• Wed, Nov 28 2012

Psychologists Make It Hard For Patients To Embrace Talk Therapy

Psychologists are having trouble drumming up business not because psychology has a “branding problem” but because they refuse to let go of outdated talk therapy models and embrace evidence-based mental health treatments, writes Maia Szalavitz at Time. As someone with a little experience in the mental health care system, I couldn’t agree more.

The very very very important point that Szalavitz makes is that it’s really had for patients today to find therapists willing to give them the treatment they need. She’s writing in response to an article in the Sunday New York Times from psychotherapist Lori Gottlieb — yes, that would be the same Lori Gottlieb who wants you to just settle already – who hired a branding consultant when she was having trouble drumming up patients for her therapy practice.

Gottlieb and many psychologists see therapy “in a more ‘Woody Allen’ mode, like the endless sessions of psychoanalysis practiced in the 1950s and 1960s,” writes Szalavitz.

“She wants to explore ‘unconscious feelings’ about other people transferred to the ‘blank slate’ of the therapist and to provide the ‘opportunity’ for a patient to ‘truly understand himself and, ultimately, change.’

 

But psychological research on effective treatment for disorders like depression, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder and the like has moved far beyond this view.  Indeed, the most effective treatments for these conditions do not prioritize digging into the unconscious.  As Yale psychologist Alan Kazdin put it when we discussed a 2011 article he wrote on the problems with individual talk therapy, “If you want to get over an anxiety disorder, do graduated exposure. But sit down and relate to me or love me like your mom and dad? There’s no evidence for that.”

Szalavitz concludes that “Psychotherapy doesn’t have an “image problem”: it has an evidence problem.”

The lack of embrace for these evidence-based methods — graduated exposure for anxiety disorders,  dialectical behavior therapy for borderline personality disorder, cognitive behavioral therapy (CBT) for everything from mood and anxiety disorders to eating disorders, personality disorders and psychosis — is evident if you’ve ever searched for a therapist. I’ve been seeing mental health professionals about depression since 2008, during which time I’ve moved all over the place and switched health insurance plans a few times. I’ve had to look for a quite a lot of psychiatric doctors as a result, and one thing I’ve noticed is that you’re given very little to go on when choosing between them.

In writing about health for a living, dealing with my own mental health issues and reading the psychiatric memoirs that are, like, one of my favorite literary genres, I’ve learned quite a bit about what in vogue in terms of treatment. So I’ve actually tried to look up psychologists in various cities based on different therapy methods, with very little success.

While the insurance company booklet might tell you a doctor specializes in “mood disorders,” you have no idea if they’re going to want to try CBT, talk about your last relationship or hear about your dreams. And the doctors’ or health groups’ websites themselves are often no better. Unless someone super-specializes in one type of therapy, you’re unlikely to see anything about their treatment methods or beliefs at all. I’ve given up and just gone with a psychiatrist and a Wellbutrin prescription several times because at least I know what I’m getting into that way.

Maybe that is a branding issue — this isn’t the 1960s, and people don’t want to just blindly go into therapy. Psychologists and counselors should get better about communicating with potential patients what kind of treatment philosophies they prescribe to and what the patient can expect.

But it seems like it’s also an issue of too few doctors being willing to let go of the therapeutic profession as they imagined it and embrace new ideas about psychology and therapy. Szavalitz points to a comment on Gottlieb’s original piece that illustrates the problem well:

I have serious OCD. I spent more than a month on a fruitless search for a new therapist who practices ERP (exposure and [response prevention]). It is the only treatment recommended by the Obsessive Compulsive Foundation and other organizations, and it is the treatment with which I have had the most success. And yet, here I am, in a city with perhaps the highest number of therapists per capita, and I am unable to find an ERP therapist who takes insurance. Instead, I’ve encountered therapists who claim to treat OCD with everything from traditional talk therapy and hypnotism.

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  • Marsha Linehan

    diabolical?

    • http://twitter.com/enbrown Elizabeth

      right. fixing.

  • http://twitter.com/valstipsforteen Val

    I think you mean “Dialetical Behavioral Therapy”, not “Diabolical Behavioral Therapy”. :)

    • http://twitter.com/enbrown Elizabeth

      hahaha, yes. Thank you.

  • http://www.facebook.com/people/Eve-Delaunay/100000191704123 Eve Delaunay

    It’s hugely misleading to say that talk therapy is outdated. The term talk therapy covers the range of talking cures including evidence-based approaches such as cognitive behavioral therapy. All of the ones you listed including DBT, graduated exposure, CBT are not done through some magic pill but through the therapist talking to the patient or patients. “sit down and relate to me or love me like your mom and dad” is psychodynamic therapy, which just one of the variants of talk therapy. Your article is a bit misleading as if all “talk therapy is bad.” There’s plenty of research based evidence that it works, and some talk therapy are
    evidence based approaches.

    • Psych Student

      Thank you! We differentiate between “talk therapy” and “medical therapy”. The difference is, are we going to talk about your problems (in CBT we talk about problems and focus on behavior and making behavioral changes, but we’re still talking), or are we going to give you pills or are we going to do a combination of both. But therapy is talking.

  • GJ Thrive

    One researcher in Chicago sat down to compare several prominent modalities and ended up determining that they were equal and the most important component was the quality of the relationship. (sorry can’t cite my source – middle age brain).
    So it’s possible that gradual desensitization doesn’t work if it’s being offered by a dick.
    And if you don’t believe the Freudian notion that we bring past relationships into our present-day ones – read Siegel’s contemporary work on the brain and memory (MIndsight is a good start).

  • Shayne

    Eve’s response is a far more eloquent version of how I was going to respond – well said. Evidenced based forms of treatment are incredibly emphasized and valued in graduate school training for clinical psychology, so it’s certainly something that newer clinicians (graduating now or in the past 5-10 years) are aware of and have greater skill with utilizing – at least based on my experience.

  • Cassandra

    I honestly completely disagree with at least 80% of what you said up there. Every therapist I’ve met in the last four years is completely obsessed with tactics and theories from acronym-laden “evidence-based” manualized therapies, to the point of being unhelpful, nonresponsive, and unsupportive.

    In my experience, in therapy today it’s more important to sit and do another rehearsal of a “mindfulness” exercise that I’ve TOLD them four times causes me discomfort and makes me a) dissociate and b) want to quit therapy, than to try and help me figure out why the exercise upsets me. “Why” is completely unimportant – just act like a little automaton who perfectly recites what the therapist wants to hear.

    And if you don’t go along with this kind of strategy, you get labeled with phrases like “borderline traits” if you’re female and “narcissistic traits” or “antisocial traits” if you’re male.

    The “evidence” that DBT “works” relies upon a definition of “working” that limits itself to reducing parasuicidal/self-harming behavior in young women diagnosed with Borderline Personality Disorder. If you’re a skeptical non-suicidal patient with severe depression and anxiety, every therapist in my city still wants to treat you with DBT and then wonders why on earth you’re still suffering so much.

    I’d also be willing to pay out of pocket if I could find a therapist who didn’t say stupid, obnoxious crap like “it must be very difficult to suffer as much as you do.” Jerks.

  • Psych Student

    Currently, in the psychological profession, there is a swing away from Freudian psychology and psychoanalysis (which is a rare practice to find now anyway) towards more “evidence-based” ideas such as CBT. There is still an aversion by the stodgy old men who run the APA to accept that an integrative (or eclectic as some call it) approach which allows for a combination of theories and techniques is the next wave of practices. We (psychologists) don’t often ask clients to lay on a couch for an hour 4 times a week for 3 years. Insurance won’t cover it and we’ve moved past that. Even therapies that are heavy on the, let’s call it “feelings talk” can be done in a couple of months. Sure, it would be nice to have more time, but there are time-limited therapies that get people in and out and on their way rather than asking them to commit to a 3-5 year exploration of their life.

    I appreciate that certain disorders are treated best by certain types of treatment. OCD is best treated with CBT. Some clients are best served by not focusing on changing behaviors but by talking out their feelings (a strict CBT model doesn’t involve much feelings talk). It’s unfortunate that clients may not know what they want/need when they seek out a therapist (or know the terms they should be looking for on websites). It is important to remember that as a client, you can therapist-shop. Look for someone who is a good fit for you. If you find a therapist who wants to relate your past feelings/interactions to your current state and you want someone who presents a straightforward behavior modification plan, then drop the first therapist and find someone else (I *know* this can be a struggle in an insurance situation, but you can try looking into low-fee clinics/finding psychologists-in-training to talk to – we receive a ton of supervision and work really hard, I promise). If you feel like you’re therapist doesn’t talk about your feelings enough and wants to focus on behavior change but you want to figure out what impact your parents had on you, then find someone who can give you that. As a client, you deserve someone you like and feel comfortable with and there is a therapist out there for you, even if they are hard to find. And it’s true, overall, the theoretical orientation (psychodynamic, CBT, psychoanalysis, etc.) doesn’t matter, it’s being able to talk to someone that helps. But those are averages and statistics. For the individual, the theoretical orientation matters and has an impact. But talk therapy is effective, and it does help.