The long and short of it.

April 25, 2012 11:41 AM

Do people spend too long in therapy? Or is saying so possibly misconduct?
posted by Obscure Reference (41 comments total)

Irate Guy ("someone is wrong on the Internet!") is only saying that misrepresenting your professional licensure is possibly misconduct.

Saying people spend too much time in therapy is merely mean and nasty and dangerous and also that guy is a poopyhead, according to this guy.
posted by Gator at 11:48 AM on April 25, 2012

and the forbes response isn't clear about what's wrong with saying you are licensed in several states. Or is the quibble that the guy's a licensed contractor or booking agent or talent agent, and not some type of therapist ?
posted by k5.user at 11:52 AM on April 25, 2012

If a patient comes to me and tells me she’s been unhappy with her boyfriend for the past year, I don’t ask, as some might, “How do you feel about that?” I already know how she feels about that. She just told me. She’s unhappy. When she asks me what I think she should do, I don’t respond with a return interrogatory, “What do you think you should do?” If she knew, she wouldn’t ask me for my thoughts.

What if she asks you whether she can eat this chicken that's been sitting out overnight?
posted by The Bellman at 11:56 AM on April 25, 2012 [8 favorites]

Woody Allen. Daphne Merkin. Case closed.
posted by Ideefixe at 11:58 AM on April 25, 2012 [1 favorite]

The spittle-flecked hissyfit is because he thinks the other guy is implying he's licensed in psychology, rather than psychotherapy. I suppose an equivalent thing to get enraged about would be a paralegal implying that they're licensed to practice law? I dunno, but the hysterical tone of Irate Guy made it very hard to take his concerns seriously.
posted by Gator at 11:59 AM on April 25, 2012

sheesh....Forbes complaining a typical NYT-Shill-Thinly-Disguised-As-Article drivel piece?

pot meet kettle.

Forbes is probably just pissed that they didn't get the article first.
posted by lampshade at 12:00 PM on April 25, 2012

and as a layperson who doesn't know any better, the difference between psychology and psychotherapy is __ ? (I know a psychiatrist is someone who's finished med school and has a MD after their name and can prescribe pills.. But therapists/psychologists sound like they fall into the same bucket.. )
posted by k5.user at 12:01 PM on April 25, 2012

These have been making the rounds on psychotherapy listservs I'm on, and while I've got some problems with Alpert's position, I'm not very fond of Essig's response. This is what I wrote about this elsewhere:

While I agree with some of the points Essig makes, as a Master's level social worker I'm reluctant to align myself too closely with him. His treatment of Alpert's qualifications leads me to think he's no fan of anyone who isn't a psychologist. When he wrote:

What kind of a psychologist would do such a thing in public? Is this
what being a “media-friendly” psychologist means? Has my profession
really sunk this low? Well, no. No worries on that account. I checked
to see if he was a psychologist in New York, a title that requires a
license and a doctorate in psychology, and saw that he was not.
However, a Jonathan Albert is licensed as a mental health counselor,
which is a masters-level degree that does allow the use of the title
of “psychotherapist” which is how he is described in the Times.

I felt that this was something he would have written as readily about a social worker, and it seems unjustifiably dismissive to me.

Even his gotcha about Alpert's use of "advanced degree in psychology" rubs me the wrong way. Alpert may be a prat for using that formulation, he may be trying to mislead, and it may display plenty about his own sense of professional self-worth, but it doesn't appear to be strictly incorrect. According to his Psychology Today profile he received his Master's degree from Yeshiva University. That degree is offered from the Ferkauf Graduate School of Psychology, and is described as offering "theoretical and applied principles of psychological counseling."

In both cases, Essig resorts to ad hominem to address what he should be able to address with actual content. I'm not sure how much of an improvement on Alpert's insults that is.

The discussion of how long therapy should take, and what constitutes good therapy, is one I'm intimately interested in, but neither of these positions seems like one that is all that interesting.
posted by OmieWise at 12:09 PM on April 25, 2012 [2 favorites]

and as a layperson who doesn't know any better, the difference between psychology and psychotherapy is __ ?

Among other things, a "psychologist" in New York must have PhD in psychology and at least two years of actual experience counseling in an accredited, supervised program. Your "psychologist" has at least done this before. Your "psychotherapist" might have no relevant education or experience at all, other than writing provocative opinion pieces for the Times--not that there is necessarily anything wrong with that.
posted by The Bellman at 12:11 PM on April 25, 2012 [1 favorite]

Your "psychotherapist" might have no relevant education or experience at all, other than writing provocative opinion pieces for the Times

I don't believe that's correct. I don't believe that just anyone can call themselves a psychotherapist. At least where I live it at least takes a professional license to do that, and you that license is only granted after education, internship, and supervision in either counseling, social work, marriage and family therapy, or psychology.

In other words, psychologists are one type of psychotherapist.
posted by OmieWise at 12:16 PM on April 25, 2012

Guy 1 seems more than happy to trot out a couple of light journal articles to poo-poo traditional psychotherapy (whatever that is these days), but doesn't have anything in the way of evidence for his own, totally better, approach besides the usual anecdotal bullshit. Guy 2 has nothing much to add to the conversation.
posted by NathanBoy at 12:17 PM on April 25, 2012

Sounds like Alpert is kind of a wanker with just a touch of the snake oil salesman thrown in to walk the plausible deniability tightrope.

Essig, likely should have reported his concerns to the appropriate licensing authority to look into and he, himself, written a better piece for some publisher other than Forbes.
posted by edgeways at 12:20 PM on April 25, 2012 [1 favorite]

In other words, psychologists are one type of psychotherapist.

Isn't a psychotherapist an MD, while a psychologist isn't necessarily?
posted by empath at 12:22 PM on April 25, 2012

I believe that this article has pretty much the right of it. When I was a child, I was admitted into therapy for years, and various family members pursued a similar course. When I got older, it was a bit of a pain, and I realized it just wasn't making any difference in my life. Many times I wished (even as a child) that my therapist would just share his opinion and give some advice. I stopped going, and never felt that it made any difference one way or another.

As for family members who continued going to therapy and swore by it, I noticed a strange tendency that I would call the therapy treadmill. Periodically, they would have 'breakthroughs' about themselves, but frequently these breakthroughs didn't lead to any real changes. Meanwhile, the patient would go through stages of elation and seeming wisdom, proclaiming the dysfunctional ways they handled things in the past. In fact, they would often use this to glibly brush aside past misdeeds, proclaiming them to be the actions of their old retrograde self, which they have since moved beyond.

Meanwhile, while behavior might improve for a short period of time, it was often in such a specific manner that it didn't really speak to the underlying problems. And in time, even that improvement would disappear. Wait long enough, and these patients would have the exact same revelation a decade later.

Some people use therapy merely as a way of moving their problems into a clinical setting. Within that setting, everything is labeled and forgivable. It can sometimes even give permission to act in a dysfunctional way...after all, they have an official diagnosis to explain why they act impulsively, dishonestly or inconsiderately. Everything is manageable, and all problems are (eventually) soluble. This process is often abetted by professionals, perhaps unconsciously, who validate the patient and the process at every turn.

This is not to say that there aren't people whose problems could be successfully tackled by therapy, and I suspect only a minority of patients end up on the treadmill that I describe. I do not think that therapy is akin to phrenology. However, I do not think that having a psychological problem necessarily makes someone an ideal candidate for therapy. A prospective patient has to be truly open-minded and capable of self-examination without having actually performed much fruitful self-examination; obviously, an uncommon pairing. Also, the relationship between patient and therapist is crucial, and I suspect that most prospective patients can only benefit from a minority of actual therapists (not because most therapists are incompetent, but because of that mysterious alchemy). And finally, the actual problem has to be something that can be solved by therapy, which isn't always the case. Therapy can be a life-saver for some people, but under the wrong conditions, it can be slightly worse than useless. And I think that conditions are more often wrong that right, to the extent that therapy can be a pretty unreliable approach.

I'd also add, if I may be forgiven some snark, that many if not most therapists are former patients. I have also seen this occur from inception to conclusion several times. This is understandable, but it also means that many therapists are very non-skeptical about what they do. After all, questioning therapy wouldn't just be a of questioning their profession, but also their sanity. To be clear, I'm not levying the standard criticism of the lunatics being in charge of the asylum. People tend to be non-skeptical about their chosen professions, in general, because they have a lot at stake in the accepted practices. I'm just saying that a lot of therapists have even more than the usual stake in their practices.

As for Essig's reply, one thing that he doesn't really consider is that maybe Alpert isn't making the claim because he wrote a book so much as he wrote the book because he believes the claim. Whatever criticisms you can fire at the NYT piece, I don't see the reply as having any traction whatsoever.
posted by Edgewise at 12:24 PM on April 25, 2012 [12 favorites]

Isn't a psychotherapist an MD, while a psychologist isn't necessarily?

No. I'm a psychotherapist. I am not an MD. All psychiatrists are MDs. Some are also psychotherapists.
posted by OmieWise at 12:26 PM on April 25, 2012 [1 favorite]

Let me amend what I just wrote: I think the NYT piece is correct in its criticisms, but I have no idea if Alpert's approach is any better. The pessimist in me suspects otherwise.

Isn't a psychotherapist an MD, while a psychologist isn't necessarily?

I believe that you're confusing psychotherapist with psychiatrist.
posted by Edgewise at 12:26 PM on April 25, 2012 [1 favorite]

Woody Allen. Daphne Merkin. Case closed.

Really? With n = 2?
posted by en forme de poire at 12:40 PM on April 25, 2012

I will preface this comment by saying that I have a master's degree in clinical psychology, and am currently in training to receive my Ph.D. in the same field. I see patients in a clinic that is oriented toward delivering CBT, which is a short-term treatment. We thoroughly assess patients at intake (using validated instruments and diagnostic interviews). The vast majority of patients who come to our clinic have anxiety and/or mood disorders (often more than one). These disorders have been shown to respond best to short-term treatments, yet many patients have been seeing other providers for YEARS. "Talk therapy," "supportive therapy," whatever you want to call it. I'm appalled at the number of clinicians who will continue to see patients (and take their money, bien sur) for lengthy periods of treatment, despite substantial research evidence indicating that most of these disorders will respond to relatively brief treatment (16-20 weeks, generally).

I don't expect patients to realize how outside the norm this is (though we could do a MUCH better job of educating the public about the science behind psychology), but clinicians need to ask themselves serious questions if they have been treating a patient with, say, panic disorder for over a year. That is not an acceptable outcome for that patient, and they need to be referred to someone who can help them (perhaps someone with more training in CBT for panic, or maybe to medication treatment). I don't claim that CBT helps everyone, not even everyone with "straightforward" anxiety and mood disorders, but research tells us what a typical course ought to be and if you as a clinician are not achieving those results it is your responsibility to consider why, and whether your patient would be better treated elsewhere.
posted by Bebo at 12:49 PM on April 25, 2012 [4 favorites]

Licensing varies by state.

In MA, anyone under the sun or the moon can put out a shingle and call him/herself a psychotherapist.

But not anyone can call themselves a:

*Licensed Mental Health Clinician (requires a Masters degree in counseling, fieldwork during the degree, and coursework in specific content areas as well as supervision prior to and after taking the licensure exam --- this was going to be my field before I had a baby).

*Licensed Independent Social Worker (requires a Masters degree in social work and much of the similar requirements above but there are a few differences between the licensing requirements as well)

*Psychologist (requires a Ph.D. or a PsyD among many, many, many, many other things. Only psychologists are licensed in psychology! LMHCs and LISCWS are licensed in counseling and social work respectively even if their practices are similar)

*Psychiatrist (requires an MD and other rigorous training)

I think the same is true in most other states --- you may see LPC (Licensed Professional Counselor/Clinician), which is similar to the LMHC in most jurisdictions.

All of the above may or may not practice psychotherapy. All of the above may or may not be psychotherapists. But not all psychotherapists will have one of the above licensing credentials --- and those are the ones to look out for.
posted by zizzle at 1:01 PM on April 25, 2012

I remember being taught in a professional ethics course that it's technically legal for anyone, regardless of training or education, to charge a fee for psychotherapy as long as they never claim to be licensed.
posted by Mrs.Spiffy at 1:22 PM on April 25, 2012

Some people just need to talk, other people need to be told what to do.

Having been considerably more social after High School, I can see the latter being needed more and more these days. No, you should not take out another line of credit. No, you shouldn't try to make things better with the SO that hit you. Yes, you should expect the road to fitness to be a long and hard one, get started now or you'll be suffering from X,Y, and Z down the road. Yes, you should do things for yourself, happiness is much of what makes all of this worth it.

Or perhaps, instead of psychotherapists we just need a Lucy's Answers booth every couple of blocks.
posted by Slackermagee at 1:22 PM on April 25, 2012

Therapy can — and should — focus on goals and outcomes, and people should be able to graduate from it. In my practice, the people who spent years in therapy before coming to me were able to face their fears, calm their anxieties and reach life goals quickly — often within weeks.

Bulllllllllshit.
posted by You Guys Like 2 Party? at 1:33 PM on April 25, 2012 [2 favorites]

Ooookay. Psychologists are not the only people who are licensed to provide therapy and mental health counseling. There's a whole slew of mental health certifications that you can get, and lots of them involve training and licensure in therapeutic theory, technique, and practice. Just because someone only has a master's degree rather than a doctorate doesn't mean they are unqualified to provide therapy.

And good thing, too, because how many of us can afford to talk to a psychologist for an hour a week? Heck, my health insurance won't even cover me for an ADHD assessment and there's no way I'm dropping nearly a grand out of pocket for four hours with a psychiatrist, the resources for that just don't exist in my life. Many of the people who need therapy are much more likely to end up dealing with someone with a MSW and a license than someone with a PhD in psychology, and that's fine because you know what? Therapy isn't that hard. Some people are poorly suited to be therapists, but for those who are well-suited to it it is not this huge thing that requires a million years in school to learn to do properly.

Therapy requires a certain type of innate personality and it requires the proper mental framing on the part of the therapist, a mental framing that allows the therapist to avoid leading their client and to help create a space and a framework in which the client can do their own work, rather than simply have that work done for them. Therapy is not the same as going to a trusted friend to get advice on how to deal with a problem. It's also not about submitting yourself to the analysis of some expert who is capable of using sheer theory and deduction to see what's happening in your mind better than you can yourself.

Therapy is about spending time talking to someone who is willing to facilitate and encourage your own authentic exploration of your issues and their underlying causes while simultaneously staying out of the way so that you don't end up simply confirming your therapist's personal opinions about what's causing you difficulty in your life. (It's important to remember that no therapist can be helpful if their client is not willing to do their work in a serious and authentic way. A good therapist can encourage this to happen, but must always be careful to avoid leading the patient.) It's not about breakthroughs or cures, it's about empowering people to work through the dysfunction in their lives and figure out, on their own, what if anything there is to be done about it.

I see no reason why an extra two years in school and the prestige of a "Dr." in front of one's name should make someone who is not inherently well-suited to this kind of interaction better-suited to it. If anything, I feel like the kind of people who seek out the money and status that comes with the PhD Psychology might be more likely to be ill-suited to be good therapists, given the self-effacement and the lack of ego that is required for a therapist to be effective.

Yes it is definitely important for there to be some significant formal education involved and a period of supervision after that education before someone is licensed to perform therapy independently. There is definitely a lot of theory out there and a lot of technique, and much of that is helpful to a good therapist. (Good therapists also have to have a good sense of what parts of psychological theory are counterproductive, as well. There's a stunning amount of unhelpful B.S. in the field of psychology even today. Did you know that 30% of psychologists still use some variant of Freud's psychoanalytic technique, which is based on a body of work that my psychology instructor charitably described as "not evidence-based"?) And it's definitely important for someone to work under the supervision of practicing therapists for a while before spreading their wings, because it's a field where theory and practice are often quite divergent. But social workers and other non-PhD therapists go through that too. The underlying field might be a bit different (More empirical, less theoretical, for instance. Or more holistic, less individualistic. Or more systems-based than pathology based. There are lots of points on the continuum.) but the basic ideas are the same.

Bottom line: PhDs aren't the only ones doing good therapy, nor should they be. There aren't enough of them to go around and there's no reason to believe that all else being equal they are any better at it than any other type of licensed therapist out there.
posted by Scientist at 1:42 PM on April 25, 2012 [7 favorites]

I'm not a therapist, but I'm a longtime therapy client, and I'm reading some very unfair generalizations about psychotherapists and psychotherapy in this thread.

Alpert and some commenters are implying that all therapists are, for example, only interested in their clients' money or in maintaining a perpetual client base. Yes, there are ineffective and misguided psychotherapists out there, just as there are ineffective and misguided members of any profession. There are also some terrific therapists out there.

Anyway, I read Alpert's article on Sunday and it's been bothering me for several days.

He does make one good point in his marketing piece disguised as an op-ed, which is that if you've been in therapy for years and it's not helping you, it's probably time for a change. You might need a different therapist with a different approach, or you might benefit from taking a break from therapy for a while. But that doesn't mean all long-term therapy is automatically useless.

What Alpert seems to be promoting isn't really psychotherapy. For example, he writes:

In my experience, most people seek therapeutic help for discrete, treatable issues: they are stuck in unfulfilling jobs or relationships, they can’t reach their goals, are fearful of change and depressed as a result. It doesn’t take years of therapy to get to the bottom of those kinds of problems. For some of my patients, it doesn’t even take a whole session.

It sounds like he's less of a psychotherapist and more of a life coach. Psychotherapy is less about solving specific problems and more about changing your sense of yourself and your outlook on life. Sometimes an unfulfilling job or relationship is not the real problem but merely a symptom of the problem. If you just "fix" your client's relationship situation or job situation and send him away, you might have just treated the symptom, and the disorder will just re-manifest itself later in another problem.

Some people have lifelong psychological issues that pervade their lives, because somewhere along the line -- because of a troubled childhood or a traumatic incident, for example -- they learned patterns that have kept them stuck. People like that can't be "cured" in 8 to 10 weeks.

(As for the Forbes piece: Essig doesn't just accuse Alpert of obscuring his credentials. He makes some substantive arguments about how Alpert has cherry-picked and misinterpreted his research. It's not that bad a response.)
posted by Tin Man at 1:54 PM on April 25, 2012 [6 favorites]

Two words no psychologist or psychiatrist will ever say : "you're cured"

They like to have regular customers.

Psychotherapy works. There are mounds of research showing this. The mechanisms by which psychotherapy works may be poorly understood, but it does help people. Unfortunately, therapy can never "cure" a mental illness, much like the fact that no treatment can cure Hep C. However, I'd venture a guess that you're not dropping into discussions on other incurable illnesses to take cheap shots at doctors doing their job.

As an anecdote, I did (cognitive behavioral) therapy for several months for chronic depression and generalized anxiety, and after I'd developed better patterns for my thoughts, my therapist and I agreed to stop meeting. Not cured, but at least able to live my life in a useful way. Which is all in addition to the fact that I was seeing my therapist at a reduced rate since my insurance was poor at the time. Clearly they hadn't taken enough classes in bilking people when getting their degree.
posted by TypographicalError at 1:58 PM on April 25, 2012 [1 favorite]

And I'm not so bad off that I'm willing to consider pills.

You know, pills are not the last, drastic resort that you should only take if you're actually seeing imaginary Technicolor lemurs and they're telling you to assassinate the alderman. They're a tool, just like various forms of therapy, and they're what some people need. Maybe even you. Maybe not, but either way medication isn't something you have to be some nebulous form of "so bad off" in order to benefit from.
posted by Gator at 2:37 PM on April 25, 2012 [8 favorites]

What's underlying a lot of the talk here is the unstated assumption that going therapy is a weakness and that being on medication for mood disorders or mental illnesses is the worst type of that weakness.
posted by You Guys Like 2 Party? at 2:46 PM on April 25, 2012 [4 favorites]

>Some people have lifelong psychological issues that pervade their lives, because somewhere along the line -- because of a troubled childhood or a traumatic incident, for example -- they learned patterns that have kept them stuck. People like that can't be "cured" in 8 to 10 weeks.

That's one way of looking at it.

Another possible way of looking at it-- one that I use, but one that probably wouldn't work or even begin to seem intriguing to someone else, so I wouldn't suggest doing it-- is starting to think to myself,

"'The pattern' isn't keeping you stuck... the pattern isn't an external force, doing something to you... no, you just ask certain habitual questions, with a certain attitude, and with certain favorite unpleasant associations... and that's all 'the pattern' is... and you're the one doing the pattern, and you're the one that can creatively begin to wonder about creating a new, more enjoyable pattern for yourself."

Not that this is something someone else should begin to apply to his or her own life, today, but I like to remind myself:

"Want different results?

Want a different state of feeling?

Just change the questions you're asking yourself, and the tone of voice you're asking these questions in, as you challenge yourself to discover new and more interesting questions to ask."

Not, again, that I'd suggest someone else might benefit from applying this simple step to some very particular and pressing issue-- this is just what, I, personally choose to *focus* on.
posted by darth_tedious at 2:51 PM on April 25, 2012

I'm not a therapist, but I have been in therapy for four years now. That's a lot of money -- nearly $60,000 -- and I consider it by far the best investment of my life.

Cognitive behavioral wham bam stuff is great for some people, but not all. Just like psychodynamic woo woo stuff is great for some people, but not all. Every single CBT instructional guide and mood chart and "think of a happy place" failed utterly for me; what I needed was to understand myself and the patterns I kept finding myself in. That's something I couldn't get from CBT -- it came only with long-term, intense therapy over many years.

Studies show long-term psychotherapy is effective -- especially in the weeks and months after therapy ends.

My study, with a sample size of one, shows that Alpert is a massive asshole I wouldn't trust to water my plants, much less probe my psyche.
posted by harperpitt at 3:11 PM on April 25, 2012 [3 favorites]

Psychotherapy is less about solving specific problems and more about changing your sense of yourself and your outlook on life.

But who does that? People usually go to therapists because of specific problems. If, during the course of therapy, they decide that they need a more holistic approach that encompasses their entire lives, then bully for them. But what about people who just want to deal with something specific, without dredging up their entire psyche? If therapy doesn't have a good answer for them, then it fails to directly address what most patients are actually looking for. Surely, there are some problems that can be solved without years and years of talking, digging and rooting. As with a house, you don't always need to tear up the foundations if the problem is a missing shingle.
posted by Edgewise at 3:15 PM on April 25, 2012 [2 favorites]

In the end, the person I have seen twice a year for 10 years should have a shingle the says" effective listener and human connector". Those two items are lacking from the bulk of my relationships despite my MeFi like personality or maybe because of it . I am grateful for our meetings, they remind me of the ever-changing human that lurks in all of us, and is yearning to be accepted and recognized. I am a better person as a result of consistently connecting with him.
posted by Xurando at 3:26 PM on April 25, 2012 [2 favorites]

As with a house, you don't always need to tear up the foundations if the problem is a missing shingle.

The problem is, is that sometimes you don't know which shingle is missing. And to stretch (and mix?) the metaphor, you can't figure out just which part of the house is leading to you to keep having leaks, or picking the wrong people, or ending up in dead end jobs and so on.

I've been going to therapy on and (mostly on) for quite a few years. I can't decide whether I should stop or not. But as my therapist said to me something something 'freud something something and success in love and work' and basically at the moment I have neither and can't figure out where the hole in my roof is quite located.

It's complicated. Is the emperor naked? I'm never really sure.
posted by bquarters at 3:55 PM on April 25, 2012 [1 favorite]

But what about people who just want to deal with something specific, without dredging up their entire psyche? If therapy doesn't have a good answer for them, then it fails to directly address what most patients are actually looking for. Surely, there are some problems that can be solved without years and years of talking, digging and rooting.

True. But Alpert is asserting that short-term therapy is the only good type of therapy and that all long-term therapy sucks and that the only thing long-term therapists do is sit there without saying anything except "How does that make you feel?" Which is not true at all.

As for "what most patients are actually looking for": I would ask how you know this.

I also wanted to respond to your earlier comment:

everything is labeled and forgivable. It can sometimes even give permission to act in a dysfunctional way...after all, they have an official diagnosis to explain why they act impulsively, dishonestly or inconsiderately. Everything is manageable, and all problems are (eventually) soluble. This process is often abetted by professionals, perhaps unconsciously, who validate the patient and the process at every turn.

This hasn't been my experience in therapy. My therapists have on more than one occasion challenged me and not just validated everything I say or do. As for "forgivable": what should a person do about one's own past bad behavior? Berate themselves for the rest of their life? Self-forgiveness is part of being a healthy human being (which does not mean just dismissing one's past behavior -- you can't forgive unless you first understand).
posted by Tin Man at 3:56 PM on April 25, 2012 [1 favorite]

The problem is, is that sometimes you don't know which shingle is missing.

Therapy isn't an empirical process. There isn't an equation or a formula. It's work. Which is why the whole notion of "My patients were "cured" before the first session even ended!" is so laughable.
posted by You Guys Like 2 Party? at 4:04 PM on April 25, 2012 [2 favorites]

Here's the thing about therapy: it's like anything else. In any profession with clients, you get some people who have one simple need that can be helped immediately, some people with a few needs, and some people with complex needs further complicated by other barriers in their life. The ethical thing to do is to give each client the service they're requesting, not to fit every client into the same mold.
posted by epj at 4:25 PM on April 25, 2012 [4 favorites]

True. But Alpert is asserting that short-term therapy is the only good type of therapy and that all long-term therapy sucks and that the only thing long-term therapists do is sit there without saying anything except "How does that make you feel?" Which is not true at all.

You're right, of course. Different strokes for different folks, as they say. My own feeling, however, is that while there are certainly people who can benefit from long term therapy, they are in the minority. As I said, I feel that a person and that person's problems must fit a certain profile to benefit from therapy, and this is probably even more true for the long term variety.

As for "what most patients are actually looking for": I would ask how you know this.

In other words, I can't possibly know this, you seem to be saying. Well, I'm just applying common sense, here. What motivates people to go to therapy in the first place? It doesn't make sense to me that more than a small proportion of people would seek out a therapist because, as you put it, "changing your sense of yourself and your outlook on life". If that doesn't seem to be common sense to you, then I guess we just have a different sense of what motivates people to do things. Do you really imagine that a large proportion of patients have this in mind when they first show up at a therapist's door?

I also wanted to respond to your earlier comment:

Perhaps I didn't emphasize this enough, but I wasn't even talking about the majority of people in therapy when I described the things that you're responding to. I'm talking about things that I've seen, first-hand. It is even possible for a person to obtain benefits from therapy while indulging in some of the things that I mention. As usual, it's probably not an either-or situation so much as a matter of degree.

As for "forgivable": what should a person do about one's own past bad behavior?...(which does not mean just dismissing one's past behavior -- you can't forgive unless you first understand)

Again, I'm talking about a certain kind of person who dismisses their past behavior as though it was enacted by someone else, who they (supposedly) no longer are. In other words, such people do not take ownership of their behavior until they feel that they have "risen above it," at which point it wasn't really the person they are now. And again, this doesn't always take place in the confines of therapy. I've seen people have these "self-divorcing" revelations without the assistance of a professional. If you haven't encountered this kind of behavior, then you probably have no idea what I'm talking about. Don't feel bad about that, because these kinds of people are in a state of perpetual crisis. So in answer to your question, I'd say a person needs to take ownership of their past behavior rather than dismissing it as the misbehavior of "past me, who I am no longer."

Therapy isn't an empirical process. There isn't an equation or a formula. It's work. Which is why the whole notion of "My patients were "cured" before the first session even ended!" is so laughable.

I partially agree (and fully agree with your last sentence), but I wouldn't go quite to the extent that you imply. I think the idea that all but a small subset of possible patients can benefit from years and years of therapy is misguided. To justify such long term work suggests to me that the patient needs to alter his or her way of thinking and feeling on a deep and fundamental level, and is capable of doing so within the bounds of therapy. I have grave doubts about this proposition, and I agree with Alpert that a lot of people in those circumstances have probably achieved limited results. Again, not all. I'm not saying that mainstream therapy is pure quackery.
posted by Edgewise at 4:47 PM on April 25, 2012

The problem is, is that sometimes you don't know which shingle is missing. And to stretch (and mix?) the metaphor, you can't figure out just which part of the house is leading to you to keep having leaks, or picking the wrong people, or ending up in dead end jobs and so on.

I couldn't agree more. The question is, is therapy the key to answering these questions for a given patient? I believe that the clinical context itself can be very reassuring, because outside of that, what is there but chaos? Where is the authoritative voice to tell you what is healthy and what is not? Nevertheless, I have come to the conclusion that sometimes the truth lies within the chaos, and cannot be separated from it.

Please do not think I am recommending that you leave therapy. I would feel really stupid making such a recommendation to a stranger about whom I know nothing. When I say these things, I'm mostly talking about things in my own life. It's hard to avoid generalizing, but I'm cognizant of the fact that different approaches work for different people.
posted by Edgewise at 5:10 PM on April 25, 2012

"Transference" doesn't work on me. The famous doctor/patient bond doesn't do anything for me. The doctor is a person who I'm paying to help me. He may be a caring person, but he's doing it because it's his job.

You could say that, but you'd be wrong, and you'd demonstrate that you don't really understand what transference refers to.

Transference is the transferring of attitudes, positions, and ways of relating from primary early relationships to later secondary ones. It isn't always straightforward, but it's the unconscious use of previous relationship patterns in the present. Now, you may argue that that doesn't ever happen with you, but your comments here, in which you seem to attribute motivations and lacunae to doctors who you've never worked with, certainly reads as transferential to me.
posted by OmieWise at 5:12 PM on April 25, 2012 [1 favorite]

I'm a marriage and family therapist, with my focus on Jungian psychology. I work with adults with persistent mental disorders, and my area of strength is with people struggling with severe psychosis; my supervisor transfers these clients ot me, and by and large I get them stabilized ("cure" with people with medication-treated psychosis pretty much doesn't exist in this culture).

For a lot of surface or situational problems, cog-b therapy is highly effective and works best in under 20 sessions. It's essentially training in thinking. I use some cog-b, but unlike people working with a non-persistent mental illness population, I have to do a lot of repetition and very little homework because the negative symptoms (confusion, memory loss, disorganized thinking, etc...) impair my clients' ability to internalize and utilize cog-b without significant supports. Most of my clients I've treated for 2+ years. Some, we're in maintenance - they have a living situation, they have enough food, they aren't behaving bizarrely enough in public to cause the police to be called - we're satisfied. Some of my clients have had significant improvements, including one who is steadily working her way through building decision making skills and impulse control skills now that we've somewhat handled anger management (her skills slide significantly when I'm not around, but it's beginning to show up with other clinicians and with her family).

Transference is when an unresolved relationship with a past figure gets hooked on the therapist, at which point one can work through the damage in that relationship so that the person feels freed of the pain caused by it. An example would be a client of mine with severe attachment issues who is gradually working through feeling secure enough in our relationship that I can go on vacation without her having a major episode of abandonment and increased psychotic symptoms. We're almost there, but it took three years. I have clients where we're two years in and finally narrowing down on the current and past causes so we can hopefully get them resolved. I deal with a much more impaired population than most, but I'd imagine some people are passing as functional who have similar impairments.

I went to therapy for about five years, and stopped when I was no longer in the situation that was causing most of my symptoms. Things I learned during that time I then used to maintain my mental health afterwards. Sometimes, therapy is a way to get through an intolerable situation without suicide or narcotics, and I'm grateful I neither succumbed to death or drugs.

So yeah, sometimes a short treatment is appropriate. Sometimes, it's not. Trying to make a blanket statement, or claim clinicians like me are somehow inferior because I can't cure psychosis in 12 easy sessions... well, it's sort of missing the ultimate point of psychology and therapy.
posted by Deoridhe at 7:45 PM on April 25, 2012 [5 favorites]

Either way, it doesn't work on me.

Yeah, I'm not going to belabor this, but transference isn't something that "works on" you, it's something that happens to you. The fact that you can't seem to talk about it without being derisive, or referring to it as magical, indicates that your attitude (relationship) toward transference and its place in therapy exceeds your factual knowledge of it (provided in this thread). That's what transference is.
posted by OmieWise at 5:28 AM on April 26, 2012 [3 favorites]

Unfortunately, therapy can never "cure" a mental illness, much like the fact that no treatment can cure Hep C. However, I'd venture a guess that you're not dropping into discussions on other incurable illnesses to take cheap shots at doctors doing their job.

That's not true. Phobias can be cured, but psychology hasn't yet discovered anything as powerful as penicillin or the polio vaccine. Unfortunately, the tools that we have to modify nervous systems are still primitive. Another confounding factor is the fact that many patients seem to respond well to sham treatments. There have always been quacks and charlatans. Before germ theory, hospitals were very dangerous places for sick people to visit. Evidence based medicine is recent, and not as widely practiced as it ought to be. Enforcement problems arise because many people would rather pay for ineffective treatments than admit that their conditions are intractable. They're also overconfident in their ability to distinguish placebos from effective treatments. Certain conditions (e.g. back pain, motion sickness, arthritis, the common cold) support a vast industry that offers dubious products. Other chronic conditions, like HIV or diabetes, would be harder to treat with snake oil without running into obvious and dire consequences.

Though authorities will occasionally crack down on the most egregious offenders, many dubious treatments and therapies can be sold with impunity. The demand is just too strong, and the public understanding of medical epistemology is too weak.
posted by Human Flesh at 9:56 AM on April 26, 2012