February 10, 2016
The American College of Physicians has released a new clinical guideline on the treatment of depression in the Annals of Internal Medicine. They suggested that psychotherapy is as effective for treating depression as antidepressants, and “given its relative lack of potential harms, should be strongly considered as the first-line treatment.” This is consistent with the American Psychiatric Association guidelines on major depressive disorder from 2010, which show therapy and antidepressant medications as being similarly effective.
The two issues that I, personally, have with this are: 1) that the guidelines specifically mention CBT and do not adequately discuss the benefits of other modalities of psychotherapy which may lead health care providers and patients to assume that CBT is the only mode of treatment that is so effective, and 2) the suggestion that psychotherapy has a “relative lack of potential harms.” The word “relative” is key here: psychotherapy has significant fewer potential side effects than medication, but this does not mean that psychotherapy is side effect-free. Therapy can be difficult for many patients at different times along the course of treatment and patients should be aware of this from the outset.
January 27, 2016
The US Preventive Services Task Force (USPSTF) now officially recommends that primary care health clinicians screen all of their patients for depression. Though this is wonderful, this is very, very long overdue. The costs associated with depression and other mental health screen are insignificant relative to the potential gains of “catching” otherwise unrecognized suffering patients. Physicians and other front-line, primary care providers are offered screening guidelines by the AMA via this JAMA article.
Hopefully with more patients being routinely screened, including pregnant and post-partum women – – an often overlooked depressed population, more people will receive quality treatment consisting of psychotherapy and/or antidepressant medications.
November 18, 2015
I teach a great professional development and clinical consultation class at Loyola University Maryland. Yesterday morning my doctoral students and I had a great discussion about what makes psychotherapy work (among some other very stimulating discussions). This morning I received an email with a link to an article entitled, Revival of psychotherapy? How “talk” therapy changes our brains and genes. This short piece reviews some of the recent literature about the effectiveness of psychotherapy, including referencing statements from the American Psychiatric Association and the American Psychological Association. But the article gets even better when it approaches some newer thinking including the possibility that psychotherapy may actually make structural changes in our brains. Scientists have long known that repeated exposures to stimuli (aka, learning) can create new and more efficient neural pathways in the brain. We are now more confidently hypothesizing that the same thing occurs when patients “vent” in therapy… but instead of just venting, what may be happening is that the patient is packaging her thoughts into a narrative that the psychologist can understand, and that in the process of this processing she is starting to think her thoughts differently, to appreciate new facets of her history and to consider alternate perspectives about all this. In other words, she is being exposed to new “stimuli.” And in doing this multiple times (patients often tell the same or similar stories many times over the course of psychotherapy – – and this is a good thing), she may actually be forming new “connections” in her brain and this might be part of why talk therapy does, in fact, work for so many people.
June 30, 2015
I stumbled upon this brief piece in the Huffington Post about when patients should consider doing psychotherapy, trying medication, doing both at the same time or not doing anything at all. I liked this article because it was short and to the point while giving some nice examples behind the answer to the question: “it depends.”
As a psychologist I have many patients ask for medications and I have many patients refuse my suggestion that they consider medications. I work with only a handful of psychiatrists who I trust, and one of the things that I really like about them is that they don’t always prescribe medication on the first visit and sometimes they don’t prescribe at all. Now days many psychiatrists have defaulted to the role of “prescription mill” and they just see patients on the quarter hour, back to back, writing scripts as quickly as they can. I feel fortunate that I have good relationships with some very thoughtful and knowledgeable psychiatrists.
I also feel fortunate that as a psychologist I have the luxury of time to get to really know my patients, develop a strong therapeutic relationship with them and then help them improve various aspects of their lives. One of my favorite things to do in therapy is to review my clinical notes with a patient when we’re close to terminating treatment. I have found that when people are feeling better they often forget just how bad things were when they first came to me. When we read through the chart together they are reminded of the incredible progress they made.
June 24, 2015
Over the years of doing psychotherapy with individuals and couples I have often observed a thematic trend from patient to patient. Sometimes I get a bunch of calls about relationship problems or several existing patients will bring up similar issues in the same week or even the same day. Lately I have noticed that I am talking with a bunch of folks about forgiveness. Often the historical issue that my patient is struggling with is an “unforgivable” event but we still find ourselves discussing what forgiveness means or what it looks like. I like to think about forgiveness as being a selfish – rather than a selfless – process. Sometimes we forgive people, not for them but, for ourselves.
Think about the amount of time, energy and emotion you devote (and continue to allocate) toward maintaining resentments, being angry and keeping hatred alive. Now imagine how liberating it would be to be able to let go of that and how you might reallocate that time, energy and emotion. I’m sorry, but I don’t have any magical answers about how this process unfolds other than to say that it is just that: a process, and it begins by talking about the transgression against you. Eventually you may or may not opt to have a conversation, write a letter or engage in some sort of symbolic gesture to “interpersonally” forgive your transgressor. I recently read an interesting article in the Huffington Post about forgiveness but the most inspiring thing I’ve come across regarding the concept of forgiveness was a great story on NPR’s The Story (scroll down to the second story and if you want to listen to the show, you can skip the first third of the mp3 file).
November 25, 2014
An article was recently published in The Lancet Psychiatry and nicely summarized in Forbes describing the benefits of even short-term psychotherapy on repeated suicide attempts and suicide related deaths. Not surprisingly, the data suggest that talk therapy serves to significantly reduce the frequency of suicide following a previous suicide attempt. The Forbes article also very briefly summarized several recent studies on the efficacy of psychotherapy as an adjunct to or instead of psychiatric medication.
September 10, 2014
Research has shown that when depressed people exercise 3-5 times per day for 45-60 minutes per session and achieve a heart rate of 50-85% of their max heart rate, the exercise is as effective, if not more effective, than medication. The Atlantic published a nice summary of the research and relevant literature.
October 14, 2013
When people compare psychotherapy to medication, one of the arguments often used is that psychotherapy does not have any “side effects.” I totally disagree… everything we do has side effects. Every time we opt to turn right we do so at the expense of turning left. But even beyond that, psychotherapy surely has side effects… even negative side effects. For example, it is not uncommon for a patient to leave a particularly difficult therapy session feeling lower in mood after coming to a hard realization about the viability of a significant relationship that is crumbling, or after discussing a particularly painful time in their life. But that doesn’t mean that this “side effect” is a bad thing. In fact, when this occurs, it is often very situationally appropriate, and sometimes is the first time that a person has really grieved a lost (or soon to be lost) relationship, fully addressed a painful memory with logic and emotion, etc.
I found a nice blog post from GoodTherapy specifically addressing myths about psychotherapy including whether therapy makes things worse.
September 24, 2013
My friend and colleague, Mike Plaut, has another paper out (actually it’s still in press) in the Journal of Health Care Law and Policy. Mike’s writing is great – almost conversational – so I always enjoy reading his stuff. In this paper he describes the work he’s been doing for years at the University of Maryland’s Medical School with health care professionals who act out sexually with patients. Similar to the work I do with disruptive professionals, Mike works individually with physicians and other providers rather than working with groups, and he tailors his interventions to the individual. Now, in contrast to most of my work, Mike holds tighter to the role of the academic advisor than therapist or even coach, as he guides the professional through the relevant literature and has them write a paper about the reason for their referral to him. I typically blur the boundary between coach and therapist as I believe there are more similarities between remedial coaching and psychotherapy than differences, and I have found this to be an invaluable approach to my work with physicians, psychologists, nurses, other healthcare providers and other professionals who have gotten themselves into hot water at work, usually because of interpersonal problems.
September 13, 2013
Yet another article was published recently that touted the positive effects of psychotherapy. In this study the authors noted that psychotherapy was as effective as antidepressant medication at treating and preventing relapses of depressive episodes. Of course the side effects from psychotherapy are much less than those from medication, which is nice. But what made this article special was that it was published in JAMA Psychiatry. Yup, one of the best professional publications for psychiatrists said that medications are not better that psychotherapy. This is great for several reasons. First and foremost, it’s a wonderful demonstration that the ever-increasingly medicalized field of psychiatry is willing to acknowledge the benefits of non-medical approaches. Of course the content of the article is great too; there are many people who cannot tolerate psychiatric medications or simply do not want to use medicine to treat their psychological issues, and this (and many other) article(s) supports these individuals in not caving in to popping a pill to rid themselves of psychological pain. Now, please don’t get me wrong… in no way am I opposed to appropriate use of psychiatric medication. However, I am very frequently disappointed by medical professionals who prescribe antidepressants, sleep aids and antianxiety medications without considering empirically validated better options first or at least in conjunction with the medications.