Monday, June 21, 2010

What Makes it Psychotherapy?

Years ago, I had a student who repeatedly asked me how psychotherapy works. "How is it different than a conversation?"

When I think of psychotherapy, I think in terms of the
talking itself as being the aspect that helps-- and yes, of course it can be used in conjunction with medications. I think of it as being structured--in terms of time and place and frequency-- and being all about the patient. And whether or not it's actually discussed, some of what works is about the relationship--most people don't get better talking to someone they despise, and the warmth, empathy, feeling listened to and cared for, well, they're all important. And I also think of it as being a process over time. These are all parts of my definition, however, and they may not be parts of yours.

So what about about a one-time event? If someone meets with a therapist once, has wonderful insights and feels better, is that psychotherapy? (--Clink, this is your cue to put up a post about the taxi driver in New Orleans). If someone meets with their priest/hairdresser/auto mechanic once or twice or 57 times and feels better, is that psychotherapy? If someone talks to a friend over coffee every morning while the dogs play, is that psychotherapy (...clearly, it is "therapy" because most things involving either chocolate or coffee have some therapeutic value)? If a patient meets with a therapist every week for an hour-long session for years on end, but never utters a single word, is that psychotherapy?

Some psychiatrists include education about illness and medication as part of their definition of psychotherapy. Others measure it by time---if it's 20 minutes it's a med check, if it's 45 minutes, it's psychotherapy....

Okay, so what makes it 'psychotherapy?' FYI: there's no "right" answer.


Awake and Dreaming said...

I think a big part of it, but by no means the only part, is that the receiver of said "therapy" identifies it that way? Or maybe not... Hmmmm I think in school the answer we learned had something to do with a purposeful conversation and something about goals. Oh school. How relevant to the real world you are.

Anonymous said...

My husband seems to believe you have to seek out a therapist to help you accomplish something--such as losing weight, getting a better job, improving your job-interviewing skills. I was told to go to psychotherapy in between med-check appointments.

I go to therapy 24 times a year and it's mostly talking. I do almost all the talking and the therapist listens. I guess it's just a supportive environment to help me deal with the stress of having a mental illness, the chaos that's caused, and a place to vent about the ignorance I encounter.

Robert Morse, M.A. said...

Here is how I view my profession.

Psychotherapy is a collaborative and goal oriented effort focusing on the patient's presenting problems. It is an alliance that requires trust and cooperation as the process can at times conjure up uncomfortable thoughts and emotions for both patient and therapist when discussing matters that the patient may or may have not been comfortable sharing with others.

The therapist acts as a facilitator and guides the conversation in a manner that will hopefully over time allow the patient to be able to find resolution and create the changes which he or she desires (elevate mood, relieve anxiety, work through a difficult situation, etc).

The success or failure of therapy is going to be the result of how forthcoming the patient is with the therapist, the patient's level of; motivation, effort, and desire for change, as well as the therapist's own ability to properly recognize and lead the patient to finding the solutions he or she seeks with the information provided in the sessions. Coupled with an empathic and neutral/non-judgemental perspective on the part of the therapist.

Psychotherapy of all theoretical orientations are empirically shown to be about 50% effective, with the aforementioned features of the patient and the therapist playing the largest contributing roles. CBT, or cognitive-behavioral therapy, is currently the most popular form of psychotherapy.

tracy said...

:*( Got fired by Psychiatrist/therapist...he gave me no referrals....where to go from here....?

Anyone? Thanks.

Anonymous said...

Tracy, first go out for dinner. Order wine with it.

Sarebear said...

Goals? what goals?

JUST kidding.

He's never forced any goals on me, though.

The therapy has sometimes had to serve a particular need at a particular time, and he has even volunteered extra appointments, occasionally at his expense, for some of those occasions, like when I was so terrified facing my first knee operation (I thought I was going into the first of two, a week apart, at the time, didn't know until close to a week later that I'd be putting off the second one, there was NO BLOODY WAY IN HEAVEN OR EARTH I could do two a week apart, two knee replacements).

I was terrified out of my bloody mind.

For the second knee surgery, I literally was practically scared to death; I came the closest to killing myself I'd ever been since my attempt in the 90's, only to realize I couldn't. It was this, and feeling trapped by the now non-existent MRI bill.

He upped the frequency of therapy before the second surgery as well, although he didn't know how bad things were until three weeks before, but neither did I until then. I didn't know I was that scared.

Guess I had reason to be, since this one has been so much harder and painful a recovery than the first one, but life does what it does and you just have to deal.

I'm just glad I've got a good therapist who helps me LEARN to deal.

Mindful said...

From the perspective of a someone who has been in therapy for some years, therapy is an amalgam of many and varied factors: a relationship between the psych and client based on trust, emapthy and compassion; the expert hand of the psych who acts as a guide or navigator rather than the expert prescribing advice; the willingness of the client to yield to the process and be open to new possibilities; and the ritual of meeting whether it's once a week or once a month.

Sunny CA said...

Your description fine: a process over time of talking which is structured in time and place, about the patient, which includes a positive relationship with the psychoanalyst.

What is also important to me has been my psychiatrist's completely non-judgmental acceptance of me and my past which is an aspect of what helps create trust in the relationship and allows further disclosure. That trust is another aspect of a good psychotherapy relationship and what helps build trust also includes feeling that the psychotherapist is rational, reasonable and has good perspective. One aspect that separates psychotherapy from talking to a friend is that friends are more likely to try to jump in with both feet and badger to try to "help" a friend. Friends aren't necessarily trusted to have better perspective though plus there can be a hidden agenda that a friend has in a situation making their (often unasked for) advice suspect. So trusting the psychotherapist has to include that he/she has the patient's best interest at heart, and that the psychotherapist's opinion is likely to be an objective, "right" opinion. Then comes emotional support. I think at this point in my psychotherapy we have fully explored my past, I have made a lot of changes and my situation is very stable. Really, it seems at times that not all that much psychotherapy is going on. I continue to go to my psychotherapist though, because he is emotionally supportive. Talking to him makes me feel that I don't carry all the burdens of life alone. He is a port in the storm; a rope to hang onto. I think I continue to do as well as I am doing because I am seeing him. I am afraid of continuing on alone, at least with my current thin support system. My psychiatrist at this point knows me better than anyone else does, and he knows my flaws in thinking about myself, so can quickly point these out when they appear which sets me on the right course better than a friend could do.
Sarebear and Robert Morse: My psychotherapist and I have never discussed "goals" for the psychotherapy. I have no idea what sort of "goals" Robert Morse might have in mind, but I think that specific goals created at the start of psychotherapy would have the potential of limiting the potential benefit, though perhaps there is someway to create a broad goal that would encompass a shifting situation and state of being. I think that there were unstated goals in my psychotherapy, but that these changed over time.

Sarebear said...

I, too, have a thin support system, and believe that, at least at times, that he has acted as the "rope to cling to", so to speak.

I'm not sure that he's ALWAYS in that role, but at times, perhaps.

There have been some unstated goals at different times, as well as perhaps some outright stated goals, like, I don't want to be someone who is so impulsive, but . . . . impulsivity is something I fight as much today as I did the day I entered therapy, and I think may be an issue more for medication than it is for therapy, but I'm not sure. I've not talked about how to control my impulsivity in a long time, maybe because I'd given up, I'm not sure. I can always try s'more.

Sarebear said...

It would help the impulsivity if I actually TOOK my ADD med more consistently, ROFLmao. Um, yeah. JUST a little bit, you think?

Sunny CA said...

Well, I need a "rope to cling to" a lot less than I did at times in the past. It's just when/if I need it, he is there so that is one aspect.

Also, perhaps my psychiatrist has or had goals I was not aware of. My own goals were probably more nebulous like "figure out what is going on", "survive through this", "improve my situation". We did figure it out, help me to survive, and improved my situation. I just think I don't feel far enough away from where I was to figure that I have it made alone without support. Also in improving my situation I/we dismantled my support network. Granted it wasn't working, but I haven't replaced the key figures in my life that are now missing so I feel more alone and more dependent in some ways.

Sarebear said...

I got the story wrong (thanks for telling it to me wrong, hubby, lol, the exam was AFTER she stole the cars, I was like, why would she just up and do it in the middle of one?) That's why I deleted my comment.

Rach said...

I've had two very different therapy experiences (actually 3, but only 2 of them really count).

I think the fact that there's a theoretical component to the conversation, be it CBT or psychodynamic or whatever makes it psychotherapy as opposed to just a conversation. There's also this idea that a conversation involves two way communication, which is not always the case in psychotherapy (or maybe just psychoanalysis?).

The issue of goals is also interesting. I've had one shrink who never asked me about goals, and one who asked me from the get-go - what did I want to get out of the experience. In both cases I got a lot more than I bargained for - not that it's a bad thing!

Anonymous said...

OK, so here's the rat story:

Dinah, Roy and I were walking down Bourbon Street at midnight during the APA conference. (Three psychiatrists REALLY didn't fit in down there, even though we were wearing duck necklaces.) All of the sudden this huge rat ran out of an alley about two feet in front of us. Dinah screamed and did one of those cartoon-like "peddling in the air" jumps, then turned and ran. Roy and I were in hysterics. We all got back safely. Not sure what happened to the rat.


Anonymous said...

Can you tell me how to add you to my blog roll on wordpress? Im new to this blogging stuff and cant remember how I added others now.

By the way, Im a 37 year old female, and have been in and out of therapy since I was 19. I wasnt properly diagnosed until age 25 though.

Anonymous said...

the difference between therapy and not-therapy?
ninety bucks ;>