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

No comments:

Post a Comment

As always, your comments are helpful.