Dr Robert London

Reframing Therapy for the 21st Century

Clinical Psychiatry News - Volume 37, Issue 1, Page 16 (January 2009)

As a psychiatrist who has treated thousands of patients, I've been struck by the turmoil on Wall Street, and the extent to which this crisis has forced patients and potential patients to rearrange their priorities.

People are holding back on buying big-ticket items and are dropping services and items that they think they can live without—such as cable TV, eating out, and expensive gifts. And as we mental health professionals know, many people also are dropping our services, particularly long-term psychotherapy. Of course, this trend started long before this recession, but it's likely to continue now.

Why? Traditional psychodynamic psychotherapy has the reputation of taking a long time and being never ending. It offers no guarantee that it will help the patient get rid of the problem. Going way back to those Freudian theories that dramatically, rightly or wrongly, changed mental health concepts and then adding the myriad of variations that developed from Freud, the thinking is that if you don't quit on your own, the therapist will try to keep you there. Forever.

Just as other industries are coming up with different models to meet the changing needs of their customers, we need to change our thinking in terms of our approach to psychotherapeutic care. As a general rule, we should inform those patients with less complex disorders that shorter, more focused approaches can help them solve their problems. Older, traditional, and long-term psychotherapeutic approaches should be used only in more complex cases.

I believe in short-term psychotherapeutic approaches that focus on homing in on the problem or problems and are aimed toward relatively rapid outcome, rather than those archeological digs that characterize traditional psychotherapy. These traditional approaches not only have a poor track record (ask the people who were in it) but also have a huge “dropout rate” (Harv. Ment. Health Lett. 2005;22:3–4).

Over the last few months, I've been conducting a very unscientific survey about why so many drop out of psychotherapy. I've been querying people who are in therapy, those who have discontinued psychotherapeutic care, and therapists—including psychiatrists.

In addition to viewing therapy as never ending, patients cited other concerns, such as the tendency to explore issues that seem irrelevant to why the patient started care, to engage patients in debates that they feel they cannot win, and to simply listen for 45–50 minutes without adding any therapeutic guidance. In one particularly poignant observation, one former long-term patient admitted: “I feel worse than before it started.”

Another interesting anecdotal point from the patients/consumers is that most really like their therapists. Perhaps that explains why it often takes months of soul searching for them to stop scheduling appointments. Another reason it might take so long is the therapist's intransigence. Often, when patients try to make the therapy more intermittent or stop it altogether, the therapist creates an emotional environment that makes the patient feel guilty or badly—sometimes by suggesting that the patient is running away from deep-rooted problems.

The therapists with whom I've spoken have reluctantly conceded that, in their therapeutic work, ending treatment is not a high priority, and many admit that their patients or clients do, indeed, drop out before the therapists believe the treatment is over.

Many therapists truly believe that they are right in promoting long-term therapy. They truly consider that they can magically catapult the patient into wellness. Sadly, these therapists have a difficult time entering the world of cognitive and behavioral therapies, where problems are alleviated in focused, pragmatic ways. These therapists are unable to define for the patient a reasonable time frame for the care or the technique to be used.

One person with whom I spoke during my survey had dropped out after 3 years because the therapist seemed to be going in a senseless direction. Over those years, the therapist continued to bring the patient back to some early sexual abuse as a child by a family member. The therapist's theory was based on the patient's aversions to certain type of foods. Those aversions had decreased the patient's socialization—especially on the dating scene.

The patient had no memories of any sexual abuse but, thanks to the therapist, had started to believe that such abuse might have occurred. She was unable to steer the therapist away from the theory that the food aversions that influenced her social life had originated in some form of abuse. Furthermore, the therapist's theory was tied up with a myriad of denials and guilt mechanisms that the therapist suggested—none of which the patient believed.

She really liked the therapist and had received some benefit. But she needed to stop. She believes the therapy would have continued “forever” had she let it.

This patient came to therapy to address socialization issues. Had the therapy been some form of cognitive or behavior modification, I believe her problems would have been ameliorated much sooner. Cognitive and behavioral therapies focus repetitively on intellectual challenges, offering the patient a greater chance of integrating new perspectives into their behaviors—both those perceived as normal and maladaptive.

Executive control appears to rest in the dorsolateral prefrontal cortex (DLPFC). That's where we process and reprocess information. It seems so clear.

Cognitive and behavioral talk therapies affect a specific area in the cortex, leading to change. Of course, explaining to a managed care company that you're having a positive effect on reprocessing information in a person's DLPFC is not going to get you paid as quickly as changing medications or dosages.

The Accreditation Council for Graduate Medical Education, through its residency review committee, has made clear that the competency requirements in cognitive and brief treatments, for example, short-term psychotherapy, should be part of psychiatric training and care programs. Does that mean you learn about it or you learn how to do it? When I ask people who have completed training, most are able to discuss it. But rare is the person who is actually able to do cognitive or behavioral work. Unfortunately, many who still do talk therapy fall back to those traditional long-term therapies, where they feel comfortable.

The talk therapy in psychiatric training and care needs an overhaul. If patients are dropping our services, we are not meeting their needs. It is essential that we make our doctors as competent in viable contemporary talk therapies as they are in medication management. We must put to rest those open-ended, go-nowhere psychotherapies that have so wrongly dominated not only psychiatry but other disciplines as well while we move forward in the current economic crisis and in contemporary care. As psychiatrists, we often set a standard for other disciplines. The standard needs to be short-term psychotherapy, with a definable beginning, middle, and end aimed at problem resolution—not trying to understand the nature of man.

Let me know your thoughts on short-term psychotherapy, using cognitive and behavior therapies, and moving talk therapy into short-term models. I will try to pass your thoughts along to my readers.

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