The Most Important Questions To Ask About Psychotherapy


Most physicians work in settings where psychotherapy is outsourced to other caregivers, leaving them to wonder exactly what transpires during therapy time.

In this post, I will share some thoughts about the role of psychotherapy in modern clinical practice and some questions that we should consider when third-party therapy is part of the picture.

The Void In Mental Health Care

The role of psychotherapy in psychiatry has diminished considerably as insurers have tried to contain costs by limiting face time between physicians and their patients.

This has created a worrisome void in mental health care because medication is an incomplete solution for many psychiatric patients. I have seen these patients. And they have not fared well.

The Problems I’ve Seen

Most of the patients I see have failed multiple prior treatments and have often seen several other physicians before coming to me. I am a second- or third-opinion consultant. And, mood and anxiety disorders are, by far, my most frequent consultation problem.

I routinely ask each of my patients: have you ever had treatment other than medications? Have you ever had psychotherapy? A dispiriting number have never had a psychotherapist.

Many more told me that they had been engaged in psychotherapy - or at least what they thought was psychotherapy. The most common response from this group of patients was: Yes, I've been seeing So-And-So for about several years now. Awesome!

Then I ask questions more detailed questions about the nature of the therapy:

“Has your counselor or therapist explained the psychological or social factors that contribute to your mood issues?”

“And how are those issues being addressed in your care?"

Oftentimes, these questions would confuse my patients. No matter how I phrased them, most of my 'treatment-resistant' mood disorder patients were apparently unaware that depression or anxiety often has specific psychological components that may be causative and that can be ameliorated by the practice of psychotherapy.

Most of the third-party-psychotherapy patients that I saw had never left their therapist’s office with a psychological explanation for their symptoms, and couldn't describe how their therapy was supposed to work. Their meds, though - they all had a good understanding of what they were supposed to be doing, even if they weren’t working all that well. The social narrative of the chemical imbalance dominates. Psychology is neglected, even though its explanations are more detailed and actionable.

The Original Breakthrough Treatment

Before psychiatry had its wonder drugs, the field took very seriously the concept of mind (psyche) and ultimately developed therapies specifically for the mind (psychotherapies).

The first of these breakthrough psychotherapies was Psychodynamics. The pre-pharmacology era also witnessed the formation of Jungian Therapy, Logotherapy, Gestalt Therapy, Behavioral Therapy, Cognitive Behavioral Therapy, and others. Each of these psychotherapies were based on a coherent theory of mind that could account for how various symptoms arose. Psychodynamics, for example, holds that symptoms arise from subconscious mental conflicts; treatment is designed to bring these conflicts to conscious awareness where reason can intercede. Cognitive Behavioral Therapy views symptoms as the result of inaccurate cognitions (e.g., I’m a failure) and its treatment seeks to reframe them more accurately (e.g., I sometimes make mistakes).

Through careful assessment and psychological formulation, the clinician could identify which facets of mental or social functioning were most relevant to the patient's symptoms. Specific therapies were chosen to work on the facets needing attention. At the same time, the clinician would recognize and build upon the facets that were healthy.

This approach was enormously successful. Though psychotherapy didn't work for everyone (neither do modern drugs, by the way), the psychiatrists and psychologists of the pre-pharmacology era helped many to recover.

Psychotherapy in those days was practiced solemnly. Statements made by patient or doctor were considered weightily. Occasionally, lawsuits were filed because of something a doctor said, or did not say, during psychotherapy.

Psychotherapy was taken as seriously then as drugs are now.

Psychiatry Leaves the Building

Psychiatry underwent many changes during the psychopharmacology revolution and emerged with a curiously narrow focus on medications. Psychotherapy training during most residency programs was shortened as attention began to focus on efficiently doing "the med piece."

A lot has happened in the therapy world since Psychiatry left the building. Specifically, there has been an explosion of educational programs that produce people who are licensed to do “therapy.” These include social workers, counselors, marriage and family therapists, members of the clergy, addiction specialists, and so on. So, the statement “I’ve been seeing a therapist for my depression” is actually not all that informative in these modern times.

The Key Questions To Ask

It appears that many of our patients are being referred to a black box labelled "therapy" or "counseling" and sometimes neither the patient nor the doctor really know what that entails. We need to know what is happening in that box if we are serious about getting our patients well.

Psychotherapy for mood disorders should follow the path of any other treatment. It should be based on an etiological hypothesis. Procedures should address the presumed cause. And (most importantly), the formulation and treatment should change if expected progress is not happening.

Patients switch drugs every few months if they are not getting results. They should similarly switch therapies (or therapists) if there is not clear evidence of progress toward recovery goals.

A lot of people confuse supportive/empathic listening for evidence-based psychotherapy. These elements can help some patients, and are prerequisites for effective care. But patients with complex mood disorders likely require more specific evidence-based interventions.

It pays to ask the questions of your patient:

  • Based on your therapist's assessment, what do you understand to be the cause(s) of your symptoms?

  • How will your therapy help you to address those factors?

  • How do you feel you have been progressing (or how will you know you are progressing)?

  • If you have not been progressing, what do you think is getting in the way?

Though these questions are no substitute for the value of speaking directly with the therapist, asking them of patients can help to reinforce that symptoms often have psychological or social causes which may require attention in order to achieve recovery. These psychological or social factors are often shortchanged. When present, they need to be acknowledged and actively addressed in treatment. Medications can’t solve everything.