Thursday, July 5, 2012

Psychotherapy: Informed Consent

There are more kinds of psychotherapy than I can count. I trained most in family systems, but my residency exposed me to Jungian analysis, Freudian analysis, psychodynamic psychotherapy, cognitive behavior therapy and biofeedback. I stopped offering psychotherapy myself a couple years ago, so when I recommend that modality to a new patient at the end of an initial evaluation I find it difficult to omit a brief lecture on the differences among psychotherapies, especially the ones I recommend for that particular patient.

If you do psychotherapy yourself how far should you go to educate the patient, especially about alternatives you do not offer? If all your patients get whichever version you provide, whether or not it is the one most likely to succeed for that patient, how much should you tell about alternatives and advantages and disadvantages? Do you know enough about different kinds of psychotherapy to adequately describe the prime candidates? If you have reason to believe the patient will do better with a kind of psychotherapy that you cannot offer, will you admit as much and refer them out? Some items for consideration:

  • How it works
  • What determines duration of treatment
  • Likely frequency of sessions
  • Who will attend: individual, group, family
  • Cost
  • Availability
  • Risks
  • Benefits

What do you do if you know (or find out the hard way) that the kind of treatment you believe would best serve that patient cannot be found in your community?

Like so much of what we do a good starting point might involve considering what you would want a professional to tell you or your loved one if the roles were reversed. So you are the patient? Take these questions with you to that evaluation and ask a million questions.


  1. I also discuss the psychotherapy issue with patients. I think that it is an informed consent issue especially when some therapies clearly perform better or as good as medications. The responses are frequently surprising. For example, many people prefer medications despite the equivalence or superiority of therapy because of the time commitment or the financial penalty by managed care systems. The issue of no available therapists certainly overlaps with managed care penetration. Luckily I live in a state with a number of private specialty therapy clinics and fairly wide availability.

  2. As someone who has been actively involved in the psychotherapy integration movement for decades, I am familiar with most of the most prominent treatment paradigns. Some problems respond best to one type of therapy or another (treating a simple phobia with psychoanalysis would be criminal), but the research shows that for most things, they all do reasonably well and one is not appreciably better than another (the so called dodo bird verdict - all have won and all must have prizes).

    Psychotherapy outcome research has a lot of difficulties unique to psychotherapy, so it's not the best guide. Can't do double blind, for instance, because that would mean the therapist wouldn't know what he or she was doing - hardly a fair test. Using "treatment as usual" as a control group is a setup for showing whatever treatment you have allegiance to is going to win. (80% of comparative studies where the authors of the study are aligned with one theory come out in favor of their paradigm - the so called "allegiance" effect.

    It's pretty clear that most of the treatment paradigms focus more on cognition, affect, behavior, or relationships than any of the others, so are only treating part of the problem. Since we are social organisms, leaving out relationship factors in favor of something else is the biggest mistake.

    There is the Unified Psychotherapy Project, run by Jeff Magnavita and of which I am a part, that is trying to come up with a more complete approach.

    I think trying to explain all of this to patients would be difficult. I only see patients with cluster B personality disorders for therapy and refer the rest out to good therapists of different stripes.

    When I start with a patient, I tell them how I work. Some people come to me after reading my books, so I really have no secrets.

  3. Maybe provide handouts? I know that is probably tedious to make a handout and print it out to distribute to new patients. But a brief, one page handout discussing psychotherapy could help people of all economic stripes. You could list some ways of getting help for people who never worry about money. And then less and less expensive therapies and resources. You could take this all the way down to: If you are too poor to pursue therapy, get at least 30 minutes of exercise every day. Eat lots of fruits and vegetables, learn to meditate, etc...

  4. Jane: handouts? In the digital age? I'm trying to figure out an easy way to provide my patients with URLs for the same purpose. Maybe a private Web page? Why waste paper when all of this stuff is online? I already have a few items on my practice Web site.

    David: Surely you don't send your patients for analysis! When you say integrated, does that mean combining methods into One True Therapy?

    1. No, of course I wouldn't refer anyone for orthodox psychoanalysis. (That's as obsolete as pure behavior therapy. Thankfully, there aren't any analysts here in Memphis anyway).

      Psychodynamically-oriented therapy? I do refer for that all the time. Very helpful for many problems, as long as the patient's family isn't highly dysfunctional.

      There is always going to be more than one way to skin the proverbial cat, and different techniques have very differing results on similar patients. It's tremendously idiosyncratic.

      Influencing others to change their beliefs and behavior is always going to be different from most other medical procedures because of that. But certainly covering all the relevant bases and not ignoring huge factors is what we aim for.

  5. I prefer paper handouts (personal preference). I also like paper books over ebooks. Also, if you have an older clientele, they may not know how to use a computer. I know my grandma doesn't. No email, no computer, no facebook.

    If you're gonna do private webpage, make a PowerPoint to go on it! Those are the best way to break down info. You can also have your own voice commentary on it.

  6. Do y'all mean to tell me Memphis is an Analyst Free Zone?

  7. A few will need paper Jane. What do you think of this one I created for gabapentin?

  8. Not a big fan of robot voices, but it was a clear summary of the drug. If you could find a less robotic voice, I would say it was perfect.

    Interesting to hear about psychoanalysis still existing and to hear about other forms of therapy. I live in an area where the therapists are all about SFBT. I don't think I've ever seen a therapist who practiced something that wasn't SFBT. Which I actually think is unfortunate for people with serious mental health issues. I don't know how you could apply SFBT to Bipolar disorder...How does that even work? Does the patient just show up every manic episode for some "brief therapy" to see him through the crisis? That actually sounds really unproductive. It would just be a series of short term therapy sessions that would deal with ending the mania (crisis) and not about preventing future episodes or catching them before they start.

    1. Jane - treating someone who is acutely manic (really manic - not with what goes for bipolar disorder today, which is often a misdiagnosed case of something called borderline personality disorder or an anxiety disorder) with psychotherapy would be like treating someone with Alzheimer's disease with psychotherapy. Maybe they just don't WANT to remember :)

    2. Actually David. I used to see a psychologist, and I looked on his website recently and he claims to practice SFBT...and he treats depression, anxiety, teenage issues like cutting class, and BIPOLAR DISORDER.

      BTW, I'm shocked he advertised that on his website, because he told me a long time ago that he only takes a limited number of Bipolar patients, because they can really spin out of control and they need a lot of care. I guess it's a bad economy, and he'll take what he can get?

  9. SFBT: San Francisco Bay Therapy? (Just kidding.) Your questions, Jane, point up the question of what psychotherapy is and what we should expect it to accomplish very clearly. Does it treat Bipolar Disorder or just provide emotional support? Does it offer solutions?

    As for my robot, I figured I would video myself, use a slightly different script, and just let patients in my practice have access to it.