Therapy should come with a warning
- It can take awhile to find the “right” therapist and you shouldn’t stop at Therapist #1.
- Therapy is a strange, unnatural combination — an extremely personal, intimate relationship in a professional setting.
- Therapists leave and therapy ends.
- It’s only 50 minutes a week.
- Sometimes a friend will work just as well.
- “Side effects” of psychotherapy are unpredictable.
- Therapists can be just as crazy as any of their clients
This is by far one of the best articles that I’ve read lately. It directly addresses one of my biggest pet-peeves — the illusion of psychotherapy as some cure-all for mental illness. People take this “well, therapy can’t hurt” approach to treatment. Not true! The quality of the “therapeutic alliance” is the best predictor of treatment success.
Why do I think therapy is tough? Well…
1. It takes forever to find the right therapist for you. Heck, it takes awhile to find the right approach to therapy (CBT? DBT? IPT? Psychoanalysis? Gestalt?), let alone a therapist who you click with!
2. You can only have problems at 4:00pm on Tuesdays (or whenever your weekly session is). Okay, so you can just talk about all the other days during the week that you struggled… but rarely do you have an appointment when you need it the most.
3. Opening up and trusting a therapist requires a significant leap of faith — especially when half the people are going to therapy because are either depressed (and cutting themselves off from other relationships in life) or seeing a therapist because they have trust/relationship issues.
4. At least with eating disorders, the “Do I deserve help? Am I sick enough to deserve help? Does she actually care about me? Will she care about me if I get better? Am I only worth caring about when I’m sick?” questions are killer. How is treatment supposed to be successful when you have to be sick to receive help?
5. When you really start to develop and good relationship, then the person that you want to talk to the MOST is your therapist… which sucks, since she’s only accessible at 4:00pm on Tuesday.
6. So you finally talk about how abusive your father was when you were little, cry, and completely fall apart for 50 minutes… and then you’re supposed to go back into the real world and be A-OK? …Really? If you’re talking about stuff significant enough to be contributing to/causing your mental illness, then you’re probably going to be less okay leaving the your therapist’s office than when you went in.
7. Since there are so many different therapeutic approaches, different therapists will tell you different things. Therapist A thinks that your mother is overprotective, which is now driving your need to control your life through food and weight. Therapist B thinks that your mother was protecting you from your abusive father, and that your eating disorder is an attempt to be more like your mom and less like your dad. Etc. etc. (I could come up with these scenarios forever…). Who do you believe? Well, you generally believe whoever you’re seeing at the time (assuming you trust your therapist and want her help).
8. You have one therapist — your therapist has three dozen patients. Remembering that you’re just another one of the many people she talks to is hurtful.
9. Ending therapy is a nightmare for anyone with abandonment issues (read: 50% of all people in therapy). The only time I’ve had no trouble ending a relationship with a professional was when we didn’t get along in the first place. Even if you’ve moved past your original problem, systematically ending such a close relationship is just unnatural.
Do I think that therapy is helpful? Yes, usually. Do I think that therapy can be counter-productive? Absolutely. Aside from all of the reasons listed above, there are several of dangers of therapy:
a) Re-traumatization
b) Disturbing existing functional relationships
c) Sick syndrome — the attitude that you are sick and are therefore excused from XYZ. You can’t help XYZ because of your disorder (and your therapist told you so).
d) Learned helplessness – from Wikipedia: a psychological condition in which a human being or an animal has learned to believe that it is helpless in a particular situation. It has come to believe that it has no control over its situation and that whatever it does is futile. As a result, the human being or the animal will stay passive in the face of an unpleasant, harmful or damaging situation, even when it does actually have the power to change its circumstances.
d) Apathy (you can only explain your life story so many times)
… and, the biggest danger of all: Starting to talk / think like a self-help book.
Interesting study comparing three different therapies for AN. Clearly we have a long way to go…
http://ajp.psychiatryonline.org/cgi/content/full/162/4/741
I agree that the above study shows how much more research needs to be done regarding AN treatment, and there are a few aspects of it that I would like to comment on. First, regardless of the other conclusions of the study, I think that this data is the most striking of all: “9% of the subjects had a very good outcome and a further 21% had improved considerably; 70% either did not complete treatment or made small or no gains.” In other words, who cares which of the three therapies was best – 70% of those who participated made small or no gains! Moreover, if you read the exclusion criteria, it says that the researchers excluded people with “chronic, refractory course of anorexia nervosa.” In other words, the study participants are supposed to be the non-chronic patients that in theory are the most treatable. Yet in this study 70% of these “most treatable patients” either dropped out or were not helped at all. Clearly, research needs to be done to figure out how to keep people in meaningful treatment. Furthermore, the researchers seem surprised that clinical management had the best outcome, but as someone who has been in treatment for an eating disorder, this does not surprise me at all. Clinical management sounds to me like the first phase of inpatient or intensive outpatient treatment – focus on the food and nutritional stabilization. Usually even with CBT, one sees a nutritionist on the side to deal with the food specific aspects of treatment. In short, what this study really shows is that a lot more work needs to be done to figure out how to keep individuals in treatment, and how to best integrate the nutritional aspect of treatment with therapy.
Right, the study didn’t show very impressive results for any treatment. I didn’t get the impression that the researcher thought the outcomes were good. To my mind it’s just as important to find out what doesn’t seem to work as to find out what does.
I agree that toughest cases were excluded. It seems to me that in the real world very often people with AN do not have access to the IP or IOP until they are quite ill (they don’t qualify for insurance coverage for that level of care early on.) It also seems likely to me even in the most treatable cases it makes a lot of sense to include treatment to get a handle on symptoms no mater what else is pursued.
If you’re interested in a comprehensive report on evidence based treatment you might want to look at this (though it’s not especially cheering.)
http://www.ahrq.gov/downloads/pub/evidence/pdf/eatingdisorders/eatdis.pdf
Your analysis is right on, especially #6 and #8. I always disliked having to go back to work after a session and having to remind the therapist which client I am, so much so that I’ve stopped therapy. I’d rather talk to a friend.
Hi, I just wanted to say that I love this post. I agree with most of your points, especially #7! Too many people get in to therapy thinking it’s a cure-all without knowing what they are really getting in to and a lot of therapists do little to help educate clients. I like the passion of your posts – you really believe what you are writing.