Importance of a “good fit”.
Today the New York Times is running a piece on psychotherapy by a psychiatrist. It’s not as bad as the usual Times articles on this topic. The headline is good, emphasizing the importance of a “good fit” in the relationship between one and one’s therapist. This is critical.
And it speaks to the importance of human relationship, rather than procedures (the medical model) in “treatment” (again, the pesky medical model).
The story’s lead, however, is misleading, perhaps even irresponsible. Here it is:
Americans seem to like psychotherapy. Whether it’s for the mundane conflicts of everyday life or life-threatening illnesses like major depression, psychotherapy is widely viewed as a healthy, if not harmless, pursuit.
While this is presented as “widely viewed”, the part about “harmless” could be misinterpreted as being true. This is far from the case. Endeavoring to undertake psychotherapy can be risky. Like surgery (again, medical model), something powerful enough to do substantial good is a double-edged sword (military model?).
The author is right in asserting that a “no pain, no gain” approach to therapy is misguided. But he fails to address that painful moments in psychotherapy, particularly in long-term therapy, can be a necessary component of facilitating growth. Perhaps this is because the medical model doesn’t really account for growth.
Limitations of the medical model.
The medical model focuses on removing pathology, without regard to underlying causes. In the medical model, it doesn’t matter how you got the illness — lung cancer, bronchitis, arthritis — removing symptoms is the order of the day. This would be less true of illness that has a behavioral component — diabetes, for instance. Still, with physicians being reimbursed by insurance companies, procedures are what get reimbursed. Getting a non-compliant patient to comply is frustrating and time-consuming and common process. It is also non-reimbursable.
Symptoms are not necessarily indicative of progress. This would not hold if one was seeking relief for a phobia, an obsession, or post-traumatic stress. Indeed, persistent deterioration ought to be non-defensively addressed by your therapist. The article rightly states that a therapist resistant to consultation is a therapist to be very skeptical of. In a non-procedural therapy, addressing concerns about effectiveness are the meat and potatoes of treatment. Concerns about competence are a natural and integral part of an honest, trusting relationship. This is bedrock.
Ambiguity in human problems.
Nor does the article adequately address an important aspect of psychotherapy. It frequently involves a lot of uncertainty. It often requires that one suspends judgment. It often requires a willingness to tolerate ambiguity. These are human problems. Increasingly, the medical model does not allow for ambiguity. Either the treatment works or it does not. This makes sense if one has lung cancer, bronchitis, arthritis. If it’s not working, try another treatment. Human problems are not the focus.
Devaluation of primary care.
This was not always the case with the medical model. Primary care physicians — pediatricians, general practitioners — often spent considerable time getting to know their patients. But this is a non-reimbursable activity. This can’t really be emphasize enough, because it reflects the current state of medicine as molded by “managed care”. Getting to know patients is a non-reimbursable activity. The salaries of primary care physicians consistently decline. The salaries of physicians that perform procedures — radiologists, surgeons, podiatrist — consistently increase.
Psychologists as primary care providers.
In this light, one could regard many psychologists as practicing primary care. And it is primary care guided by empirical research (Not incidentally, done by psychologists.). Psychiatrists don’t do a lot of studies on the effectiveness of therapy. Their research tends to be on the effectiveness of pharmaceuticals. Moreover, that research is largely funded by pharmaceutical companies themselves –a standard that would never past muster in psychological research, but that’s another post.
Kalea Chapman, Psy.D.