Am I Crazy, Or is It My Shrink

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    Am I Crazy Or s t My Shrink?

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    Am I Crazy

    Or s t My Shrink? L A R RY E . B E U T L E R P h . D .

    B R U C E B O N G A R P h .D .

    A N D

    JOEL N . S H U R K I N

    N e w Yo r k O x f o r d

    O X F O R D U N I V E R S I T Y PRESS

    1998

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    Ox ford Un iversity Press Oxford New York

    Athens Auckland Bangkok Bogota Bombay Buenos Aires Calcu tta Cape Town Dar es Salaa m

    Delhi Florence H ong Kong Istanb ul Kara chi Kuala Lum pur Madras Madrid Melbourne

    Mexico City Nairobi Paris Singapore Taipai Tokyo Toronto Warsaw

    and associated companies in Berlin Ibadan

    Copyright © 1998 by Larry E. Beutler, Bruce Bongar, and Joel N. Shurkin

    Published by Oxford University Press, Inc. 198 Madison Avenue, New York, N ew York 10016

    Oxford is registered trademark of Oxford University Press

    A ll right reserved. N o part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,

    electronic, me cha nical, photoco pying, recording, or otherwise, without the prior permission of Oxfo rd Un iversity Press.

    Beutler, Larry E . Am I crazy, or is it my sh r ink? / Larry E. Beutler, Bruce

    Bongar, and Joel N . Shurk in . p. cm.

    Includes bibliographical references and index. ISBN 0 19 510780 2 (cloth) 1. Psychotherapy—Popular works. 2. Consumer education.

    I. Bongar, Bruce Michael. II . Shurkin, Joel N ., 1938- . III. Title. RC480.515.B48 1998

    616.89 14—dc21 97 43546

    1 3 5 7 9 8 6 4 2 Printed in the U nited States of America

    on acid-free paper

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    Dedicated to our patients in hope that they will accept our mistakes and in appreciation for their

    patience while we have tried to learn. —LEB and BB

    For my children Jon Mike and Hannah with love. —JNS

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    ont nts

    Acknowledgments ix

    Introduction 3 1. What You Should Know About Therapy 11

    2 Who Offe r s Help and Does It Make a D ifference? 29 3. How Treatment Is Kept Accountable 45 4. Seeking the Healing Patient Therapist Relationship 63 5. How Helpful Is Diagnosis? 79 6 What Is Different About Different Therapies? 97 7. How We Discover What Works 119

    8. What Works with What Problems? 135 9. Am I Crazy Or Is It My Shrink? 181

    Appendix 197

    Suggested Readings 199

    Index 205

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    knowledgments

    W e would like to express our appreciation to our ed itor Joan Bossert, and the people at Ox ford Un iversity Press for bearing with u s and encouraging us to begin and complete this book They provided both the

    encouragemen t for our

    idea and the

    n ecessary suggestions to

    helpus do some of the needed library research There have been many others, as we ll, to whom we owe thanks— students, former students, family m em bers, colleagues, patients, and friends who must remain nameless for lack of space.

    This experience has been an interesting one. Two of us (Beutler and Bo ngar) have written extensively fo r professional audiences, but

    never quite thought we knew how to express ourselves to a non- professional one. W ith Joan Bossert s encouragem ent, we were able to collaborate with Joel N Shurkin and the relationship has been a rewarding one.

    LEB BB

    JNS

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    ntrodu tion

    A patient sat in my office. Fifty-three years old, she is a veteran o f our outpatient clinic, having come there for the last seven years. I am seeing her for the first time.

    Every July 1 a new crop of psyc hiatry and psychology s tudents enters the clinic and an old group o f graduates moves o ut into practice af ter their seven years of postgraduate training. As the

    D irec to r of O utpa tient Services, I [LB] was p erso nally evaluating all pat ients being trans fe rred to new therapists at the beginning o f a new t ra ining year and was interested in Mrs . T because her medica l record showed no subs tan t ia l symptoms o f emot iona l disorder for s ix years.

    Mrs. T initially entered treatm ent sho rtly after giving birth to her four th child. The baby blues were m o re severe this tim e than in

    any previous pregnancy and it got so bad just before she sought treatment that some days she could not get herself out of bed. One day, she began to hear voices telling her to kill herself and the baby, she felt worthless, and the voices said that she should be punished fo r her mother 's unhappiness. She was frightened and decided to seek help.

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    I N T R O D U T I O N

    The f irst therapis t she saw in the clinic was a third-year psychi- atry resident , a young m an completing h is t ra ining and about to

    enter pract ice as a full-fledged psychia t r i s t . He saw her in psy- chotherapy on a weekly schedule, talking with her about her feel- ings of motherhood, and s tar ted her on a medicat ion, the name of which she could no longer remember.

    Mrs. T noticed some real improvement within a short time. The voices went away after a few weeks and she began feeling better. By the end of three m ont hs of treat me nt, she was m uch better. By then, however, the young psychiatrist , on whom she had become depen- dent, told her he was leaving. His t raining was ending.

    Mrs . T became depressed— not as depressed as she had been—but her appetite decreased and she began experiencing some difficulty sleeping. The young ps ychiatrist talked her into transferring to a new, first-year resident, fresh out of medical school, to help her work through her sense of abandonment.

    Since that t ime, she has seen five other therapists . As each aca- demic year ended, she is t r ans fe r red to a new resident or clinical psychology intern.

    Mrs . T tells me she has not been depressed since the original ther- apis t left and has experienced no r e tu rn of the voices. I ask why she is still coming to the clinic. She admits that she really doesn t

    know, but each therapist recommended that she t ransfer, so sheimagined that i f she did not , she might re lapse and become depressed again. Long after she had returned to health, she was still receiving—and paying for—treatment.

    At least 100 million people currently living in the United States will, at some time in their lives, experience problems in relationships,

    become depressed, or develop anxiety so serious that they will merit psychiatric diagnosis and would benefit from the services of a men- tal health professional. Twenty-eight percent of the U.S. population (more than 70 million people) will have such problems in any given year. However only one-fourth of them will actually get treated.

    Those who want treatment will seek it from psychologists, coun- selors, psychiatri sts , social workers , nurses , family doctors, and min-

    isters. The educat ions of these professionals will run f rom specialized

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    INTRODUCTION 5

    training in psychology and m ental health to medicine; some will have no formal t raining in mental health treatment at all. These profes- sionals will come from different backgrounds, have different types of training and experience, and will use different methods.

    Most of those s eeking help w ill benefit from only a few treatment sessions; some w ill need and receive long-term and continuing treat- ment over several years. Some will feel bet ter just by making an appointment, and will need nothing more. Some who require long- term treatment wil l terminate or be terminated from t reatment too early and their symptoms will return. Some will get t reatment that will mak e their lives worse, not better. Some of those who need only short-term treatm ent will get continuing and expensive treatment for common, ordinary problems that pass with t ime, and will pay for it even when support may be available f rom their own friends and family.

    Unfortunate ly, many mental heal th pract i t ioners don t know which patients will experience which results.

    One of the saddest and most disconcerting facts facing the health care industry today is that most counselors, psych