More than two years ago, I wrote a post on this blog entitled, “Is psychotherapy going to POT?” Tongue in cheek, I was protesting the proliferation of brand-name, evidence-based therapies with all their acronyms: CBT, DBT, ERP, EMDR and the like. There’s no way any therapist can learn to practice 150+ brands, and a half-century of research attests to the difficulty of demonstrating that any one brand is generally superior to any other. Accordingly, I declared myself a practitioner of plain old therapy — relatively unstructured “talk therapy” without any special technical procedures. And I liked the acronym.

This post led to an interchange on the blog with my colleague, Tom Ellis, an expert therapist and research-minded psychologist who expressed some reservations. In his post, “Make my psychotherapy plain, but with a twist,” he took issue with the implication that there is nothing new happening in the field of therapy and pointed out the benefits of recently developed specialized procedures and treatments for certain disorders, such as panic and obsessive-compulsive disorder.

POT vs. BEER?

In conversation, Tom expressed concern that I might be communicating to therapists that whatever they’ve been doing all along is perfectly fine and they don’t need to learn anything new. I responded with another post, “Can we grow more potent POT?” In so doing, I acknowledged the need to continue refining psychotherapy on the basis of new knowledge, which I had aspired to do in homing in on mentalizing in the context of attachment relationships as a common therapeutic factor that cuts across different brand-name therapies. “Mentalizing” refers to being aware of mental states such as desires, feelings and thoughts in oneself and others, and “attachment” refers to relationships with strong emotional bonds, such as parent-child relationships, romantic partnerships and patient-therapist relationships. Tom responded with a second rejoinder, “Psychotherapy: Bring on the POT, but don’t forget the BEER,” a new acronym for “But Empirical Evidence Required.” In other words, Show me the data!

Therapists like POT

There was a playful quality to this blog-post interchange, but Tom and I are equally serious about current debates in psychotherapy, often pitting two broad camps against one another, that is, the clinicians versus the researchers. Tom and I share allegiance with both camps. After this initial foray in the blogosphere, I started to take the idea of plain old therapy more seriously, and for the past two years I’ve been talking about it in presentations and workshops locally, nationally and internationally. As intended, “POT” elicits amusement, but I’ve been surprised at therapists’ sheer enthusiasm for it. I went public in print, responding to an invitation to write for the “From the Expert” column in Psychiatric News with an editorial, “Reviving Plain Old Therapy.”¹ Ultimately, I took it so seriously that I wrote a book about it, entitled Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy.²

Why POT?

I have a few ideas about the basis of therapists’ enthusiasm:

1. Like me, many therapists are put off by the implication that they should learn a whole bunch of different therapies.
2. Many of the brand-name therapies were developed to treat specific psychiatric disorders and, like me, many therapists are generalists who work with patients with diverse problems, many of whom struggle with multiple disorders at the same time. We generalist therapists are the counterparts to general practitioners in medicine. Such physicians, too, must refer patients to specialists when indicated.
3. My emphasis on plain old therapy is consistent with the well-demonstrated contribution of the therapeutic relationship to the treatment outcome³ as well as a current humanistic counter-reaction to increasingly technological approaches to psychiatry, now abetted by enthrallment with neuroscience.⁴
4. I use the “old” in plain old therapy with some irony, because I find a substantial evidence base supporting the effectiveness of plain old therapy in contemporary attachment theory and research, including the recent work in mentalizing.⁵ When I discuss this work on attachment with patients and clinicians, many find it intriguing and eye-opening. Hence I was pleased when my colleague, psychiatrist Robert Fischer, who is executive director of the Optimum Performance Institute commented in an article that plain old therapy “actually is the most novel approach I have heard in the past 15 years!”⁶

Notwithstanding my confidence in the value of reviving plain old therapy, we therapists have no reason to be complacent about our work. The fact that a half-century of horseraces comparing different brand-name therapies has failed to reveal champions and that their commonalities are therapeutically significant does not mean that all are equivalent for a given individual.⁷

In the face of disagreement among proponents of different approaches as well as between clinicians and researchers, there is considerable consensus on one point: We are far from understanding the specific psychological and interpersonal processes that render psychotherapy effective.^{8, 9} I think mentalizing in the context of attachment relationships points us in the right direction, and new research supports this path.¹⁰ Indeed, we always desire more empirical evidence but, meanwhile, I think plain old therapists stand on solid ground.

Editor’s note: If you enjoyed this post from Dr. Allen, please check out some of his other recent posts:

• Was the Sandy Hook mass shooting evil?
• Can’t AND won’t
• Can’t OR won’t?

References 

1.       Allen JG. Reviving plain old therapy. Psychiatric News. 2012;47(10):3.

2.       Allen JG. Restoring mentalizing in attachment relationships: Treating trauma with plain old therapy. Washington, DC: American Psychiatric Publishing; 2013.

3.       Norcross JC, ed Psychotherapy relationships that work: Evidence-based responsiveness. Second ed. New York: Oxford University Press; 2011.

4.       Bracken P, Thomas P, Timimi S, et al. Psychiatry beyond the current paradigm. British Journal of Psychiatry. 2012;201:430-434

5.       Allen JG. Mentalizing in the development and treatment of attachment trauma. London: Karnac; 2013.

6.       Fischer R. Reflections on “Reviving plain old therapy”—A recent article featured in psychiatric news. Optimal Performance Institute. 2012;June 7.

7.       Budd R, Hughes I. The Dodo bird verdict—controversial, inevitable and important: A commentary on 30 years of meta-analyses. Clinical Psychology and Psychotherapy. 2009;16:510-522.

8.       Kazdin AE. Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology. 2007;3:1-27.

9.       Mansell W. Core processes of psychopathology and recovery: “Does the Dodo bird effect have wings?” Clinical Psychology Review. 2011;31:189-192.

10.     Rossouw TI, Fonagy P. Mentalization-Based Treatment for self-harm in adolescents: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2012;51:1304-1313.

Can the future of psychotherapy be found in an iPad?

As I read Dr. Allen’s recent blog post “What’s Next? Psychotherapy by iPad?,” I had a few thoughts. I was reminded of the seemingly natural gradiosity that we humans possess in believing that there are certain behaviors that only we can do, or that we do best. I recall reading When Elephants Weep: The Emotional Lives of Animals and having that same thought: Is it not grandiose to believe that, as a species, we have the corner on the market of complex emotional worlds? As an avowed middle-aged geek, I was also reminded of Data from Star Trek: The Next Generation and his quest to be human. In one episode, the wise Captain Picard mused that perhaps humans ought to aspire to be more like Data.

Attachment and machines

In all seriousness, I think one question that begs to be answered is whether or not computers can simulate mentalization. I have a pleasant memory of the old computer program ELIZA that was created in the 1960s and programmed to give Rogerian-type responses to “clients” who chatted with it. Many people found ELIZA to “feel” strikingly human and some reported feeling helped by “her.” A more modern version of ELIZA can be found in MindMentor, a computer-programmed “chat therapy” developed by a pair of Dutch psychologists. According to one survey, 47 percent of individuals who used the program reported that they had been helped by it. Did they feel heard? Did the program mentalize them? Is it possible to attach to a computer in the same way that persons attach to other non humans such as family pets?

Though I realize I am straying away from the topic of mentalization and attachment, as Dr. Allen alluded to in his post, there are other, non-human modes of treating people out there. There are CBT sites, for example, that purport to help people with depression and OCD. Also, as he mentioned, thousands (millions?) of self-help books exists that presumably have helped individuals in their recovery. Did the individuals reading these books feel “heard” or “understood” when they turned the pages? Did the books “speak” to them?

In the future

The most recent Monitor on Psychology, a publication of the American Psychological Association, just arrive in my inbox, and on the front page, it says “Beyond one-on-one psychotherapy.” In Dr Allen’s post, he rightfully mentioned recent thinking by psychologists that we need to try to reach more clients. We ought to be able to provide services in many modalities, and to people who are geographically, financially and mobility challenged. It seems to me that ongoing debate and study regarding alternative delivery methods is inevitable. It’s conceivable to me that, in the future, I might pull out my smartphone and utilize an “app” that helps me think about an interpersonal problem I might be having. Will I feel “attached” to my smartphone? Well, I already am. (Just a little textual cue so that you might better mentalize me and the playful spirit with which this post was submitted.)

Current trends in the delivery of mental healthcare bring this question to the fore. We have long known that psychotherapy is a limited resource, plainly inadequate to meet mental health needs. This limitation is true not only of individual psychotherapy but also of all forms of psychotherapy combined: individual, group, couples and family. Not only is the distribution of mental health services grossly uneven geographically, the pervasive limitations of resources have also become more glaring in the context of healthcare debates and global economic woes.

New service delivery mechanisms

Thus, not without justification, Alan Kazdin and Stacey Blase argue that we must develop and disseminate a far broader array of non-psychotherapeutic interventions, even if the magnitude of their effectiveness is more limited than psychotherapy. Small effects with wide reach are better than no effects, given the unmet needs for mental health services. Joining a venerable chorus, these authors also advocate greater emphasis on prevention as well as the benefits of early intervention.

Yet, as a committed practitioner of Plain Old Therapy, I’m jarred by their advocacy of impersonal interventions now made possible by burgeoning new technologies. Telephone therapy is not new, and enhancing it with video seems eminently sensible; this expansion of service delivery can greatly enhance the likelihood of developing therapeutic relationships. How much is lost (or gained?) in video versus face-to-face interactions is an empirical question. But, as Kazdin and Blase review, we now have an expanding array of web-based interventions and smart-phone applications, for example, to monitor mood and promote coping skills, which are derivatives of cognitive-behavioral therapies.

Key limitation of technology

I find persuasive Kazdin and Blase’s basic point that we need to expand the reach of mental health services and that any form of help we can provide—even if modest in its effectiveness—is all to the good. Moreover, as these authors state, new technologies can serve well as adjuncts to psychotherapy. Books have done so for decades.

Although we don’t seem to be able to live without them, computers don’t mentalize—hold mind in mind. For that, we need parents, friends, romantic relationships and—especially when things have gone wrong to the point that these ordinary relationships cannot adequately provide needed help and support—psychotherapists.

Reference

Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6, 21-37.

We’ve had more than a few discussions on this blog about therapeutic techniques. Eminently-qualified, highly-regarded psychologists have written serious pieces about how they use BEER, POT and other treatments to help patients. With all the brainpower we’ve got at Menninger, you’d think someone would’ve clued in to what now seems like the obvious next step: clothing-optional therapy (COT).

No, really. Check out this article about Sarah White, a woman who calls herself the “Naked Therapist” because she takes her clothes off as she talks to people. The article is safe for work, but let me nutshell it for you:

A 24-year-old “psychology buff” has set up a business in which she charges people $150 to chat with her about their problems while she removes her clothing. She has no credentials or qualifications and is not licensed by any sort of governing body.

We now live in a world in which naked therapy not only exists, but is covered by the New York Daily News, the fifth-most widely circulated newspaper in America. According to Google, there are 24 news pieces about Ms. White’s business. People are paying attention to this woman.

All of the sudden, that Psychology Today cover I wrote about awhile ago now doesn’t seem so outlandish.

Naked “therapy?”

There’s a short video at the above link (also safe for work) that gives you a brief glimpse into a session as well as some of Ms. White’s musings on her new venture. She certainly sounds sincere, but I got a good chuckle out of her using the word “patients” to describe her clients. The article has a great quote from Diana Kirschner, a New York-based clinical psychologist, that I’m sure sums up what a lot of licensed professionals are probably thinking:

“She’s using the word therapy here, but I don’t consider this therapy. I consider this interactive soft-core Internet porn.”

I found the clothing-optional part of the session just plain weird, but fortunately the video stops before going too far down that road. Imagine having a serious, heartfelt conversation with someone and then, right in the middle of it, they get up, move around the room for a minute and then return to their seat like nothing happened. That’d be distracting, right? Now imagine that, instead of just moving around, they also peel off layers of clothing. I’m no doctor, but I cannot fathom how this would help anyone.

Are we honestly supposed to take this seriously? Ms. White has her own website (which I was hesitant to visit, mostly for fear of legitimizing this and because it felt icky), and the first image you see is her in what I imagine is meant to be a sexy picture. There are a few paragraphs about her and her interests, and then she signs off like so:

xoxo

Sarah

I would say that the only thing missing is a smiley face, but there’s one at the end of the second paragraph.

Perpetuating stigma

It seems clear to me that therapy is not Ms. White’s top priority. It also seems clear to me that this kind of story can only help perpetuate stigma. Why go to a legitimate, qualified doctor when you can pay someone to strip while conducting a “therapy” session? How serious can mental illness be if this woman can claim to be helping people deal with theirs?

Serious mental illnesses need serious mental health professionals. And I guarantee you all of them wear clothes.

Editor’s note: If you enjoyed Cody’s post, then check out two of his most recent ones:

• Is it OK to diagnosis Winnie the Pooh and friends with mental illness?
• Giffords shooting calls for measured, rational response

First, a clarification: My post “Make my therapy plain, but with a twist” ended with the question (comment, really), “Who says there is nothing new in the world of psychotherapy?” One could easily get the impression that this referred to Dr. Allen, whose post I was discussing. It did not. In fact (as is clear in his latest post), Dr. Allen appreciates advancements in psychotherapy as much as anyone I know. I erred in not noticing the apparent implication of that closing sentence.

However, that’s not to say that sentence was thoughtless or random. In fact, it was born of frustration (call it a pet peeve) over the course of 30 years in the field, hearing statements from a range of people, including patients, students and professionals, that “all therapies are the same,” “There’s nothing new under the sun” and “It doesn’t much matter what a therapist does, patients will get better.”

New remedy on offer

I’m sure Dr. Allen is as bothered by such statements as I am. True, a variety of interventions are generally (though not always) beneficial. However, it does not follow from this that it doesn’t matter what you do. There is plentiful evidence that some interventions work better for some disorders than others (for a sampling of research supporting this statement, visit www.academyofct.org). It is also true that therapy also can cause harm (more on this, perhaps, another time).

Dr. Allen’s post reminds us that the argument about common factors versus prescriptive therapies is a bit like the old “tastes great-less filling” debate: It doesn’t really take us anywhere. Is cure more about empathy or cognitive restructuring? A caring relationship or skill acquisition? Active listening or exposure to feared stimuli? Answer: Yes!

I think what Dr Allen and I are both saying is that the field is moving in the direction of an old-yet-new psychological remedy that I propose we label POT/BEER: Plain Old Therapy, But Empirical Evidence Required!

What works, and why?

The human element that Dr. Allen so eloquently describes has brought comfort and healing to innumerable distressed souls through the years, not only by mental health professionals, but also by members of the clergy, school teachers, family members and other caring individuals who listen well and without judgment. This must continue to be appreciated and cultivated, even (and especially) as we introduce new, more prescriptive, interventions based on the latest research. At the same time, we must seek to better understand how, why and under what circumstances these “common factors” work.

This is not as obvious as it may sound. For example, when therapy relieves depression, patients and therapists alike may give an assortment of explanations: Because I felt accepted and understood. Because I helped her to better understand her past. Because of increased self-affirming thoughts. Etc. All of these processes may have, in fact, occurred, but what was the actual mechanism that lifted the depression?

This is something that we in the research arena seek to understand, because the short answer at this stage is we really aren’t sure. What’s more, we cannot assume that all common factors are helpful for all people.

For example, is empathy beneficial for all patients?

A lesson learned in therapy

The Devil Wears Prada

This may seem like a silly question: Isn’t empathy good for whatever ails you? I will never forget the lesson I learned early in my career from a patient who consulted me for interpersonal problems that she was having, both at work and in her personal life. The reason was clear—she was a bully! Think Meryl Streep in The Devil Wears Prada: a self-made woman who worshipped her creator! She was always right and God help anyone who disagreed with her. Her controlling style made ordinary conversation difficult and therapy well nigh impossible.

Or so I thought, until it occurred to me that my usual efforts to communicate warmth, understanding and acceptance were going nowhere. To the contrary, this woman viewed such “softness” as a sign of weakness, to be disrespected or even exploited. When I adjusted my stance to one of greater distance and started communicating some actual disapproval, her behavior changed dramatically; she actually started listening a bit, and we were able to do some meaningful work.

We can speculate about why this proved helpful; but, the fact is, I was improvising—flying by the seat of my pants, because there was (and is) little in the research literature about matching my relationship style with a specific individual’s problems. As a clinician, I recognize this as part of the artistry that Dr. Allen describes. As a scientist, however, I find it less than satisfying. And as a teacher, I know that “improvise” is an instruction that sends therapist trainees into a state of panic. I hope it is not unrealistic to hope for greater precision in our interventions as our science advances.

As Dr. Allen notes, research into curative factors is in its infancy. We need to know what each individual needs and why he or she gets better. On the other hand, I suspect that how we help that individual get better will always share much in common with Plain Old Therapy. Indeed, it is safe to say that simple humanity will always be a key ingredient in the elixir of healing.

Last month we shared with you what I’m sure we can all agree is the ideal psychiatric environment: Strobe lights, thumping bass, Lil’ Jon imploring you to “get outta your mind,” a cheering crowd and a frank and open discussion on accepting who you are through the medium of dance all added up to a fantastic two-minute clip that’s no longer available because Fox doesn’t want people to get excited about the incorrectly punctuated So You Think You Can Dance. You can, however, find a very low-resolution copy here.

Today, we present you the other side of that coin, the side that’s all scratched up and ugly like Two Face’s coin in The Dark Knight:

I’m pretty sure no one would see a therapist if the sessions went like this. In fact, I’m pretty sure a few therapists like this would kill the industry.

Aside from the obvious, there’s a lot wrong with this GEICO commercial. A quick rundown:

• No one goes to the trouble of finding a therapist, scheduling a visit, clearing it with the insurance company, working up the courage to admit they need help and actually going to the appointment to talk about the color yellow.
• I’ve been in a few psychiatrists’ offices, and I have yet to see a couch/recliner like that.
• It’s a little dark in there, no?
• What, exactly, is a “jackwagon,” and why is it a bad thing?

Of course, absolutely none of these issues stop the commercial from being hilarious. R. Lee Ermey is a national treasure. I laugh every time he tosses the tissues away in disgust.

But I’m curious what you think. Is this commercial harmless fun, or does it contribute to the stigmatization of mental illness?

“All those years, all that money….”

So begins “My Life in Therapy,” an autobiographical saga that appeared recently in The New York Times Magazine. Here, Daphne Merkin writes in great detail about her 40-plus years (!) in therapy, mostly psychoanalysis. Early in the piece, she starkly declares,

“To this day, I’m not sure that I am in possession of substantially greater self-knowledge than someone who has never been inside a therapist’s office.”

Oof.

At this writing, more than 600 comments to her article have been posted online, ranging from “Thank you for this eloquent and insightful account” to “Grow up and get a life!” By eyeball reckoning, the latter outnumber the former by at least 2 to 1.

What’s interesting (ironically) is that Ms. Merkin never quite comes out and says how she feels about her therapy experience – whether she is satisfied, frustrated about the time and money, enraged about the lack of results or grateful for having had the opportunity. Perhaps some of each.

Reading the article brings to mind a fairly common question raised by therapy patients: How do I know when it’s time to stop therapy? To the casual observer, this is a silly question: Obviously, you stop when the problem is resolved – the panic attacks stop or the depression lifts.

But as you know if you’ve been there, sometimes it’s not so simple:

If my problem is low self-esteem, how do I know when I have “enough” of it? Ditto for reducing one’s stress level or increasing assertiveness. Not to mention more nebulous objectives such as figuring out who I am or finding intimacy in relationships.

Sadly, therapists are often of little help here. Patients asking this question may be met with platitudes such as “Things take time,” or simply more questions, such as “What do you think it means that you ask this question?”

Well, as Freud famously commented, sometimes a cigar is just a cigar, and sometimes a question deserves an answer!

Here’s the short answer: Therapy should end when your goals have been reached or when it becomes apparent that it’s not helping.

Two qualifications: “Supportive” therapy may go on for extended periods of time without apparent progress in the sense that a “cure” is never achieved, but the individual needs help to prevent relapse or severe deterioration. Such therapy, while life-sustaining for some, is quite different from what Ms. Merkin describes.

Second, therapy for the purpose of personal growth and self-knowledge may not fit the framework presented here. I think this may be why Ms. Merkin isn’t more upset: Her therapy may have been more about the journey than the destination.

Fair enough. But it’s my impression that relatively few people enter therapy with the equivalent of a EuroRail pass, without limits on time or money, just traveling for the sake of the scenery. Most are interested in results – a destination, if you will – and most, in my experience, would opt for the quicker, rather than the scenic, route.

If this is where you are “coming from,” then your best bet is to talk frankly with your therapist, preferably early in the therapy process. Now not all therapists speak this “language” (important information, in my opinion), but many, perhaps most, will be more than happy to “go there” with you.

So, what should you discuss? There are actually two related questions here:

1. What exactly are we trying to accomplish?

2. Are we there yet?

You’ll notice right away that it’s difficult to answer the second question without a clear answer to the first. The first, in turn, requires “operationalized” goals. This means defining your objectives in ways that are specific and observable.

For example, “being better adjusted” is hard to measure and means different things to different people. But if you were asked, “What would we see if you were better adjusted?” you might list things like worrying less, socializing more and sleeping better, all of which can be measured.

Even an apparently straightforward goal like “overcoming my depression” is too vague, because it may mean one thing to you and something quite different to your therapist. But exploring this together with your therapist might help identify goals like crying less often, resuming sexual activity, reducing indecision and thinking better of yourself, all of which reflect recovery from depression. Such goals are observable and less impressionistic than simply wondering if you are “getting better.”

Another goal to consider (a given with many therapists) is the internalization of the therapeutic process, what some refer to as “becoming your own therapist.” This is important when it comes to relying on yourself rather than needing to re-enter therapy whenever life presents you with new challenges.

So, here’s the bottom line: It’s time to end therapy when you determine that your goals have been met (unless, of course, you want to set some new goals). On the other hand, it may also be time to stop (or make a change) if, after reasonable time and effort, your goals haven’t been achieved. The definition of “reasonable” is a matter of opinion, of course, but let’s hope that it’s well this side of 40 years.

More invested in what is important than what is new, and protesting the proliferation of new therapies with their accompanying slew of acronyms (e.g., CBT, DBT, IPT, MBT, etc.), I have declared myself a practitioner of POT: Plain Old Therapy. In response to this declaration, my colleague, Tom Ellis, responded, “Who says there’s nothing new happening in the world of psychotherapy?”

Dr. Ellis has not persuaded me to give up POT. But his counterpoint to my blog post leads me to introduce a caveat: while respecting the essential ingredients, we must strive continually to improve the quality, effectiveness—indeed, potency—of POT. In advocating POT, I do not mean to imply that we learned long ago how to conduct psychotherapy in the most effective way and that there is no need to question, modify or improve our practice. We have much to learn from research on psychotherapy and, indeed, the quality of research on psychotherapy is improving. Dr. Ellis’s critique made me aware of the extent to which I am continually striving to learn more and improve the quality of my practice.

Perhaps being hooked on POT will allow me to speak out of both sides of my mouth without concern for self-contradiction. On the one hand, I believe that some essentials of psychotherapy are venerable and cannot be improved upon. These essentials boil down to the quality of the human relationship the therapist is able to establish with the patient.

In this sense, therapy is an art.

Therapists vary from one another in their capacity to form a therapeutic relationship, and their capacity to do so also will vary from patient to patient. I think this therapeutic capacity is fundamental to the therapist’s humanity. We all share a common core of humanity, but I believe that we differ from one another in being more or less skilled in being human. I find myself admiring some individuals who seem to me to be gifted at being human.

I also find psychological theory and research helpful in understanding what goes into this skill at being therapeutically human: the capacity to mentalize (i.e., to be emotionally attuned to mental states in self and others) and the thoroughly intertwined capacity to form secure attachment relationships. This core of our humanity develops—more or less completely—in the context of attachment relationships. What makes for a good parent or romantic partner makes for a good psychotherapist. Of course, as effective psychotherapy demonstrates, we can always improve our individual humanity, that is, become more skillful at being human. Perhaps it makes sense that psychotherapy is a common part of the training (or development) of psychotherapists—maybe the most essential part for many.

The conduct of psychotherapy is a rather messy amalgam of the therapist’s humanity and expert knowledge, art and science. Thus, on the other hand: in addition to developing increasingly refined evidence-based treatments for specific disorders, we can continue to refine our understanding of the “common factors” that cut across different brands of psychotherapy (i.e., cognitive-behavioral, interpersonal, psychodynamic).

Group psychotherapy

Whether we call it “talk therapy,” “generic psychotherapy” or “plain old therapy,” we can clarify what we are aspiring to do and do it more effectively. From this perspective, we have most to learn from research on “mechanisms of change,” that is, the psychological processes catalyzed by psychotherapy that facilitate amelioration of psychiatric disorders along with improved functioning and quality of life. Attachment security and mentalizing capacity are examples of potential mechanisms of change, but research on these factors in psychotherapy is in its infancy.

Dr. Ellis has made me aware of the hope that the POT of tomorrow will not be the POT of today. In writing this post, I was reminded of the 2008 address our esteemed colleague, Irv Rosen, gave to graduates of the Menninger training programs. Among many other distinctions, Dr. Rosen was the first graduate of the Menninger postdoctoral training program in clinical psychology. I conclude with a quotation from his inspiring address, which applies to psychotherapy as well as psychiatric treatment as a whole:

The techniques that characterize a clinic or hospital at any given time are ephemeral, provisional, to be inevitably replaced by newer and better methodologies. What forms the core of a place of healing are its values…. I am confident that those values of hope, transmitted through a caring relationship and sustained by a spirit of ever-present inquiry, will continue to inspire your work….

To the good fortune of a great many, Dr. Rosen, a master therapist, served for many years as the director of the psychotherapy service at The Menninger Clinic when it was located in Topeka, Kansas. As I hope this brief quotation illustrates, he is an exemplar of a person who is gifted at being human.

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.”

New weapons

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.

Making strides

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!

Third-wave therapies

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?

The field of psychotherapy suffers from acronymania: a proliferating plague of acronyms. Your psychotherapy brand will not be taken seriously if you don’t have a good acronym for it, preferably three letters, although you can get by with four or two. A short list: CBT, DBT, TFP, DIT, CPP, TPP, SIT, ERP, IPT, PCT, CFP, EFT, MBT, RLX, EMDR, ADEP and PE. Ideally, your therapy will qualify as an EBT or EST (evidence-based or empirically-supported treatment), that is, a treatment of experimentally-proven effectiveness that comes with a manual instructing the therapist on how it’s to be conducted.

More acronyms, please

Of course, we also have acronyms for psychiatric conditions: MDD, OCD, PTSD, BPD and so on. The crowning glory is having an EST for a particular condition: CBT for MDD, ERP for OCD, PE for PTSD and MBT for BPD (translation: cognitive-behavior therapy for major depressive disorder, exposure and response prevention for obsessive-compulsive disorder, prolonged exposure for posttraumatic stress disorder and mentalization-based treatment for borderline personality disorder, respectively).

We are truly blessed that clinician-researchers have developed all these ESTs for various psychiatric disorders. We need these specialized treatments for specific disorders and symptoms. Yet there are two problems with this state of affairs. First, to be fully competent in treating a range of psychiatric disorders, the therapist would need to learn 150+ treatment manuals—a daunting task. Second, many patients who seek treatment have a number of different disorders and problems at the same time (e.g., depression, anxiety, alcohol abuse, an eating disorder and personality disturbance).

Do we send such patients to several psychotherapists, as we might send patients to several medical specialists? Does the same psychotherapist administer several treatments sequentially, one after the other, or even concurrently?

Common factors

The problem I am addressing is not unique to psychiatry or even general medicine. We live in a world of increasing specialization such that individuals can hardly even keep up with the knowledge in their own field of endeavor. In the field of psychotherapy, there has been, in response to ever-increasing specialization, a countervailing movement for decades: the emphasis on “common factors” that account for the effectiveness of the therapy, regardless of the therapist’s specific technique or the brand name of the therapy. There is solid research support for this focus on common factors: it is extremely difficult to demonstrate that any good type of therapy is more effective than any other.

For example, we know that a positive therapeutic alliance—a trusting relationship in which the patient and therapist are working together toward common goals—is a major contributor to the effectiveness of therapy. Another important common factor is the therapist’s empathy. Recently, we have been advocating another common factor based on attachment theory and research: mentalizing, that is, an open-minded or mindful attentiveness to mental states such as thoughts, feelings and needs in oneself and others. It is a truism that psychotherapy requires interest in what is going on in the mind—and a meeting of minds. We use our colleague, Peter Fonagy’s, phrase for this process: holding mind in mind. We describe the ubiquitous role of mentalizing in relationships—including psychotherapy relationships—in our book, Mentalizing in Clinical Practice.

New psychotherapy brand

I am more concerned with common factors than specific techniques; I aspire to mentalize and help my patients to do so with me; and, not denying my competitive response to social pressure, I feel a need for a catchy acronym.

Hence, after more than four decades of practicing psychotherapy, I have decided on my own brand of psychotherapy: POT, Plain Old Therapy.

A patient once asked me at the beginning of our first session, “What kind of therapy do you practice? Talk Therapy?” I replied, “Yes, Talk Therapy, that’s what I do.” But I like POT better than TT.

To the extent that psychotherapists are returning to a common core of effective elements, the psychotherapy field might be going to POT. For many patients whose symptoms are multifaceted and rooted in problems with self and others, POT is in order. I acknowledge that POT is not optimal for treating patients with specific disorders for which effective specialized treatments are available. But even these specialized treatments, well delivered, must be laced with POT.

In his popular book, A Secure Base, John Bowlby, the psychiatrist and psychoanalyst who pioneered attachment theory, stated that the psychotherapist’s role is

“to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.”

In a trauma education group, I once remarked, “the mind can be a scary place.” A young woman in the group spontaneously replied, “Yes—and you wouldn’t want to go in there alone!” She thus epitomized Bowlby, and I have never heard such a trenchant characterization of psychotherapy since. This is POT, as I endeavor to practice it.