Tuesday, August 23, 2011

Psychotherapy Reinvented

Psychotherapy is expensive, time-consuming, and too often doesn't work well enough. It needs to be reinvented or at least made more time- and cost-effective.

Traditionally, the first therapy session or two is spent on intake, asking lots of questions to gather information about the client. I'd replace that with a probing questionnaire to be sent to the therapist in advance of the first session. Not only would that save the client time and money, it would give both client and therapist a chance to reflect on the questions rather than have to try to be maximally insightful on the spot.

I believe it's worth creating a video version of the questionnaire. Of course, each therapist could create his or her own, but I'm wondering if the following is worth a try: A preeminent psychotherapist who is eclectically oriented (using cognitive-behavioral as well as traditional techniques) would create a probing new-client questionnaire and then, instead of giving it to the client in text form, ask the questions in a YouTube video, charging a small fee for each use. I believe that many clients would prefer seeing that world-class therapist ask the questions and might give them greater thought. There's certainly little downside to that approach.

More therapists should offer sessions by phone or SkypeVideo. I've found that, if the client is open to it, those are nearly as effective as in-person sessions. Not only does phone/Skype therapy avoid the client having to shlep to and from the therapist's office, it gives clients more therapists from whom to choose. That's especially important for clients in regions with few top therapists, for example, rural areas.

Of course, every situation is different, and severe cases may need more long-term therapy, but I believe that, in most cases, psychotherapy need consist only of one two-hour solution-generation session followed by one one-hour session to assess how helpful the solution(s) have been and, if needed, to tweak solution(s) or generate new ones.

How could it all be done in two sessions? Not only is there the efficiency that comes from a probing new-client questionnaire completed and reviewed by the therapist in advance, the therapist and client knowing there's only one session to develop solutions motivates them to make the most of the session time. (Remember Parkinson's Law: Work expands to fill the time allotted?) Too often, much time in therapy sessions is wasted on unimportant tangents. Another benefit of developing the solution(s) in one session is that both therapist and client have all the input currently in-mind rather than having to recall it from notes and memory of the previous session(s.)

Generally, therapists should try to elicit solutions from the client--they're more likely to be helpful and certainly to be acted upon. But, unlike in traditional models of therapy, sometimes the client really does need and is open to the therapist's input. So if a therapist would like to suggest a possible solution, s/he should do so. The key, however, is to offer it in a client-empowering way, for example, "Would you mind if I suggest something?" With assent, then say something like, "I'm not sure I'm right but I'm wondering if it might help if you did (

Other time-effective techniques used in psychotherapy and coaching should be part of the therapist's repertoire. One example: Ask the client, "If I waved a magic wand and your problem were solved, how would your behavior be different?" After they explain, ask, "Could you change any of that now?"

Unlike in many traditional therapy sessions, the first session should end with a specific behavior(s) the client is enthusiastic about trying. Examples:

The moment an irrational fear enters consciousness, say "Stop" and ask yourself, "What's the next positive step I can take?"

Write down everything you eat.

Write a letter of reconciliation to your mother. Set it aside for a day. If it still feels good, send it.

Every time you drink something, say aloud, with expression, "I deserve to be good to myself." That will build the brain memory neurons associated with that constructive thought.

In the follow-up session, the client would report the extent to which the solution(s) have been helpful. If changes are needed, the therapist should, as recommended above, usually first try to get solutions to come from the client. If the client didn't do the homework, the therapist should try to ascertain if that was because of a fear, ran into a conundrum, the assignment ended up feeling inappropriate, etc, and try to help ensure that, subsequently, the client be more likely to complete that assignment or a more appropriate one.

At the end of the second session, unless it's clear that more sessions are needed, it's often best to end with something like, "I think you've come up with all the tools you need. So do you agree we don't need to see each other for a while?" If the client agrees, the therapist should say something like, "But I care about you and so I'd welcome your emailing me about your progress, and if you do feel you need another session, just let me know." That makes the client feel supported, assures the client that s/he can have more sessions, and increases the chances that therapists get feedback that can improve their effectiveness.


Anonymous said...

I suffer from long-term chronic depression and severe anxiety. I take meds as well as see a therapist monthly (during crisis times, weekly). I could not function without my therapist's support. I talk to her about things my family and friends don't want to hear. My therapist helps me maintain equilibrium. Psych meds have a long way to go. If in the future they become more effective, with fewer side effects, we may need less psychotherapy. In the meantime, those of us with chronic mental health problems need both meds and therapy.

Anonymous said...

Marty, I think this CBT oriented approach works well with moderate issues. However, I find that CBT is limited to the capabilities of the patient. ie If they're not mentally capable of making change in their life, then maybe EMDR or other approaches are more suitable.

A therapist once approached me about Skype and it turned me off. Skype is great for business meetings or long distance relationships, but Skype is impersonal. Reminds me of that George Clooney movie "Up In The Air" when they fired people via Skype.

There is a therapist in the Bay Area, Dr. Janice Cohen, who is very solution based and practices what you preach. She is not cheap at $250/hour. But if people can't or won't do their "homework", it's a therapist job to find out what is stopping them.

Marty Nemko said...

Dear Both Anonymous Commenters,

Yes, I certainly agree, per my post, that severe problems often need longer therapy.

Yes, and good point regarding clients who don't do their homework. For example, in the model presented, if a client comes in for the second session without having done their homework, the therapist should indeed try to unearth why and try to get the client to do the homework subsequently. I'll add that point to the post. Thanks.

Anonymous said...

I really like the part about the questionnaire that is sent before the appointment. I think this should be done before every appointment, but it doesn't seem realistic in my experience that patients would have the discipline to do this consistently. The main problem as I see it is that people with psychological issues are often lonely, isolated, and inactive. Their only comfort is talking about their problems to someone. And even if they have to spend thousands of dollars, going to the therapist gives them the mirage of improvement and change as well as routine, and they keep going without really confronting their own limitations and problems, which are too scary, unpalatable, etc. to tackle. On the other side, why would the therapist refuse all that money when the patient is willing to keep spending it? I definitely agree with you that psychotherapy is too often useless, but I just don't see this changing anytime soon.

Anonymous said...


You and your commenters raise excellent points mixed in with oft-repeated psychotherapy myths and misunderstandings.

1. Therapy has already been "reinvented" by Albert Ellis in 1956 with efficiency and cost-effectiveness as a priority. As an REBT (Rational Emotive Behavior Therapy) therapist the average duration of my therapy, for example, is 8 - 10 sessions.

2. Entire sessions devoted to intake discussions, probing questionnaires, or videos are rarely needed and occupy valuable time. These are examples of, as you state in another context, "Too often, much time in therapy sessions is wasted on unimportant tangents."

Initially posing the question "what problem(s) would you like help with?" is usually sufficient. In my first session we typically answer this question, discuss the concepts and tools we'll be working with, and begin applying them to the client's specific problem. We conclude with homework assignments, which often include a cognitive exercise, a behavioral goal, and bibliotherapy.

3. "Traditional techniques" typically do not address the core issues and often lead to expensive, time-consuming tangents occupying hours, days, months, or years. Avoid them.

4. Phone therapy works well with those individuals comfortable with it and is often more efficient than in-person. It saves travel time and increases scheduling flexibility. Some people are even more comfortable on the phone than with face-to-face sessions.

5. Occasionally severe cases could use longer term therapy than 8 - 10 sessions. However, usually a more important variable involves both the client and therapist working especially conscientiously and efficiently at solving the client's problems.

On a clinical note, severe cases typically involve a "secondary disturbance" (disturbance about being disturbed) and addressing this early in the therapy can make a dramatic difference in the duration and depth of the solution.

6. Marty, I agree with you solutions can be presented in the first two sessions. However, more sessions are often desirable to help the client master them and develop the habit of regularly practicing them.

7. You state: "Therapists, of course, should try to elicit solutions from the client--they're more likely to be helpful and certainly to be acted upon." I've heard this many times in my 35 years as a therapist, yet have never been shown supporting evidence. How an untrained, inexperienced client would have solutions for life-long problems he's never solved is beyond me.

8. You further state: "sometimes the client really does need and is open to the therapist's input." Sometimes? I submit it's a rare client who would spend his hard-earned money and precious time on a professional consult and then be closed to the professional's input.

I hope some of my thoughts are helpful.

Michael R. Edelstein. Ph.D.

Marty Nemko said...

Michael, I do believe that many times, clients only need a facilitator, someone who will ask the right questions and help them tease out their own solutions.


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