David Baxter PhD
Late Founder
To Reap Psychotherapy?s Benefits, Get a Good Fit
By RICHARD A. FRIEDMAN, M.D., New York Times
August 21, 2007
Americans seem to like psychotherapy. Whether it?s for the mundane conflicts of everyday life or life-threatening illnesses like major depression, psychotherapy is widely viewed as a healthy, if not harmless, pursuit.
Yet unlike most other medical treatments, psychotherapy can take considerable time. An infection can be cured in days, but remission of severe depression or anxiety disorder usually takes weeks or months, and a personality disorder typically requires years of intensive psychotherapy.
So if the outcome may be months or years away, how can a person tell whether his psychotherapy is any good?
It?s harder than you?d think. For one thing, people commonly equate feeling better with getting good treatment. But since psychiatric disorders fluctuate spontaneously with time, like most illnesses, many patients would get better even if they got no treatment at all. A patient getting bad psychotherapy might flourish, while another patient getting exemplary treatment might suffer terribly.
Judging from one of the largest surveys of psychotherapy to date, most Americans who try psychotherapy think it is beneficial. In its 1994 annual questionnaire, Consumer Reports asked readers about their experience in psychotherapy. Of 7,000 subscribers who responded to the mental health questions, 4,100 saw mental health professionals. Most reported feeling better with therapy, regardless of whether they were treated by a psychologist, a psychiatrist or a social worker. And those in long-term therapy reported more improvement than those in short-term therapy.
Of course, not all therapy is helpful, and some of it can be downright harmful. Many patients have problems with relationships in the first place; they can find it difficult to extricate themselves from bad or ineffective therapy.
I recall a successful writer whom I saw in consultation. At 44, he had been in psychotherapy for several years and felt that while he had gained much self-understanding, his chronically depressed mood had not changed.
After seeing his depressed partner respond vividly to an antidepressant, he wondered if he too might benefit from a similar drug, but his therapist was opposed.
?He told me that I would be forestalling symptoms with medication that would return years later when I stopped medication,? the writer said. He persisted and got a second opinion.
?Be very wary of any therapist who discourages a consultation,? said a colleague of mine, Dr. Robert Michels, university professor of psychiatry at Weill Cornell Medical College. ?If a patient is uncomfortable at the start of treatment, he should leave. But if a patient dislikes his therapy later on, he should discuss it with his therapist, and, if they can?t agree, then it?s time for a consultation. A competent therapist should welcome it.?
It is hardly surprising that many patients are reluctant to seek a second opinion; they may fear rejection by their therapist, or hurting the therapist?s feelings. And therapists, having egos like everyone else, may resist an independent consultation because they see it as a sign of their own failure, not to mention the obvious financial incentive to hold on to a patient.
It?s not just patients who have a hard time knowing if their treatments are helping them; sometimes the therapists themselves can?t tell.
In a study published last month in the journal Psychotherapy Research, Michael J. Lambert and Cory Harmon, psychologists at Brigham Young University, gave psychotherapy patients a questionnaire about how they were feeling and functioning. They randomly gave feedback from the questionnaires to half the patients? therapists; the other half received strengthened feedback, which included patient self-assessment plus specific information about how the patients viewed their therapists and their social supports. These two groups were compared with a control group of patients whose therapists received no feedback.
The researchers found that giving feedback to therapists clearly improved treatment outcome: When therapists received no feedback, 21 percent of their patients deteriorated. With therapists who received regular feedback, 13 percent of patients deteriorated; with strengthened feedback, 7 percent of patients deteriorated.
The clear implication is that therapists are not always the best judge of how their patients are doing, perhaps because they are blinded by their own optimism and determination to succeed.
Some therapists might even view worsening during treatment as a sign of progress ? a misguided ?no pain, no gain? view of psychotherapy.
It?s probably easier to say what is bad psychotherapy than what is good, but there are qualities that all good therapies share. You should feel that you are understood as an individual, and that your therapist is compassionate and nonjudgmental. Good therapists should be able to explain the nature of your problem, and which of several treatments might help you.
Ask yourself not just whether you are getting better, but whether you are getting optimal treatment. Information about psychiatric disorders and recommended treatment can be found at several of reputable Web sites, including those of the American Psychiatric Association at www.psych.org, and the National Institute of Mental Health at www.nimh.nih.gov.
The psychiatric association?s treatment guidelines describe what is considered state-of-the-art treatment for various disorders and the empirical basis for the recommendations; see them at www.psych.org/psych_pract.
While it will not guarantee good therapy, seeing an accredited mental health professional provides some assurance of skill and competence.
Feeling better is important, of course, but it is possible to feel good and be stalled, where little significant change is taking place. If you are in therapy, don?t just rely on your own feelings to judge the treatment; speak to good friends and family members and see what they think about how you?re doing.
In the end, psychotherapy is a very personal business. If you need brain surgery, it doesn?t really matter if you like your surgeon as long as he?s skilled and competent. But in therapy, skill and competence are necessary but not enough; personal fit, more than almost anything, can make the therapy ? or break it.
By RICHARD A. FRIEDMAN, M.D., New York Times
August 21, 2007
Americans seem to like psychotherapy. Whether it?s for the mundane conflicts of everyday life or life-threatening illnesses like major depression, psychotherapy is widely viewed as a healthy, if not harmless, pursuit.
Yet unlike most other medical treatments, psychotherapy can take considerable time. An infection can be cured in days, but remission of severe depression or anxiety disorder usually takes weeks or months, and a personality disorder typically requires years of intensive psychotherapy.
So if the outcome may be months or years away, how can a person tell whether his psychotherapy is any good?
It?s harder than you?d think. For one thing, people commonly equate feeling better with getting good treatment. But since psychiatric disorders fluctuate spontaneously with time, like most illnesses, many patients would get better even if they got no treatment at all. A patient getting bad psychotherapy might flourish, while another patient getting exemplary treatment might suffer terribly.
Judging from one of the largest surveys of psychotherapy to date, most Americans who try psychotherapy think it is beneficial. In its 1994 annual questionnaire, Consumer Reports asked readers about their experience in psychotherapy. Of 7,000 subscribers who responded to the mental health questions, 4,100 saw mental health professionals. Most reported feeling better with therapy, regardless of whether they were treated by a psychologist, a psychiatrist or a social worker. And those in long-term therapy reported more improvement than those in short-term therapy.
Of course, not all therapy is helpful, and some of it can be downright harmful. Many patients have problems with relationships in the first place; they can find it difficult to extricate themselves from bad or ineffective therapy.
I recall a successful writer whom I saw in consultation. At 44, he had been in psychotherapy for several years and felt that while he had gained much self-understanding, his chronically depressed mood had not changed.
After seeing his depressed partner respond vividly to an antidepressant, he wondered if he too might benefit from a similar drug, but his therapist was opposed.
?He told me that I would be forestalling symptoms with medication that would return years later when I stopped medication,? the writer said. He persisted and got a second opinion.
?Be very wary of any therapist who discourages a consultation,? said a colleague of mine, Dr. Robert Michels, university professor of psychiatry at Weill Cornell Medical College. ?If a patient is uncomfortable at the start of treatment, he should leave. But if a patient dislikes his therapy later on, he should discuss it with his therapist, and, if they can?t agree, then it?s time for a consultation. A competent therapist should welcome it.?
It is hardly surprising that many patients are reluctant to seek a second opinion; they may fear rejection by their therapist, or hurting the therapist?s feelings. And therapists, having egos like everyone else, may resist an independent consultation because they see it as a sign of their own failure, not to mention the obvious financial incentive to hold on to a patient.
It?s not just patients who have a hard time knowing if their treatments are helping them; sometimes the therapists themselves can?t tell.
In a study published last month in the journal Psychotherapy Research, Michael J. Lambert and Cory Harmon, psychologists at Brigham Young University, gave psychotherapy patients a questionnaire about how they were feeling and functioning. They randomly gave feedback from the questionnaires to half the patients? therapists; the other half received strengthened feedback, which included patient self-assessment plus specific information about how the patients viewed their therapists and their social supports. These two groups were compared with a control group of patients whose therapists received no feedback.
The researchers found that giving feedback to therapists clearly improved treatment outcome: When therapists received no feedback, 21 percent of their patients deteriorated. With therapists who received regular feedback, 13 percent of patients deteriorated; with strengthened feedback, 7 percent of patients deteriorated.
The clear implication is that therapists are not always the best judge of how their patients are doing, perhaps because they are blinded by their own optimism and determination to succeed.
Some therapists might even view worsening during treatment as a sign of progress ? a misguided ?no pain, no gain? view of psychotherapy.
It?s probably easier to say what is bad psychotherapy than what is good, but there are qualities that all good therapies share. You should feel that you are understood as an individual, and that your therapist is compassionate and nonjudgmental. Good therapists should be able to explain the nature of your problem, and which of several treatments might help you.
Ask yourself not just whether you are getting better, but whether you are getting optimal treatment. Information about psychiatric disorders and recommended treatment can be found at several of reputable Web sites, including those of the American Psychiatric Association at www.psych.org, and the National Institute of Mental Health at www.nimh.nih.gov.
The psychiatric association?s treatment guidelines describe what is considered state-of-the-art treatment for various disorders and the empirical basis for the recommendations; see them at www.psych.org/psych_pract.
While it will not guarantee good therapy, seeing an accredited mental health professional provides some assurance of skill and competence.
Feeling better is important, of course, but it is possible to feel good and be stalled, where little significant change is taking place. If you are in therapy, don?t just rely on your own feelings to judge the treatment; speak to good friends and family members and see what they think about how you?re doing.
In the end, psychotherapy is a very personal business. If you need brain surgery, it doesn?t really matter if you like your surgeon as long as he?s skilled and competent. But in therapy, skill and competence are necessary but not enough; personal fit, more than almost anything, can make the therapy ? or break it.
