Lynne S. Gots, Ph.D.
Licensed Psychologist
When Therapy Does More Harm Than Good
By Lynne Gots, posted on July 2nd, 2012.
As a specialist in anxiety, I’ve seen countless people after they’ve gone through months—years, even—of ineffectual psychotherapy. Yet I’m surprised time and again by the inaccurate beliefs guiding the practices of so many mental health professionals. Some of their methods, which derive from unsubstantiated theories, can interfere with progress or even make anxiety symptoms much worse.
A psychoanalyst once told me how frustrating she found treating people with Obsessive-Compulsive Disorder (OCD). “They never get better,” she said.
Unlike her, I really enjoy working with people who have OCD, in large part because they often do make dramatic strides in treatment, and in a relatively short time. But I don’t doubt she didn’t see much progress.
A psychoanalytic therapist would encourage her patient to explore childhood experiences to uncover the allegedly unconscious forces behind symptoms. In theory, once a person figures out the deep-seated reasons for feelings of anxiety or for intrusive thoughts, distress will dissipate. In practice, however, this solution frequently becomes part of the problem.
People with anxiety strive above all to maintain control—over their physical sensations, their thoughts, and the outcome of events. Paradoxically, when they avoid upsetting situations, analyze every last detail of a thought, or try to figure out the reason for their worries—all common but counterproductive tactics—they become more anxious. These efforts backfire because they prevent the anxious person from learning to tolerate uncertainty and handle uncomfortable feelings. From a cognitive-behavioral perspective, developing a tolerance for uncertainty and acquiring the skills for coping with emotional distress are the primary goals of therapy.
Focusing on the whys can be problematic for two additional reasons. First, trying to figure out the origin of a worry can serve as an avoidance tactic, encouraging rumination (something people with anxiety already do too much of) over action. Second, emphasizing the need to understand where an anxiety issue originated gives undo credence to the thoughts.
Many people I treat have a type of OCD characterized by repugnant mental obsessions (such as the fear of being a child-molester or of committing a violent crime). They’ve become trapped by their thoughts precisely because they’ve attributed too much significance to them. We all have strange and sometimes disturbing ideas from time to time. If we don’t make too much of them, they usually just come and go. Not so if you have OCD.
Obsessive worrying starts with ordinary random thoughts. Say you’ve just read an article about the Sandusky trial. You’re appalled by the witness testimonies. You think, “How could anyone do that? I could never imagine doing that!” But then you start to wonder. “Why am I so interested in this case? Does that mean I unconsciously want to molest children?” The more you think about it, the more anxious you get. You try to push the thoughts out of your mind but they keep coming back. Thus are the seeds of a full-blown obsession planted.
In the interest of fairness, I should point out that psychoanalysts aren’t the only therapists who can make a problem worse by using counterproductive approaches. I’ve heard of cognitive-behaviorists who, apparently not having kept up with the current literature, advise patients to practice “thought-stopping”—visualizing a large stop sign or snapping a rubberband on the wrist whenever unwanted thoughts occur-—to short circuit disturbing cognitions.
This technique gained a fair amount of traction twenty or so years ago. I’m embarrassed to admit I myself recommended it to more than a few people back in the day. But we now know from the social psychology research on thought suppression that trying to push thoughts out of our minds only intensifies them. So it’s more helpful to make peace with unwanted mental intrusions than to engage in efforts to banish them.
Another misapplied behavioral method, one commonly recommended for managing panic attacks, is relaxation training. Sometimes practicing deep-breathing can be helpful, especially for controlling hyperventilation. But trying to relax often can lead to more tension in a person who fears the sensations caused by extreme anxiety. So learning to ride out a panic attack using “interoceptive exposure”—invoking symptoms such as dizziness or a rapid heart rate to practice allowing them to pass without trying to control them—is much more effective in the long run than trying to head off the feelings by attempting to relax.
If you’re not sure you’re benefitting from therapy, tell your therapist. Discuss the treatment plan and the rationale behind it. Gather information from the websites of credible organizations (no message boards, please) and don’t hesitate to inquire about the latest research. The process of psychotherapy is often more an art than a science. But if you think you’re making no progress or find yourself feeling worse, an unscientific approach may be the reason.
Tags: anxiety treatment, cognitive-behavior therapy, psychotherapy
Posted in Anxiety, Obsessive Compulsive Disorder, Psychotherapy, Techniques |
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 |
