New York Times (21 Aug 2007) includes an article: “To Reap
Psychotherapy’s Benefits, Get a Good Fit” by Richard A. Friedman, M.D.

The author note states: “Richard A. Friedman is a professor of
psychiatry at Weill Cornell Medical College.”

Here’s the article:

Americans seem to like psychotherapy. Whether it’s for the mundane
conflicts of everyday life or life-threatening illnesses like major
depression, psychotherapy is widely viewed as a healthy, if not
harmless, pursuit.

Yet unlike most other medical treatments, psychotherapy can take
considerable time. An infection can be cured in days, but remission of
severe depression or anxiety disorder usually takes weeks or months, and
a personality disorder typically requires years of intensive psychotherapy.

So if the outcome may be months or years away, how can a person tell
whether his psychotherapy is any good?

It’s harder than you’d think. For one thing, people commonly equate
feeling better with getting good treatment. But since psychiatric
disorders fluctuate spontaneously with time, like most illnesses, many
patients would get better even if they got no treatment at all. A
patient getting bad psychotherapy might flourish, while another patient
getting exemplary treatment might suffer terribly.

Judging from one of the largest surveys of psychotherapy to date, most
Americans who try psychotherapy think it is beneficial. In its 1994
annual questionnaire, Consumer Reports asked readers about their
experience in psychotherapy. Of 7,000 subscribers who responded to the
mental health questions, 4,100 saw mental health professionals. Most
reported feeling better with therapy, regardless of whether they were
treated by a psychologist, a psychiatrist or a social worker. And those
in long-term therapy reported more improvement than those in short-term
therapy.

Of course, not all therapy is helpful, and some of it can be downright
harmful. Many patients have problems with relationships in the first
place; they can find it difficult to extricate themselves from bad or
ineffective therapy.

I recall a successful writer whom I saw in consultation. At 44, he had
been in psychotherapy for several years and felt that while he had
gained much self-understanding, his chronically depressed mood had not
changed.

After seeing his depressed partner respond vividly to an antidepressant,
he wondered if he too might benefit from a similar drug, but his
therapist was opposed.

“He told me that I would be forestalling symptoms with medication that
would return years later when I stopped medication,” the writer said. He
persisted and got a second opinion.

“Be very wary of any therapist who discourages a consultation,” said a
colleague of mine, Dr. Robert Michels, university professor of
psychiatry at Weill Cornell Medical College. “If a patient is
uncomfortable at the start of treatment, he should leave. But if a
patient dislikes his therapy later on, he should discuss it with his
therapist, and, if they can’t agree, then it’s time for a consultation.
A competent therapist should welcome it.”

It is hardly surprising that many patients are reluctant to seek a
second opinion; they may fear rejection by their therapist, or hurting
the therapist’s feelings. And therapists, having egos like everyone
else, may resist an independent consultation because they see it as a
sign of their own failure, not to mention the obvious financial
incentive to hold on to a patient.

It’s not just patients who have a hard time knowing if their treatments
are helping them; sometimes the therapists themselves can’t tell.

In a study published last month in the journal Psychotherapy Research,
Michael J. Lambert and Cory Harmon, psychologists at Brigham Young
University, gave psychotherapy patients a questionnaire about how they
were feeling and functioning. They randomly gave feedback from the
questionnaires to half the patients’ therapists; the other half received
strengthened feedback, which included patient self-assessment plus
specific information about how the patients viewed their therapists and
their social supports. These two groups were compared with a control
group of patients whose therapists received no feedback.

The researchers found that giving feedback to therapists clearly
improved treatment outcome: When therapists received no feedback, 21
percent of their patients deteriorated. With therapists who received
regular feedback, 13 percent of patients deteriorated; with strengthened
feedback, 7 percent of patients deteriorated.

The clear implication is that therapists are not always the best judge
of how their patients are doing, perhaps because they are blinded by
their own optimism and determination to succeed.

Some therapists might even view worsening during treatment as a sign of
progress — a misguided “no pain, no gain” view of psychotherapy.

It’s probably easier to say what is bad psychotherapy than what is good,
but there are qualities that all good therapies share. You should feel
that you are understood as an individual, and that your therapist is
compassionate and nonjudgmental. Good therapists should be able to
explain the nature of your problem, and which of several treatments
might help you.

Ask yourself not just whether you are getting better, but whether you
are getting optimal treatment. Information about psychiatric disorders
and recommended treatment can be found at several of reputable Web
sites, including those of the American Psychiatric Association at
www.psych.org, and the National Institute of Mental Health at
www.nimh.nih.gov.

The psychiatric association’s treatment guidelines describe what is
considered state-of-the-art treatment for various disorders and the
empirical basis for the recommendations; see them at www.psych.org/
psych_pract.

While it will not guarantee good therapy, seeing an accredited mental
health professional provides some assurance of skill and competence.

Feeling better is important, of course, but it is possible to feel good
and be stalled, where little significant change is taking place. If you
are in therapy, don’t just rely on your own feelings to judge the
treatment; speak to good friends and family members and see what they
think about how you’re doing.

In the end, psychotherapy is a very personal business. If you need brain
surgery, it doesn’t really matter if you like your surgeon as long as
he’s skilled and competent. But in therapy, skill and competence are
necessary but not enough; personal fit, more than almost anything, can
make the therapy — or break it.

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