More people are in therapy now than a generation ago. Some benefit from it, some don’t. Not everybody is comfortable opening up to a stranger, something I totally understand, because I would find it hard to bare my soul to someone in the transactional way in which therapy occurs in practice. That is why I empathize readily and try to put patients at their ease. It is also why I feel for those who are mortified at the thought of opening up, and weep hot tears of shame after they do.
It was in 2009 or so that I began to notice that therapy had limitations. Sometimes therapy didn’t help a patient at all. Sometimes it created a new set of problems for the patient, usually interpersonal, which made me question what I was doing wrong.
At that time I could not find much useful research on why therapy might be ineffective or harmful. I went over the notes of my sessions and summarized their outcomes as honestly and objectively as I could, trying to figure out how therapy worked, or didn’t work, for different patients.
A combination of psychiatric medicines and psychotherapy using an eclectic approach benefitted at least 80% of patients. Some patients said their medicines were very effective and they didn’t need to know what was wrong with them, and that it was enough that I knew what was wrong with them!
But when patients did benefit from therapy, I was never convinced that it wasn’t only because I had seen many more summers than a lot of my patients had, plus I had looked closely at the inner lives of hundreds of people over the years. Then, was it more of experience and less of method that mattered? It’s hard to tell, because for a professional in any field, domain knowledge becomes second nature, something taken for granted.
Many types of therapy exist, with rigorous rules laid down for their practice. But I still see therapy as quite subjective because, no matter what a method is in theory, it finally passes through the medium of the therapist’s psyche and is influenced/modified by the person she is and the antecedents that made her who she is. It is not as simple as cooking from a recipe, though, in that too, the nature of ingredients can differ due to local factors and the final product can turn out different than what is expected.
As a psychiatrist I am expected to be neutral when a patient tells his story. But I have to separate the chaff from the grain in his jumbled outpourings, for which I have to judge what is chaff and what is grain. A certain amount of subjectivity creeps in right away. And every prompt and um-hum might seem a micro-judgment to him, regardless of my neutral tone and expression.
The deepest currents of meaning and knowledge take place within the individual through one’s senses, perceptions, beliefs and judgments . . .
This requires a disciplined commitment to remain with a question intensely and continuously until it is illuminated or answered . . .
– Clark Moustakas
Psychotherapy as a treatment modality is necessarily, inherently, a heuristic process for a psychiatrist attempting to tune into a patient’s frequency. She first has to put herself in his shoes to see where he is coming from.
I am well aware that I can fall prey to cognitive biases in this heuristic process: availability bias, confirmation bias, egocentric bias, framing, representativeness – and all sorts of unconscious ones besides. And, sometimes, I do. Just as judges do, despite having strict laws to base their judgments on, because judges are also human, and deal with the unpredictable doings of other humans. An investigative interview conducted by police to gather information can also falter if a suspect is hard to read, or ready to confess to anything he’s accused of, out of sheer anxiety.
There are hundreds of variables in the complex therapeutic relationship between psychiatrist and patient that influence what is said and what meaning is taken. The patient is not a passive recipient of psychotherapy; he is a thinking person who is weighing what and how much he can tell his doctor.
Intuition, thin-slicing, tacit knowing and non-verbal communication are as important as what is being said. Sometimes I pick up on a tell and pursue it with surprising results, but cannot explain how that happened, not even to myself. If I were contributing data to an evidence-based study I would feel restricted because staying with a script would mean not following up important leads that I catch in the spaces between utterances, the non-verbal parts.
I have often been guilty of positivity bias and shown more optimism than a patient’s situation merited. I have had to check my inner Pollyanna several times when empathy and wishful thinking briefly eclipsed facts.
So, basically, I have to watch out for my own biases all the time.
I recently revisited the problem of negative effects of therapy after a 20-year-old girl told me that she had confronted the adults in her joint family about the sexual abuse she had been subjected to by a family member as a little girl. She had not wanted to, but an older cousin who had been similarly abused by the same person had convinced her she should. She felt exposed, angry and confused, because the adults ‘trivialized’ it – played it down – exactly the way she knew they would.
In the earliest years of my clinical practice I might have naïvely suggested exactly what the cousin had, with the expectation that her mother at least would support her. And I might have counted the unhappiness and anger she felt when that didn’t happen as some sort of ‘negative effects of therapy’.
Now, this young girl wanted to transcend that experience, build a successful career, so that the memory – and the perpetrator – became insignificant in her life. She didn’t want to talk about it. In fact, she said, “I will not be a victim and give him so much importance”. To deal with it in her own way was her prerogative; sometimes therapy means leaving well alone. True, time might never heal a wound completely, but neither might therapy.
There’s more literature published on the negative effects of psychotherapy now than what was available to me in 2009.
These are some of the negative effects of therapy listed by various researchers. Most psychiatrists encounter them and find ways to reduce their impact.
- Worsening of symptoms: Symptoms can worsen temporarily in the first 2-3 sessions because old scabs may be peeled off, leaving old wounds exposed.
- Treatment failure: The worst cases I have seen are those where someone unfamiliar with mental illness has failed to diagnose a psychotic break and has tried to reduce the patient’s agitation with ‘counselling’.
- Emergence of new symptoms: Patients who present early in the course of a mental illness can develop new symptoms unrelated to therapy, e.g. obsessions being addressed in therapy could turn out to be prodromal symptoms of schizophrenia. Acting out, common during therapy, might be reported as an alarming new symptom, or worsening caused by therapy.
- Heightened concern regarding existing symptoms: The line of questioning leading to a diagnosis can be unsettling for a patient. Explaining the biological or psychological basis of symptoms helps, also outlining what can be done, treatment-wise.
- Suicidality: a patient treated for depression sometimes snaps out of inertia and finds the energy to plan and execute a suicide. So all involved – doctor, patient and the people the patient lives with – must be alert to signs. In some cases, depression might be the only visible part of a deeper disturbance, and the provisional diagnosis might not point to the possibility of self-harm.
- Occupational problems: People sometimes function best on high alert, juggling multiple balls and deftly keeping them all up in the air, albeit at a steep cost to their mental health. If a patient is distracted from this hyperfocused state too fast with the intention of reducing anxiety, he might lose focus and drop all the balls, and this can cause serious problems at work. Therapy takes time.
- Stigmatization: This can happen when a patient shares the fact of his treatment with people he believes are his wellwishers, but they use it to control him instead. He might be disillusioned and need support to hold on to the gains he has made.
- Changes in the social network: Self-awareness and insight are products of therapy. A patient might distance himself from toxic people and develop healthier social ties. This could have negative effects on his support system, yet be positive for his growth.
- Strains in relationships: If a patient gains new perspectives and seeks a more equitable relationship, a close family member whose self esteem is tied up with his sick role might react angrily and put a strain on the relationship.
- Therapy dependence: A clarification at the beginning that therapy will only be for a short time – the way a plaster cast is retained only until broken bones are healed – can pre-empt dependence.
- Undermining of self‐efficacy: Some people fall in their own estimation if they see themselves as needing to be propped up by another person. A psychiatrist must watch for this and prevent damage to a patient’s self-image.
Recent studies have concluded that adverse effects occur in 5-20% of patients, and 50% of patients show no clinically significant change with therapy. Most of the published research is based on patients being treated by therapy alone. Since psychiatric treatment is a combination of phamaco- and psychotherapy, our patients ought to be doing better than what these numbers show . . .
Psychotherapy is not like fundamental Physics. It’s a human interaction, with all its imperfections. If anything, mental illness is closer to String Theory in its simplest form! Most psychiatric symptoms are an exaggeration of normal thoughts and feelings, like the vibrations of strings that make them look like particles. They can be toned down with medicines and psychotherapy.
Calling therapy an art would make the treated patient a product. Calling it a science would mean that a patient’s recovery is backed by strong measurable evidence and the results can be replicated in another patient by repeating the process. How is that possible, when each patient, his circumstances, as well as a therapist’s own inner life are all in flux all the time? The approach has to fit the need of the moment and a lot depends on the rapport between doctor and patient.
It is difficult to observe the effects of psychotherapy on patients – the way one might study the effect of heat on copper sulphate crystals – because the therapist factor greatly affects the process, as does the patient’s capacity for introspection and abstraction. For that matter, even pharmaceuticals do not have the same effect on every patient and, therefore, a list of possible idiosyncratic side effects comes with every medicine.
Therapy is only possible because the experience of being human is common to all of us. We have all been there, or been somewhere like it.
‘It came upon her now, as it always had done: a happy flood of feeling, a wild unrest. This moment counts. This moment, and no other. That old man with a crutch, that woman crying, the boy with a spinning top, those lovers smiling: they were part of something known and shared and remembered, an oft-recurring richly coloured pattern. The child who fell in the gutter was herself and so was the the girl who waved from an upper window, “This was what I was once, I’ve been them all” – that aching heart, that burst of sudden laughter, those angry tears, that bubble of desire.’
– From Mary Anne, by Daphne du Maurier
So, the ability to synthesise the disparate facts of an anxious or depressed patient’s life into a cogent whole that he confidently recognises as a better and manageable version of himself is perhaps neither an art nor science. It is a perspective, or a skill, like the ability to do mental math like a whizz, or the ability to visualise a prospective movie frame by frame while reading a novel.
A psychiatrist ultimately uses her personhood as an instrument to empathise with the patient; she syncs her mind with the patient’s, then disengages herself to analyse the information objectively. It takes time, effort and a lot of introspection to get closer to the unachievable target, perfection, on the lines of ‘aim at a star and you’ll shoot high’. Even so, some unexpected developments – side effects – can occur in the process of therapy and must be dealt with as par for the course, the way we do with medications.