Lynne S. Gots, Ph.D.
Licensed Psychologist
How Long Should Therapy Take?
By Lynne Gots, posted on April 23rd, 2012.
Picture a day bed draped with an exotic, patterned blanket on a faded Oriental carpet in a room decorated with African sculptures and shelves overflowing with books. This image accompanied an opinion piece in yesterday’s Sunday New York Times about the ineffectiveness of long-term, unstructured, open-ended psychotherapy.
Although the author Jonathan Alpert doesn’t say it, the picture does. The kind of therapy he’s describing, in which the therapist listens passively with just an occasional nod or a “How do you feel about that?” is the psychodynamic approach practiced by Freud and his disciples. Even in the absence of compelling scientific evidence to support its effectiveness for a host of psychological problems, this type of treatment still has a tenacious hold on many practitioners today. But that’s a topic for another discussion.
The article has inspired a barrage of outraged Tweets and blog posts by therapists who’ve perceived it as a disloyal attack on our profession. Many of them practice long-term psychotherapy and, understandably, feel the need to defend their approach. While I’m not as offended by Alpert’s allegations as those colleagues, I still take issue with much of his argument.
When people seek me out for treatment, they’ve usually done their research and know I practice Cognitive-Behavioral Therapy. CBT is much more focused, problem-oriented, and time-limited than the traditional therapeutic approach that keeps patients on the couch for years on end, perhaps with no resolution of their neuroses (think Woody Allen). So if you’ve decided to work with me, you’re not expecting the process to drag on indefinitely.
Even so, problems aren’t always neatly resolved in the twelve to sixteen sessions described in the treatment manuals. That’s why, when I’m asked how long therapy will take, I always say, “That depends.”
Depends on what, exactly? A variety of factors enter into the algorithm—your willingness to push through discomfort, the presence of complicating conditions (depression, substance abuse, marital problems) secondary to the problem that brought you in, scheduling and financial constraints, the level of your current distress, among others.
I’m not trying to be vague or evasive. To the contrary, from the first session I try very hard to help my patients define clear, specific goals and understand what it will take to reach them. But it’s not nearly as simple as Alpert (“Manhattan’s most media friendly psychotherapist,” according to his website) makes it seem when he writes, “Many patients need an aggressive therapist who prods them to face what they find uncomfortable: change.” (I don’t think it’s by accident that Alpert, as media savvy as he appears, is touting an all-out assault on the fear of change. His new book, Be Fearless: Change Your Life in 28 Days, is due for release any day now.)
More important than having a particular therapeutic style, I believe, is understanding how change happens and being willing to confront the obstacles as they come up, even if it means putting the therapeutic work on hold for awhile or discontinuing treatment altogether until the interfering conditions can be resolved. Better yet, predicting and addressing potential difficulties at the outset can help speed the progress of therapy and minimize both the patient’s and the therapist’s frustration.
To that end, I spend a lot of time up front laying a solid foundation for the treatment phase of the work, sometimes taking a month or more to build the base. (So much for 28 days, and the treatment hasn’t even begun!) As tempting as it may be to offer a quick therapeutic fix, I’ve learned from experience and some unsatisfactory outcomes not to jump in too fast. And while I agree “it doesn’t take years of therapy to get to the bottom of . . . problems,” I’m also highly skeptical of Alpert’s claim that “for some of my patients, it doesn’t even take a whole session.”
Most critical to me—and, I hope, to my patients—is for us to have the same agenda. So if someone has learned to cope with her panic attacks but wants help in sorting out career issues, say, I’m fine with continuing treatment for as long as we both agree it’s helpful.
Many of my patients are ready to wrap up therapy in two months, or six. But I’ve been seeing others for four or more years, though not ever week, certainly, and not because they’re not making progress. If that were the case, I’d have referred them on long ago, possibly to a psychodynamic therapist with a different set of skills from mine. Still, I know some more orthodox cognitive-behavioral therapists wouldn’t openly admit to extending the length of treatment past the standard guidelines despite the prevalence of this practice.
Sometimes people like to come back every so often, or even on a semi-regular schedule, to stay in shape. It’s like continuing to see a trainer after you’ve achieved your peak level of fitness. Reevaluating your routine and shaking it up from time to time can help keep you on top of your game.
So I wouldn’t necessarily conclude, as Alpert does, that an extended course of therapy means the treatment is bad or ineffective. I wouldn’t even agree that someone who’s in therapy to feel better (a situation he likens to relaxing “spa appointments”) without working on specific goals for change is wasting his time, although I personally wouldn’t be treating that individual. What’s most important, in my view, is to assess what you’re hoping to get from your treatment. And if you don’t feel you’re making the progress you’d like, by all means bring it up with your therapist for review.
You might need to tweak the approach, or you might need to move on. It depends.
Posted in Behavior Change, Mental Health and the Media, Psychotherapy |
Vogue Article Sparks Controversy: Should Kids Diet?
By Lynne Gots, posted on April 4th, 2012.
There’s been much buzz recently over an article in the April issue of Vogue, in which writer Dara-Lynn Weiss chronicles her yearlong mission to put her overweight seven-year-old daughter Bea on a diet. At four feet four inches tall and 93 pounds, Bea was in the ninety-ninth percentile for weight and, technically, “obese.”
To her credit, Weiss acknowledges her own problems with food and body image. “Whether I weighed in at 105 pounds or 145 pounds hardly mattered—I hated how my body looked and devoted an inordinate amount of time to trying to change it.” By her own account, even though she’s currently at a healthy weight, she still seesaws between bingeing on “decadent pursuits” (cheeseburgers, cupcakes, and cookies) and purging—if not through vomiting or laxative abuse (although she admits to having used those methods, too), then by going on juice cleanses or rigidly adhering to a restrictive food plan for a week or two.
Clearly, then, Weiss is no role model for either healthy eating or body acceptance. “Who was I to teach a little girl how to maintain a healthy weight and body image?” she says, in her only display of self-awareness in the entire article.
Who, indeed?
Over the course of the weight loss project she undertakes on behalf of Bea, Weiss earns herself a lifetime membership in the Tiger Mother club. (Ironically, she criticizes the “Tiger Moms who press their kids into private-school test prep at age four, or force them to devote countless hours to piano or dance or sports [yet] find it unthinkable that anyone would coax a child to lose weight.”)
She polices the little girl’s food choices. She berates a Starbuck’s barrista for not knowing the exact calorie count in a kid’s hot chocolate. She withholds dessert, extra portions, and dinner (when she felt her daughter had consumed too many calories at a school French heritage celebration). She alienates friends and family, including her husband, who “soon tired of the food restrictions and the glacial rate of weight loss and stopped actively participating.”
The “Red Light, Green Light, Eat Right” program the family followed, created by Joanna Dolgoff, MD, seems, at least on the surface, to promote sensible eating habits without being overly restrictive. For example, on her website, Dr. Dolgoff distinguishes between “healthy” and “junky” green light (low calorie) choices. But Weiss manages to put her own personalized, eating-disordered spin on the doctor’s recommendations, filling Bea up with diet soda and fat-free, processed snack foods while limiting fruits (which can be eaten freely) because she found Bea’s consumption of them “excessive.”
By demonizing entire categories of foods, making others available solely on the basis of their negligible calorie counts, and subverting Bea’s hunger with low-cal cookie facsimiles devoid of nutritional value, Weiss might as well be giving her daughter a tutorial on how to develop an eating disorder. And instead of seeing Bea’s weight as a behavioral issue involving modifiable eating and exercise habits, she prefers to medicalize it, liking the word “obese” because it “carries a scary, diagnostic tone.” Some sports are added, and Bea even enjoys them, but physical activity doesn’t become a family endeavor because Weiss herself hasn’t been to a gym in over a decade.
By her eighth birthday, Bea had grown two inches, lost sixteen pounds, and acquired, as a reward for her weight loss, a feather hair extension and wardrobe of designer dresses. Weiss hastens to add, “Incredibly, she has not yet exhibited symptoms of intense psychological damage.”
Talk to me in ten years.
When Weiss presses her daughter to take pride in her new appearance, telling her how different she is from “that fat girl [who] is a thing of the past,” Bea responds with a depth of insight that far surpasses her mother’s. “That’s still me,” she replies. “I’m not a different person just because I lost sixteen pounds. Just because it’s in the past doesn’t mean it didn’t happen.”
In the way of many controversial media figures these days, Weiss has gotten herself a book contract. I wonder what she’ll write. . . A parenting book? A diet book? Or a sociopolitical treatise on the childhood obesity epidemic in early 21st century America? I can hardly wait to find out.
Tags: dara-lynn Weiss, diet, eating disorders, Parenting, seven-year-old
Posted in General, Mental Health and the Media, Parenting |
Self-Help and Change: No Quick Fix
By Lynne Gots, posted on March 26th, 2012.
I’ve alluded in previous posts to the misleadingly reductionist methods promoted by self-transformation gurus. In a recent article on the science website Big Think, Jason Gots (Full Disclosure: he’s my nephew) makes a similar point about the process of personal growth. I hope my recent meditation chronicles have also shown that it takes hard work to eliminate bad habits, adopt better ones, and rewire the brain.
Even the research tested, cognitive-behavioral treatment protocols—which in countless studies have proven to ameliorate complex psychiatric syndromes, such as depression, obsessive-compulsive disorder, social anxiety, insomnia, and attention deficit disorder, to name just a few—have their limitations when it comes to real world applications.
Why? Because the manuals presume an ideal situation in which life and people don’t muddy the pure, scientifically controlled waters.
In reality—that is, in settings like my office where clinicians see real people with complex problems and complicated lives, not carefully screened research subjects who get eliminated from clinical trials if they don’t precisely fit the study criteria, miss appointments or fail to comply with the treatment regimen—change just isn’t as straightforward as the books would have us believe.
One of the challenges I face as a clinician is managing expectations. If, from the outset, I don’t help patients anticipate the difficulties they may encounter with the therapy (and sometimes even when I do), they may get frustrated and end the treatment before they’ve given it a fair chance. I partly blame the self-help movement on causing some people—particularly many of the perfectionists I see, who tend to view the process of change through an all-or-nothing lens—to give up too soon when the results they envision aren’t as immediately forthcoming as they’d hoped.
I don’t mean to sound overly pessimistic about personal growth. If I believed that modifying the ways we think and behave were unreasonable goals, I’d be in the wrong line of work. But expecting an instruction manual to magically transform your life without requiring you to make a long-term investment of time, energy, and honest self-reflection amounts to believing in, well, magic.
Posted in Behavior Change, Mental Health and the Media, Perfectionism, Self-help |
