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.