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.