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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.
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.
Rishab Gupta is a third year resident in psychiatry at SUNY Downstate Medical Center in Brooklyn. He is also enrolled in a PhD in Neural and Behavioral Sciences at Downstate. He graduated from All India Institute of Medical Sciences (AIIMS), New Delhi in 2008. Being extremely interested in understanding human behavior since his medical school days, he joined Psychiatry residency at AIIMS in 2009. After finishing his training, he continued to work in the Department of Psychiatry at AIIMS as a trained psychiatrist. He is very passionate about academics and loves teaching and pursuing clinical research. He has presented his work at multiple national and international platforms and published numerous papers in different domains of psychiatry. Because of his unquenched thirst for learning he joined SUNY Downstate Medical Center as a Psychiatry resident in 2016. After graduating, he plans to pursue fellowship in Neuropsychiatry because of his active interest in disorders lying at the interface of Neurology and Psychiatry. He aims to be an academician and pursue research into the neurobiology of frontotemporal dementia, and psychotic disorder. When he is not in the clinic or learning psychiatry, he enjoys reading trivia, making jokes, doing social networking, trekking, listening to Punjabi music, and bingeing on various TV shows and movies.
Nwayieze Ndukwe
Dr.Nwayieze C. Ndukwe, MD, MPH, is a psychiatrist based in New York and New Jersey who enjoys exploring the interesection of mental health and popular culture. Dr.Ndukwe serves a associate professor at Mount Sinai Hospital systems in New York City and Mountainside Hospital in Montclair. Dr.Ndukwe was trained at Mount Sinai Beth Israel, and is board certified in Psychiatry by the ABPN. Dr.Ndukwe also holds a Master's in Degree in Public Health from Rutgers University.
Candace Good
Dr. Good specializes in college mental health as a staff psychiatrist at Penn State Counseling and Psychological Services. She is also the founder of Sig: Wellness, LLC, an integrative psychiatry practice in State College, PA. Her office includes a mind-body studio to encourage yoga, meditation, and other healing arts for stress management. The space serves as an incubator for other female wellness practitioners to grow their presence in the community. Dr. Good welcomes freelance writing and editing projects relevant to her specialty and blogs at https://howtoshrinkashrink.com.
Dr. Good is board-certified in both general and child & adolescent psychiatry. She maintains a clinical faculty appointment with the Penn State College of Medicine, where she also completed her medical degree and residency training. Over the past 15 years, her clinical work has included care of families in both rural and underserved communities as well as academic settings. Administrative roles have included medical director at the Western Psychiatric Institute and Clinic Center for Children and Families, vice president of Sunpointe Health, and both unit director of behavioral health services and department chair of psychiatry at the Mount Nittany Medical Center. In 2017, she was elected to the Board of Trustees of the Pennsylvania Medical Society (PAMED) and was recognized as a Distinguished Fellow of the American Academy of Child & Adolescent Psychiatry (AACAP).
Dr. Good enjoys knitting and spending time with her family, especially her daughter and rescue hounds, Abbott and Flip.
Dr. Chepke attended NYU School of Medicine and completed psychiatry residency at Duke University, where he also completed undergraduate studies. He is Board Certified by the American Board of Psychiatry and Neurology and is a Fellow of the American Psychiatric Association. He currently has a private practice in Huntersville, NC, serves as medical director for a level 3 residential adolescent treatment facility, and is an Adjunct Clinical Professor of Psychiatry for the University of North Carolina-Chapel Hill Medical School at the Charlotte Campus.
Dr. Chepke has particular interests in treatment-resistant/severe persistent mental illness, as well as patients with both psychiatric and neurological disorders. He is a member of the CURESZ Foundation Clozapine Experts Panel and Tardive Dyskinesia Experts Panel, as well as a member of the International Parkinson and Movement Disorder Society. He also emphasizes engaging his patients in psychotherapy and strongly encouraging integrative approaches including physical health and wellness through exercise and dietary modification and supplementation. Dr. Chepke’s research interests are in neuropsychiatry and drug metabolism/interactions and is currently a principal investigator for several clinical trials.
Nishi Bhopal, MD is Board Certified in Psychiatry, Sleep Medicine, and Integrative Holistic Medicine. She grew up in Vancouver and completed her undergraduate studies at the University of British Columbia. Her interest in medicine and love of travel took her halfway across the globe where she graduated with a degree in medicine from the National University of Ireland, University College Cork School of Medicine. She went on to complete her Psychiatric residency training at Henry Ford Hospital/Wayne State University and then a fellowship in Sleep Medicine at Beth Israel Deaconess Medical Center/Harvard Medical School. She now calls the Bay Area home and practices outpatient psychiatry in San Francisco. Dr. Bhopal is passionate about helping her patients find health and wellbeing through a combination of modern medical science and the wisdom of traditional eastern practices.
Dr. Nissa Perez completed her undergraduate work in psychobiology at UCLA and then obtained her medical degree from University of Southern California. She completed residency at UCLA San Fernando Valley Psychiatry Training Program and is a Board Certified Psychiatrist. She worked for one year as an attending in her residency program and has been in private practice for the last four and a half years, now in San Jose, CA. She incorporates psychopharmacology and psychotherapy into her practice and draws from multiple therapeutic modalities, primarily psychodynamic and mindfulness, but also incorporates cognitive behavioral therapy.
Dr. Perez is also an avid meditator and yogi. She meditates daily, regularly practices yoga and has attended multiple silent meditation retreats. She blogs at AMindfulMD.com.
Dr. Leslie Walker obtained her MD and MS (Neuroscience) degrees from the University of Michigan. She finished residency at Johns Hopkins Hospital in 2000 and has been in solo practice since then, first in Baltimore and then in Cleveland. She has particular interests in treating women as well as physicians, and for five years served part-time as the psychiatrist for the Women's Trauma Treatment Program at the Cleveland VA Hospital. She enjoys teaching residents and medical students at Case Western Reserve University School of Medicine, and she speaks nationally to physicians on psychiatric topics, work/family balance, resilience, and self-care. She is married to an academic neurologist and has one child in college and one in graduate school, making her officially an empty nester! Next goals: starting a blog and publishing a book.
Erik Messamore, MD, PhD is an expert in the fields of psychopharmacology, complex mood disorders, psychosis and schizophrenia.
He earned a PhD in neuropharmacology from Southern Illinois University and completed a Postdoctoral Fellowship at the Karolinska Institute in Stockholm, Sweden. He received his Medical Degree from the University of Illinois and completed a residency in Psychiatry at Oregon Health & Science University in Portland.
His current research is focused on characterizing the blood flow response to niacin among people with schizophrenia. This research may ultimately improve our ability to detect schizophrenia at its very early stages and to categorize psychiatric illness along physiological lines.
He currently serves as an Associate Professor of Psychiatry at the Northeast Ohio Medical University (NEOMED) in Rootstown, Ohio. He is also the Medical Director of NEOMED’s Best Practices in Schizophrenia Treatment (BeST) Center.
He is a seasoned clinician and accomplished scientist, with a passion for improving the lives of those affected by mental illness.