Sunday, June 20, 2010

Psychotherapist Activity

The activity of the psychotherapist refers to how active or passive the therapist is. How much talking does the therapist do as opposed to the patient. How much listening. How much leading versus following does the therapist do? How actively engaged is the therapist? Is the therapist 'explaining', 'educating', "clarifying", "motivating?", "exhorting" or simply 'listening' and perhaps 'reflecting".

The "activity" of the therapist differs dramatically across "schools" of therapies and in different "therapeutic contexts". As a formally trained and certified hypnotist and hypnotherapist my "activity" as a therapist is at it's highest when I'm using this therapeutic modality. As a fully trained and certified short and long term psychoanalytic psychotherapist my "activity" as a therapist is "lowest" in the long term psychoanalytic modality. The activity of the therapist increased dramatically even within the psychoanalytic therapies when the therapy changed from long term (years) to short term (weeks) of therapy.

As a formally trained emergency psychiatrist I noted that time constraints had a major impact on the 'activity' of the psychotherapist. In crisis intervention psychotherapy the therapist is most active, asking leading questions, proposing solutions and being at times very directive. "Don't kill yourself", is a standard psychiatric emergency crisis intervention therapeutic statement that would be unlikely to be heard in psychoanalysis where the classic therapist might well say, "How do you feel about my not expressing an opinion on your suicidal threats."

Just as the shortening of the length of psychotherapy interactions has impacted on the activity of the therapist increasing their involvement and activity, so have all the major advances in psychotherapy 'techniques'.

Cognitive therapy, the mainstay of therapy for mood disorders, is a form of 'educational' or 'counselling' type of therapy in which the therapist is very active literally 'teaching' the patient or client how to change their thinking by becoming aware of 'cognitive distortions' and doing exercises which are specifically 'taught' by the therapist, that help an individual break negative patterns of thinking and behavior.

Motivational therapy, the cornerstone of work with addictions, is itself quite similar to a variety of traditional 'soft sell' and 'hard sell' and "closing" techniques from sales and marketting. Having trained formally as a salesman in my youth taking a number of the standard business psychology courses in on the job training with the company I worked for, I was years later struck by the similiarity of these to the "motivational therapy" I was learning in the classroom as a sub specialist psychiatrist. With reference to the activity of the therapist, 'motivational therapy' is a form of therapy in which the therapist is decidedly active and clearly has a "distinct" and "limited" goal. This is very different again from the 'open ended' free flowing journeys of discovery which occurred in the analytic tradition where the goals were fairly open and somewhat more vague. Stopping using crack cocaine is a different outcome from 'self actualization'.

Dialectic therapy, developed specifically for work with personality disorders, is an interactive therapy in which the therapist is actively engaged in a more political or philosophical discussion with the patient. The therapist is not passive and is increasingly involved verbally moment to moment.

As a psychodrama therapist I was as active as an 'theatre director' giving patients exercise and commenting directly on their 'performances' with 'feedback' akin to that known in the 'performing arts'.

There is still a place for the 'passive' therapist in psychotherapy, the traditional psychoanalytic therapies still have tremendous power of efficacy for certain types of disorders. Interestingly psychoanalysis itself is no longer funded in Canada because it was unable to demonstrate that with it's long term labour intensive regimens that it was in any way superior in 'evidence based' 'outcome'measured' studies. It was appealing naturally for the psychoanalysts. Once the principle schools of psychoanalysis were restricted to credentialed psychiatrists they're now open for most anyone as those with specialty training and phds are turning more often elsewhere for equally or more robust therapeutic modalities.

That said there will always be a place for the Freudians, Jungians, Adlerians and so on. Increasingly their place is with therapists themselves. Having spent years in therapy as part of my psychoanalytic psychotherapy training I am the strongest proponent of psychotherapists being 'required' to undergo therapy themselves.

The psychoanalytic therapies, short term and brief, are still proven "evidence based" therapies and indeed have been shown in studies to be superior to psychopharmacology alone in some cases and to improve psychopharmacology outcomes in all cases pointing to the power of the therapies that derived directly from the original psychoanalysis modalities. In all these modified therapies though, the activity of the therapist is increased.

The trend indeed has been that with the shortening of the length of therapy, the more specific the outcome focus is, and the more trained the therapist is, the more active the therapist is.

I am especially aware of this having trained over a quarter of a century ago as both a hypnotist and a traditional psychoanalytic psychotherapist. I have tapes from my early years in which I literally said nearly nothing, hello, good bye, how do you feel about that, in my psychoanalytic therapy compared to when I did hypnosis in which the patient was wholly passive and I spoke throughout the whole session. Both forms of therapy required the highest level of theraupeutic training and supervision. Both have the 'evidence based' validity when done by therapists formally trained and the therapy is specifically applied to those conditions amenable to the specific techniques. What is distinctly different is the activity of the therapist is literally night and day.

At least half the psychiatrists today are not trained in psychotherapy. They are solely psychopharmacologists. The psychopharmacologists 'psychotherapy' approach and training is no different than what I learned as a family physician, that is an educational and mildly marketing approach to a therapy. As a country gp I would tell you that you had pneumonia and give you the pills which would treat the pneumonia and encourage you to follow my advice. Modern psychopharmacology is this same "medical model" and the activity of therapist is directive and 'parental' in contrast to some forms of psychotherapy in which the therapist is a 'co traveller' , and more 'consultative'.

I have chosen to write on the 'activity' of the therapist because it's a common complaint of patients that they didn't benefit from 'counselling' and that the 'counsellor' just repeated what they said. This was the Carl Rogers technique of counseling shown to be beneficial in studies of highly motivated educated and somewhat priviledged college students. The Rogerian school has been beneficial in that as a 'technique' it is the 'easiest' to learn and requires the 'least training' and is likely to do the 'least damage' as the therapist is really being predominantly 'reflective' and largely passive. It's limitations showed up rapidly when it was applied outside the academic setting where it was shown to be largely 'ineffective' in changing major behaviours. This kind of counseling compared to psychotherapy is best seen as massage compared to surgery.

A lot of people may only be exposed to this form of "psychotherapy" and naturally have a jaundiced view of the field in which they simply 'vented' and the therapist 'listened' and the session cost but no change occurred. In deed there are studies now showing that "passive" therapists can be dangerous as they 'validate' harmful behaviours by lack of action. Their greatest harm is in the area of 'sins of omission'. Therapists who work in addictions are commonly disheartened by hearing that crack addicts and alcoholics and sex addicts have spent years telling therapists who have acted almost like voyeurs what they were doing without the therapist being anything more than reflective and clearly not knowing what therapies work with what conditions. Give a boy or girl a hammer and everything is a nail is one of the major concerns in the psychotherapy field.

Fortunately a major study done in Kaiser showed that 10 sessions with psychiatric psychotherapist with 10 years or more of clinical experience were all exceedingly positive in helping people get better regardless of the school of therapy that the psychiatrist was originally trained in. A colleague trained in Rogerian therapy 20 years ago is now doing 'motivational therapy' and 'selling lifestyle' change with the 'best of them' because "it works'.

Unfortunately many patients want to use tax dollars to express a litany of complaints about their ex or their boss and not actually 'do' anything about changing their behavior or their thinking. They want the therapist to nurse them and their 'self pity' and 'blame'. Psychotherapists in private practice being paid by the individual for this hour of 'ego massage' are happy to support the patients illness as it pays for their Porsche.

However increasingly psychotherapists are paid by third party payee services or by clients who realize that they need to see results. This has lead to the increasing activity of the therapist because clearly there has been the trend to more activity of the therapist the shorter the number of the sessions as evidenced by the dramatic difference between the interaction of the emergency psychiatrist and the traditional psychoanalist, the different ends of the spectrum.

Indeed a sad study of women going to counseling following separation showed that those who had counseling for 2 years took 2 years longer to get into a new relationship and there was no evidence that the delay improved the selection of the new relationship because the therapy focused on talking ad nauseum about the failures of the 'ex' and the outside world. The researcher was interested in the cost to women of this prolonged negativity and that they socioeconomically were less successful than those who had less therapy and went back to dating accepting their failure and getting on with the original plan of partnership.

Increasingly therapy has focused on 'change'. Change has referred to 'objective' change and 'behavioural' change with 'measurable outcomes'. I first became interested in therapy because the psychoanalysts, particularly Freud, focused on "resistance to change'. In conventional medicine this was organized under the heading of 'non compliance' and 'non adherence to medical regimen'. As a family physician I saw clearly that the majority of chronically ill patients were so because they had 'lifestyle' illness and wouldn't change their behavior. The classic example was smoking which was the principal cause of lung cancer. At the time the principal role of the gp was to put band aids on these illness and make a fortune from revolving door medicine. Only community medicine and psychiatry were looking at this in the way that every area of medicine does today.

Twenty five years later and countless degrees and years of psychotherapy training I am still faced with patients with life threatening behavior who feel the solution to their problem of chronic suicidal living is that I 'change" not "them". Not only this they really like the "passive" therapists who 'listen' and 'agree' with them. I am not surprised. More money has been made off selling tobacco and drugs than has ever been made by therapists helping people stop the addictions of negative living.

The same is true with thought process, relationship formulas and interactive styles. My patients are usually happiest for the short run when we "collude" and agree to talk about the 'bad boss", "the bad wife", the "bad insurance company". Historically this is not psychotherapy. This helps initially to 'establish a therapeutic relationship" but ultimately therapy aims at helping a person become aware of their "choices" and how to make "better choices" and how not to "blame" but move from a 'victim' role to a survivor and on to where one sees adversity as a 'challenge'. The bottom line therapy is about making the 'best of a bad lot' more often but the therapist must 'actively' be involved in this process. Merely 'listening' is often harmful, especially in crisis or emergencies. More and more patients are coming to therapy in real need in real crisis and don't have the finances or time to wait years for 'self actualization'.

I remember the first line of the psychoanalyst, "You must agree not to change your job or your marriage for the first year and you will be required to pay me $500 a week. We will meet every day when I can fit you into my schedule. Therapy will take from 3 to 5 years and some people will require 10 or more years. Are you ready."

In the public health system I work in the majority of my patients are not ready for this 'commitment' and indeed would give a kidney to have the kind of problems that people have after they're rich, in long term established families and steady high paying jobs. That said, more and more I think therapist need the kind of therapy that traditional psychoanalysis offered.

With the recent increase in general practitioners doing psychotherapy I am hopeful that they will undergo psychotherapy themselves. When psychopharmacologists stopped undergoing their own psychotherapy, I feel patients suffered. The mind is not the same as the kidney but to listen to an arrogant psychopharmacologist speak in his parental tones, relationships and the self are really just the same as "infection". Just trust him and he will give you the 'pill' that will cure 'your life'.

The traditional psychoanalytic process helped one understand therapist factors in therapy, the transference and countertransference. People 'talk' about this as if they 'know' but really it's an 'experiential' process and having worked as a family physician in the internist tradition and as a psychiatric psychotherapist I know the difference. I am biased.

Even my surgical colleagues have told me that their surgery and their whole approach to surgery improved after they themselves had to go under the knife. While we can't expect neurosurgeons to undergo brain surgery as part of training, there is no such restriction on psychiatrists and therapists. It is specifically in the therapeutic context that the activity of the therapist is most observable.

In closing, there are many ways to skin a cat but it's very unlikely that a cat will skin itself.


Aim said...

This needs to be published! Brilliant analytic-critical article. It'd be great if you can offer some suggestion about how we might improved the education system re psychologist/psychiatrist with the regards to how might we achieve a more balances cohort of those coming from various schools of thought. also, how can we tread the line between producing more psychologists/psychiatrists to meet the ever increasing demand and not having to opt for the quickest, easiest to grasp school (the Rogerians?)

cognitive therapist said...

Today, because of new science and techniques, there are current workbooks are three to four times more effective than other early life skills workbooks. While most life skills providers are still rooted in the old methods of the 1970s and 80s, we have embraced the new psychological systems that have proven to change faulty thinking errors and overcome self -defeating behaviors.

William MacGillivray said...

Your comments and the supporting comments promote evidence based treatments without any seeming need to provide evidence and the comment by "cognitice therapist" asserting that "new science and techniques are three to four times more effective" is simply wrong. Psychoanalytic psychotherapy has been demonstrated to be more effective and its results more long lasting than other forms of treatment (please see Jonathan Shedler's article in recent issue of American Psychlogist). Particularly egregious, however, is your characterization of psychoanalytic therapists as greedy purveyors of "ego massage" to whiners and complainers. This argument is not only inaccurate but a moronic slander against an entire profession even as you insist there are benefits to depth therapy. We do not need such defenders.

haykind said...

My, my, we are sensitive and highly selective. Where once all the heads of psychiatric schools were psychoanalysts this is rarely the case today. I personally don't know of any insurance company funding psychoanalysis. Certainly in Canada it was unable to defend itself against the competition. Which seems to me it really could use all the defendors it can get. The day that psychoanalysis was the only game in town is decades gone. Why is that? Whole schools of psychiatry reject outright the validity of any psychotherapy as anything but 'adjunctive' therapy to psychopharmacology.
One of the difficulties with 'psychoanalysis' was that it became more a religion to some, especially given the investment of time and finances for individuals. Besides what's wrong with ego massage. It beats 'moronic slander', and other ad hominem fallacies. Anger management is an increasingly successful, especially as group therapy, and one perhaps I should have mentioned.
The 'evidence based' research is obviously there for those who have eyes and those who have ears.

haykind said...

This paper was about the 'activity' of the therapist. It refers to a particular 'trend' driven by time constraints and finances. Rolls Royce might well have been a very fine auto once but today it's been replaced.
I gave you Cameron et al in your defence but would suggest you consider such names as Aaron Beck, Miller, Silkworth, Skinner,Prochaska,Erikson, Perls. All and more considered different ways to skin a cat.
Forgive me, are there no other gods but psychoanalysis? And really are there no self interested therapists? Do some patient not just want to complain and reject any feedback at variance with their particular paranoid take. Mad Magazine did a particularly cutting criticism of the psychotherapists of the world's worst tyrants.
Is this a counter transference ego lacunae I sense in your jumping to defend whole profession against me, a card carrying and dedicated member?