Wednesday, May 27, 2015

Should "Research" Guide Psychotherapy?

A couple of  months ago,  a patient was telling me that a research study from some years ago that had concluded that there's no such thing as bisexuality was recently debunked. (She probably was intrigued by this because she's bisexual).  I told the patient that I was surprised anyone had believed the original study, because bisexuality has been documented in historical, religious and literary texts going back thousands of years.

We live in a society that often seems to worship science, or what is alleged to be science, and denigrates common sense and the accumulated wisdom of the human species. The media play a strong role in this disinformation, advertising the results of each recent research study on a popular topic with headlines that blare "Scientists Say...." "Studies Report..." Any scientist knows that one research study is almost meaningless. Research results have to be replicated to have any credibility.

Social science research is trickier than research in the natural sciences, because research into human behavior is often based on the self-reporting of the subjects. I was amused by a recent story in The New York Times that declared "Severe Mental Illness Found to Drop in Young, Defying Perceptions"
Not only was the headline and much of the article based on one research study, but the study was based on parental perceptions. Surely one does not have to be a scientist or a psychotherapist to know that parents' perceptions of their children are distorted by the parents' wishes and fears. Although the study compared two sets of parental perceptions, from the past and the present, the changes in perceptions might have nothing to do with changes in  the children's symptoms. The study may in fact be more useful for how it is documenting that parents are increasingly underestimating their children's symptoms. That possibility would be in line with research (as well as anecdotal observations by therapists) that people are becoming more narcissistic and that parents are more psychologically invested in their children, than in the past.

I frequently get communications from health insurance companies exhorting clinicians to use "evidence-based" practices. I often wonder which evidence they have in mind. Over the course of my career and my life, I have seen different types of therapy first promoted and then debunked. When I decide what techniques to use with patients, I don't base my decisions on the latest research study. I base my decisions on what theories and techniques have stood the test of time, and what techniques I have found previously helpful in my own practice for particular types of patients. I use my professional experience, common sense, and the accumulated wisdom of previous generations of therapists.

Tuesday, May 12, 2015

Bad Therapy

I often see people who've seen previous therapists. Some of them report positive experiences, and some report negative experiences. In either case, I often find that people don't give me a lot of details about their previous therapy. This is a problem, because it's important for me to know what worked and what didn't work in someone's previous therapy.

I have pondered if some persons think that if they talk at length about a previous therapist's failings, I will side with the previous therapist. This is not true, as I am well aware that many therapists are not good. In fact,  I sometimes say to friends, "I wouldn't refer a cat to 80 percent of the people in my field." It's not a joke.

When I do hear complaints about previous therapists, the most common complaint is that the therapist talked about him/herself. Why does this happen? Probably for many reasons. One possibility is the decline in the popularity and influence of psychoanalysis and of psychoanalytic training. Although psychoanalysis has some limitations as a treatment, it does insist on the neutrality and relative anonymity of the therapist. Other schools of therapy don't necessarily encourage therapist self-disclosure, but they don't place as much of an emphasis on boundaries as psychoanalysis does.  Unfortunately some less-than-competent therapists may assume that if their training didn't emphasize boundaries, it means boundaries aren't important.

I usually limit information on my personal life to answers to direct questions asked by patients, in cases where the information might be relevant--for example, if someone asks me "are you going away on vacation?" I will answer, as this could relate to the issue of whether I can be contacted in an emergency. Another example would be when a patient discusses a movie they've seen and wants to know if I have seen it. I've found that discussions about movies are often quite meaningful, as which characters patients identify with, or which ones remind them of their family members, can lead to interesting discussions.

Therapists should not talk about events in their personal lives or personal problems.  I've heard two (!) stories about therapists who talked about their own upcoming weddings--I can't think of any way this could  be appropriate and it could be damaging to the patient.

I've developed a hypothesis that some therapists talk about themselves because they are bored by their patients and don't feel a connection with them, and are hoping that if they talk about something they have "in common" with a patient it will help them feel more connected and less bored. This boredom usually represents a type of narcissism. Unfortunately, some people become therapists for the wrong reasons. Some people believe that as a therapist they will be super-important to their patients and will wield great influence over their patients' lives. Although this can happen, it's not a good reason for someone to become a therapist. People with narcissistic problems are often attracted to the field of therapy.  These persons should not be therapists, but they are not screened out of graduate school programs.

Other personal problems of therapists that interfere with therapy include difficulties with the opposite gender or with cultural differences.  I've heard stories about  male clinicians who gave compliments to female patients on their clothing and make-up. It apparently didn't occur to these clinicians that this behavior might be seen as objectifying by their patients--the clinicians probably thought they were boosting the patient's self-esteem.  I've also come across female therapists who can't work with male patients due to projections of anger or disgust that come from their own experiences with men. In conversations with therapists from other parts of the country, I've discovered that religious bigotry is not uncommon. It's hard for a bigoted therapist to practice in New York, but once in awhile I've come across a homophobic therapist here, or other types of issues.

The worst failings of other therapists that I have come across, however, are inaccurate assessments. Sometimes the end result of these errors is tragic. In the worst cases, there may be a preventable suicide. Fortunately I haven't heard very many of those stories.

Errors in assessment and diagnosis often stem from  a belief that recognizing someone's severe pathology is tantamount to not liking them or not recognizing their strengths: Years ago, while working in a clinic,  I worked with a paranoid schizophrenic whose previous therapist encouraged him to attend college. The vast majority of people with schizophrenia cannot complete college. The patient dropped out and was left with student loans he could not repay as well as a blow to his self-esteem. In another case, a therapist treating a family member of one of my patients didn't notice the woman's severe personality disorder and the extent of her pathological behaviors, which were affecting my patient. Many therapists have bought into society's stigma against mental illness, and this makes them believe that diagnosing a patient with a disabling condition is equivalent to condemning them or not liking them. 

Being a therapist requires a sober view of humanity and its problems combined with a genuine interest in other people and their lives. Unfortunately, my field is filled with therapists who aren't really that interested in other people--especially those who are different from them--and others who confuse recognizing their patients' serious problems with not liking them. I keep a short list of other therapists to whom I can refer people when I can't treat them. I wish there were more people whose professional expertise and behavior I could trust.