Monday, April 23, 2012

Endless Therapy...and some other stuff, too.

Yesterday's New York Times appears to be dedicated to psychiatric bloggers. I got a head start with the article on SSRI's, but it's going to take me a while to catch up.  Jesse-- can't I get you to post about Richard Friedman's article, "Why Are We Drugging Our Soldiers?"  You're my military buddy!

So I'll start with "In Therapy Forever?  Enough Already."  Oh my.  By Psychotherapist Jonathan Alpert who authored Be Fearless; Change Your Life in 28 Days.  Excuse me, Mr. Alpert, but when is your next opening?  I got me some issues that could use a quick fix.

Alpert writes:

Talk to friends, keep your ears open at a cafe, or read discussion boards online about length of time in therapy. I bet you’ll find many people who have remained in therapy long beyond the time they thought it would take to solve their problems. According to a 2010 study published in the American Journal of Psychiatry, 42 percent of people in psychotherapy use 3 to 10 visits for treatment, while 1 in 9 have more than 20 sessions.
For this 11 percent, therapy can become a dead-end relationship. Research shows that, in many cases, the longer therapy lasts the less likely it is to be effective. Still, therapists are often reluctant to admit defeat.

He goes on to say:

Therapy can — and should — focus on goals and outcomes, and people should be able to graduate from it. In my practice, the people who spent years in therapy before coming to me were able to face their fears, calm their anxieties and reach life goals quickly — often within weeks.
Why? I believe it’s a matter of approach. Many patients need an aggressive therapist who prods them to face what they find uncomfortable: change. They need a therapist’s opinion, advice and structured action plans.

Okay, so I'm all in favor of goals and structure and action plans.  But a lot of people come for longer than 10 visits, they aren't all "failures" or stuck in a bad place (some, granted, are), and putting into words what happens in therapy and why it is helpful is really, really hard.  The psychoanalysts invented their own language for what happens in therapy, and it's not one I was ever able to master.  

Okay, so why would therapy take more then 10 appointments, in bullet points:
  • Most people don't come to see me to fix a discrete problem.  They usually come because they are uncomfortable with their feelings or behavior patterns --and screaming really loudly "STOP DRINKING" does not seem to work for me, maybe Jonathan Alpert has a better style.  These problems, like depression or anxiety or irritability or mood lability or panic attacks or being really stressed out,  come and go.  The problems don't get 'fixed' with an action plan.  They sometimes get fixed with medicines and therapy often provides some tools for better coping.
  • Therapy offers a place to talk about feelings and behaviors that people are not comfortable talking to their friends about.  Sometimes the issues are on-going and a single "dump" isn't enough.  In these cases, therapy offers comfort.  Insurance companies don't want to hear that: we need measurable goals that can be achieved in 3 sessions.  Comforting those who are suffering is not allowed. (Please forgive my sarcasm)
  • People usually can generate their own list of action plans and they come to treatment because fixing the problem is complicated and often they have stuff to work through before they can leave the lousy husband, or feel good enough about themselves to quit the job, or perhaps they shouldn't quit the lousy job because while they want to, it pays the bills and they can't find another job.
  • Psychiatric problems wax and wane and people need more support when their symptoms are more intense, and less when all is well.  It's not uncommon for people to come in more often during difficult times and less often during the good times.  
  • Some people have problems such that they drive people away and have trouble with intimacy.  The therapeutic relationship may fill that void or be a place to examine those patterns.  Sometimes people who don't have problems with intimacy still find the therapeutic relationship to be really useful.
  • For people with behavioral issues, therapy provides a degree of accountability that can be very helpful.
Some people come for a few sessions, they feel better, and that's great.  Some people have an on-going mental disorder and regular therapy sessions provides a safety net: a means to monitor moods, anxiety, delusions, hallucinations,  or the stresses in life, and to talk about relationships, all as part of an ongoing process of coping with a chronic disorder and keeping the symptoms in check or catching relapses early.  Some people find it helpful to go to therapy and talk about the thoughts that go round in their heads, and that's about as scientific as I can get for them.  And finally, some people find that the therapeutic relationship adds a level of comfort, introspection, meaning, and focus to their lives that helps them siphon their emotional energies into creative and productive outlets.  (There, I made up my own language).

So if you're a chronic patient and it feels useful, don't worry about it.   You may not even be a failure.  If you're frustrated that therapy isn't helping you to fix what you wanted fixed, go see someone else for a consult and second opinion.   


Sarebear said...

I struggle mightily with feeling and thinking I am a failure. Especially considering my huge issues with efficacy . . . it took me over a year of working on efficacy to now be atthe point of being able to do something fairly consistently, and that's doing the dishes. Several week ago, I added doing the laundry, because a couple months of doing the dishes fairly consistently has built my sense of efficacy . . .FINALLY some progress!

Now, I did work on other things last year but the main goal was efficacy. It takes a LOT of strength of character to keep failing, and to keep coming back, face the problem(s), and try again. Over and Over and Over . . .

Actually, we try not to frame anything as failure . . . that's a pretty loaded word for me.

Iactually, after 7 years of therapy, early last year decided to examine therapy itself, look under the hood s'more, kick the tires, see what wasn't working and what was. Together, we changed a thing or two. Now, it's not that I didn't gain anything in those 7 years, I gained alot! BUT, since one can fall into ruts, and I thought some change might be needed, I thus went about following my instincts in this matter.

I may "not even be a failure", according to what you say in your post? And above, where you say that "the aren'tall "failures" or stuck in a bad place (some, granted, are), is that parenthetical referring to both failures and stuck, or just stuck? Given your second reference to failures, I'm guessing both.

I just am really leery of that word and don't like the label, I use it too often on myself. Otherwise enjooyed the post!

Oh, some might say my therapist "should" have done some of the tire-kicking himself, long before I did, but . . . I have what he calls a "kickback" reaction, to feeling p ushed, prodded, ordered, even strong suggestions . . . while sometimes I wonder if him tiptoeing around this kickback reaction makes my therapy less effective, the tire-kicking I did has led to a productive year and ahalf .. . even if it took me over a year to make progress on the efficacy, I kept hammering at it and would not let up. So, I'm pleased.

Sarebear said...

Oh, so going to see someone else andget a second opinion, well, knowing how loooong it takes for me to trust someone (and I don't trust anybody, really), I'd never just give up on the therapeutic relationship that easily (not that I think you are necessarily implying easily; one would hope that any problems in or with therapy would be brought up with the therapist to try to work them through and then if not working, second opinion etc.)

Not trying to criticize you, just saying what worked for me! I think some tire-kicking now and then is definitely in good order.

Anonymous said...

The problems in his practice mustn't be very large if he's managing to fix them in ten sessions. It took me seven sessions to trust my therapist enough to actually say something relevant, the next two to lay out the problems from small to large, and ten or so after that to fix the smaller of my issues.

The larger issues? The mood-dependant issues? Many, many months. And in those months it was keeping me in a safe little bubble while my psychiatrist tried to find medication that worked. The goal, at that point, was not to "fix" anything, it was to keep me alive until the medication worked. I was in no state to be able to fix anything, what I needed was a cheerleader, a comforting voice, somebody to be accountable to for the six days between visits with them, and somebody to remind me of all the reasons not to do anything rash.

Therapy isn't just about "fixing" things. It's about so much more than that, especially for those with illnesses that aren't ever going to completely go away. I actually find it really offensive that this guy thinks there's some time limit in effective therapy. His one-size-fits-all ideas about what therapy should look like would have ended extremely poorly for me. I'd have walked out thinking I were a failure for not fitting into his teeny tiny box.

Kimberly said...

From over the years I've learned getting better is in all honesty... A SIMPLE CHOICE. I'm not saying its easy and that everyone can get to that point in their life's. Most go through therapy for many years like myself(19yrs.. I'm 33 now) without a single day of relief.

It doesn't mean I'm healed either, we all have up and downs. It just means I've come to the conclusion that I do not want to be a victim anymore! Why give those who have hurt me that much power over my emotions and adventures?

Therapy is in my opinion a temporary safe place to first & formost to learn.... scream, cry, threaten, whine, complain, show anger, hurt ect.. all those bottled up emotions we hate to let show.

Sunny CA said...

I had a different reaction when I read this today, than when I read it in the NYTimes. When I first read it, I thought...gosh...maybe "I am a failure" for continuing 6 years. Last visit was about a month ago, and he and I both left the door open to go back, and I may.

Today when I read it, it occurred to me that HIS patients leave after 1 or 2 sessions because he is such an intolerable, pushy, obnoxious person. (fill in with the a word that fits the bill). He sounds like an arrogant know-it-all. Imagine that he would know what is right for every person that shows up at his door. It is hard to believe his thinking was not shaped when he was studying his specialty. I don't believe his figures about the number that stay in therapy longer, anyway. There are many private-pay patients who would not be in insurance company rosters even if he found these somewhere.

Gosh, Sarebear, I usually struggle with getting my dishes and laundry done, also. I am working full-time and make it to work, but when I get home can't move. I have to push really, really hard to do either of those things. Maybe more therapy, but will see what happens after I sleep for a month this summer when school lets out (I teach).

Liz said...


can you do a post on how you know it's time to take the training wheels off and terminate? or what about how to terminate effectively? (in general, of course :-))

this summer, i'm finishing up my year long stay in dbt. i'll also be finishing my work with my graduate student individual dbt therapist... in august, i'm moving with my family to another city.

i'm wondering what factors to consider as i determine whether to transition into working with a new person, or transition out of counseling all together.

OTHER NOTES: i have stayed WAY too long with therapists who were WAY not effective for me; inertia is a bitch, and sometimes it's difficult for either party to say, "hey, this isn't working... maybe we should try something else, or maybe this relationship isn't effective and it's time for a new therapist..."

jesse said...

What surprised me is that such a simplistic and almost mindless article was published in the Times. Ten sessions? Just tell the therapist what you want to work on? Therapy often tackles the most complex problems of human relationships. His approach impresses only those who know little. The danger in it is that insurance companies would love to find an excuse to cut benefits, and he supplied it.

Sarebear said...

I don't have a job (well, yes mother is a job, but you know what I mean) and when I say doing the laundry, I don't include folding and putting away. That's a whole 'nother animal.

So all this time on my hands andI don't do much? But I know JUST whatmy theraist would say to that.

And so I'll say thoe things to myself instead and keep on pluggin' away.

Note, I'm not trying to say I'm worse offthan anyone, if anyting, maybe 'm trying to show how awful I am that I do so litte? I dunno. UGH stupid keyboard. It can't keep up with my 90wpm anymore.

My therapist and I have recently talked about DBT and he reiterated and reassured me quite a bit he's not trying to dump me, but since I brought it up in conjunction with having sought out some supporton a BPD forum, it became a topic for discussion. I looked it up and it's $1400 just for 28 weeks of the full course of group session, and they and research recommend goin gthrough that twice, so that's $2800, not to mention what the individual therapit would cost.

There's some other things too, you needto be motivated, there's stuff you have to record during the week and stuff, and motivation is . . . not my strong suit.

BUT I'm trying to entertain the notion, though it's academic du to $$$ at the very least.

Dinah said...

SunnyCA: I like your take on it that he chases his patients away.

It seems to me that accomplishment/efficacy is a matter of semantics and definition. Can't do the dishes/ won't do the dishes/ don't enjoy doing the dishes or find it fulfilling? I might buy paper plates (I have a whole drawer of them, thank you) and cross that goal off my list.

Isn't contributing on a blog 'doing something'? It's participating in a dialogue, connecting in a way over a thought-provoking conversation, and it makes the blogger (who 'wastes' a huge amount of time that could be spent in other ways) feel valued, appreciated, or at least worthy of argument if that's what transpires.

Our society defines for us what are good and bad ways to spend our time (reading: good; TV: bad; Facebook: silly, etc; exercise: good, gardening: good )
Maybe the individual needs to rethink this in their own terms.

I digress. And termination, oh, that's a hard one. Often people decline to set an appointment and say "I'll call you" and don't, or just sort of slowly taper to oblivion then call when times are tougher.
Okay, it's late, I'm not giving the most thoughtful of responses.
Why do I have to prove I'm not a robot. Iknow I'm not a robot.

Anonymous said...

His view may be a bit extreme, but there is something to be said for recognizing when therapy isn't working. I didn't recognize it with my first therapist and spent 2 years in therapy only getting more depressed. My therapist finally sent me to someone else for a consultation, who correctly diagnosed me as bipolar. I was on meds and fine in 6 months. There are lousy therapists out there - probably lots of them - so I think it makes sense to switch if a person is making no progress.

Sarebear said...

Thanks, Dinah. I often disqualify the positive, or don't even think of it and head right to negative.

Hope I didn't offend you by just zooming right past the time and involvement you put in here!

I appreciate your kind words.

I do periodically asess now how helpful therapy is being, every couple of months. I do worry occasionally that I'm so "attached" to this therapeuic relationship that I may not consider important things that needconsidered. Thn again I get po'd at him often enough cause I'm idealizing him and bam less attached (yarg, the whole i love you/hate you borderline thing). But I think now I'm keeping that in mindso I'm good. I hope. Lol.

Sunny CA said...

Sarebear, I was very attached to my psychiatrist when I really needed him. When I got on my feet and developed other relationships, the need diminished and it happened without ever getting mad at him. I did tell him that I am not planning to come to sessions for the time being, but may need or want to come back in the future. I think that is a considerate thing to do after a long relationship and not just disappear without calling. I may go for a few sessions when I am not working this summer.

jesse said...

@Anon, it is indeed very important to recognize when therapy is not working. One of the problems with his approach is that he is using simplistic yardsticks that "load the dice" against patients whose problems are complex.

Do you remember that scene in Hamlet where he is approached by Rosencrantz and Guildenstern? They press him for information:

Ham. I do not well understand that. Will you play upon this pipe? Guil. My lord, I cannot ...I know no ouch of it, my lord. Ham. ’Tis as easy as lying... Look you, these are the stops. Guil. But these cannot I command to any utterance of harmony; I have not the skill. Ham. Why, look you now...You would play upon me; you would seem to know my stops; you would pluck out the heart of my mystery; you would sound me from my lowest note to the top of my compass; and there is much music, excellent voice, in this little organ, yet cannot you make it speak. ’Sblood, do you think I am easier to be played on than a pipe?

So, for those still following this, people are vastly more complicated than any simplistic system; we are harder to play than pipes.

Anonymous said...


This is not a new concept. Solution focused counseling has been around for decades. I don't believe that it is useful in the long term for complex issues. Employee assistance programs an insurance do love it. On the other hand, I don't believe therapy that lasts forever "cures" anything either. I think it can be useful but let call it what it is--supportive therapy.

Sarebear said...

Even after 8 years, I"m still dealing with issues that need to be processed, and it's not just supportive. I don't feel that anyone was saying my therapy was, and it's not a bad thing to be, but . . . I've learned, over these 8 years, that some issues, need the help of life experience, in conjunction with therapy, in order for something to "click" in the brain, mind, heart. One, two or all three of those.

I was hit by my mom as a teen. I hadn't been able to see that as abuse, acknowledge it as such, until January of this year. And then, well, more urgent issues came up (do I think the anger and pain that is bubbling up from realizing she abused me contributed? Sure, not caused tho. I'm responsible for myself.)

I'd talked about it in therapy a year or less before my knee surgeries; even then that was 6 years into it; I takes me a LONG time to trust. Anyway, I spent two sessions on it and felt there wasn';t anything to say, tho the issue felt like a nest of snakes or wasps that I was brandishing a looong stick at.

Then, experiences with my latest psychiatrist, led me to connect up some stuff from therapy with the experiences of abuse, and . . . things started to open up, come out, I can finally acknowledge it was abuse (even though I feel like I'm still just poking the corner of a nest of snakes with a big stick).

Anyway. I have plenty o stuff to work thru, and some stuff no matter how much you talk about it, sometimes needs something . . .external to therapy, to happen, to help nudge things along.

Like a recent insight I had, where I hope I've drastically reduced my fear of what other people think of me. They don't know me, really KNOW me, so why am I afraid what they think? I still have to test this out tho. We'd talked about that issue for years, and while I understood the healthier way to think with my head, I just couldn't BELIEVE it until something that happened in my life prompted a feeling and a thought to hook up and merge with all that therapeutic talking, to create a BELIEF in this notion, now. Well, about 6 weeks ago, this happened. Right in the middle of a different kind of hornet's nest.

Anyway. No, I didn't need to have cheated to find this insight, but I believe that the emotional distress from that led to this nsight . . . it could have been a variety of events that could have set it in motion. Without all the groundwork in therapy, though, I couldn't have made the connection.

So while in therapy we pursue lots of healthier ways of thinking, ways of countering the maladaptive stuff I do, processing past traumas, etc., sometimes it has to be the right time in my life for that essential insight to occur; some series of events or experien ces triggers the connecting up of therapy stuff with insight and emotions.

Sorry so long . . . I'm still working on a large variety of stuff in therapy, and I've not even gone in depth about some things yet, even after 8 years (like the OCD).

Anonymous said...

Thank you Dinah for those bullet points.
I have been in therapy and on various medications for depression for the last four years. When I am not feeling well I say to my therapist "Why am I still here? Shouldn't I be better by now? What is wrong with me?" When I am feeling well I can recognize that being in therapy for four years does not mean I am a failure, but that I am taking care of myself.

Cha said...

I'm doing my own therapy and trying really hard not to make an appointment. I have finally realized after soooo many years that I am way to attached. Sometimes I wish he would just tell me that we are done. Do doctors also become attached to their patients?

Anonymous said...

Haven't read through everything, but here is my take.

Some of these habits, people have had for a LONG time, like 30 + years. While great progress usually happens in therapy, there can be some back sliding and a tendency to revert back to your old ways. That's why we need the reminder and to get back on course. I took a month off recently from therapy, and then realized I still needed some help.

I have a great rapport with my therapist, and they kick me in the butt from time to time. It's up, it's down, however, they have really helped me through some challenging times. Within a 9 month time period, I had major surgery, lost a really close friend to suicide, and my spouse of 17 years walked out... AND I have BP Disorder. Ah the stress! Stress is hard on anyone. Stress and BP? It's like a major explosion waiting to happen.

My point is, there is no way that I would have been able to get through as much crap as I have gone through at this point, without the psych (meds) and the psychotherapist. They fill in the gaps and make sense of what family and friends are not able to do.

Everyone should go to therapy in my opinion. We all have stuff to work through. If you have the right person, you really could benefit from it. But it does take some time to develop the trust. If it isn't there within a few sessions, it is time to move onto someone else.

Liz said...

sarebear: my dbt group leader will do a payment plan-- as in, i pay nothing now, but promise to pay later....... it's worth thinking about. no kidding-- dbt has been a life changer for me. i suppose it doesn't always work as well as it has for me, but it has absolutely brought me back from the brink and set me up with skills that are leading me to accomplish my goals and build a life worth living. i can't say enough positive about it. i hope you are able to find a way to make it work. i didn't worry, at the time, about motivation-- the group gives skills to help increase motivation, or at the very least, helps me to be willing to do what i need to do.... i hope hope hope hope that if you decide dbt might help you that you are able to find a way to participate.

Chewing Taffy said...

Oh, wow. What a list! I'm with SunnyCA...his patients declare they're "done" after a few sessions because...well, with all that warmth, who would stay?

Therapy has been such a huge help to me in creating healthy relationships. What do you do when you grow up in a crazy, chaotic environment to learn another way of relating to people?

It's like that old Bob Newhart clip...STOP IT. Just...STOP IT.

That would be great if it worked. :-)

Sunny CA said...

My psychiatrist told me about that Bob Newhart clip and I really enjoyed watching it on YouTube. Every once in a while (not excessively often) he parodies the clip and we both roar with laughter.

My psychiatrist told me in the past that there were several long-term patients he has had that he missed for months afterwards. He gets attached also. I don't know how common that is. The positive side of that is that his concern is genuine and he really does care. He is not putting on a facade.

I agree with the anonymous just above me, that habits and ways of interacting have been established for many years. I was in my 50's when I started seeing my psychiatrist.

Jane said...

I think I'll be the Devil's advocate. Maybe the guy is not pushy and too simplistic for his own good. Maybe it is just as he says. The majority of his patients do not enter therapy with him because they are managing long term issues (like severe mental illness). He admitted that there aren't generally very many people who seek therapy to help manage their schizophrenia. People are seeking him out because of a relationship problem with family, problems with their job, etc. It's people with specific problems, and they tend to be aware of the problem. That way is can be addressed quickly and efficiently. There is not convincing the patient of what is wrong (they already know). He's just guiding them through a problem. That's the kind of clientele he has and that was who the article was addressing. If someone enters therapy for a specific issue (marriage trouble), and the patient has no mental illness, it shouldn't require years of therapy to work through that. The therapy probably is a failure if that is the case. If your marriage is troubled for years, even with therapy, then that is definitely a failure.

He's not talking about people with severe BPD or schizophrenia. He admits those aren't the people who usually seek him out.

jesse said...

@Jane, so he's doing focus-oriented problem resolution. Well and good. But why then call it therapy, and talk about endless number of sessions? He is being provocative, I think.

Anonymous said...


Gasp!!! Provocative? I don't know anyone else who likes to be provocative. Do you?

Jane said...

Actually Jesse, you got me he really conducting psychotherapy? Or is this just doing "focus-oriented problem resolution." I went on wikipedia and looked up psychotherapy. In the "psychotherapy" article it lists a lot of the different therapies and one of them was "brief." Here is the definition:

'"Brief therapy" is an umbrella term for a variety of approaches to psychotherapy. It differs from other schools of therapy in that it emphasizes (1) a focus on a specific problem and (2) direct intervention. It is solution-based rather than problem-oriented. It is less concerned with how a problem arose than with the current factors sustaining it and preventing change."

So I guess he is doing a form of therapy. And he is being provocative to get more clients...but really...he's not just trying to get business with that article. He's also turning business away by being that provocative. He basically told everyone with issues more complex than "should I take job A or job B" not to knock on his door. No one with schizophrenia is gonna track him down to be his therapist after reading that. He says most of his patients want help with "depression and anxiety." But I'm curious as to how many of those people are having major depressive episodes or crippling anxiety from PTSD flashbacks, because he already claims that those people don't often come a knocking.

It's probably in the same way that someone who only needs and wants brief therapy is not gonna track down you or Dinah. They don't need meds, and they could probably find someone for far cheaper to meet their needs. You and Dinah are the "big guns." You've got the power of the medicine cabinet and psychotherapy training to treat severe cases. The author of that article is not treating severe cases and conducting long term psychotherapy, because all of those people are seeing someone else (like you or Dinah if they have money, or a free health clinic if they have no money).

jesse said...

@Jane, Anon, et al, one of the reasons I love Shrink Rap is that there are so many thoughtful and insightful comments. It is true that therapy, by some definitions, is what Wiki says. I think of therapy as aiming to achieve internal change, rather than simply being problem resolution, but problem resolution in itself can be a valid and important goal. I do believe, however, that the best people doing short term therapy are those who understand long term therapy, while those who only understand short term, crisis oriented, problem resolution techniques not only know nothing about longer term work, but do not know what they do not know.

OK, I know that many will disagree with this, but I must stop here. Dinah is already thinking that this subject would make a good blog, if I'm not mistaken!

Jane said...

Actually...thinking on this later...I'm not entirely sure why people pay to see that therapist. If some of his patients figure out a solution halfway through the first session, as he claims, what does that say about the patient? If the problem could be resolved that quickly, then maybe it didn't really require a therapist to begin with.

The only issues I could think of that could be solved that quickly are people who are getting hypnotized to stop smoking or get over a phobia and they already know how to go under. But he didn't mention hypnotherapy as part of his I don't know.

Anonymous said...

Can someone tell me what BPD stands for? Is it bipolar disorder or borderline personality disorder? I see it in the comments and I'm never sure.

Anonymous said...

On this blog, I have always assumed "BP" to mean Bipolar Disorder and "BPD" to mean borderline personality disorder.

Good question!

Jane said...

I'm gonna add one last comment, because I was reminded of something last night. Dr. Drew (from TV) was talking about Hangover Heaven on his show last night. A doctor in a big RV looking thing travels around Vegas in it and has an IV set up to treat people with hangovers. He pumps saline into them so they can recover quicker and go out and party more the next day. Dr. Drew didn't like this because the doctor behind Hangover Heaven doesn't screen for alcoholism. He just treats them and sends them on their merry way. But the Hangover doc told Dr. Drew that most people don't experience hangovers from alcoholism when they go to Vegas. It's as simple as they had too much to drink the night before, they had plans to go skydiving the next day, and now they need a quick recovery. Hangover Heaven has nothing to do with enabling alcoholics. So he doesn't screen for alcoholism...

That relates to this, because the author claims in his article that he already knows that brief therapy is not as effective as long term therapy in helping people with severe mental illness. He has heard this from his detractors who are against brief therapy. But he gives the Hangover Heaven Doc excuse: Most people who seek therapy do not have a severe/chronic mental illness. His therapy is not for those people.So it's a moot point.

Which begs the question...does the therapist have a duty to screen for people who may require long term therapy? Even though that is not his area. Does the Hangover Heaven doctor have a duty to screen for alcoholics, even though his service is not geared towards alcoholics? Just because a small minority of people might use these services because they have an underlying condition that needs treatment, does that mean the treating therapist or doc has to screen for it?

Sideways Shrink said...

Jesse and Jane
I think you are both getting at a similar idea, sort of like one of those visual tricks: what do you see in this picture--the ladies in profile or the vase? When you can only see one thing it is all you look for. The same goes for diagnosticians and therapists. I saw bizarre things in New York while training that I thought I would never see again, but I have seen the weirdest of all of them again, all of them, but I wouldn't have recognized them if I had not known what I was seeing.
Jane--As for therapists with any license having a "duty" to screen patients for another kind of therapy, of course, they do, ethically. But most therapists are willing to go from short term to long term (in fact we like this scenario because patients quit therapy who we sometimes feel could benefit from long term therapy). As for therapists who offer only short term therapy, they are bound by the same ethics but it is about vision. Another medical metaphor is that if you see infection and all you have is penicillin, you give penicillin. The more complicated idea that they could have a fungal infection or an auto-immune disease simply does not compute.
As for screening, I was taught a funny adage in school: you don't have a drinking problem unless you drink more than your psychiatrist......

jesse said...

@Sideways, "when all you have is a hammer, everything looks like a nail."

A good psychotherapist (physician, psychologist, social worker, and so on) has learned not to exploit patients by conducting the sessions in a way that is in the therapist's interests, not the patient's. This takes training and experience, not just good intentions.

Have you ever gone into a good hardware store and asked for nails, but after describing what you wanted to do were told that it would be better to use screws, or a special glue? We are much more complicated than construction projects (or pipes) and any system that is simplistic and reductionistic is bound to have severe deficiencies.

Unknown said...

Having practiced therapy for the last three years in a state-insured, chaotic clinic with a strongly brief therapy mindset culture, I can tell you that what I have noticed is that the relationship between my client and me is the most important intervention I have. I am a "solution focused therapist", but that's just my modality, its not what makes therapy work. I liked what Jesse said about keeping it about the client, not me. If it were up to my interests, I would see each client 6-8 times, follow the same pattern each time, and then say goodbye to take them off of my monstrously large caseload. But the people I work with don't work like that. They drop off for a few months, then drift back in. Or they need a lot of care really quickly and I see them twice a week for several months, then they stabilize, or sometimes they just need to check in with me every few months when things seem overwhelming. It is more important to me to be what the clients need than to follow a strict plan. Now I have that luxury, because of where I work. I understand that if I was working with insurance companies, it might be much more stringent.

I just hesitate to condemn long term therapy because its a luxury I wish I had, and I don't experience mental illness. I just see the value of having access to a personal counselor to help with the rough road. I would love to have what I give my clients- an open ended pass to all the care they want, not all the care I think they need. Ironically, my client's on state insurance get all the care they want, and my own insurance company only allows 3 sessions a year before I am paying out of pocket.

Would we cap other services? Stop going to see your doctor, your dietitian, your personal trainer, your pastor, out of some belief that the people who fulfill these functions will become a crutch? I am much more comfortable letting my clients decide when enough is enough than cutting them off before they are ready, or imposing my own ideas about how much progress they should make in how much time, which seems to be the implication in some of this kind of work.

Anonymous said...


I have a health concern that warrants seeing a physician. I tend to go for a check up every 12 -18 months and maybe once every 2 or 3 years for something in between. This time, I have something that is rather worrisome and is on the list of things one ought to get checked sooner rather than later. The earliest I can be seen is in 6 weeks so I guess we do cap doctors appointments.

EastCoaster said...

There was a really good thread on unfogged about this. My favorite was the introduction to the post.

I don't recommend reading too much stuff there. It's highly addictive, and it takes a few months to understand all of the inside jokes and obscure philosophy allusions, sometimes tongue in cheek.

Still, this line is priceless:

Here's a piece from the Times, written in the untranslatable dialect of the Upper West Side (where there is no word for "Iowa" but they have twenty distinct morphemes meaning "let's get take-out!")

EastCoaster said...

As is this from the guest author if the post in response to a comment about informed consent to psychoanalysis which now seems to include requiring people to give potential patients information about cognitive behavioral therapy:

For some reason I find that funny. I guess I immediately start imagining ludicrous extensions of the policy. "While the practitioners here at the Kohut Institute offer services informed by the theory and methodology of Self Psychology, we are required by law to mention the alternatives presented by the Kleinians, the Middle Group, and the Anna-Freudians. Also, it is your legal right not to make conscious the unconscious at all. Or to start your own goddamn school."

EastCoaster said...

I don't see my other comment.

There was from the original guest poster a response to a comment about the ethics of informed consent to psychoanalysis which is equally wonderful. (It appears that giving information about CBT is considered the standard, at least for trainees):

For some reason I find that funny. I guess I immediately start imagining ludicrous extensions of the policy. "While the practitioners here at the Kohut Institute offer services informed by the theory and methodology of Self Psychology, we are required by law to mention the alternatives presented by the Kleinians, the Middle Group, and the Anna-Freudians. Also, it is your legal right not to make conscious the unconscious at all. Or to start your own goddamn school."

Anonymous said...

Carolyn writes, "Would we cap other services?"

Actually, there are all kinds of caps in health care. It's certainly not limited to mental health care. Take physical therapy, for example. Patients cannot have physical therapy paid for by insurance for as long as they want it, even if they think it's helping. My grandfather had a stroke, felt that he was benefitting from physical therapy but at some point Medicare said enough physical therapy, because it was determined by someone somewhere that he had improved as much as he was going to. Is it wrong that he was cut off? I don't really think so. It was worth it to him to continue physical therapy, and he continued at his own his own cost.

I don't know where the line should be exactly with psychotherapy but I wouldn't be comfortable with it being paid for ad nauseum by insurance for years and years, either. I'm actually okay with caps on it, but maybe the caps should be tied to improvement. Of course, I'm not sure what the measurement of improvement would be exactly, so I guess that's a bit problematic.

I don't know, I have kind of mixed feelings about it. Like others here have mentioned, it takes me some time to trust people with the difficult stuff. I don't spill my guts with someone I met 5 minutes ago, that's just not how I am. But, how much of that should insurance be expected to cover? I cannot say that 100% of what I've dealt with in therapy has to do with mental illness, so how do we separate out what parts insurance should cover?

I'm a big believer in the benefits of therapy, which requires a good therapist and someone who has at least some motivation to improve. I'm pretty confident I would be dead right now had I not had a therapist who walked with me through some pretty dark times. Back when the depression was really dark, the goals were very small - take a shower, brush my teeth, etc. Sometimes I didn't meet even those goals. There were times I walked around dog crap covered in moldy fuzz that sat on the carpet for weeks. Hope to never repeat those days.

That being said, not all I dealt with in therapy had to do with depression. I can also be lazy sometimes. If I'm honest, there have been times I've used therapy as a crutch. I suspect I'm not the only one. If therapy is meeting the patient/client's needs for intimacy with other people (and I don't mean sexual intimacy) then there's not much incentive to form other relationships where those needs can be met. A good therapist will know that and not let the patient/client become too dependent. My therapist is very boundaried and kind, but she has also given me a compassionate kick in the butt at times, for which I'm grateful.

I don't really know what I'm debating here, my thoughts are kind of all over the map. Per usual.

Abbey Normal

Anonymous said...

Whoops, I meant "ad nauseam." My brain is tired.

I'm off topic here, but there was some mention a while back about doing a post on religious delusions. In particular, how psychiatrists differentiate between someone who is having a religious delusion versus someone who simply has strong religious convictions. I hope you guys will post on that topic at some point. I would really be interested in hearing your perspectives on this.
Abbey Normal

Anonymous said...

So it's supportive therapy, so what?! Is that like some kind of inferior therapy to "real" therapy? Like the nursing home of therapies?
The prevailing idea is that people are "supposed to" move from therapy to getting support outside of therapy - from family, friends, churches, workplaces etc... But how does that account for an introvert, with minimal family, who works temp jobs in a society that doesn't like to talk about or think about deep things, personal painful things, or even feelings? Wouldn't this person benefit from long term supportive therapy?
I wonder if there are any studies on what types of people use long term psychotherapy...(yes, of course, rich people!)

PS I'm not a robot, I swear!

Anonymous said...

Anon, you make good points, and I admit my views are definitely colored by my own biases and experiences. I'm very introverted, and I isolate. I don't know. I guess I'm concerned about the therapists who encourage patients to be very dependent because I know that eventually that therapist is going to move, or retire or die, or the patient can't afford to go to therapy anymore, etc. Then, what happens to that patient? Who will they have?

I have had both kinds of therapists. The one who tried to meet my every need and one who did not. Had I not run out of money for therapy, I would probably still be sitting in the first therapist's office, with him being my only contact with the outside world. The first one reinforced my isolation, and I became much more dependent on him and helpless. I went from therapy once a week to him telling me I needed it twice a week, to him calling me every night to check on me. This wasn't helpful at all, and I left therapy with my meager savings completely depleted and without any support system.

But, then I say all that and I'm left wondering if I really want some nameless person in an insurance company making the treatment decisions of when enough is enough. I'm not really comfortable with that either. So, maybe caps aren't the answer. Hopefully, the therapist or psychiatrist would do the right thing by the patient.

I wish there was some way to protect patients against the therapists who encourage complete dependency, because they can do so much damage.

Abbey Normal

Anonymous said...

I do not think we need to have MDs providing supportive therapy. Otherwise, there is nothing wrong with the idea.

Anonymous said...

Dear Abbey Normal
Sounds like the problem was the therapist, not the number of sessions.
For me the rule of thumb is: Stay if youre finding it helpful, leave if your not. I've done both -mostly leaving my EAP people who don't want to dig too deep, and staying with people who kept coming back to the stuff I didn't want to talk about.

By coincidence I went to a conference last night for survivors of sexual abuse - of the 4 speakers all had been in therapy for between 5 to 10 years.

Anonymous said...

Anon, I think you're probably right. My experiences (both good and bad) have had more to do with the therapist rather than the number of sessions.

While I agree in theory with the rule of thumb of staying if it's helpful and leaving if it's not, I'm not sure patients always recognize when it's not helpful, particularly if the therapist seems nice.

It's just not that easy to leave. It doesn't take long to have made a huge financial investment, not to mention the emotional investment in the therapeutic process. I wonder if in cases where therapy isn't working, if patients did as I did and thought they weren't improving because of their mental illness or maybe because they had never had good therapy and didn't know what that looked like. I scratch my head as to why I stayed with the first therapist so long when I was clearly downhill.

While the article did seem a bit unrealistic, I think it made a good point by reminding people that they should be able to expect improvement, and if they're not improving then maybe they should look elsewhere. So, whether it's 5 sessions or 1500, I don't guess the numbers matter, what matters is that it's helping.

Abbey Normal

Anonymous said...

Thanks for your article. The comments are interesting. I've found psychotherapy to be very helpful and necessary. I've been in therapy for 11 years. I saw someone post that it is rich people who stay in therapy for a long time. This isn't always true. I've gone into debt to pay for therapy because I have a severe mental illness and without therapy I don't know how I would've functioned to work. I wouldn't have gone into debt if my insurance company were to cover psychotherapy at the level that they cover my visits to my orthopedist, podiatrist, and general physician. I've found therapy to be much more effective than medication with far fewer side effects. I'd rather be dependent on a therapist than on a drug (I'm going through withdrawal from a psychiatric medication right now and it really sucks).

I'm dealing with an insurance company demanding information from my psychotherapist to determine whether or not the treatment meets standards of care. They are threatening to not pay for any future sessions. They'll pay for more meds, of course, even though the meds have far more dangers. I'm rambling.