Upside Down Medicine

Psychotherapy Part I: Is It for Real? Does it Work? What Do I Look For?


Psychotherapies work, and work well. They are gaining ever more attention and prominence, even in the world of medicine. In Part I will discuss personality, personality disorders, and the variety of "talking therapies" to treat them. Medical and medication therapies are outlined in other posts. The question of how therapies achieve their goals, their mechanisms of action, are touched upon here, but will be elaborated more extensively in Psychotherapy: How Does it Work?  Part II

Let's begin with some basics. Even before we consider psychotherapy, we need to ask: What is the "psych" in psychotherapy, This is Greek  for "mind," such that psychotherapy refers to treating the mind. What functions constitute mind? Simple. All thoughts, feelings(emotions) and behaviors fall into the realm of psychology. Moreover, though less intuitively, most thoughts are themselves connected in the mind to specific feelings as well as to specific behaviors. For instance, on a  cold wintry Sunday afternoon, anticipating return to my stressful job tomorrow, I may feel both anxious and blue as I anticipate being once again derogated by my boss. I ask my wife if we still have that leftover spaghetti with gobs of hot marinara sauce and maybe some of that Italian bread as well,as comfort food. A glass of Barolo wouldn't hurt either. Note the connections among the emotions(anxious, sad), the thoughts("comfort food would be great"), and the behavior(seeking out the pasta). Indeed, I likely have sought out spaghetti so many times before under similar circumstances that anxiety+sadness, thoughts of pasta, and seeking behaviors are now part of my MO, a small part of my personality. Friends may actually know me as "the weekend pasta guy." So, too,  for other thoughts, feelings and behaviors.

Taking this thought one step further, given the connections among all three of my Sunday psychological functions, it would follow that the motions stimulated by the anticipation of Monday morning would lead to the thought and behavior specified, But one might also imagine that I was kindly invited by my Italian friend's wife for her homemade pasta one night mid-week. It might not be surprising then that, sitting at her table and enjoying her family's traditional pasta and red sauce, I might be prompted to feel suddenly sad and anxious and to have thoughts of Mpnday morning, though this is 4 days from now.

That is how the mind works. This phenomenon was well illustrated in literature by Marcel Proust at the beginning of "Remembrances of Things Past."  Eating a morning madeleine, a French biscuit, floods him as an adult with memories of being sickly and laid up in bed as a young boy. (It is also interesting to note that Proust also divined a piece of neurophysiology. As it happens, the human smell center at the anterior poles of the temporal lobes are quite close to the brain"' memory center, the hippocampus, Not surprising, then, that smell and taste, which run together in the brain, would be especially intimate in its connections to the thoughts we call memories).

The sum total of these triadic constellations makes up your personality: The traditional way you think, feel, and behave over time. Actually, and more precisely, personality consists of two broad parts. The first is "temperament." This refers to or, as it were, inborn personality: When I was rotating through  Obstetrics in my third year of medical school, we were taken to observe the newborns in their nursery incubators Some were quiet and placid, some were chronically fussy, some preferred sleep, while others were alert and curious and already trying to connect to their surrounding. These inborn traits involving anxiety levels, energy levels and curiosity will remain with these tots throughout their lives.

However, and likely more important, another powerful input gets laid over the inborn temperament :internalized experiences. What does this refer to? The child's brain is akin to wet cement which will not fully harden until the mid twenties. Impressions laid on this wet cement will become permanent as the brain matures. We call this process "internalization." This is why a victim of rape may fear men and become hypervigilant her whole life. Conversely,, it is also why a child properly nurtured and loved will likely be trusting of others and at ease in their presence. If you examine your own personality characteristics and think back on your early experiences, you will come up with many interesting correlations and presumptive experiences which you have internalized and which lead you to certain common ways of thinking, feeling, and behaving in adulthood.

I like to tell my patients that the sum total of our temperament plus internalized experiences constitute a kind of the player piano program which keeps playing the same melody oiver nd over again. This melody can be pretty to the ears and make others smile. But thed melody cAn also be harsh and hard on the ears of others. When our personalities are hard for others to bear, we are said to have  personality disorder. The narcissist, for example, traditionally and frequently sucks up al the oxygen in the room by drawing all the attention to himself, leaving others feeling empty and enervated. A borderline personality will frequently cling desperately to others, and rage and self-injured when they feel(easily)abandoned, leading others to distance themselves precisely the antithesis of what the borderline person seeks.

To put an even finer point on personality disorders, one can distinguish between  a pure personaity, also called character, disorder, and what is called a make others suffer. Consider the antisocial personality disordered individual who lies, deceives others, behaves destructively towards others, steals, and experiences no remorse. Such individuals rarely come voluntarily to therapy, because they suffer no pain internally. If they are forced into therapy, they therefore have little motivation to change. Their behaviors are experienced by them as  "ego-syntonic," that is, they see their misbehaviors as quite okay.Those personality disordered individuals who do come voluntarily and who are motivated for treatment  are the character neuroses. They experience pain as a result of their personality problems. A female patient of mine entered therapy because she felt, hard though she tried, no man wanterd her. Meanwhile, all of her girl friends were marrying and having children. Another patient, astute, came in pain because others would not bend to her will and give her whatever she wants. "Doc, I know it's crazy(ego-alien), but I get overwhelmed with anger when this happens" .Another highly talented and productive(for his company)individual  came for treatment because of the great disparity between his talents and his career achievements.

Psychotherapy is a multifaceted phenomenon with many moving parts. There are numerous kinds of therapy, each addressing a different part or set of parts of the psychological triads discussed earlier, Thus, behavioral therapy addresses the patients behaviors. If the patient with social phobia, self conscious, fearful of others' judgments, and avoidant therefore of social functions, is seen by the behavioral therapist, the latter will not be attending to the individual's anxiety of early childhood, Instead, the therapist will subject the patient to gradually exposing her patient to ever more intense social scrutiny, while training her patient to relax through deep breathing with each increment of social exposure. The therapist here is addressing the patient's behaviors  exclusively., When treatment is successful and the patient is turned into a social butterfly, the old feelings of fright and thoughts of low self-esteem, connected as they had been to the behavior of social avoidance will likewise melt away.

The pure cognitive therapist will address the patient's thought patterns exclusively. The patient may be depressed and complain that people never like her. Therapist: "Let's examine that belief for a moment. Do you recall any time in the past when someone was fond of you/" Patient: "Well, of course, there was Bob in college who would throw roses beneath my dormitory window," Therapist: So there were some occasions where you were liked. The next time you have the thought that no one likes you, can you think back on Bob and recall his being head over heels for you?" Patient: I guess I've tended to have all- or- none thinking on this subject." As she develops more nuanced thinking, her emotional pain and failure to seek out male relationships should improve as well/

Other therapies are Interpersonal Therapy which focuses on the patient's relationships and interactions- a form of therapy addressing emotions primarily. Cognitive-Behavioral Therapy addresses both parts of the triad simultaneously. Dialectical Behavioral Therapy is relatively specific for Borderline disorders. EMDR is a form of behavioral therapy meant to stimulate, through rapid eye movements, painful memories(thoughts) previously suppressed and inaccessible so they may be reworked and defanged.

My own predilection is insight-oriented psychotherapy, heavily influenced by psychoanalysis. However, whereas traditional psychoanalysis had the patient lying on a couch, out of sight of her analyst, four or five times a week for four or five years, insight therapy has the patient sitting up, facing the therapist, who will likely be much more active and responsive than the traditional psychoanalyst. Here, the patient and therapist enter.,often avowedly, into a joint endeavor to,  essentially, uncover and put into words  the  patient's(implicit) player piano program, which is currently dysfunctional. This is done through elaboration and examination of the patient's current life experiences, past history, traumatic memories,  dreams, body language, as well as his/her emotional responses to the therapist. I prefer this therapy because of its depth relative to other forms of treatment, Here, thoughts, feelings. and behaviors become grist for the examination mill. It is the process, to borrow the title of a notable book, of "disclosing man to himself."

I have simplified the descriptions of the therapies to highlight their unique differences, In fact, most therapies are essentially "eclectic," insofar as they borrow features from one another. Even the purest behavioral therapist, for instance, spends time talking to her patients. In the process she is developing emotional ties with her patients, attachments which are healing in sand of themselves. The Freudian psychoanalyst, trained to remain remote in his presentation and therefore not try to direct the patient's behaviors, will likewise jump in actively and advise behaviors when confronted with a patient who does not recognize the imminent danger he or she may be facing.

One caveat for the therapy consumer: It is vital to select a therapist with whom you have "chemistry," one who "gets you." Absent this emotional attachment, no therapy will be successful. Years back, Carl Rogers, the psychologist who developed Client-Centered Therapy, linked positive therapy outcomes largely to these qualities of the therapist: unconditional positive regard and acceptance of the patient, non-possessive warmth, genuineness of the therapist(including genuine empathy). and non-possessiveness(meaning, "I do not need to hold on to you for my own emotional or financial needs"). These are the elements of "chemistry" you should be seeking in your therapist. Ideally, therapists should be sensitive to initial interactions in which they do not "click" with the new patient, and refer to a colleague who might be more suited to the patient. In practice, this often does not happen, and patients are mired in as non-productive, indeed wasteful, treatment. If you do not feel the "chemistry, " the "click," the attachment,  do not blame yourself. It does not exist. You should absolutely shop around until you find a therapist with Rogerian qualities.

A final word of practical advice: If your issues are primarily symptomatic, i..e., depression, anxiety, hypomanic symptoms, ADHD, etc., you would best advised to consult first and foremost with a (medical) psychiatrist. Many symptomatic conditions can be treated relatively  quickly and efficiently with medications or other somatic therapies.(though some symptoms can  be addressed with Cognitive Behavioral treatment as well). You might also need psychotherapy for underlying psychological problems.. However, symptomatic syndromes nearly always significantly exacerbate personality problems, such that it is difficult to determine just how intense and impairing are the character issues until the symptomatic syndrome has been treated. On many occasions, therefore, what looked like character disordered problems at initial evaluation  decreased significantly in intensity once the symptomatic syndrome was well treated medically. Unfortunately, many is the patient who visits a psychologist or other therapist for great lengths of time and does not improve, because her symptoms were never addressed medically.