If Not Medications, Then What? Psychotherapy.

In my last blog post, I wrote about the book Anatomy of an Epidemic and the possible dangers posed by long term use of some psychiatric drugs. 

So what are the alternatives?  Well, the logical alternative to psychiatric medication is psychotherapy.  As a psychologist, I actually view psychotherapy as not just an alternative, but actually the first line of treatment for most psychological disorders.   However, I am a realist, and I know that in this technological age filled with advertisements of every kind for psychiatric drugs.  Many people may not longer see psychotherapy as the first line of treatment as I do.

The research literature is too voluminous to try and analyze it here, just as actually analyzing the effects of psychiatric drugs cannot be done in a small blog post.  If you are really interested in the research literature on the efficacy of psychotherapy, try the National Library of Medicine web site,  http://www.pubmed.com/.  Then type in "efficacy of psychotherapy" or "metaanalysis of psychotherapy outcome".  If you want even more information, try Michael Lambert's latest edition of the book titled Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (only $185.20 in hardcover!).

Numerous types of psychotherapy are available.  Psychotherapies used to be classified in the following ways: cognitive, behavioral, psychodynamic, client centered, eclectic, group therapy, family therapy, and so on.  However, these days classifications of therapy tend to focus on diagnostic categories and which of the types of therapies listed above have been found to be efficacious.  These are referred to as empirically verified therapies.

Here is a list of therapies proven to be efficacious in research research studies.  This list was created through the American Psychological Association and was copied from the American Psychological Association web site.

Examples of Empirically Validated Treatments

Well-Established Treatments Citation for Efficacy Evidence

ANXIETY AND STRESS:

Cognitive behavior therapy for panic disorder with and without agoraphobia ...... Barlow et al. (1989); Clark et al. (1994)

Cognitive behavior therapy for generalized anxiety disorder............................ Butler et al. (1991); Borkovec et al. (1987)

Group cognitive behavioral therapy for social phobia..................................... Heimberg et al. (1990); Mattick & Peters (1988)

*Exposure treatment for agoraphobia.......................................................... Trull et al. (1988)

*Exposure treatment for social phobia......................................................... Feske et al; Chambless (1995)

Exposure and response prevention for obsessive-compulsive disorder............. Balkom et al. (1994)

*Stress Inoculation Training for Coping with Stressors................................... Saunders et al. (in press)

Systematic desensitization for simple phobia ............................................. Kazdin et al; Wilcoxon (1976)

DEPRESSION:

Cognitive therapy for depression ...............................................................Dobson (1989); DiMascio et al. (1979)

Interpersonal therapy for depression.........................................................................................Elkin et al. (1989)

HEALTH PROBLEMS:

*Behavior therapy for headache................................................................. Blanchard et al. (1987); Holroyd & Penzien (1990)

*Cognitive behavior therapy for irritable bowel syndrome................................ Blanchard et al. (1980); Lynch & Zamble (1989)

*Cognitive behavior therapy for chronic pain .............................................. Keefe et al. (1992); Turner & Clancy (1988)

*Cognitive-behavior therapy for bulimia........................................................ Agras et al. (1989); Thackwray et al. (1993)

Interpersonal therapy for bulimia ................................................................ Fairburn et al. (1993); Wilfley et al. (1993)

PROBLEMS OF CHILDHOOD:

*Behavior modification for enuresis............................................................. Houts et al. (1994)

Parent training programs for children with oppositional behavior ...................... Walter et al; Gilmore (1973); Wells & Egan (1988)

MARITAL DISCORD:

Behavioral marital therapy......................................................................... Azrin, Bersalel et al. (1980); Jacobson & Follette (1985)

SEXUAL DYSFUNCTION:

Behavior therapy for female orgasmic dysfunction and male erectile dysfunction LoPiccolo & Stock (1986); Auerbach & Kilmann (1977)

OTHER:

Family education programs for schizophrenia ............................................... Hogarty et al. (1986); Falloon et al. (1985)

Behavior modification for developmentally disabled individuals ....................... Scotti et al. (1991)

Token economy programs ......................................................................... Kazdin (1977); Liberman (1972)

Probably Efficacious Treatments Citation for Efficacy Evidence

ANXIETY:

Applied relaxation for panic disorder ........................................................... Öst (1988)

*Applied relaxation for generalized anxiety disorder....................................... Barlow et al., (1992); Borkovec & Costello, (1993)

*Exposure treatment for PTSD................................................................... Foa et al. (1991); Keane et al. (1989)

*Exposure treatment for simple phobia........................................................ Leitenberg et al; Callahan (1973); Öst et al. (1991)

*Stress Inoculation Training for PTSD ......................................................... Foa et al. (1991)

*Group exposure and response prevention for obsessive-compulsive disorder .. Fals-Stewart et al. (1993)

*Relapse prevention program for obsessive-compulsive disorder..................... Hiss et al. (1994)

CHEMICAL ABUSE AND DEPENDENCE:

*Behavior therapy for cocaine abuse .......................................................... Higgins et al. (1993)

*Brief dynamic therapy for opiate dependence.............................................. Woody et al. (1990)

*Cognitive therapy for opiate dependence.................................................... Woody et al. (1990)

*Cognitive-behavior therapy for benzodiazepine withdrawal

in panic disorder patients ...................................................................... Otto et al. (1994); Spiegel et al. (1993)

DEPRESSION:

*Brief dynamic therapy ............................................................................. Gallagher-Thompson & Steffen(1994)

*Cognitive therapy for geriatric patients....................................................... Scogin et al; McElreath (1994)

*Psychoeducational treatment ................................................................... Lewinsohn et al. (1989)

*Reminiscence therapy for geriatric patients .............................................. Arean et al. (1993); Scogin & McElreath (1994)

*Self-control therapy ................................................................................ Fuchs & Rehm (1977); Rehm et al. (1979)

HEALTH PROBLEMS:

*Behavior therapy for childhood obesity ...................................................... Epstein et al. (1994); Wheeler & Hess (1976)

*Group cognitive-behavior therapy for bulimia .............................................. Mitchell et al. (1990)

MARITAL DISCORD:

Emotionally focused couples therapy ......................................................... Johnson et al; Greenberg (1985)

Insight-oriented marital therapy.................................................................. Snyder et al. (1989, 1991)

PROBLEMS OF CHILDHOOD:

*Behavior modification of encopresis .......................................................... O'Brien et al. (1986)

*Family anxiety management training for anxiety disorders............................. Barrett et al. (in press)

OTHER:

Behavior modification for sex offenders....................................................... Marshall et al. (1991)

Dialectical behavior therapy for borderline personality disorder........................ Linehan et al. (1991)

Habit reversal and control techniques ......................................................... Azrin, Nunn et al; Frantz (1980)

Azrin, Nunn & Frantz-Renshaw (1980


It is an encouraging list.  It is somewhat outdated now, but it shows just how far psychotherapy conceptualization and research has come. 

It is important not to let the TV commercials subtly influence you into thinking that medication for psychological problems is all that exists.  The problem is not that other treatments do not exist; the problem is that they have not been adequately publicized to the public.

Navigating the Maze of Psychotherapy--And Choosing a Therapist

It can be quite a daunting experience to try to choose a therapist.  It would be kind of like me going to Manhattan to choose an investment banker for a company (if I owned such a company).  I wouldn't be able to tell one investment bank from another.  The bankers would all come with impressive offices and impressive titles, and they would have all graduated from impressive institutions.  I would be out of my league.

I'm sure that it must be much the same for individuals trying to find a therapist.  Where to start?


Let's take a look at some of the obvious practical issues which I think influence people choosing a therapist:

• Are they on my insurance plan?
• What type of therapy do they do?
• How much do they charge?
• How close is their office?
• How often will they be able to see me?  Want to see me? 
• How often can I afford to go see them?

These are the practical issues which I suppose influence people in their decision making.  (I don't know if there has every been a study on what really guides people's decision making.  It would be an interesting study for some aspiring graduate student out there.)
Now, here are the issues which I think are most important

• What is the conceptual framework of the therapist?
• Will you be able to build a therapeutic alliance with them? (Or perhaps the question is will the two of you be able to built a therapeutic alliance together?)
• Will you feel accepted by them and be able to tell them about the parts of yourself that you hide from others?
• How much experience has the therapist had?
• What is their reputation in town?
• How "professional" are they?  Do they have good ethics and good boundaries?
• Are they burned out and tired, or do they still have an energy and zest for what they do?
• Are they able to see problems in only one way?  Or can they work out of multiple frameworks?

These latter questions are very difficult to answer.  Even colleagues that I have known over the years are still a little bit of a mystery to me because I have never had the opportunity to listen in to one of their sessions.  I know how they come across to me, and I have an idea of their conceptual framework, but I have not actually seen them do therapy.  So if someone came to me asking for a referral, it would still not be a slam dunk process for me to decide whom I would recommend.

But nevertheless, in case you are one of those individuals who has made the decision to seek therapy, here are some ways you might go about it.

Many people start by checking the list of providers in network on their insurance list.  That is not a bad place to start, but it is not the sole consideration.  Insurance companies are getting more picky.  If there have been ethical complaints and lawsuits, a therapist may be taken off their list  So being on an insurance list is one consideration, both ethically and financially.

Check with your family doctor.  They may have had experience with referring to a specific therapist, and they know whom their clients have liked and who they haven't liked.  Similarly, ask a pastor, or ask friends.

Place a call to the therapist's office, saying you would like to talk to them and ask questions.  Notice how long it takes to get a call back.  In some instances, you might not ever receive a call back.  If you receive a returned call the same day, that is a good sign that if you had an emergency they would get back to you.  Now some doctors are really, really busy.  And I am not criticizing a doctor who would not return a phone call to a stranger within 24 hours.  But it could still be useful information for you to have.

Ask questions (maybe some of the ones above).  You're not exactly looking for an exact set of answers.  You want some idea to the above questions, but you are also listening to the tone of the person and asking yourself whether you might be comfortable with them. 

Are they defensive about you asking questions?  Or do they take it in stride?  Do they seem sure of themselves?  Unsure?  Cocky?  Dogmatic?

You might also ask if the doctor would be okay with you seeing them a few sessions and then deciding whether to stay in therapy with them.  Again, it's not their exact answer which matters.  It's the way they handle the question that gives you the most information.

So, good luck.  Remember, you know more than the therapist about some things (such as what is going on in your life), and they know more than you do about some things.  So don't be afraid to dialogue with them and ask how it is that they can go about helping you.  Have confidence when you talk to the therapist, and if they make you feel intimidated, well, maybe you need to keep looking.

One Way of Understanding How Psychotherapy Works--Achieving Higher Levels of Integration in Our Neural Processing

One of the basic concepts in the book that I have already referred to--the Neuroscience of Psychotherapy--is that therapy helps people to achieve a higher level of neural integration.  What does that mean exactly?  Well imagine a house with several computers in it, and each computer is linked by a single line to one central router.  Actually, that is not too different from what most of us have.  Now, imagine in the future that each computer is linked directly to every other computer, and every router is linked directly to every other router.  A new level of  functionality could be be achieved by that integration.

The theory is that many people lack neural integration because of a variety of factors, mostly environmental.  These could include neglect of the individual by their parents when they were growing up.  They could include defense mechanisms such as repression, denial, reaction formation, and so on.  When we have a feeling (such as anger or lust) and our response is "that's not me!" then we are preventing integration.  (A different response might be "Wow, some part of me feels that!?")  Integration can be vertical (neocortex down to limbic system) and lateral (right to left brain, etc.)  The technicalities are not important here.  What is important is that in psychotherapy, people have the opportunity to grow new dendritic branches to make more connections.  This in turn increases their level of self awareness of the problem and increases their flexibility in problem solving.

Imagine the following.  You are in a bad part of town.  It is dark.  You want to get to the freeway, but you keep hitting "dead end" and "detour" signs.  Now imagine a totally different scenario--no matter which way you go, the streets lead to more streets, and all of them give you routes to the freeway.  This can be seen as the role of therapy, opening up new routes to flexible action through the growth of dendritic branching and the increased integration of the brain.  This helps to overcome old defense mechanisms and can lead to totally new ways of behaving.

The idea that our brains can continue to change and grow is an exciting one.  It means that we don't have to be stuck with the attitudes of our childhood.  We don't have to continue in old, well-trodden, but self-defeating ways.  It is the goal, and the job, of a good therapist to help make that happen.  Sometimes we succeed, and sometimes we don't, but that it is the goal.  And when it happens--it's exciting!

A Very Sophisticated Book

One of the most sophisticated books I have read in a long time is The Neuroscience of Psychotherapy: Healing the Social Brain. Psychotherapy books in the 1970's (a long time ago when I was in graduate school) were often criticized as being "pop psychology." This is anything but. It is not easy reading for the layman. But for the sophisticated reader, it can't be beat as a way of understanding how psychotherapy relates to brain functioning. The book tackles the problem of integrating two very different paradigms, or heuristics--psychotherapy metaphors and neuroscience concepts. Both are important.

There is at least one more paradigm which has to be integrated with these two, which is the spiritual paradigm.

I once had a patient, a computer programmer, tell me that he had been reading about how computers can be described as operating at seven different levels. I'm no computer wizard, but I can imagine what he means: the atomic level, the circuit board level, the basic machine language level, the macro language level such as A++, the final interface level with the human operator, etc. The same is true of humans. Their functioning can be described at many different levels, and it is hard to integrate all of these together. It will be a long time before we can integrate all of them. But in the meantime, Louis Cozolino has made a really great start in this book.

It's Been a Long Time Since My Last Post

And I think that it's about time that I shared some more of my thoughts here. One of the main things that I have been struck by in this last year is the importance of taking personal responsibility. Therapists don't cure patients. We are more like teachers and guides than we are like shamans or even medical doctors. We guide, we encourage, we even correct people when they are about to walk off of a cliff. But ultimately, we don't heal or cure. We each have to take the curative steps for ourselves. One of the problems, however, is that oftentimes, patients are so lost, they don't know what those steps are. And that's where the therapist comes in. So step one is that the therapist clarifies what steps need to be taken.

The therapist also clarifies and simplifies. I have often mused about how confused I would be if I was not a psychologist and had a mental health problem. I could imagine myself in front of a row of books at Barnes and Noble wondering which one to read. Or I could see myself looking through the Yellow Pages wondering which therapist to call. And even if I did buy an appropriate book, it would be doubtful that I would be able to stay with what it was recommending. So the therapist clarifies what is important. He/she does this partly by simplifying and leaving out the least important theoretical understandings.

And the therapist encourages. That's how people stay with things. Encouragement from a teacher. It is very difficult for any of us to teach ourselves. I have a jazz piano teacher. And I have an oil painting teacher. For all of the above reasons--to clarify, to simply, and to encourage. But ultimately, I have to practice and practice and practice. I would never expect that they could just magically make me into a good artist or jazz pianist just because I show up and pay them money. But I think that sometimes clients think that will happen. Effort, practice, thought, mistakes, persistence, and so on, are all part of the process.

The Triple Layer Cake

There is nothing like cake to get my attention. So maybe I have your attention, too.

This is the way I explain depression to my clients. It's like a triple layer cake.

Layer one is the original depression. Let's call it biological depression. Something has happened in the brain in response to stress. As a result, mild to moderate depression has set in. The person is having difficulty concentrating, less enthusiasm for doing things (anhedonia), and some fatigue. As a result, they aren't getting as much done. Their grades are going down in school. They are snapping at their children.

Now here is the kicker. Now they start to criticize themselves: "I am lazy." Or, they may think or say, "I am stupid." And so on. They are not able to deal with their decreased efficiency. They think that they "should" be totally in control of themselves, their symptoms, their behaviors, their lives, and if they are not, then they are defective. Now we have the second layer of the cake--being depressed about being depressed. This drives the person down deeper into depression--perhaps from being mildly to moderatly depressed all the way down to severely depressed.

Now for the third layer. The person stops doing the positive behaviors they used to do. They quit socializing. They quit doing their hobbies. They start developing the habit of thinking negatively. Old, good habits start to extinguish. New, bad habits are taking their place.

If the person is treated with an antidepressant, they may recover their appetite, their energy, their sex drive, etc. And this may well help layer two--their self blame, since they have less to blame themselves for.

However, the habits of negative thinking, avoidance, and withdrawal may remain even though many of their depressive symptoms are in remission. This is one of the tasks of psychotherapy--to make sure that the person fully returns back to their normal self.

Many of my clients find that this simple little model helps them understand how their depression became severe in the first place and also focuses them on what they need to be doing to recover. Namely, they need to quit blaming themselves for any remaining depression. They need to overcome their acquired habit of negative thinking (e.g., as in cognitive therapy), and they need to get back to their old positive habits of socializing and having pleasurable experiences.

The Therapeutic Alliance

In my testing and therapy, I am constantly struck by how much we don't know. How different is Bipolar II from Bipolar I? How different is Aspergers from Autism? Does depression permanently damage the brain, or are brain cells regenerated (as they are sometimes in the hippocampus)? And on and on. We know so much and so little. There is so much depression research appearing that a person could spend all of their time just reading it. But the big questions often elude us. And our patients must patiently suffer through our lack of awareness. It is as if we are always in the dark ages. Future generations will look back and marvel at how little we know, just as we look back and marvel at the treatments used in Freud's Vienna (and those were better than what was being used in the rest of the world!). It is my goal to use the best of current knowledge. What isn't known has to be imagined. We have to connect the dots and extrapolate in between for the benefit of our patients. And we have to learn from our patients. They teach us. The most exciting situation is when the partnership (AKA "therapeutic alliance") actually forms, and the patient and I go on a voyage of discovery together. We put together what we know, and something very important happens. It is an exciting experience.

The Soap Opera Rule

Sometimes in therapy, when my clients are trying to figure out what decision to make about a personal problem, I invoke the Soap Opera Rule. The SOR is very simple. Figure out what they would do in a soap opera if this situation were to arise--and then do the opposite!

What is the reasoning behind the SOR? Soap operas make money by never resolving problems. The scripts stir up problems with games, self-defeating decisions, addictions, and dramatic interpersonal moves which only serve to complicate situations further. Soap operas do not try to calm situations and resolve them. In real life, dramatic moves interpersonally very often create more tension and problems than they solve. When things are going poorly in our lives, we may long for that major, dramatic action which will cure everything in one fell swoop. But it usually doesn't happen that way.

What generally does work well in real life is calm, deliberate action which is above board and straightforward. It may not be the material for a great novel, but in the end it often accomplishes what we want most--strong interpersonal relationships and success in other areas of our lives.

What Does Therapy Have to Do with Jazz Piano Lessons?

My hobby, my main hobby, is jazz piano. I love jazz, and I enjoy expressing myself through jazz piano. Unfortunately, my musical IQ is not at the genius level. In fact, it is far below it. And at times, I find the lessons I am learning to be difficult, tedious, or even confusing. During some lessons, my teacher will demonstrate a chord voicing. I see her fingers on the keys, but I don't really comprehend what chord structure she is demonstrating. To her it is simple. For me, it sometimes makes me feel that I need to be in a remedial piano class.

So what has that to do with therapy? Everything. Learning something which is complex and complicated is difficult. It takes energy. It takes perserverence. There are times when we feel we are just not capable of learning it, and other times when we are sure that "other people" could learn it much more quickly. There are times when we are tempted to think that the way we used to do things was good enough, and we wonder why we are going through this grief of learning something a new way when it is so frustrating.

The answer is that there are points, when after considerable mountain climbing, we are able to look back over the terrain that we have covered, and we see just how far we have come. It is then that we realize that it has been worth it. But during the climb, we often wonder why we are doing it--why we are putting ourselves through it.

Taking lessons is in itself a lesson in humility. One of my graduate professors called the rejections he received on articles submitted for publication his way of learning humility. Taking flying lessons, and now taking the jazz piano lessons, is my way of learning and/or remembering what it must be like for my patients at times. I am presenting to them ideas and concepts as if they are simple and can be comprehended quickly. However, sometimes the brain goes into a "fog," and the concepts which seem simple to the teacher can be incomprehensible at the moment for the student. Perhaps all teachers need to be students at times, and need to try learning something really difficult. I know that every time I leave one of my jazz piano lessons, I have greater respect and empathy for what my patients are going through--not just in their daily lives but in undergoing the process of therapy itself.

The Importance of Regular Body Rhythms

Recent research has shown that in Bipolar patients, but also perhaps with Unipolar depressed patients, the 24-hour sleep/awake cycle is very important in establishing a normal mood condition. People with Bipolar Disorder are very susceptible to disruption of their moods when their 24-hour sleep/awake cycles are disrupted. Bipolar Disorder, for example, is the only psychiatric disorder which can be triggered by something positive happening in the person’s life. When a person has positive events occur it may lead to changes in their routine and in their sleep/awake cycle. When people stay up later and later, it can trigger the onset of a bipolar episode. In working with bipolar patients, we emphasize the importance of getting regular sleep, and regular waking periods. That is easier said than done, but it is important.

Research has also shown that in addition to having regular sleep/awake periods that it is important to have regular social interaction. The body sets its 24-hour cycle not just on the basis of sunlight, sleeping and waking, but also on the basis of regular social interaction. This could include something such as going to work, going to church, going at a regular time for doughnuts with a social circle, and so on. For that reason, the therapy based on this principle is called "Social Rhythm Therapy” because it involves both biological rhythms and using social events to set those biological rhythms.

For many individuals, the seasons of the year are important, and getting enough sunlight is important in stabilizing their moods. For that reason, one option is for people to stabilize their moods by walking every day at noontime for an hour. This ensures that they will get enough sunlight, and it also establishes a particular time by which the body can set its internal clock.

Persons living with Bipolar Disorder often seek out excitement and stimulation. They like change. However, too much change and too much stimulation will often trigger episodes of mania or depression.

The Problem with Anger

First of all, I want to make it clear that anger is a normal feeling. There's nothing unhealthy about feeling angry now and then. In fact, it would be abnormal and unhealthy not to feel angry now and then. The problem with anger comes when it loses its rightful proportion in our life.

First of all, let's take a relatively common situation. You are driving in traffic, and another driver cuts you off. He is driving recklessly, perhaps speeding. The typical response of most persons is anger, and that would be normal and natural. The anger comes--it peaks--and it goes away. We forget about it.

However, for some people, the anger comes, and then it gets stronger and stronger. The reasons for this are not fully understood. But one reason it can happen is that persons are using negative self talk to build up their anger. "That stupid person. How dare he do that? Somebody ought to teach him a lesson!." This type of thinking increases the anger.

Another approach to the same situation would be to acknowledge one's anger and then steer a wide berth around such a person. That is, to let the anger come--and then to go, without the negative self talk strengthening the anger.

Some persons are chronically angry. They keep resentments alive on, and on, and on. This is not the same as anger. It is very unhealthy psychologically and physically. It has negative effects in every area of one's life.

I have been asked by some patients, and indeed I have asked myself at times, if this approach to anger isn't really just suppressing it. And suppression and repression can have negative consequences, too. The answer is no. First of all, I am recommending that you be fully aware of your anger at first. There is no suppression here. Secondly, I am recommending that you don't rehearse negative thoughts. In other words, there is a difference between smothering a fire and not putting more wood on a fire. Thirdly, I am recommending that after having an awareness of the feelings and thoughts, that you simply let go. You therefore maintain an awareness of all the thoughts and feelings that you did have, but you are choosing to let go. The choosing is an important part of the process. When you choose to do something, it is conscious and deliberate. This has no negative psychological effects as far as I know. In fact, it has positive effects because it frees you up to go on with your day in a positive constructive way. It also frees you from some of the negative physical effects of chronic anger. Some of these are explained in my handout on coping with anger at www.DrBeckham.com/CopingHandouts.htm .

Therapy As a Rapid Process

Perhaps this will sound confusing after my last post, but therapy can sometimes be a rapid process. How can that be after pointing out just how long it can take to get to the bottom of things in my last post?

The fact is that not everyone comes to therapy with the same expectation. Some people are coming for an overhaul and others for a tune up. And others are coming to get their engines jump started. In fact some psychotherapy theorists have argued that all we should really be doing as therapists is helping people to get "unstuck." The idea here is that people are generally coming up against one problem after another, and that is a normal situation. However, sometimes they come up against situations which they can't solve. They are not thinking creatively or "outside the box." With help, however, they can solve their dilemma and continue to go on with their lives.

Another way of looking at therapy as a rapid process is to consider mild to moderate depression. The client comes in in a demoralized state. They have started thinking negatively. They have quit being assertive. They have pulled away from friends. They have quit eating and sleeping in their normal patterns. All of these problems tend to pile on top of each other and compound each other. Very often, as the therapist helps the client to improve one area, there is a positive spreading of effect so that the other areas start to improve. Instead of a negative chain reaction, there is a positive chain reaction.

Many therapists today teach cognitive therapy, which is a set of skills designed to overcome irrational negative thoughts. This therapy was originally designed to be administered in 20 sessions. However, even that is a long time for many patients. The average number of sessions for a client to stay in therapy is 6 to 8 sessions.

There is no "right" length of time to stay in therapy. It is up to each patient/client to decide how much change they want to accomplish. It is also up to them to decide how much of their personal lives they want to disclose in order to accomplish that. The important thing is for the client to be up front with their therapist, explaining what they want to accomplish and how much time they are willing to invest in that. The therapist can then tell them if their expectations are realistic or not.

Therapy As a Slow Process

I will be writing another column on Therapy As A Rapid Process. Today, I want to address the opposite side of the issue. Sometimes it is a slow process. There are several reasons that it can be slow. One is that it takes time to trust the therapist. I used to think that it would be possible to derive a full treatment plan from an initial, thorough intake. Wrong. The fact is that sometimes the client does not trust the therapist enough to tell them what is bothering them until perhaps the tenth, twentieth, or thirtieth session.

Secondly, sometimes the client themselves does not know what is bothering them. Or perhaps they have a vague idea of the problem, but they have a hard time focusing in on it or articulating it.

Other times, therapy takes quite some time because there are years of habits. The habits can include negative thinking, fear, avoidance, and so on. These do not change overnight.

Fortunately for some patients, they have adequate insurance to allow them to stay in treatment and do the work they need to do. Unfortunately, others do not, and they are only able to take advantage of the "front end" of therapy. But that is much better than nothing.

Next time, how therapy can be a rapid process...

The Two Kinds of Problems

Most of my clients have one or both of two kinds of problems: they are either troubled with negative thoughts which make them feel angry, depressed, anxious, etc., or they avoid dealing with issues and problems.

Negative thinking is something I deal with a lot on my website (DrBeckham.com). However, I don't deal that much with avoidance on the web site. There are two ways that people avoid--externally and internally. Externally, people may avoid dealing with problems. As a result, the problems just keep getting bigger and bigger, causing more and more difficulties in the person's life.

The other type of avoidance is not facing their own internal thoughts and feelings. They try to stuff these internal issues into the closet so to speak. However, after a lifetime of closet stuffing, they often end up with a problem. They only way they know to deal with things is to throw them out of site in the closet. But every time they open the closet, there is so much in there, that it all starts to tumble out. In other words, a person can only repress and avoid thoughts and feelings so much before there is no way to stuff any more. The thoughts and feelings which they thought they had successfully managed to avoid are now coming out as symptoms and interpersonal problems. That is where a therapist can be helpful. Because when everything starts to tumble out, a therapist can help to sort it all out so that it is not overwhelming.