Tuesday, September 30, 2008

Evidence-based support for long-term psychotherapy

I invite the interested reader to have a look at an article in the Journal of the American Medical Association, 300(13), pp. 1551-1565 (as of today, it is the current issue).
It presents some compelling evidence that long-term psychotherapy is significantly effective in treating a wide variety of psychiatric illnesses, including those illnesses that are more complicated, perhaps not neatly fitting into a single diagnostic category. It specifically shows a superior benefit for "psychodynamic" psychotherapy. Psychodynamic therapies are more intensive, philosophically and intellectually challenging styles of psychotherapy, which also emphasize the importance of examining closely the patient-therapist relationship during the therapy sessions. Most psychotherapy research has looked at short-term therapy (typically lasting a few months), and the evidence base formed from this research has caused a standard of practice to evolve which supports short-term but not long-term therapy. This is very problematic, because such a standard of practice is literally "short-sighted": Many patients require, and benefit greatly from, longer courses of psychotherapy. I do understand that it is difficult to do long-term research studies for any type of treatment (it is much, much easier to do an 8-week study than a 5-year study!), so this paper is very important.

Interestingly, the study did not show a specific benefit from the therapist having more years of experience. But this is not a surprise to me. In my experience with teaching medical students & residents, and also encountering many different supervisors during my training (which is now a decade ago), I found that differences in each individual's style, personality, attitude, and comfort with patients, were far more significant factors which influenced their helpfulness as clinicians or therapists, rather than years of experience. I can think of examples on both sides: the passage of years may magnify authoritarian or arrogant tendencies, and reduce open-mindedness, in some psychiatrists, particularly if they are ascending some sort of professional hierarchy, if they are trying to earn the most possible money, or if they are not enjoying their work. Clearly, this is not beneficial to patients or students. On the other hand, I have encountered many psychiatrists whose talent and wisdom have grown and deepened over time; in these cases I think years of experience have allowed a gentle, compassionate, understanding calm with patients, with a continuing open-mindedness to learn and continue growing, personally and professionally, as therapists and teachers.

The study did not show evidence that a "manual" helped the therapy be more effective. Again, this is absolutely not a surprise. Imagine trying to have a conversation with someone who was basing their responses to you on what a "manual" advised! While the use of manuals has been a well-meaning device for helping therapists-in-training to learn, and for measuring the effectiveness of therapy techniques in research, such devices in many cases can obtund the type of creative, spontaneous, friendly, wise, and sometimes playful interactions that I believe are the foundations for good therapy. These qualities I think are harder for therapists to learn or to teach, though I think that a sort of apprenticeship model is most likely to work best. It is not a surprise to me that the best such apprenticeship models are themselves long-term ones (over years), as opposed to having a therapist-in-training constantly migrating every few months, to some new or different therapy style or supervisor. Mind you, I do think it is important for any therapist to learn every major type of therapy, from a variety of different mentors, and in my opinion it is then necessary for the budding therapist to form an individual style that suits them best. In this way they will be truest to themselves, and therefore be best able to help their patients.

Tuesday, September 9, 2008

Rates of Change - filling a milk jug

Some symptoms or problems can improve within a day.
Others could take a week or more.
In mood and anxiety disorders, and in other struggles towards life improvement, many significant changes or improvements can take several months.

With this kind of time scale, it can be hard to perceive any change happening in the present moment.

So, consider this analogy:

Let your symptoms or problems be represented by an empty 4-litre milk jug.

Let your efforts to improve your symptoms or problems be represented by a dropper, which will add individual drops of milk to the jug. Each major step towards substantive change is represented by a full jug. In many ongoing processes of life change--such as dealing with chronic depression--you may need to take repeated such steps, but I think each single step can be very important and significant.

A single drop is about 1/20th of one millilitre in volume. So, in order to fill the jug, you will need to add 80 000 drops.

In order to add 80 000 drops in about 2-3 months' time, you will need to add about 1200 drops per day, or 50 drops per hour, or about 1 drop per minute.

This is the rate to keep in mind with regards to substantive life change -- it is like adding 1 drop per minute in order to fill up a 4-litre milk jug. The moment-to-moment pace may seem slow, but it is not imperceptible, as long as you have a way to visualize it. Keep using your dropper. Be patient.

(To extend this analogy a bit further, I guess we should say that it is important to make sure your jug doesn't have any leaks -- many therapeutic efforts cannot catch up with what is lost from a leaky jug! Leaks may be caused by chronic stresses, addictions, unaddressed physical health problems, unhealthy relationships, etc. )

Thursday, September 4, 2008

Managing Relationship Conflict

This is no easy subject. So much depends on the specifics of the situation and of the relationship. And perhaps different people deal with conflicts best in their own different ways.

But I think a few generalizations can be made:

1) Once anger has risen beyond a certain point -- and this point may vary, for different individuals, or for different situations -- there is no benefit to continued conversation. Anger is often a state of "outward flow", a state of action; an angry person may not be able or willing to listen or receive an "inward flow" of information or feedback. There needs to be a break, to cool down, after which if there are issues to discuss, both people will be able to hear each other better. Most issues of conflict are more fruitfully discussed when both parties are in a calm state.

2) If you are feeling unsafe, bullied, or subject to physical aggression, it is necessary to find a safe place as soon as possible. This may mean leaving physically. Or it may mean leaving the relationship. From the safe place, it will be necessary to carefully assess what to do next. It can be hard to think or plan clearly when you are in a dangerous position. You may need to seek external help, for shelter or safety.

2) Practicing empathy. While the capacity to empathize is to some degree an inborn, heritable trait, it is also a skill that can be practiced and improved. The simplest exercise is, in an argument, to simply state how you believe the other person is feeling, and why. We all have a powerful resistance to actually do this, even though most of us acknowledge that it's a good idea.

3) Apologizing. But only if you truly believe that you have been out of line.

4) Accepting apology. Which doesn't necessarily mean accepting a repetition of the status quo.

5) Be wary of the same old conflictual pattern happening over and over again.

6) If there is some positive territory, allowing some time and space for that. This could be shared interests, pleasures, activities, or mutual friends.

7) There are workbooks and other reading material which deal with relationships, managing or resolving conflict in marriages, etc. If this is a theme in your life, I strongly encourage you to acquaint yourself with this literature, and to work through a workbook or two (best if both you and your partner do it, of course). As with all self-help literature, you may find some of it preachy, trite, biased by the individual views of the author, etc. but I do think it is important to acquaint yourself with what is out there, some of it can be very helpful or at least an introduction to ideas that can help.

8) An external mediator, such as a therapist, can be helpful. It can often be important to find a mediator who does not have a specific individual alliance with either person in the conflict (i.e. the mediator should be neutral). And it can be important to find a mediator who is experienced working with relationship conflict. I believe it is important to consider that a mediator may help a relationship improve, but may also help an unhealthy or unsustainable relationship end more peacefully.

9) Maybe I should have "ranked" this item higher than (9) since it is very important: if there are untreated psychiatric symptoms in either individual member of a conflicted pair, then it can be very helpful to address and treat those symptoms. High levels of irritability can be treated with various types of psychotherapy, lifestyle change, and/or medication--with a reduction in an individual's irritability, that person may be able to negotiate conflict more peacefully and productively. In some depressive or anxious states, feedback which sounds critical in any way can lead to feelings which are so badly hurt that the conversation cannot continue. This emotional lability or hypersensitivity can also be treated through psychotherapy, lifestyle change, and/or medications.