Tuesday, July 10, 2012

Bad or Mismatched? More on Ineffective Psychotherapy

My last post, Psychotherapy: The Down Side has lots of interesting comments.  As usual, what our readers have to say is the most interesting part.

I asked both Dr. Ron Pies and Dr. Lou Breger to write guest posts about the topic.  Dr. Pies put his in the comment section, so I'm reprinting it here.  I asked him because he's written a book about how to choose the "Right" psychotherapist, so I figured he would enjoy the discussion.  Stay tuned for Dr. Breger's guest post later this week.

Dr. Pies writes:

Dinah has invited me to comment on this interesting discussion, and I'm pleased to do so! I have found the discussion informative and sophisticated, and actually have little to add, except for a few important distinctions; namely, it's helpful to distinguish "bad therapists" from "bad therapy", from "inappropriate" or "mismatched" psychotherapy. I will focus on the last category.

Historically, we have two fairly extreme examples of "mismatched" or inappropriate therapy. The composer, George Gershwin, complained of chronic headaches. These were (mis)diagnosed as a psychosomatic problem, and treated with psychotherapy. He turned out to have a brain tumor! The take-home here is to be sure that so-called psychiatric problems have been properly evaluated for an underlying OR contributing medical or neurological cause.

The other historical example comes from the treatment of Borderline Personality Disorder. Leaving aside the many controversies regarding this diagnosis per se, the syndrome (it is probably due to a variety of causes) was first identified in patients who "fell apart on the couch"--that is, they had very bad reactions to classic psychoanalysis. The deeper the analyst probed, the more regressed the patients became.

It is now generally acknowledged that while psychodynamically-oriented therapies may be adapted for use in patients with Borderline PD, "classic" psychoanalysis is usually contraindicated or very risky. Most psychiatrists would also argue that psychoanalysis per se is inappropriate for patients with schizophrenia (in which, however, cognitive-behavioral therapy may sometimes be a helpful adjunct to medication).

Other examples of "mismatched" treatment include: 1. use of classic psychoanalysis alone for treatment of substance abuse (which rarely responds to psychoanalysis alone and may actually worsen); 2. use of psychoanalysis for most cases of male sexual dysfunction (which are often due to physical factors or performance anxiety, and can be treated in a matter of weeks with more appropriate behavioral techniques).

I do not mean to "pan" classic psychoanalysis! When used for the right type of patient with the right type of problem, I believe it may be helpful, although solid controlled studies are lacking (and are very, very tricky to design, since "blindng" is nearly impossible!).

Cognitive-behavioral therapy (CBT) may also be mismatched with the "wrong" type of patient; for example, CBT alone is unlikely to control severe bipolar disorder (though it may be a good adjunctive treatment)or be very successful with some personality disorders (e.g., antisocial PD).

Finally, there is premature or unnecessary psychotherapy. After 9/11, it was found that those exposed to the trauma actually did worse than controls when they were given a form of "crisis de-briefing" treatment--maybe because it was provided by therapists unskilled in working with traumatized patients. (It is easy to make things worse in traumatized patients, by over-stimulating the traumatic recollections without the proper psychological "safety nets").

Finally, as some readers have wisely noted, nearly every useful medical/psychological treatment can have unintended or negative consequences, if given to the wrong person for the wrong reason--including aspirin and over-the-counter antihistamines!

In general, there is abundant evidence that all the major forms of psychotherapy are of benefit for the common conditions we treat; e.g., most depressive and anxiety disorders. But correct diagnosis; matching of treatment, and a "good fit" with an empathic therapist are critical predictors of success.

With good wishes to Dinah and readers,

Ronald Pies MD

For more about Ron's and links to his many books, check out his Amazon page here.


Jane said...

Hmmmm...very interesting (says with German accent, leans back in chair, strokes fake beard).

I didn't know that about certain kinds of therapy being contraindicated in some people.

Here is my take on why psychotherapy could be bad in some cases: lack of training. A long time ago, Jesse brought up some interesting points on SFBT. Even though I was Devil's Advocate, and his polar opposite during the discussion, I actually agreed with some of his concerns with that form of therapy. For instance, what if the therapist is ONLY familiar with SFBT. Can that person really be a good judge of whether the patient will need longer term work? Shouldn't SFBT be practiced by people who are also familiar with long term therapy?

I don't want to reveal who this person is, so I won't say when and where or gender, but I have seen an MFT who practices SFBT...And I think I get what Jesse was trying to say. For instance, the therapist was pretty limited and it showed. The therapist, no joke, said that insurance needed a DSM diagnosis or they wouldn't pay. So the therapist whipped out a DSM and started reading symptoms to me. Bipolar, Cyclothymia, Dysthymia, etc. And then asked me to identify which diagnosis I thought fit best...I KID YOU NOT. The therapist asked me to diagnose or not diagnose myself with Bipolar disorder by reading out of the DSM. When I brought up having issues she wasn't familiar with (issues that I have read a therapist can help with) she told me I could check out plenty of books that could help :/

I don't want to sell the therapist short, because some of the mental exercises we did were helpful...but obviously I couldn't expect much. I think the therapist was just limited to helping with very basic depression and anxiety issues for short term.

Along with the 15 minute med check, we also now have brief therapy. And the person practicing it may have very basic psychotherapy training and impaired ability to appropriately diagnose.

Ron Pies had given me something to think about. Can an SFBT therapist spot when SFBT might actually be harmful? Should someone with a DSM diagnosis even seek treatment for the disorder from a brief therapist? hmmmm.

Sunny CA said...

Thanks for your post. I found it interesting because the content was not what I expected from the title. I was thinking along the lines of compatibility of people, whereas you pointed out how different types of therapy are appropriate for different condition.

In the comment section of the previous post, nobody pointed out how "bad" it would be to receive psychotherapy for a brain tumor. I thought this was an excellent point you made.

My psychiatrist, who specializes in 50 minute psychotherapy, is excellent in my opinion, but is well-versed in physical ailments that can appear to be psychological problems, as well as just psych problems. I told him that I frequently wake in the middle of a "nightmare". He listened to my "nightmare" tale and told me they were "anxiety dreams" not nightmares. We continued our discussion and he suggested that the cause of the abrupt waking combined with my exhaustion might be sleep apnea. I went to my general practitioner who ordered a sleep study and my psychiatrist was proved right. I have sleep apnea.

Thanks again for an interesting article.

Bing said...

Dr. Pies,

Do you really have anything to add that has not been said, or is it just that your quals lend credibility to the discussion? Bah!!

rob lindeman said...

Thank you for this, Dr. Pies,

I believe that the match between therapist and client is orders of magnitude more critical in therapy than in my line of work. Even in the so-called "cognitive specialties" like pediatrics, it isn't critical that we have a meeting of the minds with the clients. It's nice if we get along with them, but it isn't necessary to do our work.

In talk therapy it's absolutely necessary. Of course I'm not talking about liking the client. You don't have to have good counter transference all the time, but you must establish a deep and meaningful communication.

By "lying" I meant saying things to the client that you know to be false such as "your brain is sick and you must take meds for life"

Alison Cummins said...


Just so you know, nobody has ever told me “your brain is sick and you must take meds for life.” Nobody. Ever. What they have said is, “Here, try these. They might make your life better. Let me know.”

On the other hand, non-psychiatrist therapists have accused me of lying, insisting that they know things they can’t possibly. For instance, they have told me that when I was young, some monstrous person lied to me that I was incapable. (Flatly untrue. The opposite, in fact.) Or that I had unresolved conflicts with my mother. (Conflicts, yes, like anyone, but we’re both reasonable, alert, well-intentioned and compassionate people; so unresolved, no.) That by paying for weeks of therapy in advance I was abdicating my responsibility to manage my money. (Only in a fantasy world. I was working hard to live on $400/ month, including rent, utilities, food and therapy. One way I tried to do that was to hide my therapy money with my therapist so that I couldn’t dip into it for food. Transforming that act of commitment into juvenile abdication of responsibility is cruel distortion indeed.)

Non-psychiatrist therapists insisted to me that their version of reality was true, that I could only heal if I let go of my fantasies and accepted that my relationships and circumstances were what they told me they were.

The response to my account is of course to say “Well, that’s not good or appropriate therapy. So your experience is irrelevant to the determination of whether theray can have side effects comparable to those of medication.”

That doesn’t follow.
Applying the same logic to medication would get you something like this:

Evil Psychiatric Establishment: “Take drugs, they have no side effects and they make your life better.”
Hapless Patient: [takes drugs, life improves, no side effects]
EPE: See, what did I tell you!

HP: [takes drugs, life gets worse, develops diabetes]
EPE: No, that’s not what I meant. Those clearly weren’t the right drugs. Or you weren’t taking them right. Or maybe they weren’t drugs at all. Anyway, it doesn’t count. Drugs make your life better with no side effects if you do it right, and you clearly weren’t doing it right.

We don’t accept that from the Evil Psychiatric Establishment, so why should we accept it from the Puppies and Rainbows Therapist Alliance?

If someone spends time and effort finding, paying and working with a qualified therapist, that’s therapy. If the therapy made them worse, then that’s a bad side effect of therapy. It counts just as much as bad side effects of taking drugs that are determined after the fact to have been maybe not the best choice.

George Dawson, MD, DFAPA said...

Transference/countertransference, therapeutic neutrality, and being able to say something useful to the patient are important across all therapeutic orientations. Consider an example where the therapy goes bad in the first session. Assuming the therapist has a high level of expertise in a particular orientation the inability to attend to transference and neutrality issues is a common way that therapy gets derailed.

rob lindeman said...

Excellent points, Dr. Dawson. I wonder how many therapists, regardless of skill and experience, are able to realize that a therapeutic alliance is not forming and/or will not form, and recommend terminating the relationship?

How many therapists institute a "trial period" with the client's full knowledge and understanding that the relationship may end if either party doesn't feel right about it?

Alison Cummins said...

Only tangentially related to this post, but...

I’ve been following a bit of the midwife vs obstetrician (natural birth vs interventionism) wars and I’ve suddenly realized that I see parallels with the promotion of therapy (the only thing in the less-qualified person’s armamentarium) over medication/surgery (something only available from an MD). Also in fundamentalist religious communities with the promotion of faith healing (the only thing the pastor can provide) over medical care (requires getting help outside the community).

What the non-MD is able to provide is considered natural, virtuous and the only real way to do it — whether the non-MD is a therapist, a midwife or a faith healer.

An obstetrician can attend the birth of a baby born vaginally without an epidural but a midwife cannot perform a c-section. A doctor can offer compassion and caring to a patient but a prayer circle cannot prescribe medication. And a psychiatrist can offer therapy — however brief — while a therapist has nothing to offer but words.

There are people within the homebirthing community who claim that a woman whose child was delivered by cesarian section has never given birth and cannot properly mother her child. There are religious fundamentalists who worry that any “healing” that follows from a non-prayer intervention (say, insulin for diabetes or cochlear implants for congenital deafness) is demonic and can’t be trusted. And there are therapists who believe that people who use medication as part of an array of methods to improve their lives are deluded and lied-to and that their lives are not, in fact, improved.

This results in such horrors as the claim that it’s better for a baby to be born dead in a homebirth than for the mother to have had to endure interventions in a hospital; that a child who dies of untreated diabetes deserved to die because she and her parents clearly lacked faith; and that it’s better to commit suicide than to have one’s authentic self distorted by the use of psychiatric medication.

Personally, I have received better, more compassionate, more holistic care from MDs than from therapists. Therapists were reluctant to acknowledge anything that might be beyond their abilities to help me with. Because they had an agenda — they wanted to be able to help me — they reframed my problems to suit themselves.

MDs also want to be able to help me, but because they are not restricted in how they can help they don’t care how I am helped or who does it. Meds? Sure. Brief therapy? They’re right there. Referrals to more involved therapy? On it. Blood tests? Down the hall. Life just sucks? Yes it does, they’ve been there too.

Quite different from the helplessness of a therapist who can’t help me with anything but mother issues, therefore forcefully insists that my I can turn my life around if I will only agree to adress my mother issues. (And who I have difficulty discounting because she clearly has a better life than I do, has a lot more figured out than I do, is older than I am, has a PhD in clinical psychology and is hospital-affiliated.) (Can anyone think of reasons that someone might have difficulty discounting their pastor or their mothers’ community?)

I don’t need to argue with an MD because they have no need to put me in a box. They just want to help me make my life better and they don’t need me inside the box to do it. Well, if I had a kid with severe behaviour problems I would probably not get much help from Rob beyond referral to a psychoanalyst, but unless he were the only doctor in town I would be free to see someone else (he’s not my pastor or my community and our relationship does not require intimacy or abandoning my own judgement) if his approach proved to be unhelpful for my situation.

As I’ve said many times before, I have a therapist I like and who helps. It’s just that if I had to choose, I’d go with the one who can do it all rather than with the one-trick pony.

Bing said...


You are not so naive as to doubt that some therapists actually lie to their patients in service of ^ the therapeutic alliance. 100 per cent laughable and horrifying in equal measures.

Dinah said...

I am a bit floored at your comment, "
I believe that the match between therapist and client is orders of magnitude more critical in therapy than in my line of work. Even in the so-called "cognitive specialties" like pediatrics, it isn't critical that we have a meeting of the minds with the clients. It's nice if we get along with them, but it isn't necessary to do our work."

As a parent, I can't imagine taking my child to a pediatric I didn't have a meeting of the minds with, like, respect, and am able to communicate with. Okay, I can imagine it, but I can't imagine returning. Most of the people I know adore their children's pediatricians, and it has been my belief since med school that the kindest people go into peds.

I think you can be a wonderful surgeon even if you don't get along with your patients, but I don't see how one can be a decent pediatrician if you don't get along with the children and their parents.

Sarebear said...

I have now had some harmful "therapy". The adults w/add group that my psychiatrist runs once a month, and I was told was a support group? It was therapy (I've gone to a support group for other things twice before, and they are different animals).

I left feeling miserable, worthless, pathetic, selfish, without any values, and all around useless at the best, too many negative things to mention at the worst.
Yeah, a bunch of that is my own issues, but the group therapy was awful. She has all the therapeutic sensitivities of a cactus.

For the second half I was on the verge of tears (it was a 90 minute session) and couldn't hide it very well. It felt like a knife was digging around in my heart; it still does. It isn't just that the therapy touched on difficult, painful issues for me. You'd expect that, in therapy. It was the way the issues were addressed, handled, treated, the judgements that were thrown on them, the not only lack of understanding (which, one would hope you'd go to these things for some understanding from other people struggling with ADD too), but actively treating these issues with . . . a degree of disdain, among other things.

And you get so confused because she's a doctor, she's a professional, doesn't that mean that maybe I am an awful person? A person with no values? Part of me says hey, I shouldn't let anyone make me feel that way, there's something wrong if they are so disrespectful and inconsiderate . . . but, if you are to fix what's wrong with you, don't you need to acknowledge that hey, you might be an ass? (I don't think I am, but you never know). That you might be a pathetic excuse for a human being, and that you'd better stop that, right now?

Anyway. I cried and cried after I got home, and I'm still having a hard time with it. If I can't get the knife out myself I'm sure my therapist will help me with that.

Am I so . . . different, so absolutely awful, that looking for a teeny bit of understanding from someone is asking TOO DAMN MUCH?


Her "therapeutic technique" if you will, seemed to be really sucky. So why should I care what she or the others think. But when you have to sit thrugh 90 minutes of that, it kinda gets beat into you.

I'm a little traumatized. Then again I'm quite a reactive and overreactive person. Still, there's no question in my mind that she caused me harm, that it's not just my sensitivity to certain issues; she did and said and actively encouraged things that just make me want to cry and never come out.

I dunno. Maybe I am pathetic. She is a doctor.

Jane said...

It may be that Rob doesn't get along with some of his "clients" (parents), but he does have a meeting of the minds with his patients (the kids). I wonder if he is better with the kids than the parents.

Jane said...

@Sarebear: OMG! That sounds terrible. I'm not sure how to respond. I would write, "I understand" but I don't.

You know, I will add this though,sometimes...ADHD support stuff can get kinda cultish. I think any time a support group is being run by such a forceful personality that risk is there. Sometimes it's really not you...whoever is running group needs to get off the God train.

Sarebear said...

Thanks, Jane. You're very kind, and informative too! 8^]

Anonymous said...

I do understand Rob's point. Dinah seems to have taken it to an extreme, which I don't believe Rob intended by his comment, though I may be mistaken. I am a parent whose children are now too old to be seen by a pediatrician but they did have two who followed them over the years. We did leave one practice for another but to my mind, unless there is active dislike, mutual or otherwise, it is possible to work with a pediatrician one might not connect with. This is mostly true if one has a child with a medical condition in which the pediatrician specializes or has a great deal of experience. I can think of a pediatrician whose medical advice I would follow but who would be the last person I would want to have as a therapist for myself or my children. I don't think that I could work well with a therapist who was very experienced with my particular issues but with whom I could not connect.

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