Jon Allen’s post “Is psychotherapy going to POT?” is spot on in terms of describing the quandary faced by psychotherapists and their patients with respect to the double-edged sword of “prescriptive therapies.”
Indeed, recent decades have brought us many new “weapons” to use against some of the most troubling psychiatric conditions. For example, when researchers discovered that one of the defining features of panic disorder was catastrophic misinterpretation of anxiety sensations (essentially, fear of fear), it was only a short hop to developing a highly effective therapy protocol that focused specifically on that feature.
Another example is obsessive-compulsive disorder (OCD). Research now tells us that long-term, exploratory therapy seeking the unconscious roots of obsessions and compulsions is often not a good idea; rather, people with OCD need to learn to face their fear of contamination or of making mistakes in a procedure known (regrettably) as ERP (exposure with response prevention).
However, as Dr. Allen points out:
Where does it end? Are we to learn a different therapy for the literally scores of disorders listed in our diagnostic manuals? And how are our clients to sort out which therapist to seek out for what problems? Not to mention the shortage of specialists in many locations.
Dr. Allen’s point about “plain old therapy” (POT) is well-taken. Therapists who master disorder-specific therapies know their “weapons” aren’t of much use in the absence of a strong therapeutic relationship, a partnership in which the client trusts the therapist and is actively involved in implementing the treatment. Happily, some recent developments in the field have moved us in the direction of having our cake and eating it, too, with respect to “common factors” and “prescriptive therapies.”
Dr. David Barlow, one of the “offenders” in producing numerous disorder-specific therapies, has of late led the charge in identifying common threads among evidence-based therapies, with the goal of developing a “unified protocol.” Those threads are (drum roll, please) altering cognitive appraisals, modifying emotion-driven behaviors and reducing maladaptive avoidance. In other words, we need to learn to think about things differently, stop letting emotions dictate our actions and face our fears or other difficulties that we are inclined to avoid. Now there’s a full therapy agenda!
In cognitive-behavior therapy (CBT) circles, what’s come to be known as “third-wave” therapies have been tracking along this path for a number of years now. Interestingly, they have greatly downplayed the importance of diagnostic categories, noting that, across diagnoses, people tend to engage in “experiential avoidance,” such as calling in sick to avoid giving a presentation or using drugs and alcohol to numb the pain of depression. The problem (which they will bring to your attention repeatedly in therapy) is that the effort to control or get rid of unpleasant emotions often compromises quality of life more than the emotions themselves. What we most need to do is learn to accept our feelings and then get on with our lives.
More specifically, the agenda (again, regardless of diagnosis) is to pay attention to thoughts and feelings (remember Dr. Allen’s comments on mentalizing?), learn to regard our thoughts as mental activity rather than absolute truth (“Don’t believe everything you think”), and commit to living life according to our most deeply held values (such as being good parents) rather than trying so hard to get rid of unpleasant feelings (such as spoiling a toddler to avoid his or her wrath).
As Dr. Allen observes, we will always need therapists who have specialty knowledge, whether this be about panic, eating disorders or trauma; but current research on the therapeutic processes that cut across disorders will go a long way toward simplifying matters for therapists and patients alike.
Who says there’s nothing new happening in the world of psychotherapy?