Tuesday, August 15, 2006

Talk Therapy

[posted by dinah]

I began this venture with a pre-existing belief about psychotherapy. I thought of it then (when? not sure, Med School or even before) as a Process that evolves over time whereby the patient talks about meaningful ideas and events, often from his past, and the psychiatrist makes insightful interpretations that help the patient to change and modify his feelings about himself and how he interacts with the world. It was, I believed, a process which both cures mental illness, and helps people change in ways that are not necessarily about illness, but perhaps about growth. A goal and an end were essential to this line of thought. If my conception of psychotherapy sounded both vague and grandiose, well it was both vague and grandiose.

Years later, I have very different ideas about what psychotherapy is, more about what it is not, and it's taken me a while to realize how clueless I remain.

Over time, my ideas modified. I like science, I love the concrete, I want there to be a bit of predictability to how the world works and what actions effect what kind of changes. In that sense, I chose the wrong career, so it's really good that I love what I do.

I was trained to see mental illness as reasonably (though not perfectly) discrete diagnoses with clusters of symptoms defining any given illness. So, for example, Major Depression required either a persistent low mood or anhedonia, along with some combo of sleep/appetite/libido/vital sense change and guilt...etc.: this was an illness, probably with some degree of genetic etiology, and medications treat the disorder. Psychotherapy also helps, and the Cognitive Behavioral folks (Beck in particular, from my undergraduate days at Penn) say it works as well as medication, maybe better. But why does psychotherapy work? And what components of psychotherapy are necessary for it to work? Does it work differently if you're using it to treat an Axis I illness versus personality pathology or what about if someone without a diagnosis wants to change their patterns of relating (eg "I pick men who are bad for me") or is simply overwhelmed when stressful life events strike? Does the patient need to talk about specific things? What if the patient just comes and sits?

In my ideal world, medications would completely treat the symptoms of Axis I (oy!) diagnoses, and psychotherapy would be a tool which helps people gain insight into their patterns of behaving-- or perhaps more reasonably, their patterns of feeling or relating to others-- and by understanding these patterns they would be better able to modify or control them. Occasionally that actually happens.

So a patient walks in the door with an illness, I prescribe a medication and we begin psychotherapy. I meet with new patients weekly (if the situation is extreme or dangerous, more) and we see how it goes. After a number of session, a fair percentage of people announce they are better: the medications worked, their symptoms are gone, they are back to their old selves, thanks and I'd like to come less often. Some patients even wander in the door cured: a previous psychiatrist moved or died and they just need someone to prescribe the medications and be available in case they relapse (which can happen even when the meds work).

So what's the problem and why am I writing a post about this?

A fair number of patients get better (meaning their symptoms abate) and yet keep coming. I like to have a goal in my head, something we're working towards, and usually I can find some goal to justify treatment. Patients, however, don't always. It's not uncommon for people to come to therapy and simply talk about the events in their week in a way that remains very close to the surface: what movies they saw, which grocery store has a special on chopped beef, who said what to whom in a minor disagreement, dealing with the painters, not to mention endless numbers of sessions on crashed computers and broken cars....you get the idea. And yet, these same patients are the ones who will describe psychotherapy as "lifesaving" or "a safety net" and who may be troubled by a need to miss appointments. I've been left to conclude that it's not about the endpoint, it's not about symptom reduction, and sometimes it's not even about personal growth. Sometimes it's about the comfort the relationship conveys. Hard to quite articulate on an insurance company treatment plan.

My favorite vignette about this, one that I tell the residents I supervise:
When I was a resident, I rotated through a counseling center for 3 months; the care I gave had a pre-determined time-limit, unless I chose to offer the patients further care if they came to see me at the hospital. My first patient on my first day was a young man distressed because his girlfriend had cheated on him. The relationship ended; in a matter of a couple of weeks, he felt better and had moved on. This was an intact man whose life was otherwise progressing smoothly, he had no history of psychiatric illness, had never been in therapy, and no evidence of any personality disorder. He continued to show up on time for subsequent sessions, would rattle off to me the events of his week with an update of how everything was going. Everything was going smoothly. Unfortunately, he had no desire to give details such as the price of beef or he-said-she-said descriptions of conversations (I like those), so it would take him approximately 5 minutes for him to tell me that all was well. This left 45 minutes to the session. I'd ask questions, he'd answer, I tried to find something to say, tell him what type of things it might be useful to talk about, would sometimes engage him in discussions of books or movies, anything to pass the time and make some head way (into what?). He was fine; I was dying.

One week, I got sick. I called him and offered to see him at the regular time next week, or we could reschedule sooner. He chose to reschedule, and again came in to report that all was well.

At the time, I was reading Irvin Yalom's Everyday Gets A Little Closer: A Twice Told Psychotherapy, in which Dr. Yalom has his patient take process notes and he publishes both his and her notes on the same therapy: I found the idea fascinating and started asking patients to take notes on their sessions.

My time with the silent gentleman was winding down. I asked him to write something about the therapy. For the last, nearly silent session, he arrived with a paper listing items 1 to 12 of what he had gotten out of psychotherapy. I wish I'd saved that list, mostly what I recall was that it was right on target and began with, "1. I didn't realize how difficult it was for me to discuss my feelings...." It went on and on, all with useful insights he'd gained from our silent sessions.

Did making the list help him? I think so. It certainly helped me.

This may be the first of a multi-part series on psychotherapy.