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Serious Problems in Psychotherapy Require Serious Medicine

By Steven A. Frankel, M.D.

As a psychotherapy patient, do you wonder whether the work you and your therapist are doing will succeed and produce lasting results? You may like, even admire, your psychotherapist, but how do you know that as a result of his or her work you will achieve the goals for which you came to treatment?

Patients frequently remain in the dark about whether treatment is actually succeeding. The solution to this dilemma is a treatment considerably broader in scope than conventional psychological and psychiatric therapy. This treatment embodies proven techniques for accurately assessing the nature and severity of a psychological problem and for monitoring treatment progress. In using these methods, therapist and patient work collaboratively to track progress, continually providing feedback to each other.

In conducting this innovative method of treatment, the therapist assumes the kind of clinical responsibility that is typical of a physician. He or she takes responsibility for addressing the full range of the patient's presenting and underlying problems, and coordinating his or her treatment, always assimilating the feedback the patient provides.

Take my patient Cori (not her real name). She had been treated by multiple psychotherapists and psychopharmacologists. Cori was bright and empathic, but had a history of failed relationships, depression, and withdrawal when situations soured. Following the loss of a job, Cori was forced to seek support from her aging parents.

All previous attempts at treating Cori had been disappointing. The medications prescribed by Cori's psychiatrists and psychopharmacologists all created additional problems through their side effects. Psychotherapy was unsatisfactory, too. In part, what caused these failures was the inability of professionals to work closely together. Those who were medically oriented also neglected to take full account of Cori's feelings of disappointment and helplessness, while they focused on her physiology. Cori fired her last therapist after two years because she had not progressed. That was when Cori first came to me.

Cori's case was indeed challenging. She needed a full medication review and overhaul, a more functional support system, vocational retraining, and goal-oriented psychotherapy addressing not only her depression, but also practical problems interfering with her daily life. No single issue had overriding priority, and none could be resolved with conventional psychotherapy alone.

What Cori required was a new kind of approach to her treatment, one distinguished by reliable diagnostic assessment, clear-cut goals, monitoring of progress, and above all, coordination between professionals. This is the approach I use when practicing collaborative psychology. As therapist-coordinator of Cori's case, I orchestrate and monitor the entire operation, collaborating with all the other clinicians and consultants involved, and the key people in her support system. But, this brief description of my experience with Cori doesn't capture the essence of the treatment. Cori was a complex human being and this new treatment had to be characterized by profound respect for her and her thinking. Cori needed to be a fully collaborating partner in her treatment. A patient, but not just a patient.

In its comprehensiveness and use of psychological assessment, this is a novel approach to psychotherapy. When patients have a combination of symptoms, such as depression, difficulties involving family, children, relationships, or employment, and at times one or more medical conditions, the issues tend to overlap and may be hard to sort out. To find solutions to these complex problems, the therapist must closely collaborate with the patient and all the other professionals involved.

At the beginning of collaborative psychology treatment there is a clinical evaluation. This step is followed as soon as possible by psychological or neuropsychological testing. Based on these two assessments and the data they provide, the therapist-coordinator prepares a preliminary treatment plan. At this point the patient and therapist together determine the type of treatment they are agreeing to undertake. Then each clinical strategy proposed in the treatment plan is evaluated for efficacy during a trial period. Verbal or written reports, successively modifying the treatment plan, are created in response to changes and progress in treatment.

You may be asking yourself at this point why go to this much trouble and expense?

Consider for a moment the world of medicine. Would you fault a physician who is meticulous about collecting data, obtains needed consultations, regularly informs patients about findings, and revises his or her treatment plan according to whether or not progress is occurring? Of course not.

Using this collaborative psychology method, clinician and patient can determine exactly what kinds of problems need to be treated and become aware of changes in the patient's status as they occur. As the patient or his or her circumstances change, the treatment plan can be modified, so it remains maximally effective. A second clinical and data-based opinion from the psychologist who administers the assessment tests is always part of the process. This person remains available throughout treatment and even past its termination. Making the clinical process even stronger are the regular progress reports the patient receives from and discusses with the clinician.

The extra cost and time required for this comprehensive treatment approach are more than justified by its built in focus on the patient's progressively demonstrated needs and progress. The testing and self-discipline this procedure requires of the clinician assures against misdiagnosis or over-treatment. The likelihood of engaging in formulaic, unproductive treatment, such as often occurs when a therapist reflexively sees a psychotherapy patient once per week for many months or even years, is much reduced. Collaboration with spouses or family members is also encouraged when it is likely improve the treatment outcome.

And, once again, the benefits of such a process? More focused and efficient treatment that leads to substantial results. Cori is now working at a job she enjoys, her family is actively supporting her recovery, she hasn't abused any substances for several years, and is doing a marvelous job of mothering her two boys. Those are results!

Steven A. Frankel, M.D. is the author of four books describing collaborative psychology, including his most recent book Evidence from Within: A Paradigm for Clinical Practice. He has been a practicing psychiatrist for over thirty years. A graduate of Yale University Medical School, Dr. Frankel is board certified in both general and child psychiatry. He is an Associate Clinical Professor at the University of California Medical School and founder and director of the Center for Collaborative Psychology in Kentfield, CA.
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