The Science and Art of Psychotherapy: Insider’s Guide
What are the most important things to find out from my doctor when I am figuring out a treatment course?
The most important thing is to figure out how you can be helped. This process starts with proper diagnosis, including an evaluation with a psychiatrist and possibly an internist/general practitioner/family doctor/gynecologist. Once you have received a rough idea of your type of diagnosis, questions of time, money, medication, and therapy all arise. You and your doctor need to determine what kind of treatment might help you and compare this recommendation with what you feel you can do. Keep in mind that few patients want to come in for therapy at the beginning, so it may be important to secure a plan from the start that has a reasonable probability of working and that can be adapted over time to your willingness to engage in treatment.
Separately, you need to discuss time and money. A four times-a-week psychoanalysis necessarily differs from a monthly psychopharmacology visit. Look at your insurance coverage and see if your provider is in or out of your insurance network. See if you and your provider can make arrangements to set up a treatment frame-e.g., once-a week treatment with a psychotherapist (psychiatrist, psychologist, social worker, or nurse) with monthly visits to see a psycho pharmacologist as indicated. Once you have a sense of the recommended therapy and a sense of the time and money you are willing to invest, try to put those two parameters together and see what happens. It may be a matter of finding a provider who is in your insurance network or of finding the right fit between you and your provider. Usually any questions regarding publicly available information about the therapist or his or her training are welcome, as should be questions of fees, policies, and work with family members. Think twice if what you hear does not make sense to you; a consultation with a different professional can often make all the difference, even if it confirms that the first treatment provider was on target. Anyone worth his salt welcomes a second opinion.
Selma’s comments:
In discussing my treatment, the most important thing was to use my own feelings. This decision would impact a major portion of my life for a long time. Would I be willing to do this, and would I be able? It would mean vacations at a nearby park and resorting to garage sales while our friends furnished their homes, went on trips, and sent their kids to summer camp. I was asking my husband and family to sacrifice a lot for something that only I thought would be infinitely valuable to them. They could not share my treatment with me, and they liked the status quo. Only I knew that what would be better for me would influence the family in healthy, good ways. The children, of course, had no choice; I decided for them much as my friends seriously looked for the best of schools. I wanted the healthiest of mothers for my children. My husband went along with it because it meant so much to me. I had told him when we first met how I felt and I saw the dangers of not working through my longstanding problems. I knew that those 45 minutes a day would likely become the dominant theme of life; I also knew a third person would appear in our marriage. I had to make these decisions. And even though I did not discuss my analytic work, its effect was everywhere in new ways. I saw the dynamics of my family change in ways that could not have existed before.
For example, one morning my teenage daughter came into the kitchen in a fury. Nothing was right. Her hair didn’t curl, her essay assignment was terrible, and she had argued with her boyfriend and a girlfriend. She took an egg out of the refrigerator and dropped it. I was able to watch her fury without commenting, getting upset, or telling her to calm down. In fact, I was able to stay cheery. She grabbed her books, said goodbye, and started out of the house to school. I replied, “You’re going to get your period.” She just stared at me, said “No, I am not, it’s not due,” and stormed out. At three o’clock she called me to pick her up and said, “I got my period. I can’t believe you. You’re a witch; how did you know?” I said, “You told me when you dropped an egg.” We both laugh now about her mother’s being a witch.
Had this happened years before between my own parents and me, I know my anger would have stimulated their anger. They would have taken my anger personally, and in minutes we would all have been in a major fight, none of us knowing how the flare-up ever got started. Such harm would be done, especially the separation and isolation that would result from such hostility and defensiveness. The incident with my daughter demonstrated a developing closeness between us that saw us through many difficult later years, which we could not at that time foresee. This closeness grew as a function of the decision I made in asking my family to sacrifice for what became both mine and the greater good-the decision to pursue my treatment.
PSYCHOTHERAPY
What are the different kinds of therapies?
In general, you might think of treatment as being split into pharmacotherapy and psychotherapy. The former involves seeing a physician for medication, and the latter is talk therapy. A split treatment involves seeing a therapist for talk therapy and a psychiatrist for medication; a combined treatment means seeing a psychiatrist who can do both (some psychiatrists work exclusively as psycho pharmacologists and only see patients for medication work).
Psychotherapy has a seeming infinity of schools of thought, practitioner styles, history, and scientific claims to the “truth.” This dizzying array can make it difficult to navigate some of the choices you may face. A few basic parameters can help make sense of the chaos. Does your therapist believe that unconscious conflicts may contribute to your anxiety? If so, then he or she will likely recommend that you be in some type of “dynamic psychotherapy,” meaning that the dynamics (or different feelings, thoughts, and memories that shift in a fluid equilibrium) of your mind might in large part lead to the symptoms from which you seek relief. This kind of therapy can go along with medication, which might also help you free associate, or say whatever it is that comes to your mind, in addition to relieving some acute manifestations of your anxiety. In the most intense form, your therapist might recommend psychoanalysis as a treatment, which would involve meeting four times a week with your analyst to understand in a deeper way what most troubles you and to give you the chance-with the therapist’s help-to make better sense of your symptoms, thoughts, feelings, and choices. More frequently, he or she might recommend a once- or twice weekly therapy, where a basic modification of many of these principles takes place. A psychoanalyst might, relatively, work more quietly, while this kind of therapist might be more active and say more. Any therapist should remain reserved and neutral enough that you can use this kind of treatment as a laboratory within which to recreate in the therapy the very conflicts that most trouble you in your life outside the therapy. Dynamic psychotherapy can prove invaluable because it is not session-limited and can engage many aspects of your mental life. You will have a chance to make sense of the meaning your symptoms might have for you in a greater way. For instance, if you fear touching things in general but only get panicky when you touch something that belonged to your father, there will be lots to think about. These treatments can also help you integrate other parts of your life with your symptoms. A phobia that keeps you from traveling will hamper your relationship with your spouse or children; being able to resolve these issues with your treatment makes a lot of sense. A more dynamic type of treatment takes into consideration the totality of your life-its meaning to you and its overall course.
If your therapist does not believe that unconscious conflicts are contributing to your anxiety, or if your therapist acknowledges unconscious conflict as a contributing factor to your symptoms, but believes that your present treatment would be best served by a more limited course at the immediate time, you will likely receive some version of cognitive, behavioral, or time limited interpersonal therapy. These treatments focus more on the exact symptoms you experience and on their reduction via implementation of a plan, which might involve homework and more active interventions to help you change. After the first 10 to 20 sessions, you and your therapist can make an assessment about the effectiveness of the treatment and where you want it to go. Not uncommonly, patients decide to start a longer term, more dynamic kind of psychotherapy after their symptoms have become less severe. At this point, you may have become more curious about the possible origins of your symptoms than in the immediate need to feel better.
If your life seems to be ripping apart at the seams, your therapist might recommend a more supportive approach. If your panic disorder has left you unable to leave home, work, pay bills, or care for your children in the way you did before, your therapist may ratchet up his involvement with your care, possibly even recommending hospitalization. In addition to discussing the role of medication as a tool, he will work with you on your symptoms and on a plan to put the rest of your life back together. This work will be very active, including the creation of a schedule and a day-by-day plan of attack.
If your symptoms involve your entire family, if your family has suffered with you, or if they have helped enable you to create your symptoms, your therapist might also recommend an augmentation with family or couples therapy. As helpful as addressing the individual links of the chain can be, the only way to study and help the whole system is to bring the whole system under surveillance. Many families have made vast improvements from this work.
If your symptoms might improve by working directly with others who have similar problems, your therapist might also recommend group therapy as an additional modality. Groups have the advantage of conquering the shame that can so often affect people suffering from anxiety. Around the world, twelve-step groups meet to harness the power of the group as a tool to conquer shame and mobilize recovery from all kinds of anxiety. A landmark study by Dr. David Spiegel of Stanford Medical School found that women with breast cancer who received adjunctive group/psychosocial therapy lived twice as long as those receiving no group therapy. Powerful connections are made in these groups, and these connections relieve anxiety.
Selma’s comments:
I have friends who see a variety of counselors, usually social workers, for what they deem a small problem in their marriage (generally stated as the other partner’s inability to understand their needs). When I ask why not get treatment with an analyst, they say they can handle this struggle themselves, implying that analysis means changing into other than what they are now. As a child, I had an essential sense of myself. It was never articulated, but there was a deep inner feeling that I knew was what I called, “me.” I expressed myself in things I liked and things I wanted. Somehow, in my difficult home environment and with subsequent anxieties-especially around separations, like in my stormy adolescence-that sense of “me” disappeared. It no longer existed, without even a memory of the girl I once was. Some years into my analysis, I was walking on a beautiful spring day, loving the beauty of the world. I realized that for an ephemeral few minutes; I looked at the scene and felt it as I had felt it as a child. Rather than “think” this sense, (like telling myself, “I felt this way as a child”) this refound feeling felt different. That feeling I had had long ago of having my own private domain became mine again. Now I am a mature, developed person, but the essential person I was and that I knew to be me, articulated to no one, is again intact. Analysis had in fact changed me. I again had the freedom to be myself and to move away from all the defenses I had built and used in order to cope with my anxiety. I again laid claim to being true to myself. For me, it was analysis that worked.
My treatment was hard work. No one does it except you, yourself. My analyst became a trusted guide, and I suppose the work provided tools to better handle life. But the commitment to hang in there must remain, especially when you hate your analyst, when you are so exhausted from the work that you want only to sleep, and when it seems as if nothing is happening. And when things are happening, because they are happening and because you are changing, you might become very anxious over just about everything. It is hard, slow work, and the benefits are lifesaving and life-giving. Or so it was for me.
