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Sunday, March 25, 2012

The Proof Is In The Pudding

Psychiatry Grand Rounds, March 12, 2012, Herrick Hospital:  "Psychotherapy: Lives Intersecting"  Lou Breger, PhD, Prof. of Psychoanalytic Studies, C.I.T. psychotherapist

Dr Breger decided to, as the basis for a book now recently published,  contact former patients (from 50 years of practice, mind you), and poll them on what had been helpful to them in their former therapy experience with him.
First, he mentioned as the umbrella for all his results, the evidence based tenet that the relationship between the patient and the psychotherapist is paramount.  This is currently pretty well accepted as the basis for a productive therapy and is, I might mention, the almost polar opposite of what Freud designed which was the therapist sitting as an almost silent 'blank screen', taking notes while the patient was on the couch unable to see the therapist.  Suffice it to say, we have progressed from the founder's first vision.
The results that most patients of a therapy that they considered successful were, outcomes that included less depression, a decrease in anxiety and, improved relationships.  The important part of the therapeutic experience was the attention they received and the collaborative interpretations.
Here is some of the feedback he got:

  • Mistakes and Repair:  The therapist had to be able to recognize or to admit any mistakes and genuinely apologize if called for.
  • The therapist showed his humanity; he allowed his human flaws to be present and was not pompous or arrogant.
  • Humor:  This helps if it is allowed to be a part of the sessions.  I agree that humor has a place in the therapy room.  Dr. Breger told a funny story of how once, in the middle of a session, with coffee in hand, his chair broke and he went tumbling backwards into a heap of disarrayed coffee cup and ch spilled everywhere.  He and his client were able to laugh about it.
  • Insight, which most therapists think of as a signpost on the growth path, was far down on the list for the patients, but it was there.  The experience of having an insight was valued but not as highly as therapists value it.
  • The therapist assisting the client in seeing connections between events in the past and the present was valued; he gave an example of one client whose wife's car accident triggered his frightening memory of an accident he was in as a child.  My note:  Some people really resist this and want the past left alone ('let sleeping dogs lie'), but, I think that making these connections helps us to feel our life as a whole, not segmented, experience.  In other words, "It's mine, it's me.  This is my life and what happened and who I am, as a result".
  • They appreciated having their feelings being allowed instead of cut off or changed or forbidden.
  • Money:  If they honestly couldn't afford the full fee and he gave them a break, even temporarily, that meant a lot.  They felt he wanted to see them and was not just squeezing out every penny possible.
  • Self-Disclosure:  For some who had been in therapy for awhile, knowing that the therapist has problems too made the therapist less intimidating-as long as the focus didn't get turned too far for too long, in the therapist's direction.
  • Medication, exercise program design, nutritional advice, lifestyle change suggestions:  They liked a therapist who was open to other forms of treatment.  (By the way, another currently well-documented tenet is that medication and psychotherapy work well in tandem.  Medication is more effective if it is paired with therapy.)
  • Normal conversation:  They liked the feeling that they could have a genuine conversation with the therapist, that they were taken seriously, they were not just as a specimen to be analyzed.
  • Answers:  They didn't expect the therapist to have all the answers and liked it if the therapist could be comfortable in sometimes not knowing-that neither of them had to be perfect.
  • They liked it if they felt that the therapist enjoyed the patients, was warm and friendly (really opposite of Freud).  They wanted to feel that they could talk about anything and everything. 
So, there you have it, the reality of what people want and what they value when they go to therapy. How about you?  Do you agree?
  • If you want to read the book that this post summarizes, the title is in the sub-title of my post.
  • The author also wrote a book on Freud in 2000.
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