Tuesday, January 27, 2009

Learning From Things That Go Unsaid - 1

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist
Dublin, Ireland.

Most people have the idea that going to therapy is a bit like going to night class, except with a bit more conversation thrown in. They’ll sit in a room with a trained person who will listen, ask questions and then give them ideas, suggestions, tips, advice and maybe even exercises to carry out between sessions. All designed to cure whatever it is that is wrong. In short, they will learn according to whatever level of knowledge the therapist imparts to them.
This picture is of a one way street, with all the action going one way. The therapist is the producer of knowledge and insight, the client is the consumer of same. It pretty much matches the world outside the therapy room where, by and large, we are all consumers of whatever it is that ‘smarter’ people decide to produce for us.
In the broadest sense, the goal of psychoanalytic psychotherapy is to shift clients away from this mindset and position them over time as the producers of their own knowledge – that’s why we don’t give tips, advice or quick solutions that satisfy a short term need. Instead we help the client back into the driving seat of their own lives. And when it works it has profound and long lasting effects.
But the process of getting there happens on two levels – through what is actively said by the client and through what is not said in the professional relationship between the client and the therapist. I’m not talking about body language here or telepathy or mind reading. I’m talking about an unspoken discourse that the client engages in, often without understanding it or realising. As a result, some useful knowledge is available to the client that often goes unnoticed.
Why does it go unnoticed? Because, unfortunately, what you usually find is that before they come for therapy people’s belief in their own selves has taken such a battering that they cannot recognise it or if they do they tend not to give it any weight.
So what is this unspoken knowledge? Well, for example, in the first instance the act of seeking out a therapist and going to the first session is a direct communication in itself that tells us a number of things. The person has reached a point of saying ‘enough is enough’, they have at some level made a decision to change their lives, end a pattern of living that is un-pleasurable and, importantly, to put their trust in another person to help them in that process.
We can also assume – and this is something that is often overlooked – a degree of courage in the face of uncertainty. The client will have had to make the call or email and follow up on the agreement to arrive at their appointed time on the appointed day. For some this is easier than others. Often people go through a great deal of internal debate before they reach the therapy room. And if they do make it, then they have overcome a great deal of resistance.
So now we have the elements of perseverance, courage, decision-making, ability to keep an agreement, sufficient trust in another person to provide help and a real, motivating desire to get answers. But if you asked someone on their first day to name any qualities they have displayed in simply turning up they’d be hard-pressed to name two of them.
That’s not to say that once the therapy has begun the battle is over. Yes some people can treat it as a liberating way of looking at their life to date and their own place within it in order to build up a clearer picture of who they are and why things have turned out the way they have.
For other’s, though, the here-and-now pain is so great they cannot focus on the business of talking and instead produce a continuous string of demands to be made feel better. Once again, they take up the position of consumer of cure rather than producer of cure. Wanting to feel better is not a problem. But they are blinded by the specific nature of their internal pain to the fact that they have actually begun the process of doing something about it: the treatment is (the path to)the cure.
It’s like the unfit person who goes to the gym and repeatedly tells the instructor that they want to be physically fit but they refuse to use any of the gym equipment. And when the instructor encourages them to do so and work their muscles, they tell her they don’t want to because they don’t like it and they ask why can’t she make them fit without them having to do that?
In reality you wouldn't really find someone going to a gym with that mind-set. But you often find people coming to therapy with it. That's because the relationship between the client and the therapist, particularly the pscyhoanalytic psychotherapist, is qualitatively and quantitatively different to practically all the other relationships in the clients life. And it is in this relationship that the bulk of the unspoken knowledge is to be found.
I’ll continue with this theme next week because it is useful for people to understand that the way they conduct themselves in therapy, and in the professional relationship with the therapist, can tell them as much about their own selves as the things they actually talk about.

Tuesday, January 20, 2009

Surveying the Therapy Landscape

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist
Dublin, Ireland.

One of the big questions for any therapy is, does it work? And in this regard, surveys backing up the success or otherwise of psychoanalytic psychotherapy have been very thin on the ground. In fact, most of the running has been done by the ‘newer’ therapies, those that offer short term, quick solutions, ones with ‘evidence-based’ data behind them. And, you have to include drug-based treatments that have been around since the 1950s that also take the limelight with the promise of a pill for every ill, not to mention reams of data to support their position.
By contrast, the longer term psychoanalytic approach, the one that invests time in each individual client, the one that goes behind the symptoms and looks for causes, the one that refuses to accept the simple answer or the short cut, the one that is based on a speaking relationship between client and therapist and that is the oldest, original form of psychotherapy; this is the one that has had very few surveys carried out. As a result it has seemed much like a sleeping giant for many years.
There is a change of attitude on this, however, and the current debate now within the psychoanalytic field internationally is why not research and survey? Why not let the world now that a) psychoanalsyis is not dead but very much alive in both practice and education and b) it has enormous benefits to offer. But the debate hinges on finding a way of researching and surveying that respects client confidentiality and does not impinge in any way on the all-important relationship between client and analyst.
In this context it was interesting, therefore, to see new research in the prestigious Journal of the American Medical Association (JAMA) that supports the effectiveness of the psychoanalytic approach in glowing terms. The research was published in the October edition and, interestingly, this is the first such review to appear in a major medical journal.
In a comment on the findings, the New York Times said the studies on which it was based are probably not widely known among US doctors. And presumably that also applies to Europe and beyond.
Essentially, it gathered together 23 separate studies that used the psychodynamic approach (psychodynamic is another word used for psychoanalytic) covering over 1,000 patients who were in analysis for anything from over a year up to many years. It put these studies through a rigorous further analysis or 'meta-analysis' and came up with the following findings.
Intensive psychoanalytic therapy, or the ‘talking cure’ as it was named by Freud, when it is given three times a week relieved symptoms more than did short term therapies. Commenting on this, the same newspaper quoted Bruce Wampold, chairman of the department of counselling psychology at Wisconsin University as saying that although the study prompts the need for further study, it now contradicts the notion that cognitive or other short-term therapies are better than any others.
The studies that the investigators examined tracked patients with a variety of problems, among them severe depression, anorexia nervoxa and personality disorders. Psychoanalytic therapy showed significant, large and stable treatment effects which actually increased from the end of therapy until follow-up assessments were made some time later. In effect, the study is saying that the positive changes that can result are so stable and effective that they continue working even after the therapy has finished. That’s probably not going to come as a surprise to psychoanalytic psychotherapists but it is quite a claim to make publicly and one that hasn’t been highlighted in the past.
The New York Times report quoted Dr Andrew Gerber, a psychiatrist at Columbia University as saying that the research suggests that if you want to make lasting improvements you’ve got to use longer-term therapy.
The study compared the psychoanalytic treatment of personality, eating, and other disorders with therapeutic treatments that included cognitive-behavioural therapy, cognitive-analytic therapy, dialectical-behavioural therapy, family therapy, supportive therapy, short-term psychodynamic therapy, and psychiatric treatment.
The results indicated that after treatment with long term psychoanalytic psychotherapy patients on average were better off than 96% of the patients in the comparison groups.
In 5 studies of analytic therapy alone, the majority of patients had complex depressive and anxiety disorders and the majority of patients were also classified with chronic mental disorders. According to the results, long term analysis on its own yielded significantly large effects in overall outcome, general psychiatric symptoms, and social functioning in follow-up testing in all outcome areas.
Its a long study and quite complex from a statistical analysis point of view but in their conclusion, the authors suggest that further studies of psychoanlytic treatment are now required in order to unearth more hidden facts about this sleeping giant of the therapy world.
They also suggest further surveys be carried out that might compare costs of long term versus short term therapy because in spite its long term nature, analysis and the psychodynamic/psychoanalytic approach was found to be cost-effective in some of the studies they looked at. Even though it took longer and cost more, the positive effects lasted longer and kept on going after the therapy ended. Which is another thing you rarely hear being mentioned.

Tuesday, January 13, 2009

How Long Should Therapy Take?

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist
Dublin, Ireland.

A question that is often asked is how long will therapy take? Will it be six sessions or will it be sixty? And there is the financial question too. Therapy costs money so it is reasonable that people will want to know how much they have to budget for in terms of fees.
The fee is fixed (see my website) and so the budgetary maths are fairly straightforward. But there is no one answer to the question of how long it will take. It depends on what the issues are and the attitude of the person seeking therapy. My own approach is to try and keep people in therapy for as short a time as possible, particularly those not seeking an analysis. But if the situation demands long term treatment, then I am equally prepared and trained to do so.
At the beginning I tell clients that we should do a few sessions to ‘see how it goes’ and to find out if they are suitable for this kind of therapy. Besides, it generally takes about three to six sessions to actually get to the nub of some problems because often they present as one thing but are actually about another thing entirely.
Assuming they are then suited to analytic psychotherapy, I continue seeing them on the basis that they have the freedom to say at any given session that they feel they have done enough and so bring the treatment to an end. On occasions I bring the treatment to that closing point myself but more often than not I leave it in their hands.
Part of the ‘cure’ with this treatment is bringing the client to a point where they feel they are ready to leave of their own accord. But as I said, different situations take different lengths of time.
Say, for example, someone in a relationship that has long since ended has a partner who is linked in to their life through the children. This partner continues to exercise a negative influence on the person’s life and the cumulative effect of years of living this way have left the person unable to think straight or make a confident judgement call about their own life.
In a situation like this, a short six sessions of therapy can achieve quite a lot in terms of allowing the person regain confidence in their own decisions and to look objectively at the reality of the situation they are in.
The benefit is not achieved through suggesting or advising on the part of the therapist. Instead it is through considering all aspects of the situation, or as many as practicable, often from new perspectives that had never been considered before. It allows the person make up their own mind. When we are in a bad place, the last thing we are able to do is think straight.
Another example would be someone who is unable to carry out a specific part of their job requirement, say writing up reports or dealing with challenging tasks. It becomes such a problem that they are continuously worried and stressed about it. A back log builds up that threatens their sense of job security. Some forms of therapy would treat this symptom as if it were the problem and work on getting the person to confront the problematic area head on.
But what if further probing reveals that behind it there are other, more deep rooted tensions in the person’s life – an inability to conduct relationships, problematic family circumstances, questions over their sexuality? The work issues now become a symptom of the background tensions and we are into a different arena that demands a lot more patience, time and attention to small detail. In terms of therapeutic work, how long should that take? The answer depends on the person’s ability to engage with the issues, or not.
Or, take the person who comes to therapy without any definite symptom other than a vague sense that they are not living the life they want to live. They are forever getting into unsatisfying relationships, they constantly feel their contributions either socially or professionally are unrecognised or unworthy, they can’t shake the feeling that there is an ‘other’ life out there for them and, ultimately, they don’t see any way out of this? Again, how long should that take?
If there are specific ambitions or goals that have been avoided or put aside, then it won’t take very long to get to that. But if there is nothing obviously missing, no roads that were not taken, then we are once again back to a patient, steady, more analytic attempt to unknot the tangled ball and establish the core issues at work. If this person comes to therapy with a desire for quick answers they will probably be disappointed. Indeed the demand for a quick resolution is almost part of the symptom in some cases.
But the person who comes and is patient with him- or herself in the first instance and with the process in the second instance, and who is prepared to question and consider new perspectives, will find the unknotting process will take place in the most surprising and natural ways.