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Am I CrazyOr s t My Shrink?


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Am I Crazy

Or s t MyShrink?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 PressOxford New York

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

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

Mexico City Nairobi Paris SingaporeTaipai Tokyo Toronto Warsaw

and associated companies inBerlin 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 2Printed in the U nited States of America

on acid-free paper


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Dedicated to our patients in hope that theywill 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 31. What You Should Know About Therapy 11

2 Who Offe r s Help and Does It Make a D ifference? 293. How Treatment Is Kept Accountable 454. Seeking the Healing Patient Therapist Relationship 635. How Helpful Is Diagnosis? 796 What Is Different About Different Therapies? 977. How We Discover What Works 119

8. What Works with What Problems? 1359. 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 andencouraging us to begin and complete this book They provided boththe

encouragemen t for our

idea and the

n ecessary suggestions to

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

This experience has been an interesting one. Two of us (Beutlerand 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 ableto collaborate with Joel N Shurkin and the relationship has been arewarding one.

LEBBB

JNS


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Am I CrazyOr Is It My Shr ink?


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ntrodu tion

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

Every July 1 a new crop of psyc hiatry and psychology s tudentsenters the clinic and an old group o f graduates moves o ut intopractice 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 evaluatingall pat ients being trans fe rred to new therapists at the beginning o fa new t ra ining year and was interested in Mrs . T because hermedica l record showed no subs tan t ia l symptoms o f emot iona ldisorder for s ix years.

Mrs. T initially entered treatm ent sho rtly after giving birth to herfour 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 soughttreatment that some days she could not get herself out of bed. Oneday, she began to hear voices telling her to kill herself and the baby,she felt worthless, and the voices said that she should be punishedfo r her mother 's unhappiness. She was frightened and decided toseek 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 ofwhich she could no longer remember.

Mrs. T noticed some real improvement within a short time. Thevoices went away after a few weeks and she began feeling better. Bythe 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—buther appetite decreased and she began experiencing some difficultysleeping. The young ps ychiatrist talked her into transferring to a new,first-year resident, fresh out of medical school, to help her workthrough 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 clinicalpsychology 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 whyshe 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 becomedepressed again. Long after she had returned to health, she was stillreceiving—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 meritpsychiatric 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 givenyear. 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 haveno formal t raining in mental health treatment at all. These profes-sionals will come from different backgrounds, have different typesof training and experience, and will use different methods.

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

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

One of the saddest and most disconcerting facts facing the healthcare industry today is that most counselors, psychiatrists, and psy-chotherapis ts w ill continue to t reat you as long as you are w illing tocome in and someone is willing to pay the bills. It is not that theyare bad people or are intent on deceiving you; it is that they hear

your common, ordinary problems and want to help. In so doing, theymake treatment for most people more expensive and intensive thanit has to be and for some, less than what is needed.

Mrs . T s experience is not uncommon. Ini t ial ly, she did r equi ret rea tment and sought it. She received help and it was successful.But she kept r e turn ing to the clinic out of fear of having her prob-lem recur. She was not t reated badly, but she was unnecess rily

t reated by w el l-meaning therapis ts who nei ther knew wh en to quitnor made the effort to f ind out i f she really needed the expensivet rea tment she was receiving.

This book is for people who wish to seek help f rom mental healthprofessionals—clinical psychologists, psychiatrists, family workers,or others in the field. We hope to educate and inform you about w hattherapy is, how it works , how to know when it i sn t wo rking, and

wh en it s best to move on.


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6 I N T R O D U C T I O N

At times, you will find tha t w e are critical of some practices of themental health establishment, especially of psychotherapy and psy-

chotherapists, so we must emphasize at the outset that we are bothpractitione rs of and believers in psychotherapy. W hen we criticizeour profession, we criticize ourselves.

A s scientists and practitioners, w e want to make the field betterby underlining some of the abuses and the ignorance that causespatients to be m istreated. You have probab ly heard of people beingtreated in frankly unethical ways by un scru pu lou s psychotherapists.Indeed, these practices have occurred and we will report incidencesin this book. But, in some ways, these extreme examples are the eas-iest to deal with and are not the most typical instances of failure.This unethical behavior (such as having sex w ith patients or becom-ing emo tionally ab usiv e to th em ) is easier to spot th an the more fre-quent and usual case of the patient who must suffer a clinician'signorance. With an incompetent therapist, you don't feel helped andyou don't know if that is usua l or unusual . Should I change thera-pists? Am I to blame? Should I tough it out? Should I give up ontreatment altogether? W e w ill try to answer these important and dif-ficult questions.

In other words, am I crazy or is it my shrink ?This book is designed to help you answer that question, regard-

less of whether you are being treated in a grossly neglectful andimproper way or if you are receiving technically com petent but inef-fective treatment.

As clinical psychologists and psychotherapists, we [LB, BB] havespent a collective total of nearly forty years in the professional prac-tice of psychotherapy and in research on its effectiveness. W e havedirectly treated thousands of patients and consulted with our col-

leagues about countless others. Many of these patients have beenhelped by therapy, but some have not, and a few have even gottenworse despite treatment.

The public is often unaware that for most practitioners of psy-chotherapy, there is no Hippocratic oath— the oath that physicianstake to Do No Harm. And under certain circumstances, the courtssupport and protect both medical and nonmedical practitioners' use

of ineffective or even dang erous procedures. There are m any reasons


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INTRODUCTION 7

for this state of affairs, and we will talk about some of them, butnone are sufficient justification for those instances in which patientsare the losers.

Like many practitioners of therapy, we worry w hen our patients,or those about whom we have been consulted, fail to benefit fromtreatmen t. W e especially wo rry w hen we see people who get worsein spite of efforts on their behalf.

Suicide is one of the few fatal consequences of a psychiatric con-dition. It is also the most com m on em ergency in psy cho therapeu ticpractice, and the most stressful for clinicians to dea l w ith. Th e firsttime one of us [LB] had a pa tient com m it suicide it was a de vas tat-ing experience. The w om an was an inpatient in a private psychiatrichospital where I was employed. It was my first job and she was oneof the first patients for whom I had primary treatment responsibili-ties. She was admit ted af ter a very serious suicide at tempt. W e

worked together for about three months and met daily on the wardor in my office. She seemed to respond well.But then I got a job offer that seemed ideal and felt I could not

turn it down. In a scenario that was not unlike that of Mrs . T,when I in formed her that I 'd be leaving in two months , she react-ed strongly, even though she was scheduled for discharge w ithin afew w eeks. U nlike M rs. T, how ever, this patient 's cond ition deteri-

orated rapidly, requiring that her discharge be delayed. She wenthome about a month after I left, but continued to call me aboutonce a month for the next six months. Then I did not hear fromher for several months.

O ne morning her husband called to tell m e that she had cl im bedinto the bathtub and shot herself in the he ad. There followed a timeof serious self-doubt, during which I questioned my suitability for

this profession, and suffered substantial depression.While this scenario is not uncom m on for practicing m ental health

clinicians (more than 20 percent of psychologists and over 50 per-cent of psychiatrists will lose a patient to suicide at some time dur-ing their career), therapists often react to the loss, as I did, as if theyhad just lost a close friend or family member in a sudden and unex-pected acciden t. Clearly, Freu d's description of psychotherapy as the impossible profession is t rue in m any ways, and reflects wha t one


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8 INTRODUCTION

researcher, Ray Lon don, also noted in his study of psych otherapists:For many, it is also a lonely profession.

Most of us really do careW e both [LB, BB] elected careers as what the profession refers to

as "scientist/practitioners" so that we could not only practice whatwe learn w ith our patients but could teach these skills to others anddo research that would improve our work. Between us, we have beenassociated with five major university-affiliated medical schools. W ehave also been employed as professors and instructors in graduateand undergraduate departments of psychology in eight major uni-versities and colleges. We have worked in, directed, and supervisedthe treatment of patients in academic departments of psychiatry,medicine, pediatrics, family practice, urology, oncology, psychology,education, and cardiovascular medicine.

At the same time, our research responsibilities and interests havemade it possible for us to address the concerns raised about the pro-fessional practices of psychology, carryin g out research on how effec-tive various forms of psycho therapy are. W e have had the opportunityof taking our clinical observations and problems and using them tofind ways of improving both our own and others practices.

Our research has been devoted to finding increasingly effectivetreatments, testing new theories and models of emotional change,

and searching for a better understanding of why people have diffi-culties and what they can do about them. We have written over adozen books and several hu nd red pap ers and chapters on these top-ics, all aimed at ou r profe ssiona l colleagues.

But these efforts hav e ignored an im portant ingredient in the men-tal health equation—the needs of the patient. If we look at factorscontributing to the success of treatments, we find that it is not the

clinician or treatment procedure that is key, but the motivation,awareness, expectations, and preparation of the patient or client.W hile this is true, therapists m ust take responsibility for ensuring th atpatients become motivated, educated, and receptive to treatment.

Many books suggest how people can help themselves, w hat wo rks,and how they can change their lives. The promises from these booksrange all the w ay from better sex lives to wealth and fame. W e don t

know if these books live up to their promises, but we think that


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INTRODUCTION 9

insufficient attention has been paid to helping patients prepare them-selves for treatment and providing them with enough information sothey can evaluate whether they are getting the best possible treatmentfor their particular problems.

W e hope this book will help you know when therapy is doinggood, and more important, when it is doing harm. You will alsolearn when it is time to try a different treatment, a different thera-pist, or an alternative that doesn t include psychotherapy.


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1What You Should Know

bout Therapy

Few would question the observation that psychiatric diagnosis andtreatment are imprecise arts. Few know just how imprecise, however.

One of us [BB] rem em bers the case of Solomon Rubin, a sixty-year-old Holocau st survivor. On e day, Rub in s car was ra m m ed bya supe rm arket delivery truck and was crushed against a w all. Luckily,he survived w ithout major injuries, but from that moment he refused

to get into a car, m uch less drive one. He knew he needed help, butinstead of talking to his son, a clinica l psycho logist, he went to a LosAngeles psychoanalyst, w ho assumed, because of Rubin s past, thathe suffered from survivor s guilt , a comm on phenom enon amongthose who l ived through the Nazi horror. The analyst s solution:many months of deep psychoanalysis and a therapy that focusedon exploring the m em ories of his you th and surv ival at Bergen -Belsen. Then his son found out.

The son sent him to B B, who began the usual behavioral treatmentsassociated with such phobic conditions. After completing several weeksof treatment called systematic desensitization, Rubin, as homeworkassignment, began driving on short trips: a few blocks the first week,a quar ter mile the second, and so on. He was told not to rush things.

11


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2 W H T YOU S H O U L D K N O W B O U T T H E R P Y

A ll went beautifully for seven weeks until R u b in called BB in LosAngeles to ap olo gize for not foll ow ing his instructions properly. He

had gone for a short d rive on the freeway and wanted to keep going.He was calling from La s Vegas.Rubin spent a few more weeks making sure the therapy contin-

ued to work—it did—and he was finished.If Rub in did suffer from survivo r guilt, that was a separate issue

from the phobia that was interrupting his life, and once that wasfixed, Rub in could decide if he wished to reexamine his memories.He was treated w ith psycho ana lysis becau se he went to a psychoa n-alyst. A t that t ime and to this date, there is no literature to supportthe use of psychoa nalysis to treat a driving phob ia. I t wa s the wrongschool of therapy for what ailed Rubin. The psychoanalyst thoughthis approach was the right one, that he knew wha t was wrong withRubin , and, m ost im portant , that his treatm ent would cure Ru bin ofhis phobia .

Considering that there a re m ore than 400 schools of psychother-apy (actually, this figure is very conservative; it is well over a decadeold), and that n u m b e r is constantly increasing, it 's no wonder thisfield is plagued by a considerable lack of consensus. Disagreementsab ou nd regarding w ha t theories are true, the origin of psychologicalproblems, appropriate diagnostic cri teria and terminologies , the

na ture of treatm ent, or even how to judg e when treatm ent w orks.Meanwhile, new diagno stic and t reatment methods are being creat-ed a t a dizzying pace. W here does this leave y ou , the consum er?

This chap ter will explore som e of the wa ys tha t people, inclu dingpsychotherapists, attem pt to u nde rstan d w ha t is true and real. W ewill begin by looking at the differences and relative advantages ofbasing our beliefs on ex ternal, ob jective evidence rather than anec-

dotal evidence a nd emotion.A s a reader, the f irst thing you should know is that the psy-

chotherapeutic treatm ent you receive from a therapist depends on thebeliefs a nd theory y ou r doctor cu rrently accepts as true.

Theories are not facts. They a re only gu iding philosophies tha tsuggest b oth the na tur e and cau se of the prob lem s you are having aswell a s a m ethod of t reatment . For exam ple, if y ou r therapist believes

that depression arises f rom a b iological disease or is a chemical


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W H T YOU S H O U L D K N O W B O U T T H E R P Y 3

im ba lance, he or she likely will treat you with medications. If thetherapist believes the cau se rises from forgotten traumas in childhood,

he or she will seek to u ncover these childhood events throu gh tal kingtherapy. These are only theories or conceptual models throughwhich your psychotherapist 's observations are organized.

There are few absolute and invariant t ruths about what causes aperson to feel bad or act inappropr ia te ly. The same feeling andbehavior m ay ha ve very different causes for different individuals, o rfor the sam e person on different occasions, and most causes are bothmultifaceted and unknowable wi th ou r present methods.

While those who practice medicine, law, and even the constructiontrades are all guided by their particular theories, the role of theory isa bit different in the mental health comm unity. In this field, treatmentis more closely governed by the therapist's theory than the patient'sproblems. If the therapist believes that problem s com e from repressedchildhood experiences and memories, all problems will be treated bytrying to u ncover these m em ories. If the therap ist believes tha t depres-sion is a chem ical im balance, all will prob ab ly receive m edication. It isonly a modest overstatement to say that each therapist offers a treat-ment that is consistent with the therapist's theory, regardless of whatthe patient's problem is.

In essence, it is a o ne-size -fits-a ll sho pp ing ex perience for the

unknowing psychotherapy patient. If the practice of medicine wasconducted like that of psychotherapy, then doctors who specializedin obstetrics would treat headaches and appendicitis the same waythey treat pregnancy, and a neurosurgeon would do brain scans andbrain surgery on those with a bad back .

Suppose yo u a re depressed a nd ha ve soug ht help f rom a therapist.After six sessions, things are going badly. You don't feel any better,

you don't like the therapist and you tell him so, and even suggestthat you want to quit t reatment. A therapist whose theory dictatesthat you r emo tional problem s are caused by ineffective defenses con-structed so that you do not face your problem s and m ake changes inyour life will interpret your dissatisfaction as an indication that youneed more frequent treatment sessions to overcome this resistance.Your therapist m ay explain that things get worse before they get better

and that it is good for you to face you r problems. A regular Catch-22.


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14 WHAT YOU SHO ULD KNOW ABO UT THERAPY

If your stockbroker recommended such a course, you'd be a lot moresuspicious.

Alternatively, a therapist who believes that the primary healingforce f or depression is the power of a compat ible and mutua l lyenjoyed relationship between you and a healer m ay suggest thatanother therapist might better f it you r style of relating and m ay evenhelp you make the transition to a new therapist. In these two cases,you still have the same problem and symptoms. ou remain the con-stant, the therap y becomes the variable.

Different theories lead to different courses of treatment and dif-ferent reactions from the people being treated. No theory will workfor all individuals and all problems. A theory may suggest recom-mendations that are well founded, but some theories are simplybunk.

Therapists offer varying suggestions because they have adoptedbeliefs

from their mentors and colleagues about what makes peopleget better. But they usu ally fail to qu estion these assum ptions, regard -ing them as self-evident truths and applying them to everyone whowa lks through the door. Som etimes they fit, but sometimes— proba-bly between 30 and 50 percent of the time—they don't.

Central to our quest of helping you recognize when you are get-ting the right treatment is defining the quality or validity of the

knowledge you are likely to get through different avenues. I n otherwords, what type of evidence can you trust when you make thesedecisions?

• Can you trust you r own feelings about how you're doing?• Can you trust your own assessment of what treatment should

be accomplishing in your case?• Are there other sources of knowledge tha t w ill help yo u?• When are therapists making their recommendations based on

truly valid treatments, and when are they blindly f ollowing oneor another of their favored but unproven philosophies?

Yet, to be honest, there are times when therapists don't have theanswers for working with certain clinical problems. Sometimes nohard and valid evidence exists f or what particular treatment will

serve you best.


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W H T YOU S H O U L D K N O W B O U T T H E R P Y 5

The practice of psychotherapy has two basic avenues f or judgingwhether certain assumptions and practices are true and valid. Thisis true for you and also for your psychotherapist. One of theseavenues is your own personal experiences or, more precisely, theinterpretations and meanings y ou assign to those experiences. Yourpersonal experiences and memories of past events m old you r beliefsabout how and why people function and change. The result is animplied and usually unquestioned set of beliefs about what is trueand what is not. Psychologists call this set of assum ptions and beliefsimplicit knowledge, because the basis of yo ur knowledge is impliedand internal instead of explicit and observable.

The second a ve nu e to know ledge is sound scientific research.Research findings result in empirical knowledge—meaning that ithas been tested, is observable, and can be repeated with the sameresults (replic ab le)— the basic criteria of accepting information as

factual in science.While both methods are widely used, and have serious limitations,most people put more faith in their own experience than any empir-ical proof revealed throug h scientific research. A recent TV comm er-cial for a popu lar, nonp rescription pa in killer illustrates this fact. Thecharming and sincere actor asserts his belief in the effectiveness of themedication, saying: "Did I review the clinical research that proves it?

No, of course not I 'm not convinced by charts and graphs. Are you?I had a headache— I tried it . That's the only kind of research that mat-ters to me."

The lessons we learn from experience are based on m emo ries andperceptions of events that are associated w ith especially strong feel-ings. These memories are usua lly remembered as stories, with themore emotional aspects playing a more central role in the events

than less emotionally related elements. This is often done at theexpense of accuracy. Events and memories are then linked by com-m on, em otionally related themes. Scientists call this anecdotal evi-dence. Anecdotal evidence fo rm s the basis for most of our beliefsand has t remend ous power over people's lives. There is a strong ten-dency for people to rely on this implicit knowledge even when bet-ter and more accura te i n fo rma t ion is av a i lab le . Mem or ies ofpersonal experiences can easily be misinterpreted, and the beliefs


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themselves are remarkably fallible. Research studies have shownthat even whe n clinicians are repeatedly shown that their anecdotaljudgments are inaccurate when compared to those based on statis-tical form ulas , wh en placed in a situation in w hich they m ust choosebetween the two, they still tend to believe in their own clinical jud g-ments over more accurate, statistical predictions.

If we are trouble d, our person al experience m ay be especiallyproblematic. Sometimes what seems logical to us on the basis ofanecdo tal ev idence simply isn t true. But this can be hard to explainto people. Throughout this book, we will provide examples of howremembered experience can lead us astray. As psychotherapists our-selves, we have found that scientific evidence, wh ich also has its lim-itations, can supply us with the most accurate information andknowledge about our patients and their problems.

Personal Experience as Evidence ofWhether Treatment Works

While it may be difficult to believe, our senses— even our commonsense—are easily fooled. You have probably seen optical illusions,lines that seem the same size but aren t, lines that seem curved but

are straight. The optical illusions illustrated in any high school psy-chology textbook demonstrate this. But this is not just true of oursenses. More complex assumptions and beliefs that we make aboutthe world based on sensory and perceptual experiences can also besubject to distortions. An d the context of our experience has an evenmore serious effect on complex beliefs than on simple perceptions.

How many times in the night have you woken up, believing you

hear voices? Most of us have. But if we base our lives on the antic-ipation or avoidance of these voices, our lives would be disruptedand rapidly become unmanageable. As the situation passes, so doesour fear. Life returns to normal. W e think of our fearful reaction thenext mo rning and laugh . It was only a dream .

But what if our fears do not match our experience?Most of us have had a momentary exper ience of h ypervent i la-

t ion and hear t palpi ta t ion that has made us a f ra id we are having


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WHAT YOU S HOUL D KNOW ABOUT THERAPY 17

a heart at tack or maybe even dying. This fear is unjust if ied, butnot illogical, and it generally passes. But what if i t doesn t? Somepeople become so preoccupied and consumed by such experiencesthat every change in breathing, every momentary experience ofvertigo, every stomach or head pain, seems a shadow of disease,the closing footsteps of mortality.

It s not easy overcom ing the tendenc y to believe in your o wn expe-riences. Ancient peoples were convinced that the world w as flatbecause their senses could not detect any curvature on the horizon.But we don t need to find examples in ancient times. Ever watch aBoeing 747 take off? Com m on logic based only on our senses w ouldnever tell us that an object that large and tha t heav y could ever fly.Nor is it obvious to our senses that microscopic organisms cause dis-ease, or that sex causes babies. All this knowledge came from therudimentary application of science—the art of systematic and objec-tive observation.

Our personal experiences also rely on our mem ories, which are ina constant state of flux. With each new experience, our past histo-ries, in a sense, become rewritten, reshuffled. One of us recentlywrote a brief history of his early life for his children, but a short timelater discovered a description of the same events recounted by hisfather. The differences were rem arkab le. Acco rding to the fa ther s

account, things believed by the son as his own experience actuallyhappened to his sister. Another event was something that happenedto the fath er as a boy— adopted by the son thro ug h elusive process-es, apparently linked by his desire to identify with his father. The sto-ries had been told and retold so many times they became co-optedby the son.

Former P resident Ro nald Reagan serves as another exam ple of this

phenomenon. On several occasions, he told people of his experiencesduring the liberation of concentration camps in World War II. ButReagan never left the Hal Roach Training Studio in Los Angeles wherehe made training films during the war. He had begun to believe hisown movies.

It is a struggle to give up a memory that seems so real, especiallywhen it is central to our identity.

Our th inking is also affected by whether we suffer from depres-


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18 WHAT YOU SHOULD KNOW ABOUT THERAPY

sion or another mental disorder. For exam ple, depression-prone indi-viduals tend to be more likely than nondepressed individuals toattribute the cause of bad events to their own defects and unchange-able personal weaknesses rather th an to situations, temporary events,or correctable problems. They tend to believe and remember badevents more clearly and more often than good ones. Decades afterthe event, they can remember insults, slights, inconveniences, disap-pointments, crises—in minute, agonizing detail. Consequently,depressed people are often und u ly pessimistic, hav e low self-esteem,and give up quickly.

In contrast, less depressed individuals tend to have clearer mem-ories of good events than bad ones. For these individuals, the falli-ble, biased, and changeable nature of how they remember andperceive events can lead to erroneous conclusions about how help-ful a treatmen t is and m ay have disastrous consequences for those inpsychotherapy. A couple of examples from recent headlines mayhelp us make our point.

In 1994, John Hagelin, a Harvard physicis t ,* announced anexperiment designed to reduce violence in Washington, D.C. TheInstitute of Science, Technology, and Pu blic Policy, an organiza tioncomprised of believers in the Maharishi Mahash Yogi (organizer ofthe Transcendental M editation m ove m ent) , would co nduct an

experiment in which 1,000 of their leaders would meditate in uni-son. Hagelin promised that this would generate a powerful anti-violence field that not only would reduce crime by spreading tran-quillity, but would also make President Clinton more effective inrunning the country.

Hagelin declared the expe riment a complete success, even thou ghsystematic tabulations of incidents of crime and violence showed

clear increases during the time of the experiment. Hagelin and hisfellow researchers explained these facts away, asserting that the vio-lence rate would have been even higher without the meditationTheir belief was so great that they proposed the fede ral gov ernm entgive them a $5 m illion g rant to continue the experiment. They didn tget it, but they did manage to illustrate how strong one s reliance

*Dr. Hagelin may be better known as the N a t u r e Law Party candidate for Presidentof the United States in the 1996 elections.


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can be on anecdotal evidence, and how far removed it might befrom reality.

More dramatically, late in 1995, the Public Broadcasting Systempresented an expose on satanic abuse therapy. In the 1980s andearly 1990s, a number of psychotherapists became convinced thatspecific symptoms could indicate whether someone had been sub-jected to sexual abuse and reprogramming by satanic cults. Theirbeliefs became so strong that they sought evidence to justify them,and were convinced that certain family trees were replete with illic-it international alliances among covens of witches, maintainedthrough a conspiracy over the centuries. They believed that mem-bers were recruited to these covens by parents preprogramm ed notto remember their involvement in the satanic cults. These recruitswere then sexually and satanically abused, indoctrinated to murderenemies of the coven, and then trained to forget that any such pro-gramming and abuse had happened, until they could pass the ritu-als on to their own children.

On the strength of these beliefs—their theories—these well-meaning practitioners designed extensive, expensive, and life-consuming treatments to purge the evil and reveal the hidden pro-gramming. These treatments were conducted in legitimate medicalcenters and clinics. Patients were subjected to "deprogramm ing" ses-

sions, hypnosis, group confrontation, the withholding of socialacceptance, isolation, physical restraint, the use of psychoactive med-ication, and other procedures intended to get them to admit theirhistories of abuse and satanic worship and reveal their plans to m ur-der or abuse others.

These events probably seem incredible to you. They astound us.The presence of a hidden and secret society, unknow n even to its own

mem bers, that transmitted curses and witchery over centuries with-out discovery stretches the boundaries of logic and probability—unless you are Steven King or Ann Rice.

Our astonishment does not mean we do not believe childhoodabuse is a serious problem or that it does not happen. It is terribleand it oes happen. But trivializing it or perverting it with wild con-spiracy theories doesn't help the children who need our attention.

Any belief whose evidence of truth rests solely or partially on


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statements that soun d so m ething like these should be serious lyquestioned:

• It is true because im portant people believe it.• It is true but only those who believe will be able to understand

the proofs.• It is true because those who have been converted attest to it.• It is true because it produces good results.• It is true because it exists.

The last proof is refe rred to as circular reason ing and is prevalentin m any a reas includ ing the m ental health field.

The PBS progra m included reports of w hat frequently happens ingroups whose belief systems rely on such faulty evidence. The pro-gram presented ex-patients who described how they had become con-vinced that they had, in truth, been satanically and sexually abused.

They told how they were program m ed to kill m em bers of their fam -ilies and then forget their acts, even though on later reflection theyacknowledged no such experiences had ever happened. Imagine thedilemm a— if you can't rem em ber it happening, it is evidence that youhave been programmed to forget; if you can remember it, it is evi-dence that you w ere programm ed to do it. The logic is unassailable—if you believe. But it is a classic example of circular reasoning. The

proof and the symptoms are inseparable.More important, the program documented the consequences of

raising questions abou t the legitimacy of the treatment. N ursing staffwho questioned the assumptions of treatment were disciplined, dis-charged, or demoted. Patients who questioned their treatment werefound to be resistant, and sometimes were confined or restrainedto their beds by heavy leather straps for several days at a time , until

they confessed or remem bered that the satanic experiences had actually happ ened . People once treated witches this way, often tor-turin g them until they confessed their w itchery. Bu t this was con-temporary America.

In a similar fashion, it has become evident that some psychother-apists believe so firmly that certain symptoms invariably mean theoccurrence of a traum atic past event (circular reasoning) that, even

when the patient has no recollection of such an event, therapy is


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focused on uncovering these repressed mem ories. A gain, this isparticularly true of sexual abuse believed to have been endured dur-

in g childhood. (And again, we are not dismissing the very real andvery serious problem of sexual abuse .)

One survey found that 30 percent of psychotherapists believe cer-tain, inevitable symptoms identify the presence of repressed mem ories.But the specific symptoms are not consistent from therapist to thera-pist. In fact, different psychotherapists put their faith in different symp-toms as the supposedly infallible markers of abuse. Virtually everyconceivable symptom of emotional d istress has been declared by some-one as being an indicator of repressed memories of sexual abuse.Headaches, vague uneasiness, fears of heights or open spaces, sexualanxiety, depression, bad dreams, loss of weight, weight gain, suicidalthoughts, feelings of despair, low self-esteem, loss of sexual interest,and heightened sexual interest, as well as m any more symptoms— eachwas identified by one therapist or another. These therapists indicatedthat if their chosen symptom was present, they would use whatevermeans necessary to uncover the memory of the abuse—and wouldencourage a patient to bring legal action against the perpetrators ofthe abuse, even without any physical corroborating evidence.

Effective psychotherapy does not require you to be a passivereceptacle of the therapist's influence. Psychotherapy is an oppor-

tunity for ex ploration, and all assum ptions are open to question—yours and the therapist 's. Indeed , a good patient is one w ho keepsquestioning and contrasting his or her beliefs with those offered bythe therapist.

A core guideline to keep in m ind w hen trying to de termine if some-thing is factual is w hether there is any evidence— independent of yourfeelings—that corroborates your interpretation of events in your life.

For example, it is often instructive to recall a favorite event in yourchildhood and then to take your parents, brothers, and sisters asideand ask them individually to describe the events you've selected asthey remem ber them. Y ou'll find tha t their reports vary widely a bo utseveral important details. Consistency from multiple perspectives isnot a guarantee that some o bservation is accurate, but it is clear tha tthe lack of consistency should lead you to doubt the accuracy of a

reported even t, mem ory, or fact. An observation cannot be factual-


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ly correct if those who have observed it in operation cannot agreeon what they observed.

Scientific Research as Evidence ofWhether Treatment Works

Science assumes that if a belief is valid, i ts consequences can be repli-cated or reproduced in nearly iden tical fashion across occasions, cir-cumstances, or people, and that the phenomena being observed canbe recorded independent of their consequences. The entire scientificmethod is designed to ensure that the conditions of replicability andobjectivity are present. In contrast, anecdotal evidence, by its verynature, is inconsistent. Basing y our life and decisions on anecdo tal evi-dence means ignoring facts when these facts contradict your beliefs.

Depressed persons may reject

the consistent reassurances of a friend

that they are lovable an d capable. By denying the importance of otheropinions, they doom themselves to their own distorted view of thew orld, and their ow n bad feelings. They reject important inform ationabout themselves that might help them cope with their problems.

How do you approach a problem with your therapist? A place tobegin y our quest of discovering aw areness is to ask y ourself and your

therapist a series of questions. Is this explanation of your problemany better than some other one? W ould another exp lanation m akeequal sense for the presence of this symptom, or could any other setof even ts lead to y our sy m ptom ? If the answer to any of these ques-tions is Yes, then you must question your assumptions, leavingopen the possibility that more evidence m ay overturn your beliefs.

In the case of suspected childhood abuse, for example, does any-

one in the family agree that the abuse occurred? Are there any hos-pital, legal, or clinical records to indicate that traumas of w hich y ouare not aware might have occurred? Has the supposed abuser beenin any troub le of a similar sort? Do those other acts follow patternsusually associated with this type of offense?

In the specific case of childhood sexual assault, it is unlikely that a givenperpetrator offended only one child, did it only on one occasion, or did

not have other, independen tly observed psychiatric problem s as well.


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Scientific evidence has been most useful in determining what typesof treatment are effective for specific problems. For more than four

decades, scientists have made psychotherapy their topic of inquiry,and in that time we've learned a great deal about what works andwhat doesn't. But, as we said earlier, most psychotherapists operateaccording to theories or models that have not been validated. Theeffectiveness of their methods relies on their skill with common ornonspecific interventions. These interventions are methods of influ-ence that can be present in any social relationship (things such askindness, emotional support, encouragement), and are not the spe-cialized components of mental health treatment. Nonspecific inter-ventions are inherently healing, but they do not require particularexpertise or academic knowledge to implement.

A benevolent, sympathetic, and sensitive therapist can do a greatdeal. But the best outcome for the most serious problems calls for apractical know ledge of scientifically proven procedures. Un fortunately,therapists are not legally bound either to practice effective interven-tions or in form patients if they are p racticing scientifically credible pro-cedures. Historically, the proofs of various viewpoints have been leftfor the various factions to fight about— hence, the proliferation of hu n-dreds of different theories of psychotherapy.

Truth is not likely to emerge by an adversarial process. That doesn't

work well in the courtroom and it doesn't work well in the therapist'soffice either. O ne alternative to giving in to the might-makes-right doc-trine began in the courts. In legal cases involving psychotherapeuticmalpractice, the court has instituted the so-called respectable minori-ty doctrine. The law always has been troubled by the fact that whilea number of professional organizations have tried to establish diag-nostic and treatment standards, none of these efforts enjoys widespread

acceptance within the mental health profession. As a result, the courtshave taken on the task of setting the standards of acceptable practicebecause the profession cannot or will not.

The respectable minority rule holds that where there are disputesbased on differences in theoretical approaches and methods of prac-tice that cannot be settled by law, the clinician should be judged accord-in g to the school he or she professes to follow. This school must be

one with definite principles, and it must be the line of thought of a


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respectable m inority of the profession. Un fortun ately, among theprofessions that practice psychotherapy, there are hundreds of respectable minorities.

Another effort to ensure that t reatments offered in mental healthmet minimal scientific standards was initiated with the professionsof psychiatry and psychology in the middle 1980s. At the time, agroup of psychiatrists and psychologists attempted to initiate fed-eral legislation that would establish a board of review for psy-chotherapy. This board would have the responsibility of assessingthe status of scientific evidence for different types and proceduresof psychotherapy, much as the FDA is designed to do for drugs andmedical equipment . Al though it was a good idea, i t was neveraccepted because of concern for costs that could or would not beborne by the government.

More recently, the Division of Clinical Psychology of the Am ericanPsychological Association (A PA ) com m issioned a Task Force toreview all different models of psychotherapy and assess the degreeto which they were supported by the presence of adequate scientificevidence and whether they actually had benefits.

So scientific research has been successful in defining some treat-ments that work and some that don't, and a great many have beenidentified about which we have no knowledge of effectiveness.

W e've also learned a great deal abou t w hat characteristics of ther-apists make them effective, even beyond—and more importantthan—the type of therapy they practice; what types of problems areeffectively treated and which are not; what characteristics or attrib-utes of patients bode well for good outcomes; and what the limitsand strengths of our current diagnosis and treatment methods arefor helping people like you. In other words, what can you legiti-

mately expect in t ime, effort, and outcomes?If scientific research has provided so much, you may wonder why

you have not heard very much about it and why so few practition-ers tend to rely on it. There are several reasons. For example, by itsnature, em pirical knowledge— that arising from scientific f indings—is conservative. It takes time to conduct research, and the standardof evidence is designed to err in the direction of understating the

effectiveness of proce dures. This is t rue for m edical research, as well


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WHAT YOU SHOULD KNOW AB OUT THERAPY 25

as m enta l health research. In con trast, our personal kno wledge of theworld and our experience are liberal in their interpretations. We'requick to accept things that make sense, even if they 're wrong. W e errin the direction of being overinclusive rather than underinclusive.This hum an tendency accounts for the rumors of effective treatmentsand even cures being withheld from the public by the FDA.

It is not that these cures and treatments are withheld; it is that thescientific standard of truth accepted by the FDA (and b y science gen-erally) requires m ore than one supportive scientific study and speci-fies the natu re of the research design that is accep table. The resultsof a single study may be reported and accepted by the general pub-lic long before they can be validated by an independent researchteam, a requirement for FDA approval. The FDA standards, more-over, often are more rigorous than those adopted in other countries,further invoking the belief that a governm ental agency is able to stopthe distribution of effective imported treatments.

Another, and perhaps more important factor is that people tendto trust their senses and beliefs more than they trust the opinions ofothers, e specially w hen con tradic tion exists between these sources ofinformation. When scientific evidence is not consistent w ith their per-sonal experience, they accept the interpretations that arise from theirown fallible experiences.

For example, most psychotherapists in practice today report thatmost patients receive and benefit from having sessions over severalmonths. They estimate that the average number of treatment sessionsgiven to patients in their prac tices and clinics is about twenty. But actu-al patient records report that this average is much less. M any patientswho come in for a first visit never come back, and 50 percent ofpatients who seek mental health services receive fewer than ten visits.

Therapists' perceptions of their practices are distorted by their remem -bered experiences with those patients who come in for longer periodsof time and with whom the therapists develop the strongest attach-ments. Most of the mental health treatment in the United States goesto fewer than 20 percent of the people who initially seek aid.

Although therapists have a hard time accepting it, m any people ben-efit from relatively brief interventions and seem able to achieve these ben-

efits even from people who don't carry doctor in front of their names.


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M ental health counselors and o thers w ith substantially less training thanpsychologists (Ph .D.) and psychiatrists (M .D.) can be and are very help-ful to most people. In fact, it may only be those with persistent or recur-rent difficulties, who have not been helped by therapists with lesstraining, who will be uniquely in need of the levels of expertise andformal knowledge that characterize the graduate training of clinicalpsychologists and psychiatrists—those calling themselves doctor.

Psychologists and, to a lesser extent, psychiatrists are u sually trainedin research methods and should know how to critically evaluate th evalidity of the procedures used in reaching scientific conclusions. Thistype of knowledge is reflected in the M.D. and Ph.D. degrees. Otherpracticing psychotherapists often aren't trained to recognize the dif-ference between authoritative opinion and research findings.

When you seek therapy, you should be aware that most psy-chotherapists and counselors do not have an M.D. or Ph.D. degree.Remember, clinical psychologists do h ave a doctorate and psychiatristsare medical doctors and therefore M.D.s. Other therapists have anM.A. (master of arts), M.S. (master of science), M.F.C.C. (master offamily and child counse ling), M.S.W. (m aster of social work), or somesimilar type of degree. These master's degrees usually do not includetraining in reviewing or conducting research. Many psychotherapists(even some with M .D. and Ph.D. degrees) are not familiar with what

constitutes sound research methods, and they tend to rely on author-ities whom they respect.

A recent survey f oun d that while most practitioners sought to findsolid scientific evidence for their practices, they identified popularbooks and articles in organizational newsletters instead of researchtexts and jo urna ls as their most im portan t persona l sources of scien-tific inform ation. A review of these sources, however, revealed that the

auth ors were usually nonscientists, and neither relied on scientific evi-dence nor reported scientific findings accurately. Books and articlesbased on scientific f indings tend to report and support their statementsby ref erence to articles in scientific publica tions . These articles are eas-ily recognized, for the most part, by looking at their bibliographies.

But keep in mind that there is a big difference between saying thata t reatment has not been shown to be scientifically valid and declar-

ing it to be invalid. Because the rules of science are conservative, they


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WHAT YOU S H O U L D KNOW ABO UT THERAPY 27

seldom disprove a theory. No psychotherapy theory to our knowl-edge has ever been abandoned because it is invalid.

There are many d i fferent types of psych otherapy and men talhealth treatment. But only a relatively f ew have even been tested.Conversely, some of the treatments that have been most successfulin research studies for a ltering problem s such a s depression, sleep dis-turbance, and anxiety are not often practiced.

A client or potential patient who is seeking to obtain a specificform of treatment m ay find difficulty in doing so. This disparityreflects, in part, some very rapid changes that have occurred in thefield. M a n y new procedures and models of psychotherapy haveevolved, often since most current practitioners got their training. Inaddition, this disparity reflects a failure of the major professionalorganizations and quality control bodies to ensure that continuingeducation is based on good science. Few of the organizations thatsponsor, approve, and tabulate continuing education requirementstake the time to review the scientific standing of approved courses.

It is perfectly legitimate for a patient to ask his or her therapist todiscuss and provide references about the scientific basis of the treat-ment being offered. In 1995, three states advanced legislation thatwould require psychotherapists to provide informed consent topatients, which would reveal th e level of scientific evidence available

for the validity of the choice of treatment. In each case, this legisla-tion was defeated, but, good or bad, it will be back. Its mere pres-ence signals the em erging awareness that patients are consum ers andshould be in formed of the status of the treatments that they arereceiving. In the meantime, you should ask: What makes this treat-ment effective or ineffective? You should know what some of thesefactors are. W e now turn to these factors — the things that m ake psy-

chotherapy effective beyond the therapist 's own skill.

GUI ELINES TO KEEP IN MIN

W e have talked abou t tw o basic avenues to knowledge: one your ownpersonal experience, the other em pirical, scientific study. Both m ethods

are fallible. Our memories of events on which we base our beliefs, and


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the interpretations we give these events, are subject to change. Beliefsoften rely on the persuasive powers of particularly valued or admired

groups and individuals—including psychotherapists. If their logic orconclusions are faulty, then so is that of those who follow them.

If you are uncertain about the treatment you are receiving, keepthese recommendations in mind:

If a therapist suggests that any specific symptom is a sure sign o f somespecific and past event, whether or not it is remembered, doubt thevalidity of the treatment offered.When a therapist suggests that your resistance indicates the need

for more frequent, expensive, or intensive treatment, get a secondopinion.Always remain willing to question both your own and your thera-pist's perceptions. Remember: independent, external evidence is both

the most conservative and the most reliable when trying to determine

if something is worthy of your belief .

W e close this first chapter by suggesting two essential questionsfor you to pose as an informed psychotherapy patient:

Is there scientific evidence that the proposed treatment(s) will help

m e?Is my psychotherapist qualif ied by his or her education, training,or experience to provide these treatments?


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2W ho Offers Helpand Does t Make

a Difference

For the second tim e this year, M rs. R , who is thirty -fo u r, has lost herjo b . For the past eighteen m on ths she has been tryin g to p ull her lifetogether after her husband took their four children and left withanother woman. She drinks too much; she has no money, no hope,no frie nd s. She sees her choices as either su icide or one last effort toget help. Where does she go? Whom does she see?

If she goes to the typical Yellow Pages, she may f ind a list ofapproximately 135 nam es un der Marriage and Family Counselors ;87 un der Social Wo rkers ; ano ther 97 un der Psychologists ; and48 others un der Psyc hiatrists. There are also lists o f AlcoholCounselors and a cross-reference to Licensed Practical Nurses.Some names are on more than one list.

Each n am e has a slew of m ystif yin g ini t ials a f te r i t—Ph.D. ,

M.F.C.C., M.S.W., Psy.D., M.D., ABPP, M .Ed., FACP, LC SW — andthe list goes on.

Some therapists include their areas of specialization. One block adindicates tha t the therapist sp ecializes in children, adolescents, adu lts,and the p roblems of aging. Ap paren tly, this person speci lizes ineveryone's problem s. Another ad notes that the therap ist specializes

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in individual, group, and family therapy. He doesn t leave m any peo-ple out either. What kind of specialty includes virtually every m ode oftreatm ent available?

Still ano ther ind ica tes that she is a Ce rt if ied Cognit iveTherapist , wh atever that m eans; another is a Psy choanalyst ; oth-ers include a Jungian A naly st , a Training An alyst , and a grad-uate of the Gestalt Therapy Institute. It all is very in t im idating if y oudon t know what the distinctions are. Should Mrs. R know some-thing about what those labels mean before seeking help from thesepeople? Obvious ly the various therapists think that these ti t les,labels, and designations are important for the consumer.

It might help to know these things about the therapist, but for anewcomer to mental health treatment, some of the more obviousquestions aren't answered by such ads. You wan t to know:

• Is this person effective in treating someone like m e?

• Does this person know a ny thin g abo ut my religion or beliefs?• Is this thera pist a man or a w o m a n ?• Can this therapist speak my languag e?• Can an educated person who has a secure day job really

em pathize with and un ders tand m y problem s?

The sad t ruth is that the inform at ion provided to most patients by

m ost therapists is irrelevant for an sw ering their m ost pressing ques-tions. Advertisements often assume an unrealistic degree of knowl-edge on the part of prospective patients. Moreover, much of theinformat ion provided, such as the therapist 's academic credentials ortheoretical learning, is a poor predictor of how effective the thera-pist will be. M ore relevant info rm ation on sex, socioeconomic back-ground, values , beliefs, and success rates is miss ing—especia l ly

success rates.Perhaps this chapter w ould be more in form at ive if w e changed its

title to a question: How Do I Know If I Will Be Helped by thePerson I Select as a Therapist?

We wish we c ould give a sim ple answer. Actually , there is no wayto be absolute ly sure w ithout tryin g it out. But, there are som e thingsyou can do to m axim ize the possibili ty that y ou will choose a thera-

pist who can help you. This is a mult iple , stage process, and some o f


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the things you sho uld do y ou are already doing by readin g this book.These steps involve:

• Obtaining nam es of potential therapists• A ssurin g yo urself that these therapists are legitimate and ethi-

cal practitioners• Inform ing yourself about what you can expect and about your

rights• Interviewing the selected therapist

• Taking a test ride to check how the two of you do together• Knowing when to change therapists or seek outside consulta-

tion

Unfortunately, the first few steps will only help you eliminate peo-ple who have problems that could interfere with their effectiveness,those who are dishonest, or those who are poorly trained. It is im por-

tant to eliminate these therapists, though it is unfortunate both thatthe existent state laws do not effectively stop such people from prac-ticing and that so m any trou bled people seek to become psychother-apists them selves.

As a preface to our discussion, it is impor t an t to dis t inguishbetween f inding a psychotherapist and finding help. For most peo-ple who w ant aid with problem s, counseling or psychotherapy m ay

work. But there are other kinds of help. Even if you choose to seekpersonal help through psychotherapy, a great many different psy-chotherapists with many different credentials and types of t rainingare ava ilable for y ou to choose f rom. You will hav e to decide whethery ou wan t to see a counselor or a psychotherapist. A psy cholo-gist or a psychiatrist. In the next few pages we will help you knowthe difference and when it matters.

You should also know that getting psychotherapy is not the onlyalternative. There may be other avenues o f help that can be as use-ful, perhaps more so. Would a relaxing vacation serve y ou just aswell? How abou t talking to a fr iend or som eone in the clergy?

In this chap ter we will talk a bo ut the differences that exist amongpsychotherapists. We will also provide you with information abouthow to determ ine when y ou need profe ssional help and the type of

in format ion you may need to m a ke a useful decision. In this process,


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we hope to address three of the m a jor myths that have been presentin the field of psychotherapy:

• That one therapist is about the sam e as another.• That psychotherapy is psychotherapy.• That a person with emotional problems really needs to see a

psychiatrist.

Who Is a Psychotherapist?

Psychotherapists are a varied group. They differ by nature of train-ing, demographics, theoretical orientation, and level of effectiveness.No single academic degree or credential exists that signifies trainingin psychotherapy. Psychotherapists can come from the disciplines ofm edicine, nurs ing, psychology, counseling, social work , religion, fam -ily studies, and many other fields.

Clinicians also differ in what they focus on and how they conducttreatment. They tend to recommend the treatment they most closelyidentify with. Psychoanalysts advise psychoanalysis for a dispropor-tionately large group of patients, compared to those who can statis-tically be expected to benefit from it; and the same goes for behavior

therapists, cognitive therapists, and the m yriad of others. Unless youare certain that psychotherapy or counseling is what you want, youwill probably want to pick a clinician who defines him or herselfbroadly. This will partially ensure that the clinician who is helpin gyou is willing to consider a va riety of different treatment options.

Determining what a clinician does is even more problematic thandeciphering what kind of education they have had. Among the treat-

ments that each one endorses, you may find that some call themselves counselors and others refer to their treatment as psychotherapy.These distinctions are very rough and it is difficult to say that therereally is a m eaningful difference. Those who do counseling, howev-er, usually tend to believe that problems are a normal part of m akinglife changes. They m ay call you a client rathe r than a patient, butthis is likely to provide more comfort to them than to you. They m ay

also m inim ize the use or significance of diagnostic labels, preferring to


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view all or most of your difficulties as being m ore reflective of normalgrow th processes than of illnesses or disorders. If you don't thinkof yourself as ill and see yourself as going through a rough patch,you may prefer this point of view.

Those w ho tend to th ink of thei r problems as i l lnesses or addictions, in contrast, m ay find greater compatibility with some-one who designates their treatment as includ ing psychotherapy.Clinicians w ho identify themselves as psychotherapists, rather thancounselors, tend to view their work as overcoming deficits, disorders,or problems, rather than as facilitating normal growth. They m aydiagnose problem s and treat those w ho have them . It is still impos-sible to tell from these designations, however, either the quality oftraining they have received, the amount of experience they have, orthe va riability of treatm ent options they will m ake available to y ou.

Until World War II, psychiatrists provided most of the specialized

mental health treatment in the United States. But the war left

manymore ex-soldiers and their families grieving the losses and stresses theyincurred— depressed, anxious, and dysfunctional—w ith too few psy-chiatrists to go around. Psychologists and clinical social workerspicked up the slack, followed in the post-Vietnam era by nurses and avariety of counselors, und er different labels and with different degrees.

Don't be fooled into believing that a degree or a p rofessional title,

in and of itself, indicates that som eone know s how to perfo rm psy-chotherapy. Training and experience differ widely from degree todegree, even am ong those w ith the sam e degree or title. Psychologistsand psychiatrists are the usual doctors in the m ental health field,but they come from different backgrounds. Psychologists hold aPh.D. (Doctor of Philosophy) or Psy.D. (Doctor of P sychology) thatconnotes specialized knowledge of behavior, normal and disrupted

developm ent, research m ethods, and m easurem ent of em otional stateand progress. Psychiatrists hold an M.D. (Medical Doctor) or aD.O. (Doctor of Osteopathy) degree that indicates medical training,expertise in physiology and n eural contributors to behavior, and theability to prescrib e m edications. Social w orkers are designated b y thedegree of M.S.W. (Master in Social Work) or by membership in agroup, ei ther as LCSWs (Licensed Clinical Social Workers) or

NASWs (Nat ional Associa t ion of Social W orkers) . Nurses h ave an


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R.N. (Registered Nurse) or L.P.N. (Licensed Practical Nurse) degree.

And counselors carry almost any set of initials you can think of, most

of which identify them as having received a masters degree of somekind—M.S. (Master of Science), M.A. (Master of Arts), M.F.C.C.(Master of Family and Child Counseling), M-Ed. (Master of

Education), M.B.C. (Master of Behavioral Counseling), and so on.

Each state and university may use somewhat different degrees to des-ignate this type of training.

Those with these degrees do not necessarily practice psychothera-

py, and many who both have the degrees and advertise themselves aspsychotherapists have had no formal training in this practice. None of

the plethora of degrees provides any assurance that the clinician has

been trained specifically to practice the form of psychotherapy that will

be of most help to you. Some physicians holding an M.D. or D.O.degree are psychotherapists, but most are not and most have had no

substantial or special training in these procedures. Likewise, psychol-ogists hold a doctoral degree, usually a Ph.D. and sometimes a Psy.D.degree, but this is a very nonspecific designation and does not, by itself,

indicate anything about their credentials for practicing psychotherapy.

People also get Ph.D.s in English literature and geography, so it isimportant to know that a psychotherapist has a doctorate in clinical

or counseling psychology.

Only in the past twenty years have states and Canadian provincesbegun licensing psychologists, social workers, and counselors. Yetmany states still have no way of legally accrediting nondoctoral ther-

apists and counselors. While all states and most provinces offerlicenses to those who meet certain standards as physicians and psy-chologists, these laws typically do not designate whether the physi-

cian is a psychiatrist or whether the psychologist is a mental health

professional or a research psychologist who studies bees. Someonein Florida once successfully registered his hamster—to prove a point.

Several years ago, one of the authors was asked to consult withFlorida psychologists to find ways of controlling malpractice afterthe state laws that required proof of credentials for psychologistswere sunsetted —they went out of effect, having been passed foronly a designated t r ia l period. Seeing opportunities, lots of people

changed professions. A plumber, an engineer, an unemployed itiner-


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ant, an ex-English teacher, and many others hung up their shinglesas psychologists, including, the author was told, the aforemen-tioned hamster. The hamster, of course, was registered under anassumed name and with falsified credentials.

Another development began in the 1970s that also increased the dis-parity among indiv iduals with similar designations or degrees. Trainingpsychotherapists became a business. The mantra of the 1960s and1970s was mind expansion. We saw the introduction of marijuana,LSD, and o ther recreational drugs among the middle classes. No longerwas drug use a problem of the uneducated and the disenfranchised.Interest in the mind was popular, and psychology became, and largelyhas remained, the favored major among university undergraduates.

Until then, the few graduate programs that trained psychologistsin Ph.D. programs were housed in major research universities. Butwith the growing num bers of interested students, the num ber of pro-

grams and

student slots allotted to

clinical, counseling, or

schoolpsychology was insufficient to meet the demands from graduatingseniors. They all wanted to go into practice as psychotherapists. Yetfewer than 5 percent o f those who applied fo r graduate training inclinical psychology, the largest area of pro fessional psychology, wereadmitted. And in fact it is harder to get into these progr am s than toget into a medical school.

Universities have always allocated money as a function of howmany students a department or program admits. But graduate stu-dents generated more resources than undergraduates, and those pur-suing doctoral training generated more money than those pursuingmaster s degrees. It s no surprise, then, that universities expandedtheir psychology programs. Free-standing graduate schools of psy-chology, most not credentialed by the usual oversight bodies, sprang

up all over the co untry, especially on the East and W est coasts. Thesenew programs often suppo rted themselves by charg ing what the ma r-ket would bear—and that was co nsiderable. This mar ket-drive n sit-uation has in the recent past changed as accrediting agencies askedtougher questions. The highest quality schools survived; the othersdid not (we hope).

New degrees were introduced— Psy.D., M.F.C.C., M.B.C., and so

on. Even if you d idn t get a college degree, you could o btain special


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certificates in alcohol counseling or drug abuse counseling. Soon,most of the Ph.D. and Psy.D. degrees in psychology were beingoffered outside a regular u niversity, and without the benefit either o fa commonly accepted curriculum or a set of training standards.

In the past tw o decad es, we ve seen some concerted efforts toincrease the consistency of training standards, a process probablymost successful for psychiatrists and psychologists at the doctorallevels, and for clinical social workers at the master s degree level.While wide variation stil l remains even among those designated bythese titles and degrees, the t i t les have come to mean that thoselicensed under them at least share certain training experiences.

Unfortunately, that s fewer than half of those offering services aspsychotherapists or counselors.

So much for designations. They aren t very helpful, but this iswhere most people, nonetheless, must start in their quest for help.The daunting task of finding a good psychotherapist through themorass of degrees and credentials is all the more difficult becauseeven when one has special training and experience as a psychother-apist, there is no assurance that that person is any good at it. Am ongnoted psychotherapists, some have been anthropologists, and othershave not com pleted any fo rm al degree in a field associated w ith psy-chothe rapy. H ousew ives, college professors, and other laypeople can

all be as effective as psychotherapists, at least some of the time.In the next two chapters we will address the question of how to

find a good psychotherapist in the midst of this confus ion.

Will Therapy Help?

In this section, we will attempt to dispel the myth that one alwaysneeds a psycho therap ist or m ental he alth clinician with highly devel-oped skills for va rious problems. Treatments are as different as psy-chotherapists, and patients differ too. What s critical is whether youneed a professional mental health clinician at all, and, if so, whattype of therapist and treatment will be useful.

A recent survey in Consumer Reports revealed that the majori ty

of those respondents who had sought psychotherapy found it help-


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ful. You may not be surprised to know that respondents were over-whelmingly happier with the amount and quality of help they hadobtained from psychotherapy than they were about the help theyreceived from lawye rs wh en seeking legal services. This rep ort is con-sistent with most contemporary conclusions of research scientistswho study psychotherapy. Research has found that psychotherapy iseffective for most peop le for most problems most of the time. Infact, about 14 percent of those who call for an appointment beginto feel better just by making the appointment.

If you enter psychotherapy, and if you attend at least six regularlyscheduled sessions, witho ut un du e cancellations, you a re likely to findit helpful. Between 60 and 95 percent of those who seek help experi-ence benefit, depending on the nature and severity of their problem.

There is a predictable pattern this help will take. If your psy-chothe rapy is going to be successful, yo ur first indication m ay occur

before you actually notice any change in the feelings of anxiety ordepression you ve been expressing. You will pro bab ly begin to expe-rience a sense of hopefulness, albeit somewhat tentatively at first.This is a good sign, and if you don t notice it, at least from t ime totime within the first six regularly scheduled sessions, it might meanthat you and your therapist are not working well together.

It m ay no t b e until you ve attende d from fifteen to twenty ses-

sions that you—assuming that you re the average patient—beginto really notice that you are less anxious or depressed, that yoursocial functioning is getting a little bit better, that the problem forwhich you are seeking help is improving, and that you are recov-ering some of your lost self-confidence. Many people can quit a tthis point without suffering any ill conseq uences an d w ith the feel-ing of being helped. If the problem has been recurrent and is still

impair ing your abi l i ty to w o r k and relate to others, continuedimprovement is likely to continue for another twenty to thirty ses-sions. Setbacks are not uncommon and progress often is erratic, butthe sessions still are giving you benefit. Of course, this is the aver-age course of t reatment for the average patient seeing the averagetherapist. Since so many averages are unlikely to come together atonce, your circumstances may be a bit different .

At the end of one year of weekly therapy, most people find them-


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selves relatively free from their trou bling symptom s. A bo ut half o f thosewho persevere are helped substantially by psycho therapy w ithin a peri-od of six months, and about 80 percent are helped within a year.

More serious problems—ones we will explain shortly—may takelonger than one-tim e situation al problem s, longer than a year in som ecases. There is evidence f rom the onsumer Reports survey, and othercontrolled research, to indicate that the longer treatment lasts, them ore satisfaction and benefits increase, especially am ong people withm a n y d ifferent and complex problems. Improvement ra tes a lsoincrease for those with complex and recurrent problems if they havesought help f rom trained m ental health practitioners, and have friend-ships and social grou ps f rom whom they can o btain continuing emo -tional support.

If your problem is depression, the chances are very good that agiven episode will pass in a period o f three to f ou r months , even

w ithout special ized help. This m ay be difficult to believe, but mostdepressive episodes are se l f - lim i ting — despi te the feelings o f hope-lessness that accompany them, they a lmost a lways pass wi th t ime.The pro blem with de pressio n, espe cially if i t's asso ciated w ith achange in weight o r sexual interest , o r disturbed sleep and declin-ing social interests, is that it usual ly wil l com e back if you don't getspecialized help. Such treatment m ay reduce the l ikel ihood o f this

relapse, especially if yo ur depression has been going o n fo r threem o n t h s o r longer.

One of the most interesting discoveries about psychotherapy inrecent years is that w hile short-term treatm ents of twenty or so weekscan o f ten be effective for t reat ing most people with anxiety anddepression, the longer you stay in treatment, the more satisfied youwill be. This satisfaction seems to be consistent across a wide vari-

ety of problems that might motivate people to seek treatment, andoccurs regardless of who you go to for help.

However, the onsumer Reports survey revealed that therapistswith a good deal of fo rm al training as psychologists, social wo rkers,o r psychiatrists, and who worked as professional therapists in m en-tal health settings, were more helpful and effective than physiciansand lay counselors . These advanced- level profe ss ionals were a lso

ra t ed more effect ive than people t ra ined as m a r r i a g e o r f ami ly


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counselors when treatment exceeded six m onths in length.Research also indicates that yo u will need long-term treatm ent f or

very complex and recurrent problems, and when you have long-standing interpersonal difficulties such as repeated failures in mar-riage-like relation ships , excessive social inhibition s, and trou ble withthe law.

The Patient's Role

What is interesting about psychotherapy is that much depends onyou. Most of the benefit yo u receive is relative to your motivation toget well. In fact, in order of importance, the characteristics and skillof the therapist and the nature of the therapy are secondary consid-erations. To ob tain the m axim um help , you m ust be w illing to work

hard and be motivated to make a change in your life. A good ther-apist m ay and sho uld m otivate you ev en m ore. B ut you are really thekey to your success.

The most important quality of a therapist is the ability to listenand care, which can't be guaranteed by f orm al training. In fact , fo r-mal training doesn't seem to assist a prospective therapist in devel-oping these skills to any great degree. Therapists, as people, learned

these things in their own conducive family and social environmentlong before they attended college. W e call these general abilities oftherapists the common or nonspecif ic contributors to t reatm entefficacy, and they work as much to aid the effects o f medication asthey do in psycho therapy.

The other important contributions to the effectiveness of therapycome f rom specific techniques and know ledge, things taught to m en-

tal health professionals through fo rm al coursewo rk and f ieldwo rkexperiences. A m o ng the three factors that contribute to the successof therapy—patient commitment and motivation, therapist caringand support, and the technical procedures of psychotherapy—tech-nical skills and procedures are by far the least important.

Yet m any people seem to be good listeners and are helpful—neigh-bors , family m e m b e r s , f r iends o r acquaintances , even the groceryclerk o r barber, or, for that matter, psychotherapists and counselors


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whose backgrounds are a bit untraditional. By being good listeners,all these people may offer a therapeutic relationship.

But the m ore yo ur problem interferes with y our daily life, thelonger it persists, the m ore frequently it occurs, and the less you haveaccess to supportive family and friends, the more important thesespecialized skills will become.

While you may need the specialized skills of a highly trainedpsycho therapist or psycho logist, psychotherapy is only one of theavenues for change. Symptoms of depression, over a pe