Tuesday, August 24, 2010

What the heck is this "therapy" thing?

What an excellent, excellent question.

I saw a patient last week who asked me that very question. It’s a question that more patients should ask of their therapists. It’s a question I welcome – but it’s a question that does not have an easy answer and sometimes the answer is not as reassuring as the patient might hope.

I’ll tell you what my rather long-winded and sometimes circuitous answer usually sounds like.

Theories and beliefs
I often say to my patients, “Roman Catholics have their beliefs, Jehovah’s Witnesses have their beliefs, Lutherans have their beliefs and therapists have their beliefs too.” I say this because of my belief that “therapy” has more in common with theology than science. Especially in the Clinic in which I work, I often fall into the “guilt-by association” category. By that, I mean people frequently call me, “doctor”. “Thank you Dr. Bannister.” I correct them the first five or ten times – after that, I let it go.

My colleagues in other departments throughout the clinic have cool lab tests: X-rays, MRIs, pulse oximetry, SPEC scans, CT scans, EEGs. EKGs, colonoscopies, barium swallows, spirometry, ad nauseam.

In my department... we have BUPKISS, NADDA, ZIP, ZILCH! We do have our theories that we love and cling to - and we have beliefs - but we have no truly objective scientific measures. Even the much-touted MMPI-2, perhaps the best researched, oldest and SOMETIMES interesting “test” requires interpretation. It is not definitive and there is much debate within the profession about its appropriateness.

(The questionnaire results in an ever-growing number of scales which are lined up like parallel pickets on a fence, dots are assigned based on the subjects true/false answers to 567 questions. The dots on the scales get connected to produce a Dow-Jones looking graph. Ideally, an experienced trained psychologist INTERPRETS the dots by comparing it to a huge database of other scales – but 97% of the time the interpretation is done by a computer. The result is, “Individuals with similar profiles frequently complain of nervousness, suspiciousness or any number of problems. And then, “The most commonly associated diagnosis is… One might think that the "normative group" (the database of responses against which a patient's responses were compared to) would represent a representative cross-section of the population. Hopefully, there was a demographic adjustment so that if you achieved higher education - your results would be compared to others who had achieved higher education. BUT GUESS WHAT? The original "normative group was
psychiatric inpatients, hospital visitors, college students and medical inpatients. As long as this demographic matched the subjects, a degree of validity might be expected. If it didn't match... SORRY. Is this much better than the old arcade machine that featured “Zoltar”? I think Dr. Zoltar's assessment cost 25¢; the MMPI-2 will cost upwards of $200.)

Have you ever read the package insert for psychiatric medicines? In the explanation of the pharmacologic action (how it works), usually it will say “It is believed…”

REALLY? It is believed? It isn’t known?

I suppose I should mention just for chuckles that the beginnings of psychotherapy come from the very curios mind of Sigmund Freud. (not exactly a paragon of mental health) His ideas about psychoanalysis are ENTIRELY based on ONE CASE and he augmented the case description with more fiction than fact. It’s his theory – it’s his fiction – it his belief system. It was never a fact in the concrete sense, in fact the majority of remnant Freudian psychoanalysis is more of an historic relic than science. Freud was trained and known as a neurologist and a neurological illustrator – his drawings of neuroanatomy are remarkable. He always hoped his theory/belief system/religion would someday be seen as a science… now, its more of an amusing piece of psychohistory.

That’s what you get in psychiatry – and you don’t get much more in psychotherapy.

Who’s right?
Buckle your seat-belt. How many separate approaches/schools of psychotherapy would you guess there are? Let me ask another question, how many different ways are there to fix a broken leg? Five? Ten? Maybe twenty?

There are OVER 500 distinct styles/theories/approaches to psychotherapy! (Corsini, 2008) Over 500! What does that tell you? How many ways are there to fix your brakes? OK, I agree that the human psyche is more nuanced then a braking system in a vehicle, but seriously, over 500? How many religions are there in the world?

The following excerpt comes from Wikipedia:

In 2001, Bruce Wampold of the University of Wisconsin published the book The Great Psychotherapy Debate[31]. In it Wampold, a former statistician who went on to train as a counseling psychologist, reported that

  • psychotherapy is indeed effective,
  • the type of treatment is not a factor,
  • the theoretical bases of the techniques used, and the strictness of adherence to those techniques are both not factors,
  • the therapist's strength of belief in the efficacy of the technique is a factor,
  • the personality of the therapist is a significant factor,
  • the alliance between the patient(s) and the therapist (meaning affectionate and trusting feelings toward the therapist, motivation and collaboration of the client, and empathic response of the therapist) is a key factor.

Wampold therefore concludes that "we do not know why psychotherapy works".

What about Cognitive-Behavioral Therapy? (CBT)
I am often asked about various modes of treatment. Perhaps the most commonly asked about is Cognitive-Behavioral therapy. Cognitive–Behavioral therapy is one of the many beliefs out there in my profession. The basic premise is that our problematic behaviors and feelings are a products of incorrect thinking (cognitive distortions). If the cognitive distortion is corrected, the feelings and behaviors will follow. This may, superficially, sound fairly reasonable, but remember – no particular mode is more effective than the others. So why do we see the frequent pimping of CBT? The answer is because CBT is a form of treatment that naturally lends itself to a research model. Pharmaceutical researchers can easily check boxes, or provide numeric answers to questions like: How many times did the patient self-identify a cognitive distortion? Or: How many lines were written in the patient’s therapy journal between today and the last appointment? Or: How many relaxation activities has the patient identified and roughly how many days did the patient engage in the relaxation activities? This kind of numeric answer is easily crunched by a computer.

It is not so easy to quantify whether a patient feels that a therapist understands them. Empathy cannot be weighed, measure or counted.
So, CBT has become the darling of pharmaceutical companies because it is a natural partner to the rest of their “research” which will coincidentally support the release of their newest break-through drug treatment.

So, what do I do with patients?
I am indebted to a patient who was direct enough to ask this important question. My answer may seem somewhat fuzzy, especially compared to the rationale of the pseudo-scientific CBT postulate. Often, I refer to the appointments I have with patients as “conversations”. That is, after all, what we are doing – but it’s a particular type of conversation. It’s a conversation that often breaks the rules of social convention. In a conversation between you and a friend, one of the more important aspects of the conversation is maintaining the friendship. I have no desire to offend any of my patients but neither am I invested in having them continue seeing me. As much as I genuinely like my patients, I would respect their choice to not see me and I would not be heart-broken. If I think their approach to an issue is ill-advised, I will say so. I believe that the nature of my professional relationship with a patient entitles them to know what I’m thinking about their situation – whether they agree with it or not. I think of my professional conversations as polite debates. A friendly push and pull. Using the concept of dialectics, it is thesis, antithesis and synthesis.

Another concept that informs what I do during my professional conversations came from my days as a younger therapist. (Those were the days when I had hair on my head.)

Occasionally, when a therapist is feeling “stuck” with a particular situation and patient, they will consult with another therapist. This consultation has a name which is a bit of a misnomer it is called “supervision”. To me, supervision implies that my “supervisor” is there in some managerial role or using an employment analogy, they are my superior and that I am their subordinate. Really, supervision in this case is more of a consultation or a second opinion.

In my early days, I thought if I spoke with another therapist to help me get “unstuck” with my work with a patient, the “supervisor” would listen and pick-up on some aspect I’d forgotten to inquire about – or perhaps the supervisor would suggest a technique or approach I hadn’t thought of. Perhaps the supervisor would identify counter-transference that I was blind to.

Routinely, I found the supervisor’s comments to be unhelpful – but – in the process of trying to explain the situation to someone else, it was nearly always helpful. As I struggled to put into words what was happening in the therapy, I would come to a better, clearer understanding the situation. Sometimes, I considered asking my colleague/supervisor to just listen and say nothing – because I knew what I needed was to only try to explain the situation and that that act of explaining would be helpful. If the supervisor didn’t understand – they asked question for their own clarity and understanding – and that also helped me. What helped was NOT their advice or insight; what really helped was me struggling to explain and them genuinely trying to understand. It was the conversation that helped - not their suggestions.

In large measure, that is what I do. I try to understand as my patient tries to explain.

It is true that I give advice (probably too much) but that’s OK because most of my patients don’t do what I suggest – and after nearly 25 years in the profession, it doesn’t surprise or bother me because my “advice” or assessment is just part of the friendly debate. I don’t expect patient’s to agree with anything I’ve said – and I pray they don’t blindly follow my advice. (After all, in the final analysis, all of my patients are ultimately responsible for their choices and behavior. I have no special wisdom and Lord knows, I’ve gotten into more muddles than I care to admit.)

Getting back to the question about what is therapy – it’s a philosophical question. It’s the practice of a conversation, the goal of which is to help the patient.

I have always believed that with any of my patients – if I don’t learn something, then they probably didn’t either and hopefully, they learn more. I practice psychotherapy because I am genuinely interested in people. I’m interested in understanding why they don’t change when their situation is very painful. I’m very interested in understanding why after years of being in a difficult situation, they suddenly change as if someone “flipped a switch”. I’m interested in people. I ask questions because I’m trying to understand the endlessly fascinating and I would go so far as to say sacred mystery that each of us represents in a infinite number of ways.

You might be interested in looking at a few of these links if these ideas catch your interest:

Dr. Helen
Crazy Therapies
Daniel Carlat

Sunday, August 22, 2010

Who Do *YOU* Say You Are?

There’s a portion of the Bible wherein Jesus puts some of his disciples in the hot-seat. He asks them, “Who do you say that I am?” It’s an interesting question. Earlier in Jesus’ life it is reported that he was tempted by the devil:

Then Jesus was led by the Spirit into the desert to be tempted by the devil. After fasting forty days and forty nights, he was hungry. The tempter came to him and said, "If you are the Son of God, tell these stones to become bread." Jesus answered, "It is written: 'Man does not live on bread alone, but on every word that comes from the mouth of God."

Then the devil took him to the holy city and had him stand on the highest point of the temple. "If you are the Son of God," he said, "throw yourself down. For it is written: "'He will command his angels concerning you, and they will lift you up in their hands, so that you will not strike your foot against a stone." Jesus answered him, "It is also written: “Do not put the Lord your God to the test." (Mat 4:1-7 NIV)

These are events in which one’s identity is questioned. What question is more elemental than knowing who we are – yet it is a question that plagues many of us. It’s a question that for most of us is fluid. Some of us would say, “I know who I am.”

Really? Do you really know who you are? Maybe… or maybe not.

Have you ever said or heard someone else say, “I’m so mad at my self.” It almost sounds like three parties are involved. There’s “I” – and then the “self”, which is apparently owned by the “my”. Perhaps you’ve heard someone say, “I don’t know why I did such a foolish thing.” It sounds like two parties are involved.

Murray Bowen, MD discussed the concept of “individuation” (Bowen used the term in a very different manner than did Carl Jung, MD – try not to be confused.). Bowen suggested that individuation refers to one's ability to separate one's own intellectual and emotional functioning from that of the family of origin (including extended family for many generations). Bowen spoke of people functioning on a scale; individuals with "low differentiation" are more likely to become fused with the dominant family emotions they depend on others for approval and acceptance. They either conform themselves to others in order to please them, or they attempt to force others to conform to themselves. They are more vulnerable to stress and they struggle more to adjust to life changes.

Murray believed that to be “individuated” is an ideal that no one realizes perfectly. Usually, we recognize that we need others, but we strive to depend less on others' acceptance and approval. Hopefully, we do not merely adopt the attitude of those around us, but acquire their better traits thoughtfully, winnowing chaff from grain. If we are more individuated, we are less prone to impulsive reactions that were shaped by generations of emotional family traditions. What we decide and say matches what we do. When we act in the best interests of the group, we choose thoughtfully, not because we are caving in to relationship pressures.

As I’ve said in the past, I derive many of my ideas for these columns from my patient/teachers.

Recently, my patients have discussed their concept of self – some believe it is a monolith, for others it is plural. For some it is defined by the culture, their family or their imagined sense of what culture or family would want. The question has been asked, “Am I authentic or am I presenting a sham. This is an unusually difficult question that only the courageous can answer with honesty. My patient told me, “It’s a bitch when you start believing your own PR.” Another patient described it as a “soulless existence.”

20 years ago, I had a small library of perhaps 2000 books. At the time, I told my self (How many parties are in that last statement?) that I was buying these books because I might need them as reference; perhaps as I was writing some imagined ground-breaking book. In retrospect, I was amassing these books for the impression it might make on a visitor to my home. Probably, visitors would have thought, “A smart guy lives here.” I may have read 10% of the books. I told my self (There are those three characters again!) that I’d get around to reading the rest – “some day”. During a moment of unusual honesty with my self, I donated 90% of the library to a worthy cause. It felt like something had died… perhaps, some part of my fake, sham veneer. I was individuating – I felt lighter – I was less fake.

When one predominantly lives the fake life, the inevitable result is diminished self worth – because the real life is not lived – perhaps the real life is even disowned. We can develop a kind of emotional amnesia as we try to be someone other than who we really are.

I still recall the day when I received notice that I passed my State Board license; I ran five blocks to my parents home – without knocking, I burst in and threw the license down on the table in front of my father and exclaimed, “I passed the %$@#” A good, but sad example of an un-individuated person. In this case my father was baffled - it was my imagination of proving something. I was trying to prove something I imagined was important.

One patient described walking into a casino where he was known to be a big roller and bigger tipper. This self was a forgery – his real life is pedestrian. Perhaps Thurber described it in “The Secret Life of Walter Mitty”. Another patient described the thrill of high-risk sex – “It such a relief not to be the boring me.”

How many remember the movie from 2002, “Catch Me If You Can”; it’s the story of Frank Abagnale whose real life was so painful that he embarked on a series of fake identities that helped him feel better. Ultimately his fakery can’t be perpetuated any longer.

  • Is your life an unauthorized biography written by someone else?
  • Are you trying to live up to the standards set by your mother or father – grandmother or grandfather?
  • Are you trying to keep up with the Jones’ or your brother?
  • How did your idea of “a fulfilled life” develop?
  • Who is/was the author of that idea?
  • Perhaps it was the reverse – you don’t want to be like your Uncle that was disowned so try to be the opposite.

Perhaps you are one of those very rare and courageous individuals who lives an autobiographical life. Those who live their own life have not chosen the easy way; they are an endangered species and will not commonly truck with those who have taken an easy path. These intrepid ones suffer from what my teacher called, “the disease of abnormal integrity.”

  • Who are you trying to please?
  • Is your life a forgery of what you feel is expected?
  • Have you chosen your own path?
  • Are you a people pleaser?

I will end this small essay with a quote from Martha Graham:

"There is a vitality, a life force, an energy, a quickening that is translated through you into action, and because there is only one of you in all of time, this expression is unique. And if you block it, it will never exist through any other medium and it will be lost. The world will not have it. It is not your business to determine how good it is nor how valuable nor how it compares with other expressions. It is your business to keep it yours clearly and directly, to keep the channel open. You do not even have to believe in yourself or your work. You have to keep yourself open and aware to the urges that motivate you. Keep the channel open. ... No artist is pleased. [There is] no satisfaction whatever at any time. There is only a queer divine dissatisfaction, a blessed unrest that keeps us marching and makes us more alive than the others"