Making Your Psychotherapy Succeed

Chapter 1

Prologue

Many thousands of people ask psychotherapy to improve their lives. Many get better but some do not. Over the years I’d set out to capture the differences between the successes and the failures, and so on a daily basis I noted little phrases or witty comments that entered into the therapy sessions.

Each comment then grew into a small essay to explain the core idea. These then produced a list of questions about what should be discussed in psychotherapy. Too often these key questions are not given enough emphasis, which is regrettable, since they usually add a real point of direction for the therapy.

Psychotherapy is an interaction. It starts with a review of the person’s life and then seeks to modify the aberrant ways that life is being lived. Psychotherapy is a process of not what the therapist does to the patient, but what they do together. The therapist is a coach.

Psychotherapy does succeed, but its success also depends on many variables, some of which are controllable and some of which are not so easily amendable to change.

Psychotherapy is the process of learning of what is the safe way to stand up for what is right. Most people know what is right, but fear or lack the tools to act so.

He who fears something gives it power over him. - Moorish Proverb

Psychotherapy is hard work, and any member of the therapy team who thinks it is easy to do is bound to fail. Consider the work that a singer or athlete faces as they go from wanting to have a musical or sports career to actually having one.

Psychotherapy cannot be taught; the ideas and concepts behind the treatment approaches and the theories supporting them have to be felt by the therapist. It cannot be a mechanical process. The therapist must bring more than knowledge into the therapy. The therapist needs to bring themselves, with all their experiences, biases, vulnerabilities, fears, and knowledge into the therapy. The patient-therapist interaction is never hard plastic. Every word, every gesture, every joke, and every comment the therapist makes can be taken by the patient as a comment about them or an editorial about life.

Sometimes it is better to see a psychotherapist before a psychiatrist, since the former will not have medication use as an immediate option. This is why: the psychotherapy interactions will rest more of what psychosocial changes are needed and could be clinically effective, rather than the far too common jump to rely on medications if a psychiatrist is the first consultation. A good psychotherapist should always consider that the patient might need medications as well. But even when medications are needed, they are used in conjunction with any needed psychosocial modifications. It does happen that some people prefer medications only. They refuse psychotherapy; in many of these cases it is because they do not want to address the psychosocial issues in their lives, so any form of mental health care’s ability to repair may be limited from the start.

Psychotherapy needs a goal. It can exist to change things, or it can exist to maintain a status quo.

Psychotherapy is never always rapid or slow. It is an educational process. It cannot change or erase the past, though it will look for ways to find a ‘better today’ such that that today can dilute out the foul parts of a past. It cannot defuse the future, but it can seek out skills and attitudes to bolster the strength needed to face the future.

One therapy technique is to wait long enough in order to finally see the patient, or a situation, for what they really are. All of this may not come into focus until a crisis occurs. It may, therefore, in the short run, be foolish to prematurely confront a patient’s parent, or to lose the charity of a financial resource, until there are backup skills and resources.

Psychotherapy is also risky, but hopefully the risk takes place is in a protective and educational haven.

Psychotherapy is about balance. The therapy process must change what it can and balance out what it cannot. Much good psychotherapy aims to find a better way to live in spite or, or despite of, a situation. Psychotherapy will fail if this style and approach is not accepted. Patients may have to give up something if they want to get better. Likewise, therapy is not always about fixing. It may need to focus on safety or survival. Therapy may need to aim at an immediate survival technique until an escape can occur.

Psychotherapy requires that we think about our fantasies and the challenges we have in achieving them. It is also thinking about giving up some long term goals, or putting them on hold, when they are not presently obtainable. Many people invest a lot of energy into their fantasies, which, in and of itself, is not always bad. It is bad, however, when the person’s real talents or resources don’t match the fantasies.

"Judge your success by what you

had to give up in order to get it." - Unknown

Psychotherapy can’t undo a past, but it may be able to move it out of the person’s driver’s seat.

The fundamental gist and style of any individual course of psychotherapy is as distinctive and unique as our facial grimaces. But the goal of wanting to make our lives more joyful and successful is universal.

Psychotherapy can be more powerful than love because it can teach us how to offer, give up, share, accept, and use love.

Successful psychotherapy stands on an understanding of what it can and cannot do given any particular person, their realities and skills, and the environmental pressures pressing on their behaviors.

There appears, on a surface level, to be such a wide variability in the various philosophies or sciences of psychotherapy that there is no single, ‘best’ style of psychotherapy. It’s confusing, but the many different techniques of psychotherapy do all work, which brings up the fact that the energy from a guiding human-to-human interaction, regardless of its form, has therapeutic powers.

This book is about how to be a patient and the many types of items that belong to the therapy process. It is a list of ‘things to think about.’

Let’s explore how to take you on a really great tour of your life. Be brave, be honest, be patient, and work hard. Use each section as a wellspring of questions to ask of yourself and your therapist as you go through your psychotherapy.

The rewards will be worth every ounce of energy you invest in this journey.

"Our real problem, then, is not our strength today;

it is rather the vital necessity of action today to ensure our

strength tomorrow." - Dwight Eisenhower, 1958

Chapter 2

How To Get The Most From Psychotherapy

Mental health treatment usually begins when someone feels uncomfortable about something in their life. Acknowledging this discomfort is usually a good sense that there can be useful insight into some parts of the problem.

The other way that mental health treatment is often started is from pressure by someone other than the patient who says the patient needs treatment. This startup is somewhat at a handicap unless the patient also agrees that there is a problem. It's not uncommon for this situation to produce anger at the person who insisted on getting mental health treatment. The first session or two with the therapist may be completely distracted by having to cut through the anger or insult associated in the patient because he was forced into therapy. Sometimes, however, those who were pushed into therapy do come to appreciate that someone took the time, and had enough interest to see, that a problem exists, and so brought the issues to a therapeutic table.

A not infrequent problem brought to a therapist is that all problems are not easily fixable. Often the problem is bigger than the person’s resources. It may be such a big life problem, or a complex and deep family or legal issue that the best end point will be only to explore for a better way to live with the unfixable. Therapy may need to start by separating that which can be changed from that which cannot. This realization is often difficult to accept or work around, which itself is a real challenge for psychotherapy. It is doubly challenging when the issue involves a crises.

Mental health therapy is as varied and as complex as human life itself. Sometimes an intervention requires only medications; sometimes only non-medication therapies are needed. Most of the time, in reality, a well-honed treatment mixture of biological and psychological interventions need to be mixed into the person's life.

Mental health treatment is not like going to the dentist where a root canal takes away the pain. Mental health treatment is a very active interaction between the therapist and the patient. People who have the five or 10 minute medication visits are usually getting a medical model involvement rather than a mental health model involvement. This is not to say they cannot obtain relief from the medical model of treatment. But it’s too short a period of time to get more than a basic response to so, how are you doing? Unfortunately, for far too many patients, this is the style of ‘therapy’ that they get.

At the other extreme is the 60 minute or 90 minute psychotherapy session, where things are discussed and explored, hopefully so that patterns are identified that can be used to help the patient find better ways of living within the reality of the stressors in their lives. Psychotherapy doesn't make all stresses go away. But it can help people reduce the stresses over which they have some control, or to learn to work in spite of, or to work around, the stresses over which they have no control.

Some therapists will have even longer sessions, perhaps 120 minute sessions. These are more a luxury than not, and they do allow for a slower movements into and out of emotions. These longer sessions can at times be worth the time and expense. The hour unit, which is often only 50 minutes in order to allow for paper work following each session, is very common. It is based on a common unit of activity. It is not a based on a unit of concentration or endurance since people watch movies that are longer than an hour.

The first psychotherapy session is usually more of a session devoted to getting overviews and backgrounds. The therapist and patient get a feel for each other and for the therapy style. The therapist may ask many more questions than will be asked in the follow up visits. There will be questions about the educational, cultural, medical, or other backgrounds. There should be some explanation of privacy issues. I usually tell new patients that I want to begin to know them, and that will begin by having them tell me their story and what brings them to therapy. All of this can easily consume an hour. At best it lays out an initial map (there may later be many other maps) to use in the following sessions. It’s also a time to for the patient to begin to experience the therapist – is he relaxed, sophisticated, open ended or very cook-bookish, is the room comfortable and private, etc. Don’t expect too much from the first visit, for if too much occurs it is not coming from a deep knowledge of your life – be suspicious of too much too fast. By the same token, some people expect one visit instant solutions as well; such levels of expectations are usually unrealistic. You should want to come back.

The secret of success is constancy of purpose. - Benjamin Disraeli, 1882

There are as many success enhancing tricks as there are slippery pitfalls in the process of getting mental health care. The goal is simple: to look at what will make you or someone in your life have a better chance of good outcome from being in mental health care. It is to develop the innermost strengths within. Therapists should put themselves out of work.

"A teacher is one who makes himself

progressively unnecessary." - Thomas Caruthers

This book can never be finished because every day brings a new situation, solution, or insight from the universe of human experiences. An unswerving theme stubbornly remains as a mainstream of reality across all of us: that we, as people, all need to be touched, to eat and interact with others, to talk, and to fruitfully and joyfully share the flow of our emotions. When these needs don’t exist, or are rejected, therapy demands we try to find out why. We all need to learn how to assume a layer of self-responsibility regardless of our backgrounds; this is difficult for some people, perhaps because they never were forced to do it. Backgrounds can explain, yet too much concentration on them can also retard; therapy finds the battered soil, cleans out the weeds, feeds the field anew, and then grows a new plant.

Life is a process of sharing our growth with others. We need ‘good touching’ and can spend years seeking it.

Being away from, or afraid of, human touch is the most extreme form of punishment. Emotional incarceration and abuse is worse than jail time. Being able to survive a brutal bout of emotional isolation is possible if the person has some warming and solid connection to an idea or person. Therapy need to help find that balm. Children of abuse might suffer less harm if they have someone such as a loving aunt or grandparent in their lives.

Trauma can be thought of as an equal to an emotional blood clot or stroke. Then, following this stroke analogy, people need to learn to do something again: perhaps it is to walk or talk again. Psychotherapy is the rehabilitation of learning to trust or love again after an emotional stroke. (1)

The other ever-present subject in therapy is that we must look at our own choices and patterns in order to grow and be happy. This technique is used in Alcohol Anonymous. We must ask Why and what is the logic, and what is the survival element in the motivation for any of my actions or non-actions? That can be very hard to do because so many of us think that the way we presently act and think is already the best way to act. One of the most dangerous of all human processes is when someone falls in love with their own logic; this is known as egocentrism.

It’s common for a patient to ask Why can’t you fix me? The answer is because I can’t, by myself as your therapist, fix your world. Working together, and with time, we ought to be able to modify things. Shall we begin?

Another familiar question, more often implied than so stated, is Why do I have to change so much? Why doesn’t my wife have to change too? The answer is blunt but needs to be diplomatically presented: Because in some areas you are wrong and your current strategies to deal with the situations are misguided or faulty.

Therapy can appear to fail is other people in the patient’s world refuse to change as well. The uncompromising issue then becomes if and how the patient needs to change the world in which he lives.

Depression can develop if a person feels no trust in the utility of their own life skills or logic; the person will sense that their life is only a series of setbacks and failures. Depression tends to be the lack of hope that the future can be good. These people lose the ability to find joy, success, validation, or connection. This is compounded, for example, if a biologically based anxiety or depression also exists.

Human experiences are so varied that many sub-topics of problems exist. That these sub-topics overlap with each other speaks to the complexity of psychotherapy. Psychotherapy is an art that tries to correct an entity that is richly multilayered and complex. Very little human experience lives in isolation.

In fact, much of psychotherapy is the undoing of isolation. The ah-ha moments of psychotherapy explain but do not heal. Identifying, and then modifying or moving troublesome elements out of a person’s life, is not enough. The lasting and durable healing comes from the parade of ‘experiences following experiences’ of what is wholesome for the person’s psyche; these repetitive exposures change the ‘isolation of a life’ into a life that can be inserted back into normalcy.

Neurologists use the term plasticity to explain how the brain changes following repeated exposures to stimulation. (2) It is true that some psychological damages leave scars that cannot be undone, but the brain is selfish. If at all possible, it will find and train other circuits to assume the work load of the injured or dead pathways.

Psychotherapy is about change and personal transformation.

"If a man has lived in a tradition which tells him

that nothing can be done about his human condition, to

believe that progress is possible may well

be the greatest revolution of all." - Barbara Ward, 1961

An Overview and Some Common Questions and Thoughts:

Psychotherapy comes from the Greek word psyche, which means a breath; spirit; soul, and therapia, which means a medical treatment. It is the therapy of the soul.

The term is often confusing because so many people claim to do psychotherapy and they do it based on different backgrounds or with different techniques. How does one choose one which is appropriate? That can be hard. Some of the standard measuring tools may deceive. For example, you can get a superb therapist with two years of training who is young but skilled, or you can get an older person with a PhD who is sluggish, uncomfortably predisposed, or just not up-to-date. References for good therapists from local nurses and social workers are probably two of the better data sources.

Finding the right therapist can vary with the old fashion issue of a therapist-patient personality mis-match. People get along with some and not with others. We know this since childhood. We wouldn't go on a second date with someone if it didn't feel right. But a therapist is different. We look for a depth of character that brings light and strength into our world. We may not see the true character of a therapist until we’ve spent time to see and hear them under different situations.

Character is what you are in the dark. – Dwight L Moody, 1930

We need to trust the therapist. The trust issues matter a great deal because the relationship could become emotionally more intimate than that one has with anyone in the patient’s life.

We work under the assumption that therapists will focus on what is best for us and not necessarily for anyone else in our non-therapy worlds. This is mostly, but regrettably not entirely true; this will be discussed later.

There could be a problem with differing philosophies or religion – some therapists have no hesitancy in saying that they believe in a particular religious or philosophic position. That may or may not be bad for the patient.

Religion is a powerful and wonderful part of many people’s lives. For a long time many therapists shied away from bringing religion into the therapy room. Not devoting time to the spiritual modes in a person’s world could make things a bit too callous and cold for many people; it overlooks a large part of people’s lives. Spirituality is as real to many people as is the rising and setting of the sun. It is as pulsating to them as is love. So not to at least explore this is an oversight. I routinely ask all my patients what role religion or spirituality plays in their lives.

Psychotherapy is more than merely talking to someone. Talking is the tool, but listening and reacting is the process. Training to be a psychotherapist is learning more how to listen than how to talk. Likewise, learning to be a patient is learning how to be a student.

We should not choose to stay with or leave a therapist based on just a few sessions. The therapist may also need a few sessions to get a deeper background about the patient and from that to discover what goals the patient has for the therapy. The therapist may even have to decide if he should even continue to be the therapist.

There are many different types of psychotherapy because there are so many types of human experiences. Furthermore, no single therapist has the universal prescription to fix all uncomfortable experiences or fears. The best therapy cake mix combines multilayered good intentions, various backgrounds and approaches, and non-corrupting biases.

So the necessary question is what type of psychotherapy do you need?

It's like being hungry. Sometimes our bodies need more protein than carbohydrate. It may take time with a therapist to sort through the needs, denials, etc., in order to figure this out. Occasionally the first therapist passes the patient onto another therapist whose skills and other qualities better match the patient’s need. It’s rarely a case of one therapist for all and forever. The truth will emerge from this honest evolution.

"You can cover the world with asphalt,

but sooner or later green grass

would break through." – Ilya Ehrenburg, 1967

Psychotherapy is a general and neutral term referring to an interaction between a trained person and a single patient or group. Which set of life problems are addressed in psychotherapy will often depend on the specialty of the practitioner and the issue that is being treated. Psychotherapy can be time limited or on-going. (3)

Sometimes even an interaction between a patient and a non-formally trained person can produce beneficial psychotherapy-like products. It felt good to talk to my friend. This is not always bad.

Psychotherapy seeks to improve a sense of well-being. The techniques used for this are based on building new types of relationships based in part on a better understanding of a person’s emotional history and needs, learning how to dialogue and communicate, knowing how to build specific new skills, or using appropriate medications. Learning how to accept elements in life that cannot be changed or were shameful, but around which a better life can nonetheless be constructed, is very important.

Never trust the wisdom of someone who has never been a fool. -- Unknown

Psychotherapy is performed by practitioners who believe that particular theories, understandings, and skills are needed to explain and improve a person’s life. Eclectic psychotherapy is when an individual therapy uses concepts and techniques from a number of different theories. Sometimes the blending of various therapy techniques allows the patient to express themselves using different ways. These combinations can be very helpful. It follows the many domains of life, since life is rarely a single-dimensional event.

Because of insurance company limitations or geographic availability, many people have limited access to outpatient therapists. These patients may not have the option of a therapist suited to the patient’s real needs.

Hospital or day treatment centers have different therapists on staff at the same time. A hospitalized or day treatment patient may have group therapy in the morning, occupational therapy midday, music or art therapy on some days, individual therapy several times a week, and so on. They get a healthy mix of therapies. Just being in such a facility can itself be therapeutic because of simply being with other people.

Other domains separate different therapy practitioners. It is important to keep in mind that a title or specific training does not automatically provide a therapist with sophisticated clinical skills. Books, courses, and the processes of learning are open to anyone. Some professionals speak with an encyclopedic knowledge but are poor psychotherapists; the opposite can also be true.

Sometimes therapists divide themselves according to theoretic groups or limit their work to particular pathologies. For example, a therapist may choose to limit his work to child and adolescent patients. But these specialty edges can blur. A young patient may reveal that the problem rests in the parents who themselves need therapy, so the range of issues the therapist deals with may enlarge.

Therapists who choose to work only with OCD or addiction face similar blurry distinctions because of the underlying clinical problems. The abuse of drugs is very often the mixed reaction to anxiety, trauma, and depression.

Being treated by a specialist is not always needed. A specialist may be more accurate in picking a real diagnosis out of the camouflage of confusing symptoms. But any good psychotherapist, given enough time and exposure to the patient’s real data, ought to be able to do the same.

Chapter 3

Who Does Psychotherapy

This can be confusing to anyone who is wondering where they should begin their psychotherapy. The problem is that there is no trouble-free formula to help with this decision until the correct diagnosis, with all of the correct and associated psychosocial and medical attachments, is understood. The key is to start anywhere, give it some time, see how it feels, and then decide