Psychotherapy: The Active TreatmentMy friend Anne and I were talking the other day when the conversation turned to a recent airplane flight she was on. She recounted how it was on one of those smaller, turboprop planes with just 3 seats per row:

“We hit some turbulence and then it was like we were free-falling. It was only a few seconds, but it was the scariest moment in my life. I felt so helpless and out of control. I know it was irrational to think anything bad would happen, but still …”

When a person isn’t in control of his or her own destiny, most people feel powerless. Powerlessness can lead to feelings of helplessness as well. Most people prefer to be able to exert some influence on their destiny, on their future. We’d like to think that we actually have something to do with the way our life turns out, don’t we?

So why are so many people seemingly so willing to give up their power when it comes to treating their own mental health condition?

19 Comments to
Psychotherapy: The Active Treatment

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  1. “In other words, once you’ve been medically cleared by your primary care physician, there’s a chance we could probably train a gorilla to randomly choose an antidepressant that would be as effective as one chosen for you by a trained professional.”

    I’ve often suspected that is the case.

  2. “Psychotherapy: The Active Treatment.”

    There’s your slogan. Now to convince people they want to be “active” in their treatment! You have to convince them because it is going to be harder that way. At least at first.

  3. A word of caution here about antidepressants.

    The Physicians Desk Reference states that SSRI antidepressants and all antidepressants can cause mania, psychosis, abnormal thinking, paranoia, hostility, etc. These side effects can also appear during withdrawal. Also, these adverse reactions are not listed as Rare but are listed as either Frequent or Infrequent.

    Go to http://www.SSRIstories.com where there are over 3,700 cases, with the full media article available, involving bizarre murders, suicides, school shootings/incidents [54 of these] and murder-suicides – all of which involve SSRI antidepressants like Prozac, Zoloft, Paxil, etc, . The media article usually tells which SSRI antidepressant the perpetrator was taking or had been using.

  4. Having worked at an outpatient clinic for more than 6 years, and now doing temp work until I find the right mix for me now, I can tell you my opinion why patients do not instinctively pursue therapy: it requires time, money, energy, and effort, and as this medium as PART of the cause to the mentality, people expect quick fixes and a free ride.

    They just forget one little (sarcasm here) point: nothing good comes from things that are at least figuratively free, and most people come in with a presentation that did not start overnight, so why on earth think it can be corrected overnight (not literally again, but within a short but unrealistic time frame).

    Yes, it is a combination of medication where warranted, psychotherapy as the mainstay of the process, but you need to also add the desire for change and the willingness to work at it after the session is over. Therapy without, for the better term homework, or at least out of office practice and reflection, is useless in my opinion.

    Nice post Dr G!

  5. Also, a 5th option is to try changing your lifestyle. Particularly for mild-moderate depression, exercise, meditation and other stress reduction techniques can certainly help a lot. Some studies even show that regular exercise is as effective for mild depression as antidepressants are. However, with more severe depression or bipolar depression all that gets thrown out the window.

    Although I agree that pretty much everyone with a mental health condition can benefit from psychotherapy, many people in the US can’t afford it or don’t have access to it. Also, many patients can’t figure out what kind of therapist they want or that the fit is important and end up wasting tons of time and money on a bad therapist or one that wasn’t trained in treating your disorder (for example, cognitive-behavioral therapy for anxiety disorder, dialectal behavioral for borderline, etc). Basically it’s important to be an informed patient. I think too many people see one therapist who they don’t like and dismiss all therapists.

    Unfortunately my experience has been that the highly trained therapists almost never take insurance. Some will do “sliding scale,” but I worry about those who are less fortunate then me with serious mental health problems that need a skilled therapist. How are they to get treatment in a timely manner?

    You are right on about the antidepressants though. I hope they come up with blood tests soon that can show what antidepressant would work and at what dosage. The best way to tell now is to see what antidepressants immediate blood-related family members took, because apparently your response to the drugs is largely genetically determined.

  6. Why don’t more people want to go the active route of psychotherapy? It’s simple.

    If Occam’s Razor (http://www.phys.ncku.edu.tw/mirrors/physicsfaq/General/occam.html) holds that the simplest solution to a problem is most often the correct one, then “TPG’s Razor” holds that human beings will always try the simplest, shortest, and cheapest solution to their problem before they ramp up their efforts to solve it.

    Obvious simplest, shortest, and least expensive solution to a psych problem? Do nothing. The waiting-list studies prove that the problem will frequently resolve on its own.

    Next simplest, shortest, and cheapest solution? Medication. Yes, yes, there can side effects, blah blah. But for many people, the lack of engagement needed to try one or two or three pharmaceutical approaches to a psych problem before expending more emotional, financial, and other effort makes this the logical second step. It frequently works, whether by psychophamacology, the placebo effect, or both.

    TPG’s Razor would hold that only after trying these first two would most people go to the active psychotherapeutic approach that Dr. Grohol advocates. It takes more effort, costs more, requires more, and is most complicated.

    TPG’s Razor. I like it!

  7. When you are in therapy, it’s really all consuming. You can think about nothing else than ‘you’ and ‘he’ or ‘we’ and it become difficult to focus on work, school, or family.

    You are literally ‘hooked’ and along with that state, it is even much harder if not impossible to make choices that are good for you. Good choices are often substituted by bad ones to remedy the pain, anxiety and/or depression that becomes much worse than it was before.

    Therapy can literally be crazy making, and you lose the judgment to know when to stop.

    If you become too dependent and needy, your therapist fist treat you with empathy and caring, but when this becomes too tiresome for your therapist, he will turn against you, just like any other human being would from a point of defensiveness.

    Except, one learns that it was not your family who was all that horrible and your therapist that angel who would have raised you into a perfectly healthy human being.

    No, you find out that indeed, your family is not great but they will be there a lot longer than anyone ever was, and especially your therapist.

    I think the most important you can learn from a therapy relationship is to learn and experience how may years, and money you wasted while life went on on the outside but unfortunately these years got missed by you.

    And the last time you walk out of that office, you do not matter anymore. After all, it was never real to begin with.

  8. Katrin-
    Sorry you had such a negative experience! You are right that the therapeutic relationship is rather artificial since the therapist has to pretend to like and care about you even if they actually do not. However, the point of therapy, in my opinion, is to give you the skills and insight to live the best life you can. Usually this involves changing harmful thoughts, behaviors, and relationships and cultivate better behaviors and relationships. The goal of the therapist is to send you on your way, but still be there if you need them later on. (in CBT, you’re supposed to have “maintenance sessions every so often).

    Also, if you have some serious problems that necessitate extensive therapy, I do agree that it can be all consuming. Even 2 or 3 sessions a week coupled with homework and out of session coaching can turn out to be all consuming. However, when I needed that, my depression and anxiety were already all consuming, so I would rather have the therapy be all consuming! Now that I am better, therapy is just a small part of my life.

  9. Katrin
    I was wondering how long it is since you finished therapy and if you ever addressed the issues you mentioned here with your therapist.
    I was in therapy for four years, (two in group therapy and then two years in one-to-one). I agree it becomes all consuming, to the point that I was ‘zoning out’ when I was with my partner and children and my focus was all in living in a fantasy with my therapist where all would be understood and calm.
    One of the best things that ever happened was my therapist mixing up an appointment and having someone else there in my slot. This led to a real honest conversation on transference and fantasy which was ultimately healing for me. I finished therapy three months later and decided to take control of my own life rather than give my power away. I went on to train as a psychotherapist myself, and now 8 years later am still growing, learning and under no illusions about therapy since I have experienced it from both sides. The therapist is only human too, with all the flaws that go with that, and with the added pressure of trying to earn a living through this as a job which, idealistic as we may like to be is a reality. I wish you well :)

  10. Have a more inclusive idea about your “condition” “diagnosis” versus an exclusive frame of mind allows the healing possibilities to be endless (don’t knock until you’ve tried it). Healing isn’t just in three options. Life isn’t just either/or and I don’t know much of anything that fits into a neat tailored box. I haven’t quite understood why more physicians are not looking at depression and anxiety with a more whole look. Sure these problems haven’t come overnight however, they reside in the body and the body is whole. Sometimes it takes a village to raise a healthy and well-rounded child; why would it not take a village of avenues for healing to make someone whole again?

    The most important thing in this is that the patient needs to show effort and a desire to really get better; and there isn’t a profession or pharmacy out there that can give/sell you that.

    And the statement of psychotherapy not really being beneficial for those with schizophrenia or bipolar isn’t always the case. A lot of times they need the therapy to deal with the damaged relationships their disease has marred and to sort out the perceptions of reality that are askew.

    My village of healing is acceptance, lowest possible dosages of medication, therapy, exercise, healthy food, balanced sleep, and a desire to stay well and whole. Some methods of healing help blossom other methods and I can’t wait to see what these may produce later on.
    Best.

  11. I have been trying to post this comment since yesterday but it will not allow me to. I hope that slightly changing this comment by adding this introduction will help.
    KAT

    Lynn, thank you for your kind and supportive message back. i don’t really know what prompted me to respond back so negatively to the article. I think it was because ‘therapy’ was presented as harmless, effective, active vs. passive, and just a matter of the patient’s choice and his attitude being one of ‘choice’ vs. something like laziness, or not caring.

    I have had a bunch of therapy in my life, and I have seen the very best and the very worse, also experienced. I was even a therapist myself!

    I have never been disliked by a therapist, either, even to the contrary.

    I think I missed out on someone who worked more cognitive-behavioral and which would have been better for me. Instead, my two major therapists were both psychiatrists and they worked in the analytical style, or psychodynamic oriented style. It made me very confused, the transference was too strong, and I was very influenced by the therapist’s agenda. It was not all about choice and whenever we talked about something that was not the truth, I became quite disturbed.

    Everyone knows that such a relationship is not equal, and yet, as even in this article I am told to go therapist shopping, make good choices, let the therapist teach me his/her wisdom on how to think and feel correctly, when none of this has ever been an issue for me, except for my relationship with myself.

    For me it has to be all about truth, and even if my truth is not always ‘politically correct;, it’s still the truth and from there I progress to a greater truth.

    Anyway, I meant to say that therapy can, and often is, dangerous, and that much what happens is about the relationship between therapist and client. I truly cannot imagine working with a therapist who cannot stand me, and that would be very difficult to hide.

    Last, for me the biggest horror had to do with the dependency I felt on the therapist. I have, and had always in my life been very independent, and I hated becoming a burden when this was strictly against my values and wishes and not even anything I had ever had a problem with in my life before.

    My biggest preoccupation was not to hurt the therapist.

    But this is enough, and as I said, I did experience great therapy, and probably the best in the form of Psychodrama.

    Thanks again, and also John, for the article. (not edited)

    Kat

  12. Hi Colleen
    I really like the metaphor you use of the village of healing. I too found that a holistic approach was hugely beneficial. Meditation, diet, research, quitting smoking (yes it can be done!), and the recent beginnings of the exploration of spirituality in conjunction with therapy make for a new life path opening up. I have found that it is not about waiting around passively for things to change, but rather that when they become painful enough, to pull your boots up so to speak (after all at that stage all that is left to loose is your life), take a deep breath, and start with the biggest thank you for what you have right now. I can say this without feeling sanctimonious because it is based on direct experience. Life is not a dress rehearsal, it is the real thing, isn’t that wonderful?
    In my experience also, psychotherapy is hugely beneficial to people dealing with bipolar and especially borderline disorders, because the person is being addressed, and not just the ‘disease’. While acknowledging scientific research in this area, I would also question how these states of mind interact with the persons belief system and combine to form a desperate defence when there seems to be no other option. I dont think it is ever a waste of time to meet a person in a state of non-judgemental acceptance, and to value them as a human being regardless of the issue they are dealing with. Perhaps a lack of that led to paving the way to the current space they find themselves in.

  13. Lola,
    I agree that actually being a participant in your own life and your own well-being is the most wonderful gift you can give yourself and those around you. Gratitude can take you further than any other outside stimuli.

    I have also found through experience that sometimes those healing tools have to change as I change and grow. Like medication, I build a tolerance to something and have to find another avenue; however, usually one of my ‘tools’ has prepared me to then begin to develop another.

    I also like your comment of how approaching the person not the ‘disease’ in the case of bipolar or borderline is really how therapy is becomes beneficial.
    Best.

  14. Colleen
    It is always a joy to find a kindred spirit on this life journey. I wish you peace, joy, love and light all the way.

    Are you familiar with the work of Dan Millman? An american author, his books The Laws of Spirit and the Way of the Peaceful Warrior have been inspirational to me. Do you have any recommended reading that inspired you?

  15. Katrin-
    Yes, unfortunately I have had a therapist who was damaging to me. I suspect that she was a psychoanalysis one as well, even though she lied to me and said she did CBT when I asked. (I know the difference). She also refused to use diagnoses so I was under the impression that my problems weren’t that major. Later on, a psychologist correctly diagnosed me with OCD and severe depression.

    I understand not wanting to label people. However, I wish I had known that I had OCD and had her take my depression more seriously so that I would have slowed my life down and started antidepressants earlier (which helped my severe depression far more than therapy did). She also lied about insurance coverage. When I realized she wasn’t helping and decided to stop seeing her, she continued to call me for months afterwards and even tried to talk to me in public.(leading me to be afraid of going out). That’s an example of how a therapist can be damaging. So yes, even though I am pretty sure the blogger is a therapist himself and would like to believe that his fellow therapists are all competent and ethical, there is inherently some risk involved. Especially when you see a therapist that works independently without oversight or supervision. I don’t if he did this already, but I think it would be helpful for the blog to have a post about “warning signs” that your therapist is a bad therapist and what to look for in a “good” therapist. I think the relationship should be fairly equal with the power dynamic switching back towards the client as they become more stable and mentally healthy.

    I also agree with whoever talked about holistic approaches to treatment of mental health problems, especially anxiety and depression. My (current) therapist talks about the 4 antidepressants, Good Nutrition, Appropriate Amounts of Sleep, Socialization, and Regular Exercise.

    And yes therapy is definitely helpful for Schizophrenia and Bipolar Disorder provided that the client isn’t in a psychotic state. Bipolar disorder patients can benefit from therapy for their depression and to help them cope with the effects of their disease. Also, many people with Bipolar Disorder have co-morbid anxiety disorders that benefit from therapy.

  16. I agree with all you too, nice group? Katrin

    I also like the interaction!

  17. Lola,
    I have heard of his work but I suppose sometimes it takes a reminder for me to actually pick up the material. There is so much information out there; some repetitive some that is misleading, so I stay cautious. Thank you.

    The books that changed my thinking patterns really was “The Only Dance There Is” By Ram Dass. And “Quantum Theology” By Diarmuid O’Murchu.

    I too wish you peace, joy, love.
    Best
    Colleen

  18. Thank you, Lynn. Thanks for sharing. I got out of line with the rest of you when my comment was not posted for 24 hours or so. I really appreciate your comments.

    The author of this article is a psychologist and also the owner/boss of PsychCentral. He is very open to different types of views and also posts the many sides, including I believe has acknowledged that psychotherapy can be dangerous. Kat

  19. “Now where do we get a marketing campaign started to help educate and inform consumers about this invaluable treatment option?”

    Psychotherapy, which itself is a sales process, can, and should be sold like any other product or service. Just counsel some marketing professionals, if you’re serious about it.

  20. Dr. Hassman,

    Why should you expect results from something that is free? Because there is one free solution that works almost every time. The problem is that no one in mental health services is aware it exists.

    It costs nothing to examine your activities for Subliminal Distraction exposure and eliminate it. There is no medication, therapy, nor will this interfere with any modality you now have.

    If you quickly recover your doctor or therapist will claim credit. Why should you care if you eliminate your symptoms?

    I, at the risk of making myself very unpopular, will go one step further. There is no “testable objective evidence” that either drugs or therapy do anything.

    Yes, people recover while undergoing these modalities but there is no test to determine that the methodology used caused the remission.

    It has been known for almost 250 years that mental illness will spontaneously remit. How does anyone determine that a spontaneous remission did not happen coincidentally with treatment?

    No one can determine that. We believe doctors because they wear white coats.

  21. For those with Shizophrenia & Bipolar who don’t believe therapy have anything to offer I’d recmed starting w/ art therapy, music therapy, the main problems apply here to money and availability to those who need them often do not have access. I believe Dr Grohol was talking about the medicines for this group as well, these two groups most often get only meds, rarely, therapy. I happen to agree that both is far better, but like more than just talk. Movement, art, music, games,cognitive, Behavioral, I think a commbination is superer to one alone. People are complicated, multifaceted why do therapys insist on such rigid one sided approches?

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