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.