Fred Levin's Psychotherapy Newsletter

Presented by the Chicago Psychoanalytic Society

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This is volume 1, number 2, for 1996 , the second Edition of Fred Levin's Psychotherapy Newsletter.

Introduction

First, an introduction to this newsletter, and to me, your guide. The newsletter is for you, to assist you in mental health care decisions (see below). As for me, I am Fred M. Levin, M.D., a board certified psychiatrist and psychoanalyst. I have taught psychiatry (at a medical school in Chicago) and psychoanalysis (at the Chicago Institute for Psychoanalysis). I also do research on psychotherapy theory and technique. Some of you may have seen my articles (three, for example, in the most recent 1995 Edition of the Annual of Psychoanalysis) or my book Mapping The Mind: The Intersection of Psychoanalysis and Neuroscience (The Analytic Press, Hillsdale, N.J., 1991). On the basis of this 28 year experience in the field I feel I qualify as your guide.

Summary of Key Points of the Previous Issue of this Newsletter:

Organizations to Know About

There are a number of organizations that you can contact who will be helpful in finding a qualified therapist. These organizations are established to train specialists, or to organize groups of already trained specialists, hence, they know about your problems and wish to help. They cover basically three kinds of training, in psychiatry, in psychology, and in psychiatric social work. The training programs for these specialties differ, as do the requirements for trainees, in the following ways. Psychiatrists are M.D.s who spend a hospital based residency training program of 4 years studying psychiatry. Psychologists are Ph.D.'s who spend years in a hospital based residency training program studying clinical psychology. And social workers vary from B.A.'s to Ph.D.'s and often have considerable clinical training requirements before licensure. All are licensed by the State in which they reside, and each group overlaps the others. Consequently, the appropriate organizations to consult for help are the following: (1) the psychiatry department of your local medical school, (2) the psychology or social work department of the local medical school, (3) The American Psychological Association, (4) The National Association of Social Workers, (5) the American Psychiatric Association, (6) the local branch of your Psychoanalytic Society (for those in the Chicago area, the Chicago Psychoanalytic Society) or perhaps best, (7) the local Training Institute of the American Psychoanalytic Association. For further information about resources select Net Resources.

Why it is Important to Get Expert Consultation

It is crucial that the initial diagnostic consultation to determine what kind of treatment would be best, be done by an properly trained expert. This is because only an expert is likely to know all of the major options available within a particular community, and what their impact is likely to be on a given patient. Since the largest number of options exists at the beginning of the decision making process, it takes an expert to help us through the maze of possibilities. In addition, if this initial decision is made wisely, it is much more likely that the patient will get the best chance of speedy recovery. Conversely, if the initial decision is made in an uninformed or sloppy way, the chances of recovery may plummet. For this reason I have recommended using super-specialists for the initial recommendation. This is why I suggest using members of the local medical school departments of psychiatry, psychology, and social work, or, members of the local institute of the American Psychoanalytic Association. Of course such consultations will be relatively expensive, but they will save money in the long term. Remember: the cheapest treatment is the one that works!!

A Word About The Kinds of Treatment

There are a variety of psychotherapy treatments. Some emphasize psychological matters and attempt to help people understand such things as conflicts and feelings. These are called psychodynamic or insight-oriented psychotherapy and they usually involve meeting with a therapist once or twice a week. The most comprehensive kind of psychotherapy is called psychoanalysis and it involves meeting 4 or 5 times a week with someone who is either an M.D. psychiatrist, or a Ph.D. level social worker or psychologist, who then also is a graduate of an institute for psychoanalysis. I will write a separate issue of this newsletter on psychoanalysis in the near future. Then there are treatments that favor the use of medication and other biological approaches to mental health. These are usually managed by M.D.'s who may or may not have further training in psychiatry. In addition, some psychotherapy is individual (just you and the therapist), whereas some involves groups. One common group psychotherapy is called family therapy. Here the therapist invites you to come together with other people in your family (who seem to be involved in the difficulty). Sometimes the group just consists of other people the group therapists feels might form a cohesive group that might work together to help its members. Sometimes these groups are specialized (for example, all members might be dealing with the problem of drug abuse), sometimes not.

It should be obvious that it is very difficult at times to decide what approach is best for a given individual. This is one reason why I suggested above that the initial consultation be by an expert, meaning someone who is familiar with the many different approaches to psychotherapy. In this way the treatment and the illness can be matched. Another way of putting this is that each person has their own unique preferences for dealing with problems, and if these are taken into account, the person will have an improved chance of getting well. For example, some people really improve only when they understand what the problems are at some basic level; then they are able to make the necessary adjustments or changes to improve their situation. Others, however, do not really wish to learn about themselves, they just want someone to do something to make them feel better.

It is important to recognize that the various approaches to psychotherapy described above do not necessarily conflict with each other. For example, it is sometimes helpful for people to receive medication to relieve their initial serious distress from anxiety or depressive mood, and to simultaneously be involved in an insight-oriented approach that can help them learn and grow from understanding what makes them tick. At times, couples or family or group psychotherapy can be used to supplement individual work. Taking these combination approaches into account, it is often a good idea to see a psychotherapist who is open to various options, and willing to sometimes experiment in order to confirm which is the most useful approach.

If You Don't Really Like Your Therapist or They Don't Like You

Some significant research has been done to study what happens when people are in psychotherapy with someone they continuously believe does not really like them. This work shows that these patients do not do as well in psychotherapy as those who feel liked by their therapist. In my opinion, the same things is most likely the case when the patient does not really like the therapist. For this reason I suggest that you try to pick a therapist that you like and who likes you. If you make a mistake, and start with someone you do not like, and if this persists over time, I suggest that you tell the therapist how you feel, and while still letting them help you as much as they can, you might go out and interview some other psychotherapists. When you find someone you feel more comfortable with you can try them to see if things improve.

This problem, however, has a special wrinkle that can complicate things considerably, and that is the following: sometimes people in psychotherapy have negative feelings about anyone they would be in treatment with. When this occurs, then it is important to stay in treatment and try to resolve the reasons for the negative feelings. Obviously this is an important consideration, and it is one reason why, if psychotherapists are contacted by individuals who are already in treatment with someone else and asked if they would be available for consultation and possible transfer, that medical ethics requires that the psychotherapist receiving such a request respond as follows: first they need to make sure the patient has discussed their concerns with the treating psychotherapist. Second, the consultation should not take place unless the treating therapist and patient both feel that things have gotten into a stalemate of some kind, and they both are requesting a consultation. If such ethical procedures are not followed carefully the psychotherapy science could rapidly decline into a situation where every acting out psychotherapy patient was being courted by some other psychotherapist. This area is clearly sufficiently complicated such that further discussion in this newsletter will be required.

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