Tuesday, August 22, 2006

What Makes It Therapy?

[posted by dinah, part 2 in a multi-part series on psychotherapy]

In my Talk Therapy post, I rambled (who me, ramble? never!) about my ideas regarding the purpose and process of psychotherapy. I noted that patients sometimes spend their sessions discussing the day-to-events in their lives, sometimes they discuss seemingly trivial affairs, sometimes they remain mostly silent, and still they feel some benefit. If you look at that post, you must read the comments: insights from both psychotherapists and patients; I especially loved Nutty's story of the newly widowed man who called at night to talk about soccer.

ClinkShrink, in her Couch Time post, tells us she treats prisoners with medications, "I treat brain diseases." She doesn't DO psychotherapy.

It leaves me with the question: what IS psychotherapy?

I think, with the help of the late Dr. Jerome Frank (Persuasion and Healing), we've agreed that it helps (or is crucial) if the therapist is warm and empathizes.

In my mind, if I meet with a patient weekly for a 50 minutes session and we both call it psychotherapy, then regardless of what gets discussed, it is, by definition, psychotherapy. As I said in the Talk Therapy post, people mostly seem to get better regardless of what they discuss-- whether "better" means a cessation or reduction of psychiatric symptoms, increased insight, personal growth, comfort in the sense that they are understood and less alone in the world, relief at unburdening/ventilating troubling past events or feelings, or simply maintaining a status quo-- a "holding" state.

But does the interaction have to be for 50 minutes every week?
In fact, I don't see very many patients for weekly psychotherapy for the long haul. It's expensive and time-consuming. People-- with some exceptions of course-- come weekly for a while, perhaps a few months to a year or a little longer, until they feel better. Even if they want to continue therapy-- there's more to work on or perhaps they're afraid of losing the gains they've made-- they often want to come less often, either every other week, or once a month, sometimes even less. And some patients only come for a half hour, they just don't have much to say, but the contact remains helpful. And, with time, I'm finally convinced that how frequently one comes doesn't dictate how much change can be made, some people do an awful lot with a few sessions or with spaced sessions. And some people do better with less than with more: it's as though limiting the therapy gives it more power.

People change, if you believe that they do, for reasons aside from psychotherapy. Maybe it's the medicines. Maybe it's the change in season. Maybe it's that the evil boss got fired and is no longer a source of daily aggrevation. Maybe it's a streak of Good Hair Days . And people are impacted all the time in ways they feel Change their lives. Who hasn't read a book or seen a show that changed the way they view the world? Who hasn't quoted a teacher or a friend who said something wise that resonated, that helped explain something important?

During the weeks I worked in post-Katrina Louisiana, we were left to ask this question often: we were used to seeing patients over time, how could we make an impact, how could we help, seeing someone once or twice? We listened, we prescribed medications as we could, and we tried to impart a bit of hope on a place so badly in need.

People expect psychiatrists to listen. Patients gain comfort from being considered, and sometimes they find tremendous relief from simply being heard, or from getting the feedback that their responses are normal. Sometimes there's comfort and hope in learning a diagnosis. It's hard to sift out what makes a session just about medications, and not about therapy, unless the patient is only permitted to discuss symptoms (Are you hearing voices? How is your sleep and appetite? How is your mood? Are you thinking of suicide?). Presuming that at least a little bit of most encounters entails letting the patient talk about how they are and what is going on in their lives, presuming the psychiatrist doesn't re-direct them from giving any other information-- though I imagine that is what happens in 5-10 minute med checks where there can't be enough time for much else-- then I suppose most encounters have the possibility at least to be therapeutic in a way that has more meaning then pharmacologic maneuvering.
And sometimes even brief encounters can herald big insights and big changes.

My best guess is that ClinkShrink really does do a bit of therapy. If nothing else, she listens to me.


Sarebear said...

Sometime in the third session, I think, when I was trying to express something, and kept hitting corners of it without being able to figure out what IT was, Dr. Mower said, "You want to be heard."

And all of a sudden, it was as if a window inside my heart opened and a flood of emotion poured out that was overwhelming, and I just sobbed, and sobbed "Yes", over and over . . . .

The fact that he "got" me, when even I couldn't consciously approach what I was trying to convey, although I was trying to . . . that was awesome! His helping me identify what I wanted, and saying it, helped me feel SO MUCH that I WAS being heard, too . . .

And I sobbed, because I didn't feel that anyone had really heard me before, EVER.

And I sobbed, because it hurt so bad that I hadn't been heard.

And I sobbed because I wanted to be worth being heard.

And I sobbed because, to him, I WAS worth being heard, and he WANTED to HEAR me.

And I sobbed because he DID hear me, and he actively participated in doing so and asking questions when he didn't understand something; he wanted to make sure he heard and UNDERSTOOD what I was trying to say . . .

And I sobbed, because he accepted what he was hearing, and accepted me, and didn't reject me or what he was hearing . . .

And I sobbed, because I was filled with the realization that now I could be and would be heard . . . . and I was also scared by that.

Just some of the things that went into that. It's a very powerful thing/issue/subject/action/therapeutic technique, or whatever.

The fact that, this last Tuesday, he listened to me talk about the reasons I like Wonder Woman and collect Wonder Woman stuff . . . made me feel accepted, and helped me feel and come to start to feel that my interest in WW and collecting her IS acceptable. Which is why I started talking about my reasons for liking her in the first place. He seemed ready to move on from our discussion of my embarrassment over liking WW stuff, but then I just had this feeling inside and just started talking about WHY I like her, and he shifted gears as I could tell he felt that it was important for me to talk about, even though I kinda felt silly, but at the same time paused and said that, hey, this seems to be really touching something deep inside me, the part that feels not acceptable . . . well, I didn't say that like that, but I think he got the point, especially after I was done talking about why I like her, and was like, WOAH, that was REALLY good for me and I feel like, somehow, something I've ALWAYS been embarrassed by, is now much more acceptable to me.

I still find it almost magical, sort of, that just simply being listened to, and not dismissed, can have such an affect on an important issue, or small issue, or whatever. For me, the issue that was important in all that was becoming more comfortable in my own skin, and finding my personality and likes more acceptable and such, which I've always struggled with. But simply being heard, as I listed things like, the sense of freedom as she flies through the air, with the wind in her face (she flies now, they introduced that in the late '80's . .), how powerful she is, what a positive role for the acceptance of womanhood, femininity, and promoting those, and for promoting peace, although prepared to fight at times, and how interesting that combination of being an ambassador for peace and yet being an Amazon Warrior . . . how pleasing her colorful costume is to me, and other things.

Wow. Just the fact that I can type those out, and not be embarrassed by them, is HUGE for me.

Cool . . .

Sorry to ramble myself. But this aspect of therapy, is quite possibly the most healing aspect I've experienced, and it touches on so much . . .

Sarebear said...

Oh, I must clarify, that I, too, seemed ready to move on from the WW embarrassment subject at that one point too, until that feeling occurred to me.

DrivingMissMolly said...

It is my belief that there has to be an "agenda" greater than just being heard in order to be considered "therapy," otherwise wouldn't it be just venting to someone you have paid and so therefore they are a captive audience?

I can disgorge emotions and observations to a friend and that is not therapy, although it may have a therapeutic effect.

Likewise, I could have a friendly conversation with a therapist and that isn't therapy just because it is conversation and he or she is credentialed.

I define therapy as active listening with gentle guidance and feedback on the part of the therapist.

On my end, I must be honest and do the best I can to disclose information to be processed in therapy even if it is painful.

My first therapist over 17 years ago rarely said anything to me. As a result, I not only did not get better, but was frustrated and felt that I had somehow failed.

This is just my opinion. Clients, I am sure, have different needs.

I need to hear, to be heard, and to feel that progress is being made.

Jessica said...

So what do you do when the person isn't talking or they don't know what to talk about?

I recently had a session where all I could say was "I don't know"

I felt bad cause there was no place to take the session, yet I wanted to be there and talk just I didn't know what to talk about. I mean why would someone want to hear about my life??

Sarebear said...

Being heard isn't the only aspect of my therapy.

It's the aspect I chose to comment about, though.

Anonymous said...

Sarebear that was the best definition of therapy that I heard for a long time. its reminds me of what Freud said - "What the patients appreciate the most is the their therapist is making a sincere effort in trying to understand them"

ClinkShrink said...

Dinah I've spent part of the day trying to figure out the picture. It sort of looks like a histologic section of a rat brain turned sideways. I've been told that it's not good to see body parts in projective tests, but don't worry because it's normal if you're a physician.

Thanks for listening to my concerns about your picture. I appreciate your empathy and sincere effort to "get" me.

And I think you're a snappy dresser.

Sarebear said...

Thanks, Anonymous! You really made my day!!!

Dinah said...

Re: answering questions: Honestly.

Foo: see your blog for my continued thoughts.

Clink: oh gosh, you got me here. Usually, the pics just come to me, inspired... this one, I just never got. Found this abstract pic, thought it would fit the bill, but it didn't, so I tried to delete it, but you know you can't delete pics on blogger, so I started to shrink it, and as I shrank it, it distorted and I decided it was fine as is, that this would be enough to drive clink over the edge .

The "N" key is sticking on this laptop. Ugh.

And my universe has changed, no more Pluto.

ClinkShrink said...

You and Dr. A are both mourning Pluto. See my comment there re: the littlest planet.

Speaking of little planets, I'm happy that Hedberg stopped by the blog for a visit. In spite of what it says on her myspace page, she's not really a 6'4" bodybuilder. Pshaw!

Wrkinprogress said...

I'm not sure I should be commenting here as I'm not a medical professional, but in the hopes that this won't be out of line, I'd like to chime in.

As a patient, I see my psychiatrist for medication management, which involves minimal talk therapy. The things we discuss are related to how I'm feeling physically and mentally. For full-blown psychotherapy I see a PhD-level clinical psychologist. This seems to me to be the most effect use of the skills of both professionals and works best for me.

I do believe, however, that some people only need one or the other in order to make a positive impact on their lives. For me, that's not sufficient.

In my therapy sessions, there are times when we talk about everyday life, which helps sometimes to segue into the 'real issues'. Mostly, however, I talk about whatever is going on in my life, or the groups of issues/behaviours (boundaries, family crises, alcoholic sister with abusive ex who stalks her and the kids) that I sought counseling for in the first place.

I am very comfortable with both my psychiatrist (9 months' treatment) and psychologist (12 months treatment), and would not hesitate to speak to either one about anything that troubles me. Both work in concert with each other, which I also think is key to the success of many patients. But, being a layperson, that could just be my perception.