT limits it to 20 visits a year . . . . UGH AND UGH!!!

I would SO SO benefit from twice a week! I ALWAYS show up to therapy, ready to bring out stuff well, ready to work on approaching bringing out the hard stuff, when I have hard stuff to talk about anyway. I ALWAYS show up with an intent of complete integrity to myself; to not let myself get away with too much hiding (conscious, anyway), and stuff. Which is good, cause alot of subconscious hiding happens. Lol! I'm not implying you don't have an integrity, just that this promise to do what's best for me in therapy, no matter how hard, is one reason I'd SO SO benefit from a 2nd appt, because it seems like I'm trying to squeeze my life into one hours, because I'm there to WORK.

Therapy is a precious commidity to me, like sweetened strawberries atop a whipped-cream embellished shortcake (about the best thing I can think of!!!).

DANG it now I'm hungry. Lol!

Anyway, kudos on being able to even rarely talk about hard stuff; hard stuff is . . . well, it sucks.

I'm jealous of your two appt.s a week!! Let's cross our fingers and hope that I get SSDI (If I only get SSI, it's rather less money, and no medicare) when I have my hearing. It is guesstimated to be sometime between now and January . . . (I'm gonna be so BEYOND TERRIFIED) you'll be able to hear my chattering teeth and feel my quaking boots from where you guys all are . . . .)

Anyway, that would free me up to pay for two weeks/session. Oops, I mean two sessions/week. That'd be an awful long session (thought I'd leave my brain fart transposition typo in there as it's funny . . .) And then I could also afford as long of therapy as I need to figure out WHY I am the way I am and figure out if something went on in my past (not because I want there to have been something, but the "blackness/horror" I experienced, and now these disassociative thingies, well, I don't want those lingering. I want to know WHY I don't remember more than a few scenes of childhood before age 7. I could type the few scenes I do remember in a lot shorter length than this comment . . . lol!

Well, at least I know from Foo's blog this week and last, that I AM capable of the shortest comments I've ever made . . .

DrivingMissMolly said...
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DrivingMissMolly said...

As a graduate student last year I saw a psychiatry resident at the student health center. At the end of June I had to see the new guy since the "old" guy (younger than me!) moved on to PGY-4. I'll call him Dr. R.

Anyway, I had never seen a psychiatrist for more than a 5 minute or so med check so it was a pleasant surprise that Dr. R wanted to actually talk to me. 30 minute blocks were scheduled.

I loved the way he listened to me. He would sit accross from me and cup his chin in his hand and hang on my every word. I not only miss this, but I miss his physical presence. I guess I found it comforting. He was always there, always the same.

I take a little something from everyone I've seen over the years, and, I agree with "nutty," that some can do damage.

The therapist I see now annoys me in that he is so cheerful and optimistic and is constantly telling me I am getting better. It is nice to have people in my life that are nice to me.

I suffered greatly in my childhood.

SHP, you are denying yourself a great opportunity. I know that opening up the Pandora's box in therapy has probably had a part in the difficulties I am having now (am on short term disability from work), but I also know that I am a deep person. So many people lead superficial lives. I am delving into the depths and it is nice to be *heard.*

One thing Dr. R said that has stuck with me was when I said to him; "I don't know if you have the experience to help me. I think of you as either a genius or as completely incompetent." His response; "Why does it have to be one or the other; can't it be in the middle?"

That thought NEVER occurred to me. Now I realize that illustrated the classic black and white thinking of borderline personality disorder, but the possibility of a middle just NEVER occurred to me.

And the beat goes on. . .

Dinah said...

Great comments!

I have seen very few patients I'd call "worried well" though the silent patient who showed up after the girlfriend cheated on him and made the long list of useful things he'd gotten out of therapy was one of them. Mostly people come to me in a state of distress, suffering and having suffered for some time. The large majority of people I treat need medications, likely there is some self-selection process in who calls a psychiatrist.

The patient who talks about the comparative cost of beef (or coupon savings or whatever) at different markets is on 5 psychotropic drugs, she's been hospitalized a number of times, and her horrible episodes of illness last a very long time. There is no question about the "need" for psychotherapy here, it keeps her alive and out of the hospital (much much more expensive than weekly therapy sessions). I don't question her right to patienthood at all, just why it helps so much for her to come talk about everyday things: this is a person with close friends and family who are happy to discuss the price of anything with her.

As you've all said, a lot of it is about warmth and empathy.

NeoNurseChic said...
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Dinah said...

I think my "warmth and empathy" thoughts were stolen from one of my former supervisors, the late Dr. Jerome Frank, Persuasion and Healing. I only steal from the best, and I'm not completely sure that was my source.

I was concerned that I trivialized my patient's therapy, no one else did.

Difficult? But, wait, I thought I was the sweet and compliant one!

NeoNurseChic said...

I see :) No I didn't think you trivialized your patients. :)

Take care,

Anonymous said...

Why the need to talk about ordinary things? Maybe because sometimes they're how we make sense of the bigger things.

I had a friend whose wife died. He started phoning me at night and talking about football (soccer). At first I was baffled by this behaviour, since I have not the slightest interest in men's sports, but then I realised that he needed to talk and this was the only language he had in which to do it. Since then, I've had another (male) friend do the same. I don't speak soccer, but I can listen.

Shiny Happy Person said...


That may be true for you but it is not so for everyone. I fully believe that psychotherapy is not for everyone. I am still ambivalent about whether it is for me. If I decide that it is, it will be a limited period of cognitive-behavioural therapy specifically focused on relapse prevention in manic depressive illness.

It will not open a Pandora's Box.

It will not deal with past issues.

Neither of the above exist or are relevant to my illness. I do not require, and will not be having psychodynamic psychotherapy.

I am sure you intended no harm by your comment, and I apologise for my curtness, but please do not purport to tell me what is or isn't a great opportunity for me. As you yourself pointed out, sometimes it can do more harm than good.

Would you give a medication to someone who didn't need it?

ClinkShrink said...

Dinah, difficult? Pshaw!

I think you are right on the Jerome Frank quote. What a sweet, sweet man he was even if he did fall asleep during supervision. The two main things I remember learning from him are that a psychotherapist's success is more related to confidence than skill or technique (at which point, being 'only' a resident, I thought: "I'm doomed!") and also the phrase: "Sometimes it's OK to tell people they're normal." I thought that was wonderful and I use it to this day. My inmates come in with so many symptoms or complaints, and most of it just really is related to being locked up 23 hours a day in an abnormal environment. They are relieved to know it doesn't mean they are going crazy.

Quick Jerome Frank story:

I came in for supervision one week and he was hunched over his keyboard typing away. He apologized for making me wait but kept typing. Finally he saved his document, shut down the machine and explained that he had finally finished a paper he had been obsessing over and working on for weeks. It was about the use of force in international relations. At the time I was still fresh on my forensic rotation and my head was filled with ideas about mental state issues in murder and manslaughter, and mitigating issues in the use of force. I commented on an idea he discussed in his paper. As soon as I finished talking Dr. Frank looked dismayed, shook his head and turned back to his machine: "And I thought I was done," he said.

That was a high point of my training.

Dinah said...

I hadn't heard that story. It may have been the high point of your LIFE!

Steve & Barb said...

I've said this before to Dinah, and I'll say it here. Dinah's sense of humor and delivery remind me very much of the main character in the show, "Dead Like Me"... you know, the one who was turned into a grim reaper after being hit by a fiery toilet seat plummeting to the ground after the space shuttle exploded. That's a good thing, as the character's quite funny, in a deadpan sort of way.

It's on Tuesday nights here (USA Network or SciFi, not sure)... I have it Tivo'd.

DrivingMissMolly said...


I would like to offer a sincere apology to you for my presumptive post. I hope that you will accept.


sg2028 said...

i wish that you were my psychiatrist.

Anonymous said...

hmm.. I'm a little apprehensive as this is a first comment. I frequent a web board that focuses on people who self injure or have eating disorders. For me and many of the people on this board, our relationships with our therapists and pdocs are hugely important. Major attachment issues, etc. Do you see clients like this in your practice? Are these clients less common? Is it hard to have clients who feel so dependent on you?