How to Succeed in Psychotherapy (Reblog)

***The following blog post on How to Succeed in Psychotherapy was originally written by Pediatric and Pain Physiatrist Dr. A.J. Rush at PedsRehabDoc.wordpress.com

***

A lot of my patients need psychotherapy. Kids with disabilities—whether congenital or acquired, static or progressive—struggle with accepting their limitations. Kids with chronic pain, even if they aren’t depressed, panicked, or catastrophizing, need to learn coping strategies. A lot of the kids with chronic pain have survived sexual abuse (what does it say about our society that we need a comfortable euphemism which diminishes the reality of the rape of children?) and perceive their post-traumatic stress in terms of physical pain. Families need to repair broken relationships. Parents need to stop blaming themselves for something that wasn’t their fault.

Sometimes they need to stop blaming themselves for something that actually was their fault. I once had a patient with a spinal cord injury (well, a great deal more than once). Like 80% of all people with vertebral fractures he was neurologically intact after his accident. When his dad helped him get up and into the car to go the hospital his unstable fractures sheared through his spinal cord. His injury was complete and permanent. I was impressed that his dad had the courage to ask me whether his son’s paralysis was his fault. Hopefully he finds peace with that. I’ve seen people get through worse.

It is unusual for someone to initially agree to get psychotherapy. They protest that “it doesn’t work” or say that talking about their problems would make them uncomfortable. Often they’ve been to therapy before but it turns out that they, consciously or not, sabotaged the process.

Of course it’s not pleasant. The whole point of therapy is to address and resolve issues they’ve been avoiding. It’s yanking off a Band-Aid, it’s lancing an abscess, it’s obviously the right thing to do but so painful they can’t do it themselves. And only a narcissist would want to reveal their most hidden thoughts.

Modern psychotherapy isn’t like what you see on television. Someone pouring out their soul on a couch while some guy in a tweed coat takes notes makes for good drama: “So, tell me about your relationship with your mother… ” But your therapist doesn’t need to know every single little detail of your life to help you. I’m sorry to disillusion you, but human beings really aren’t as unique as they like to think they are. The same patterns of experiences and behaviors happen over and over and over again.

Modern psychotherapy is usually some variation on cognitive behavioral therapy (CBT). It’s exactly what it sounds like. In CBT the therapist and the patient think about things the patient can do differently so that they are cured. If the patient can’t do the things that they need to then together they break it down into smaller steps, identify barriers, problem solve, and so on.

For the process to begin, first the patient has to believe that the therapist is competent (please assume for the purposes of argument that the therapist actually is competent). Second, the patient has to trust them. Fearing that your personal secrets will wind up on Twitter doesn’t encourage candor. Third, there has to be a reasonable degree of match of personality and communication styles. For lack of a better term, they have to “click”. Note that I didn’t say the patient has to especially like their therapist. Paying someone a couple hundred dollars to be your friend for an hour is an entirely different… proposition.

Next the patient needs to define their objective outcome goals. “Feel better” is too vague. “Go to school fulltime” is a good long-term goal for a pain patient. “Not think about my kid’s illness” is unrealistic, but “Don’t cry at doctor’s appointments” is doable.

Often, of course, the patient doesn’t know their goals. In that case the very first goal is to identify some realistic and objective goals.

Once goals are established then together they’ll identify some target behaviors. These are “specific, measurable, and reproducible”* actions which are likely to help. There might be quite a few. Early steps for a chronic pain patient would involve resuming some basic structure in their life: getting out of bed, taking a shower, taking medications, eating regular meals, doing homework, going to bed, all on a schedule. Later there’d be physical therapy, meditation, an exercise routine, going back to school, and so forth.

Of course the patient’s going to perceive all kinds of barriers to these behaviors. If they didn’t have barriers then they’d already be doing these things on their own. So barriers are identified, broken down into smaller barriers, and the patient goes home with some homework, some strategies to try out to overcome their barriers.

The final ingredient is accountability. When the patient follows up the therapist has to hold them accountable, has to ask them what happened when they tried their strategies. If they worked then great, move on to the next issue. If not, figure out why not, break down the barriers into even smaller ones and identify some new strategies. Go forth and repeat.

Is the process pleasant? Of course not. But it works. So don’t tell me, “Therapy doesn’t work.” What you’re really saying is, “I’m scared.” That’s okay. Aren’t we all?

* Influencer, The Power to Change Anything, Kerry et al, 2008.

BIO – Dr. A.J. Rush

I originally thought that I’d be an orthopaedic surgeon. I then decided that I wanted more time interacting with unanesthetized patients, so I planned on physiatry. During my 4^th year of medical school someone asked me what I wanted to do in physical medicine and rehabilitation (PM&R), and I replied, “Something complicated, like brain or spinal cord injury.” She said that if I did pediatric physical medicine and rehabilitation (PM&R) that I’d get to do those things every day. It turned out that I was speaking with Dr Connie Domingo, the pediatric PM&R chief resident.

Next thing I knew I was in the chairman’s office, and less than a year later I began a five-year residency. I became board-certified in PM&R, Pediatrics, and Pediatric Rehabilitation Medicine. I still thought that I’d do a very ortho-intensive style of practice, so I did a 1-year fellowship in gait and clinical motion analysis, basically using 3D motion capture to analyze and treat movement disorders.

When I wound up in Grand Rapids, I soon learned that what the community really needed was holistic pain management. As a physiatrist I viewed the problem from a functional perspective; a ‘pain score’ is far less important than what a patient is able to do in and with their life. I worked with patients to understand their limitations and opportunities. I educated myself. At some point I found that I enjoy seeing adult patients, too. Eventually I was certified by the American Board of Pain Medicine.

My practice is now in relatively equal part pediatric rehabilitation, pediatric pain medicine, and adult pain medicine. I also have a fair number of medically complex adult rehabilitation patients.

You can learn more at GrandRiverRehab.com.