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A new book, "How to Go to Therapy," written by Carl Sherman (Random House, 2001), has been described by one psychiatrist as a warm and insightful step-by-step guide for prospective patients. Mr. Sherman, a long-time writer for CLINICAL PsyCHIATRY NEWS, covers the entire process- from the decision to enter therapy to the decision to terminate it.

Discussion Question: Is there a relationship between adequate preparation for therapy and its ultimate success? Are there ways that patients should be educated regarding expectations for therapy? Conversely, are there ways in which you can predict that the patient will not benefit? Can you share introductory techniques that have helped you set the stage for successful therapy?

'How May I Help You?'

The preparation that is necessary needs to be done by the therapist. It is critical for the therapist to communicate an understanding of the patient's perspective of the problem. For example, beginning the session with the simple comment, "How may I help you?" communicates a great deal.

The patient should be educated to understand that:

* Not all patient-therapist matches work.

* There are both short-term and long-term goals.

* They should get a referral from a reliable source.

* Trying to understand the origins of a patient's problems may take a long time- something like learning to play the violin or the piano. It does not happen overnight.

If a patient has difficulty trusting, it may be very difficult for them to trust the therapist. Patients who feel easily wounded will need a sensitive therapist who shows respect and realizes that interventions may be experienced like assaults.

Leon Hoffman, M.D.

New York

First Things First

For the vast majority of patients, the preparation for therapy occurs during the early phases of therapy, not before it begins. Most patients are accustomed to the interactions they have with their family doctor, but psychotherapy interactions are quite different. It is essential that they understand these differences early in the process. They must understand that they will play a much more active role.

After I've made a treatment recommendation, I spend time before therapy begins educating the patient on what to expect during therapy I also listen for this as an ongoing concern during treatment and offer to review these issues again whenever they arise. Keeping in mind that most patients don't know anything about therapy or what to expect is essential to ensuring the best possible outcome.

Allan Tasman, M.D.

Louisville, Ky.

Preparation Makes the Difference

With adequate preparation, the process can proceed much more quickly. Rules that establish who will to talk and what they will talk about, for example, can be established from the outset, rather than tediously negotiated in the first several sessions. Patients also can come to therapy with more realistic expectations.

The most helpful introductory technique begins with the therapist providing a brief summary of what will take place and concludes with offering the patient written material to review. The material is reviewed again at the start of the second session. Such an approach seems to help with comprehension and retention of the material.

Scott Stuart, M.D.

Iowa City

From Beginning to End

Patients need to be educated about the process of therapy all along the way. The burden for doing this is on the therapist, not the patient. Patients should not be expected to know how to be a patient, regardless of their level of psychological sophistication. In fact, those who seem especially prepared may be using that preparation as a resistance to fully engaging in a therapeutic relationship with the therapist.

Certainly patients should be encouraged to set goals for therapy but their expectations should be realistically attainable. Often it is hard to know what an individual can achieve in treatment, and therapists should be open to being pleasantly surprised at how much a patient can benefit. Patients who tend not to benefit as much are those who demand quick fixes and are impulsively action prone (rather than balancing the capacity to take action with a sense of curiosity about themselves).

It is critical to set a tone of thoughtful interest in the life and mind of the patient from the very beginning. It is vital for the therapist to model a tolerant and nonjudgmental attitude toward everything the patient says, as well as offering a clear sense of hope that the patient's suffering can be overcome.

Kerry Sulkowicz, M.D.

New York

Dr. Fink: The decision to go to therapy often is very difficult for the average person suffering from anxiety, depression, or a variant of these two disorders. Once a person has decided to enter psychotherapy how the therapist handles that entry and whether an effort is made to demystify the process is critical to success. Very few patients are willing to accept the silence and distance of the therapist, especially when it is ritualistic, formulaic, and can lead the patient to confusion and distrust.

Trust is essential to the success of psychotherapy and psychoeducation in the beginning of therapy Letting the patient know how psychotherapy works and what can be expected, and outlining the patient's responsibility are vital to gaining trust and cooperation.

The transference is an important element in all therapies. The physician's anonymity helps to establish and increase the transference reactions during the therapeutic process, so it is important not to be very self-revealing or too chummy Care must be taken not to violate boundaries or to act in a manner that is seductive rather than friendly domineering rather than helpful, or suggestive rather than receptive. However, I believe it is possible to create a warm, welcoming environment and to present a caring and helpful interactive relationship without destroying the transference or raising the patient's doubts and hostility which ultimately will destroy the treatment.

It is neither helpful nor useful to go into a great deal of detail about the therapeutic process per se, but it is good to give an outline of the process; some idea of a timeline, especially if it is a dynamic, open-ended therapy; your opinion of the diagnosis; and the goals of treatment.

The beginning of psychotherapy is fraught with pitfalls. It takes a skilled therapist to recognize issues and behaviors that predict failure. The perspicuity of the physician is vital until the relationship is strong enough to insure treatment continuity.

There are some patient characteristics that are predictive of failure. These include a bad fit, acting out behavior, a strong desire not to be in psychotherapy and cynicism and argumentativeness that are too difficult to overcome.

At the beginning of psychotherapy, there is no long speech. I simply give patients a one-time lesson on how psychotherapy works. When the patient arrives, I announce that I have three rules:

1. You must come on time to all sessions.

2. You must try to say everything that comes to your mind without editing, altering, or changing it in any way.

3. You must pay your bill.

As the psychotherapy progresses, I address moments of confusion, resistance, silence, bad moods, anxiety, guilt, or anger with some explanatory and reassuring comments about psychotherapy and how the feelings the patient is experiencing are not uncommon. I try to limit the patient's discomfort by helping him or her move beyond the unhappiness or discomfort that may occur with any session.

There is an old therapeutic aphorism, "forewarned is forearmed." If I perceive that the patient is about to repeat a trait or behavior that they have told me has occurred many times in the past, I will tell them that it looks like it is coming again.

Psychotherapy is a time-intensive, sometimes difficult process that requires great sensitivity an appreciation for nuance, a terrific capacity for observation, and a willingness to listen. Most people have no idea what it is or how it works, so any efforts to guide the patient through the initial phases will insure a smoother effort and a better outcome.

RELATED ARTICLE: TELL DR. FINK WHAT YOU THINK ...

Join Dr. Paul J. Fink on a rambling tour of the contemporary scene.

"Emotional Infidelity," a new book by Miami Beach psychologist M. Gary Neuman (Crown, 2001), has generated hate mail from women who accuse him of rekindling a Victorian attitude toward women in the workplace. Dr. Neuman says that going out for drinks, sharing secrets, or even reviewing weekend plans with an opposite-sex coworker constitute unfaithful behaviors. "My message is that if you want to infuse passion and have a buddy for the rest of your life, you have to keep that emotional content in your marriage. Otherwise it's not going to happen," says Dr. Neuman. In calling for new standards of behavior, he says society has underestimated the potential for workplace disruption of marriage, which is inherently fragile.

Discussion Question: Does Dr. Neuman's message resonate with you as a therapist? Is it a retrograde position vis a vis working women? What would you advise patients about emotional relationships outside of marriage? Do you see these as an important source of marital disruption? Deadline: June 1, 2002.

Child prodigies who master an entire lifetime of intellectual achievement in the short span of a childhood have long mesmerized lesser mortals. But the intellectual achievements of child prodigies may exceed their ability to cope with the psychological consequences of their extraordinary gifts, leaving them at risk for behavior problems, attention-deficit hyperactivity disorder, and depression.

Discussion Question: How do the behavioral problems of these rare children mirror--or diverge front--those of less gifted yet still-troubled children their own age? Have you ever encountered in your practice a child prodigy? Which strategies can help these children transition from extraordinary childhood to ordinary adulthood? Deadline: June 20, 2002.

This is a column for readers. We want to hear from you--with answers and questions--based on your own experience, reading, and encounters with American culture.

Share your thoughts with Dr. Fink by e-mailing him at cpnews@immg.com or by writing to CLINICAL PSYCHMTRY NEWS, 12230 Wilkins Ave., Rockville, MD 20852.

DR. PAUL J. FINK is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.
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Title Annotation:psychotherapy issues
Author:Dr. Fink, Paul J.
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Jun 1, 2002
Words:1685
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