Your second example is similar to the first, in that deep anguish in such a situation may be normal. Life is cruel at times, and mental health does not mean always being happy. Nonetheless, there may be internal factors that magnify the anguish: feelings of guilt or remorse, conflicts about the partner, and so forth. No psychotherapy can change the reality of ALS, or make it other than terribly sad. If the problem is purely external, there is no role for therapy other than simple emotional support. And frankly, the person should turn to family and/or friends for that, not pay a therapist. It is only when internal factors come into play that therapy may help.

By the way, my view of emotional support in therapy recounts the old saying, “Give a man a fish and he eats for a day. Teach him to fish and he eats for a lifetime.” There is certainly a place for emotional support in the process of doing therapy. However, the aim of therapy is not to offer such support, but to help the patient develop emotionally supportive relationships outside of therapy.

Thanks for writing.

As for Dr. Reidbord’s thoughts re treatment plans, he wrote…

“Do you prefer a carefully crafted orchestra score, or a jazz improvisation? Neither is inherently better music, although the former may be more comfortable in its predictability.”

I think both can work. But I don’t know that both are equally effective for the patient where there is real concern about the financial impact of the therapy, and worry that unconscious fiscal convenience on the part of the therapist is at least partially driving the therapy.

Too often in my experience, jazz improvisation can too often sound like the Spinal Tap “free jazz” sequence from that seminal movie! That is, aimless. That is, pointless. That is, you listen to it, and get nothing from it. On the other hand, outside of some of the most rigid CBT’ers, there’s not so much psychotherapy that’s scripted like the countdown to the launch of a space shuttle, or a performance of a Beethoven piano concerto. Flexibility is inherent. New things emerge.

However…

That said, even knowing that flexibility is crucial and that new things may emerge, when one goes to a doctor, one can reasonably expect a diagnosis and a plan for treatment. When one sees a lawyer, one can reasonably expect an assessment of the situation and a plan of attack. Plus a rough assessment of how long it will take and what it will cost. When one sees a career counselor, ditto. Accountant, ditto. Personal trainer, ditto. Why in the world would or should psychotherapy be immune or an exception? I didn’t love the Merkin piece either. I found it exhibitionistic. But if she’d gotten treatment plans from all the therapists she’d seen, and was able to measure progress/no progress against those plans, I don’t think she would have reached the determination that the psychotherapist too often reminded her of the Great Oz behind the curtain. She could saved herself a great deal of time and money, if her actual intent in entering therapy was to get better.

As I wrote in the original post, emergency treatment is almost always performed with implied consent, even over a patient’s objections. (One obvious exception is when a terminal patient refuses “heroic” lifesaving measures.) Patients who have just overdosed, shot themselves, etc. in a suicide attempt are saved, no questions asked. I can imagine ethically difficult dilemmas involving coherent, lucid patients suicidally refusing life-saving emergency treatment, but thankfully this is rare.

Performing psychiatric evaluations on patients hospitalized for non-psychiatric reasons is a specialty called consultation-liasion psychiatry (a newer term, psychosomatic medicine, is also becoming popular). Such specialists need a broad knowledge of general medicine and surgery, at least as these diseases, and their treatments, relate to mental functioning. I am not trained as a “C/L” psychiatrist myself.

I hope you didn’t mean for me to reply privately. Thanks for writing.

@TK: Psychotherapists are not tax preparers or auto mechanics. However, this doesn’t mean the “consumer” has no sense at all of whether a therapy is real or helpful. If this concern comes up early, I usually suggest to patients to give it some time, a few months say, and then decide for themselves if it’s worth their time, money, and emotional discomfort. In another post I wrote that my ultimate goal as a therapist is to make myself obsolete. One example of this is that I encourage patients to make their own decisions (rather than me making them), and to live with, and learn from, the consequences. This includes the decision to be in therapy. I’m apt to argue in favor of sticking with it, or point out that change can be slow, or even posit that doubts and an urge to flee can be a resistance worth exploring. But in the same breath I’ll note that we have to decide such things for ourselves.

I just read Daphne Merkin’s article on your recommendation. It’s an odd piece. At the risk of analyzing someone I’ve never met, it seems that her considerable intellect and facility with psychological lingo interferes with therapy. She reminds me about a fine paper I read some years ago called “Psychological-Mindedness as a Defense” by Gerald I. Fogel, and about a number of patients I’ve seen over the years who make a lifestyle out of therapy without ever letting anything change. Her search for the “perfect” therapist is misguided of course — none of us are perfect. Her rather exhibitionistic article almost seems to be another attempt to throw herself upon a hoped-for caretaker, her readers in this case, to see if we’ll love her, warts and all. Ultimately it’s sad that in focusing on analytic technique and the quirks of her therapists, she’s missed the forest for the trees.

Re treatment plans: I teach psychiatry residents about case formulation, which carries with it implications for the strategies and tactics of treatment itself. Nonetheless, I agree with Freud that dynamic therapy is like a chess game: There are standard openings and endgames, but the middle must be improvised; there is no plan. Treatment plans apply best to manualized therapies like Beck’s cognitive therapy, DBT, and some time-limited dynamic psychotherapies. Do you prefer a carefully crafted orchestra score, or a jazz improvisation? Neither is inherently better music, although the former may be more comfortable in its predictability.

I’ll be unable to blog or respond for about the next week, so it’s nothing personal if you comment further and I don’t reply (or moderate your submission to make it visible).

***

On a more serious note, I read Dr. Reidbord’s entry here just after reading Daphne Merkin’s piece that will appear in the upcoming Sunday NYT magazine, “Exploring a Life in Therapy.”

http://well.blogs.nytimes.com/2010/08/04/exploring-a-life-in-therapy/?scp=1&sq=merkin&st=cse

Permit me to quote from it fairly liberally, because parts of Merkin’s article go directly to what Dr. Reidbord wrote about so well and thoroughly.

Merkin writes…

“Therapy, as Freud himself made clear, is never about finding a cure for what ails you. Its aim, despite the lyrical moniker it is known by (“the talking cure” was not actually Freud’s phrase but rather that of Dr. Josef Breuer’s patient Bertha Pappenheim, whom Freud wrote about as Anna O.), was always more modest. Freud described it as an effort to convert “hysterical misery” into “common unhappiness,” which suggests a rather minimalist framework against which to judge progress. There is no absolute goal, no lifetime guarantee, no telling how much therapy is enough therapy, no foolproof way of knowing when you’ve gotten everything out of it that you can and would be better off spending your valuable time and hard-earned money on other pursuits.

“All of which raises the question: What exactly is the point? How can you be expected to know when being in therapy is the right choice, to know which treatments are actually helpful and which serve merely to give the false sense of reassurance that comes with being proactive, with doing all that we can? Does anyone, for example, really know what “character change” looks like? That, after all, is what contemporary therapy that is more than chitchat for the so-called worried well aims to promote.

“More pressing, who can be trusted to answer these questions? Looked at a certain way, the entire enterprise seems geared toward the needs of the therapist rather than the patient to a degree that can feel, after a certain amount of time, undemocratic, if not outright exploitative. With no endpoint in sight, it’s possible to stay in therapy forever without much real progress; at the same time, the weight of responsibility is borne almost entirely by the patient, whose “resistance” or lack of effort-making is often blamed for any stagnancy in treatment before the possibility of a therapist’s shortcomings is even acknowledged. As the psychiatrist Robert Michels observed in his aptly titled essay “Psychoanalysis and Its Discontents,” for patients, “it often seems as if psychoanalysis isn’t even designed to help them. Patients want answers, whereas psychoanalysts ask questions. Patients want advice, but psychoanalysts are trained not to give advice. Patients want support and love. Psychoanalysts offer interpretations and insight. Patients want to feel better; analysts talk about character change.””

With all due respect to Dr. Reidbord, psychotherapists are not tax preparers, auto mechanics, or personal trainers. With all of these professionals — even with physicians! — the consumer has an objective measure of whether the professional is doing the job well, and whether s/he is getting what s/he pays for. Therapy, on the other hand, is inherently squishy. Patients do want to feel better. Therapists do offer interpretation and insight to try to get them there. Mostly.

So I’m not so sure that Cynthia is way off base, trying to contain and control her concerns about whether she’s being held in therapy by the unconscious fiscal convenience of the therapist. Therapists might not want to comply with her request, but that doesn’t mean the request isn’t reasonable.

One thing that might help here — I can already predict that Dr. Reidbord is going to smilingly accuse me of offering him another blog topic — is for the therapist to write an actual treatment plan for the patient, a la the kind of thing that Richard Zwolinski discusses at great length in a long series of posts over at psychcentral.com

http://blogs.psychcentral.com/therapy-soup/2010/01/the-mental-health-treatment-plan-introduction-to-an-essential-ingredient/

and also in his book THERAPY REVOLUTION.

A written treatment plan by the end of, say, session #4, which Zwolinski notes must be and is subject to change and revision, would at least give Cynthia an actual benchmark by which to judge her progress and the work of the therapist. If definable progress is being made satisfactorily, which she could judge against her written treatment plan? I suspect she’d not worry so much.