Who benefits most from psychological therapy?

There is a saying in psychiatry, “even bad therapy is good therapy.”

I always thought this was a terrible thing to say, but really, there’s some truth to it. The basic tenet of therapy is that a person is able to vent their feelings with an objective third party. Depending on how good the therapist is, he or she will be able to help that person process their feelings in a productive manner. Bad therapists talk about themselves too much, give too much advice, and don’t acknowledge their own biases.

Good therapists are the opposite of this. And of course, there are many types of therapy, including supportive, cognitive behavioral, and psychodynamic. Without getting too technical, supportive is the most basic type, and is exactly what it sounds like. Cognitive behavioral helps a person change how they think, which in turn helps moderate feelings and behaviors better. Psychodynamic is the most intensive type of therapy, and focuses on relationships. This is the type of therapy where you end up talking about your childhood and your mother a lot.

The best candidates for therapy are people with stable lives (i.e. supportive and intact family and livelihood), a sense of introspection and curiosity about themselves, and the time and money to attend regularly. In essence, this is what is termed the “worried well.” An example is a PhD candidate who has writer’s block for their thesis. Or a couple struggling with communication issues. Of course, sadly, people with much greater difficulties and problems probably could use therapy even more, but access, finances, and life stress get in the way. Therapists also veer away from therapy with people who have more problems, because even the best therapy doesn’t help when someone needs to figure out how to put food on the table and get the rent paid.

If you feel therapy might be of benefit to you, and you have the resources to go to therapy, then go. Even if you don’t have a specific psychiatric diagnosis, learning about yourself in a structured manner only makes you a better and stronger person. Of course, it’s certainly not for everyone — therapy is one of those things that only works for you if you approach it with an open mind.

Christina Girgis is a psychiatrist who blogs at getaheadwithdrg.

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  • Elle Gee

    So – by “best candidates” it seems you mean those best able to support the therapy business. How extraordinary that the only people therapists want to treat are those who need it least. Why do it in the first place? Really, your post sounds like you’re looking to drum up business from stable, well-off people who can afford your fees and be easy to treat. You should have been a plastic surgeon.

    • http://twitter.com/getaheadwithdrg Christina Girgis

      Thanks for the comment.  I actually don’t work in private practice, and don’t see patients for long-term care (I work in a hospital and see acutely ill patients).  Unfortunately, you’re right, the people that may need therapy the most have the hardest time getting it.  I don’t feel that is right, but that is how it is right now.  If you read the link to “therapy” in the first paragraph of my post, that post better explains the reimbursement issues psychiatrists face.  I will say though, that a lot of psychiatrists who do fee-for-service only, do have sliding scales, which helps, but does not resolve the issue entirely.

    • http://twitter.com/USMCShrink Kevin Nasky

      When determining treatment for any disease/disorder, physicians have to determine not only a correct diagnosis, but also take into consideration the person being treated. The author here is making a good point: that psychotherapy isn’t for everybody. For example, someone with a below average IQ, or is a concrete thinker, or is not psychologically oriented, etc., is NOT going to be a good candidate for therapy. Though not in a typical sense, there is harm inherent in prescribing a course of psychotherapy for someone who is doomed to fail it (failed treatment may increase hopelessness and worsen patient’s mental state, may dissuade them from future treatment, etc.)  It’s better to appropriately tailor the treatment plan to the patient, yeah? Some patients who aren’t candidates for psychotherapy may do well with biological treatment with some supportive therapy (focused on problem solving rather than trying to ‘psychoanalyze’ the roots of their thoughts, moods, behaviors).

  • Anonymous

    A question I learned to ask some patients in my private practice days:
    “What’s missing in your life that you have to pay someone like me to listen to you?”

    Reasons for question:
    1.  Therapeutic goal setting.  What needs to change so you don’t see a need for my services any longer?
    2.  Highlight the fact that most people solve problems without a shrink … with the help of useful, nonpaid, “normal” social relationships.  What obstacles exist to such relationships?

    I agree with Elle Gee.  Thought about re-entering private practice more than once, on a cash only basis.  I really, really don’t like dealing with third party payers.

    Problem:  Doing so automatically excludes me from tending to the sickest, for they cannot pay (and often see no need for my services … anosognosia.)  I’d be restricted chiefly to seeing neurotics with money, whose willingness to pay me would depend upon the extent to which I was willing to meet their neurotic expectations.  Maybe when I retire … when I don’t need the income to pay the mortgage and kid’s college tuition.  To the extent that I need a patient’s money is an extent to which the tail can wag the dog.

  • Anonymous

    Dr. Girgis’ final advisement to enter therapy, introduced with, “If you feel therapy might be of benefit to you,” struck me as too sanguine.  In my experience, patients bring therapy into their lives, or allow therapy to intrude into their schedules, only when faced with near life-death crises.  This crisis could be a wife insisting on it, or else.  Or a probation officer threatening prison.  Or the loss of a 2nd girlfriend in a row and the life of loneliness it signifies. Patients do not come, and remain in therapy, because they feel it “might be of benefit” to them.  It is the life-and-death-like crises that constitute the engines of therapy, that keep the patient cracking open her or his schedule on a regular basis, that allow the patient to expose his life to a near-stranger regularly, on schedule, whether she or he feels like it at the moment or not.  Without those looming threats-to-life, I believe, there would be not real therapy.  
    Thomas A. Caffrey, Ph.D.
    NYS Licensed Psychologist

  • http://www.facebook.com/people/Jackie-Swenson/100000046998781 Jackie Swenson

    “The best candidates for therapy are people with stable lives (i.e. supportive and intact family and livelihood), a sense of introspection and curiosity about themselves, and the time and money to attend regularly. In essence, this is what is termed the “worried well.”

    “Even if you don’t have a specific psychiatric diagnosis, learning about yourself in a structured manner only makes you a better and stronger person.”

    My husband fits this profile perfectly.  He was reluctant to go to therapy, but in the end was glad he did.  He also accepted the idea of taking a low-dose antidepressant which he asked for and received from our family physician.  Seems some kind of ‘chemical inbalance’ runs in his family.  The daily 30-minute walk prescribed by his cardiologist also helps boost his ‘endorphin’ level. 

    The best ‘therapy’ he received was the statement from the psychiatrist:  “You are not crazy.  Trust me – I’ve seen crazy…”

  • Peter Schwimer

    Unfortunately your first instinct was probably the correct one, bad therapy is just that: bad therapy.  If one uses the definitions you do, either everyone should be in treatment or no one should be. Good therapy should be problem focused and goal oriented. It should also be evidenced based and in my opinion time limited  Given that, it would be difficult to put psychodynamic therapy as being the most intensive as there is little to no evidence to suggest that it is either problem focused or goal oriented. Nor does it appear to be particularly effective in bringing about change.

    Horseshrink makes a good point.  What’s missiing in life that one would need to pay someone like me?  If one is in a stable relationship and is functioning reasonably well, the most likely answer is “nothing”.

  • Anonymous

    Whoops!! You must have accidentally overlooked all the important therapy that goes on at community mental health centers. A little more thought, research would have saved this blog from being an off the cuff personal opinion piece.

  • Anonymous

    I guess I expected a little more substance from the author. “Therapy” has come to mean many things and there are many people who hold themselves out as “experts”. My own expereinces have shaped my view that therapy conducted by a psychiatrist is vastly different than the therapy conucted by someone with perhaps a master’s degree in somthing vaguely related to social science. I hnk that good psychotherpists are truly very hard to find and that it is unfortunate that more psychiatrists are not conducting pychotherapy.

  • Anonymous

    Don’t fall for this psychiatrist’s ploy that even “bad” psychotherapy can help.  Per Dr. Thomas Szasz’s book, THE MYTH OF PSYCHOTHERAPY, this is one more expensive, useless and often harmful treatment of the mental death profession.  Per Dr. Peter Breggin’s excellent book, TOXIC PSYCHIATRY, the most dangerous thing you can do is enter the office of a psychiatrist because after 15 minutes or less you will leave with a bogus but life destroying stigma like the bipolar fad fraud of today and a prescription for a cocktail of lethal medications while your social or other distress from domestic or work abuse and similar critical problems will be ignored and invalidated to blame you as being “mentally ill,” putting you in a far worse position than before to negotiate or defend yourself from your oppressors and abusers of whom psychiatry is chief.  Once stigmatized, psychiatry’s toxic treatments can be forced on you since you lose all your civil and basic rights as these psychopathic malignant narcissists lie, lie, lie to falsely claim you are delusional, paranoid, psychotic or otherwise unjustifed in your claims of abuse as the team up with your more powerful abusers against you to add insult to injury.  The problem is any mental death “expert” must use the bogus bible of psychiatry of invented victim blaming stigmas based on outer, superficial symptoms while ignoring the effects of environment, abuse, trauma, social injustice, sexism, racism, bullying/mobbing at work, etc.  Many experts have written books and web articles to expose the fraud of psychiatry in bed with BIG PHARMA including many within the profession.  Avoid them like the plague they are!  See Dr. Carole Warshaw, Dr. Judith Herman, Dr. Heinz Leymann and many others to see how psychiatry treats those suffering from domestic/work violence trauma as described above.