Psychotherapy 101

“The harvest of psychotherapy is not cure—surely, in our field that is an illusion—but instead change or growth.” (Irving Yalom, 1931--)

While on faculty at Washington University School of Medicine, I developed and taught a two-year introductory course on Child and Family Psychotherapy. My students were residents and fellows, M.D.’s and D.O.’s in their 4^th and 5^th years of post-graduate psychiatry training.  Coming into this course, these students were well trained in biological psychiatry, psychiatry as a medical specialty. Now, it was their time to be introduced to a wide range of behavioral and psychological theories and techniques.  This blog is about day-one of that course, the basics. On that first day five questions were asked and explored.

1) What is psychotherapy?  Perhaps it would be more accurate to ask, “What are psychotherapies?”, for there are many models and theories of psychotherapy.  However, with the input of my students, we arrived at the following definition that captures the common and quintessential nature of most, if not all, of the psychological and behavioral therapies.  “Psychotherapy is a process of guiding change in a patient or client, undertaken within a theoretic framework, by a therapist trained in the application and implementation of that theory.”

2) What are the goals of psychotherapy?  There are as many goals as there are theories of psychotherapy:  making the unconscious conscious, strengthening the ego, working through problems, expressing feelings, clarifying goals and beliefs, reducing symptoms, resolving conflicts, improving self-esteem, empowering, growing, finding meaning, improving relationships, self-actualizing, extinguishing negative behaviors, reinforcing positive behaviors, correcting distorted cognitive schema, etc., etc., etc.  Yet, however otherwise stated, the common purpose and goal of psychotherapy is constructive change; behavioral, psychological, cognitive, and/or emotional change.

3) How does change occur?  In medicine, change occurs either by altering structure (anatomy) through surgery, or by altering function (physiology) through the use of medication.  In psychotherapy, change occurs when someone’s way of thinking, or someone’s way of behaving, are modified through use of one or more techniques associated with psychological and behavioral therapies.

4) What skills and characteristics are found in a good therapist?  A good therapist is well-trained and well-informed. A good therapist is genuine and warm.  A good therapist is a good communicator.  A good therapist is cognitively flexible, able to tolerate uncertainty, ambiguity, and subjectivity.  A good therapist is ethical, adhering strictly to professional boundaries and standards.  A good therapist possesses a sense of humility, understanding the limits of psychotherapy or what has been called by some ‘the impossible profession’.

5) What determines good outcome in therapy?  Outcome in therapy may be less determined by the specific type of therapy and more determined by the experience, quality, and personality of the therapist.  Theory is important, but relationship is even more so.  Outcome also depends upon the attitude of the patient coming into therapy. Good things happen when a patient comes to therapy ready to learn and to change.

It reminds me of an old joke.  How many therapists does it take to change a lightbulb?  Just one, but the lightbulb has to really want to change.

Amor Fati

 “. . . amor fati—that one wants nothing to be different—not forward, not backward, not in all eternity.  Not merely bear what is necessary . . . but love it.”   (Friedrich Nietzsche, 1844-1900)

I have type II diabetes, have had it for the past twenty years. My initial reaction to the diagnosis was, “Why me?” I have no family history for diabetes. Sure, I was overweight, but not that overweight.  Sure, I sat at my desk sedentary for much of the day, but I was not that out of shape.  I was indignant and angry, wrestling with the unfairness of it all.  I felt sorry for myself. I felt scared about my future.  However, none of that lasted long. I had to accept the reality of my diagnosis. I had to change my diet.  I had to lose weight. I had to exercise.

For several years, I was able to manage my diabetes through diet alone.  After a few years, oral medication became part of my management regimen.  For the past few years, I have had to take shots of insulin with each meal.  Nevertheless, with diligent management I remain relatively free from the sequelae of diabetes. I still have good kidneys, good eyes, and no neuropathy.

Loss comes in many forms. Receiving the diagnosis of a chronic illness was experienced by me as a loss, and with every loss there is a process of grieving. At some point in time, I probably experienced each of Elisabeth Kubler-Ross’ five stages of grief:  denial, anger, bargaining, depression, and acceptance.

Recently I learned that contemporary French philosopher Andre Comte-Sponville suggested that there is a sixth stage of grief:  gratitude.  “Gratitude does not abolish grief, it completes it. . . the grateful recollection of what has been. . .”  In other words, the work of grief is complete when one can recall a loss and be able to say, “But for having had that experience my life is richer.”  Gratitude does not negate the loss and grief. It gives meaning and value to some of life’s hardest experiences.

I am not happy to have diabetes.  But without my diabetes, there is every chance that I would be in poorer health today.  Because I have diabetes, I eat a healthier diet. I keep the pounds off.  I exercise regularly. Despite the demands and inconvenience of diabetes, I am grateful that I have made lifestyle changes and can say that I feel well.

Grief is an on-going process.  There are still days I slip back into the anger and sadness of ‘why me?’  I get tired of shots and checking my glucose. There are days when I resent having to count carbs, while watching others casually eating their bread, pasta, and dessert.  However, it was my fate to get diabetes, and but for a few momentary lapses I can usually embrace that fate.  From the hard experience of diabetes, my life is better, and for that I am grateful.