Author Archives: John James

Behavior Therapy

By Paula Zuckerman, LCSW

Behavior Therapy follows the premise that maladaptive behaviors are learned and therefore can be unlearned as well. Behavioral therapy emphasizes current behavior as opposed to historical antecedents to problems. Precise treatment goals and therapeutic strategies are tailored to these goals. Behavior therapy also stresses objective evaluation of therapeutic outcomes. Common behavioral techniques include relaxation, gradual desensitization to feared objects, and assertiveness training. Behavioral interventions can be highly successful for a broad range of specific problems such as phobias, fear of specific stimuli, performance anxiety, bedwetting, and repetitive habits.

Behavior therapy draws its philosophical basis from classical conditioning techniques (think of the work of Pavlov). The behavior of individuals is thought to be governed by patterns of experience and ingrained often erroneous ideas and expectations.. These can be internal as well as external. Behaviors that are rewarding or reinforcing will be repeated and the individual will learn from experience. As a result of experience, or associative learning, individuals often respond in predictable ways to certain stimuli or life events. Notably, these learned responses are not always adaptive or effective in the present lives of individuals. Events that may have resulted in profound emotional responses during childhood may no longer be relevant. But the individual is trapped in them.

Behavior therapy attempts to reprogram the individuals responses using various techniques which hopefully will have positive results and will in turn reinforce the new, more adaptive behavior. Behavior therapy today usually does not use punishment or negative stimuli to discourage the unwanted behavior. Instead, a reward system is often used. With adults, it is considered that positive results from the changed behavior is enough reward and will encourage the individual to maintain the new response. With children, a more concrete approach, such as verbal and physical positive reinforcement, use of gold stars in school for example, had yielded encouraging results.

Behavioral therapy is often combined with cognitive therapy, where both maladaptive cognitions as well as behaviors are examined, and techniques are designed to change both. This melding is known as Cognitive-Behavioral Therapy.

Both believe that thoughts, feelings, and behavior can be modified by examining and changing automatic thought processes and behaviors. More recently, cognitive-behavioral techniques and theories have been integrated into, and used by the more traditional psychodynamic therapies. This expanded use of technique has greatly enriched the field of psychotherapy.

What To Expect From Psychotherapy

Excerpted by New York Psychotherapy Group from:
Harvard Women’s Health Watch

Mental health isn’t much different from physical health. None of us is in perfect condition, and we occasionally need to seek professional help for our aches and pains.

However, finding treatment for physical conditions often seems a much easier matter than locating the right type of psychotherapy. This may be because we as patients don’t have as clear a notion of what to expect. Success is usually determined by the subjective judgment of two people – patient and therapist.

Thus, it’s important to find a therapist with whom you can work well if you’re considering psychotherapy, whether for crisis intervention, help in negotiating a life transition, treatment for a well-defined condition like depression, or assistance in changing unproductive patterns in your life. There are several types of mental-health professional to whom you might turn. Of those who most often provide mental-health services, psychiatrists (MD’s) alone can prescribe psychoactive medications; psychologists (PHDs), social workers (LC.SWs or MSWs), and mental-health nurses must work with physicians when they think drug treatment might be a necessary or helpful adjunct.

Regardless of your therapist’s academic credentials, he or she should do a thorough evaluation during the first few visits. Like your medical clinician, your therapist needs a good deal of factual information about you, including an account of your current psychological problem, a history of past emotional problems, a medical history, the medications you’re currently taking and your past use of drugs and alcohol. The therapist should also get a family history of mental disorder. Like inherited physical diseases, hereditary forms of mental illness often become evident at different stages of life. He or she needs to be able to rule out other potential causes of the problem, such as physical illness or the side effects of drugs.

Also during the first few visits, the two of you will design a plan for your therapy that addresses your problem and establishes realistic goals. For example, some people may want only to relieve a depression; others may desire to change deep-seat mindsets and behaviors. If you’re working within the guidelines of a health-insurance plan, your goals may have to be directed at what can reasonably accomplished in a limited period. Of course, if your therapist is in private practice you can negotiate a fee or contract to continue therapy beyond that point.

*The patient/therapist relationship. Psychotherapy works by using a relationship to effect change. Because it’s impossible for therapy to be successful if your relationship with your therapist isn’t, it is very important that you’re generally comfortable with the person and the setting. This isn’t to say that you won’t feel ill at ease form time to time as new issues emerge for you to confront. Throughout, you should have the sense that your therapist is attentive and available; you should feel that he or she is someone whom you can trust and whom you feel has your best interests at heart.

*The process. Therapy is a series of conversations rather than a monologue. Contrary to the stereotype, therapist are not supposed to be coolly detached observers; expect your therapist to ask questions, make comments, and offer opinions and suggestions. He or she should not so much control the discussion as try to help you move it in the most productive direction.

As you talk, the therapist will not only be paying close attention to the content of the conversation, but also will be forming impressions of you, noting things you might not be aware of, and monitoring the emotions you engender in him or her.

*Transference. The therapy setting encourages the development of transference – the unconscious act of superimposing feelings derived from past relationships onto present ones – which can then be used to help the patient understand his or her reactions. At times, you may feel anger, hostility, or overwhelming love for your therapist. The therapist will often deal with these responses in a way that you don’t anticipate – for example, by greeting a hostile outburst with curiosity rather than anger – and in doing so may help you to recognize, analyze, and interpret your emotions.

Therapists are trained not to act on the patient’s feelings or their own, but to use their emotional response to patients as a guide to understanding the patient’s interpersonal issues and style. You can’t expect you therapist to physically affectionate or to become involved in your activities. In fact, such behavior is considered a boundary violation and a breach of professional ethics (see “When Your Therapist Gets Too Close”, HWHW, February 1994).

Psychotherapy has many purposes. It can provide relief from anxiety, phobia, obsession, compulsion, or depression. It can facilitate mourning or enable you to resolve a crisis. It can make it possible for you to change those things you can and to bear situations that can’t be altered. It may also help you to know and like yourself a little better. At the end of the process, you should be happier and more productive.

Marriage and Couple Counseling

Madeline L. Gleich, LCSW

Our Definition of Marriage Counseling Has Changed

As society has changed, the term marriage counseling itself has come to be defined more broadly. It now includes counseling sought by couples who are in many different states of personal and legal commitment. Couples frequently seek counseling before marriage, (pre-marital counseling), or before increasing their commitment, (planning to live together, marry, or have children). The complex melding of second families is another situation in which couple counseling can be very productive.

When do Couples Usually Seek Counseling?

Most counseling is sought in times of upheaval and crisis. Couples come for treatment when one or both partners feels misunderstood, frustrated and/or deeply disappointed. Frequently these feelings have been present for quite some time and a lot of hurt and anger has been generated. Each person has the upsetting sense that he or she is no longer part of an understanding relationship; they both feel misunderstood and terribly alone.

Not infrequently, one member of the couple wants to seek counseling and the other doesn’t. The unwilling partner feels pressured to “try it” or “come along and see what it’s like”. This reluctance to engage in counseling is not uncommon and is often the result of misperceptions about the process and goals of couples counseling. Many people mistakenly expect the therapist to take on the role of a judge or referee who criticizes and makes rules which they will then be expected to follow.

Another common concern involves the expectation that one partner will continually yell at the other during the therapy session. Were this to occur, it would recreate in the therapy session the same destructive situation that is happening at home. With these expectations, it isn’t really at all surprising that someone wouldn’t want to participate. Fortunately, these are not accurate representations of the process of marriage counseling.

What Actually Happens During Counseling Sessions?

The therapist does not take sides, nor does he or she make rules. Instead, the therapist works to understand the needs and desires of both parties and to help them develop better ways to understand and meet each others needs.
When I work with a couple I always question them about the positive things in their relationship as well as the areas of difficulty. I find that good things are often forgotten and discarded when a couple is in turmoil. There are usually many strengths in relationships and it is very important that these be built upon and nourished while the problem areas are also being addressed.

I don’t see the actual session as an appropriate place for partners to yell at each other for extended periods of time or to simply “vent” their frustrations. Were this to happen, it would result in a repetition of what is already not working instead of assisting in the development of better communication skills. It is very important that each party be helped and encouraged to express his or her angry and frustrated feelings. But it is even more important that this expression be communicative in nature and not primarily attacking. Learning to fight fairly is frequently an important part of the counseling process.

Poor communication is often at the core of unresolved marital problems. The more the couple tries to explain their feelings to each other, the more misunderstood each of them feels. In these situations, the therapist seeks to facilitate communication by working to understand two things: 1) what is being said; and, 2) how what is being said, is actually being heard, by the other party. The clarification of what is actually being said and how it differs from what is actually being heard, is a major component of successful couples counseling.

Unconscious expectations are also frequent sources of great disappointment and frustration between couples. Without realizing it, we have many images and ideas of what constitutes a “good relationship” and how husbands and wives are “supposed” to behave. When we commit to another person, we assume, sometimes without realizing it, that our mate will naturally fulfill these unspoken expectations of which we ourselves, are only vaguely aware. I often ask couples about their expectations and about the structure of their families of origin. Frequently, as someone begins to describe the roles and expectations which existed in their original family, they recognize many similarities in the expectations they have of their spouse. Once recognized, these expectations can be openly re-evaluated and discussed.

As frustration and disappointment mount in a marriage, couples tend to find themselves at opposite poles and when they attempt to talk things over, they “lock horns”. Learning to listen to each other and to seek alternative solutions is important for the future growth of the relationship. Counseling seeks to help resolve issues of the present and also works to develop negotiating techniques that the couple can use in the future.

What if the Relationship Doesn’t Continue?

No discussion of couples counseling would be complete, without the recognition that not all couples are able to successfully resolve their differences. Sometimes separation is the best resolution possible. In my opinion, this doesn’t mean that the counseling failed. The purpose of counseling is to promote respect and understanding between two people; this doesn’t necessarily mean they will want to stay together in a love relationship.

It has been my experience that when people really feel they understand why a relationship didn’t work, and they can respectfully acknowledge the differences between them, no matter how great those differences may be, it is much easier to say goodbye and move forward. We are all familiar with the very painful situation in which someone divorces one person and remarries only to have the same kinds of difficulties arise all over again. I believe that this occurs when that person doesn’t understand what went wrong in their original relationship and simply tries again, without realizing what needs to be different the next time around.

© Madeline L. Gleich, CSW, 1999-2011

Does Therapy Help?

Excerpted by New York Psychotherpy Group from:
Consumer Reports, November, 1995

Coping with a serious physical illness is hard enough. But if you’re suffering from emotional or mental distress, it’s particularly difficult to know where to get help. You may have some basic doubts about whether therapy will help at all. And even if you do decide to enter therapy, your health insurance may not cover it-or cover it well.

As a result, millions of Americans who might benefit from psychotherapy never even give it a try. More than 50 million American adults suffer from a mental or addictive disorder at any given time. But a recent Government survey showed that fewer than one third of them get professional help.

That’s a shame. The results of a candid, in-depth survey of CONSUMER REPORTS subscribers–the largest survey ever to query people on mental health care–provide convincing evidence that therapy can make an important difference. Four thousand of our readers who responded had sought help from a mental health provider or a family doctor for psychological problems, or had joined a self-help group. The majority were highly satisfied with the care they received. Most had made strides toward resolving the problems that led to treatment and almost all said life had become more manageable. This was true for all the conditions we asked about, even among the people who had felt the worst at the beginning.

Among our findings

• People were just as satisfied and reported similar progress whether they saw a social worker, psychologist or psychiatrist. Those who consulted a marriage counselor, however, were somewhat less likely to feel they’d been helped.
• Readers who sought help from their family doctor tended to do well. But people who saw a mental-health specialist for more than six months did much better.
• Psychotherapy alone worked as well as psychotherapy combined with medication, like Prozac or Xanax. Most people who took drugs like those did feel they were helpful, but many people reported side effects.
• The longer people stayed in therapy, the more they improved. This suggests that limited mental health insurance coverage, and the new trend in health plans emphasizing short term therapy may be misguided.

Most people who went to a self-help group were very satisfied with the experience and said they got better. People were especially grateful to Alcoholics Anonymous, and very loyal to that organization. Our survey adds an important dimension to existing research in mental health. Most studies have started with people who have very specific, well-defined problems, who have been randomly assigned to a treatment or control group, and who have received carefully scripted therapy. Such studies have shown which techniques can help which problems (see “What Works Best?”), but they aren’t a realistic reflection of most patients’ experiences.

Our survey, in contrast, is ‘a unique look at what happens in real life, where problems are diverse and less well-defined, and where some therapists try one technique after another until something works. The success of therapy under these real-life conditions has never before been well studied, says Martin Seligman, former director of clinical training in psychology at the University of Pennsylvania and past president of the American Psychological Association’s division of clinical psychology.

Seligman, a consultant to our project, believes our readers’ experiences send “a message of hope” for other people dealing with emotional problems.

Like other surveys, ours has several built in limitations. Few of the people responding had a chronic, disabling condition such as schizophrenia or manic depression. We asked readers about their past experiences, which can be less reliable than asking about the present. We may have sampled an unusually large number of people in long-term treatment. Finally, our data comes from the readers’ own perceptions, rather than from a clinician’s assessment. However, other studies have shown that such self reports frequently agree with professionals’ clinical judgments.

Who went for help

In our 1994 Annual Questionnaire, we asked readers about their experiences with emotional problems and their encounters with health-care providers and groups during the years 1991 to 1994. Like the average American outpatient client, the 4000 readers who said they had sought professional help were mostly well educated. Their median age was 46, and about half were women. However, they may be more amenable to therapy than most.

Many who went to a mental health specialist were in considerable pain at the time they entered treatment. Forty-three percent said their emotional state was either very poor (“I barely managed to deal with things”) or fairly poor (“Life was usually pretty tough”).

Their reasons for seeking therapy included several classic emotional illnesses: depression, anxiety, panic, and phobias. Among the other reasons our readers sought therapy: marital or sexual problems, frequent low moods, problems with children, problems with jobs, grief, stress-related ailments, and alcohol or drug problems.

The results: Therapy works

Our survey showed that therapy for mental health problems can have a substantial effect. Forty-four percent of people whose emotional state was “very poor” at the start of treatment said they now feel good. Another 43 percent who started out “fairly poor” also improved significantly, though somewhat less. Of course, some people probably would have gotten better without treatment, but the vast majority specifically said that therapy helped.

Most people reported they were helped with the specific problems that brought them to therapy, even when those problems were quite severe. Of those who started out “very poor,” 54 percent said treatment “made things a lot better,” while another one third said it helped their problems to some extent. The same pattern of improvement held for just about every condition.

Overall, almost everyone who sought help experienced some relief – improvements that made them less troubled and their lives more pleasant. People who started out feeling the worst reported the most progress. Among people no longer in treatment two thirds said they’d left because their problems had been resolved or were easier to deal with.

Whom should you see?

In the vast field of mental health, psychiatrists, psychologists, and clinical social workers have long fought for turf. Only psychiatrists, who are medical doctors, can prescribe drugs and have the training to detect medical problems that can affect a person’s mental state. Otherwise, each of these professionals is trained to understand human behavior, to recognize problems, and to provide therapy.

In our survey, almost three quarters of those seeking professional help went to a mental-health specialist. Their experiences suggest that any of these therapists can be very helpful. Psychiatrists, psychologists, and social workers received equally high marks and were praised for being supportive, insightful, and easy to confide in. That remained true even when we statistically controlled for the seriousness and type of the problem and the length of treatment.

Those who went to marriage counselors didn’t do quite as well, and gave their counselors lower grades for competence. One reason may be that working with a fractured couple is difficult. Also, almost anyone can hang out a shingle as a marriage counselor. In some states the title “marriage and family therapist” is restricted to those with appropriate training. But anyone can use other words to say they do marriage therapy, and in most places the title “marriage counselor” is up for grabs.

What about doctors?

Many people are more comfortable taking their problems to their family doctor than to a psychologist or psychiatrist. That may work well for some people, but our data suggest that many would be better off with a psychotherapist.

Readers who exclusively saw their family doctor for emotional problems – about 14 percent of those in our survey – had a very different experience from those who consulted a mental-health specialist. Treatment tended to be shorter; more than half of those whose care was complete had been treated for less than two months. People who went, to family doctors were much more likely to get psychiatric drugs 83 percent of them did, compared with 20 percent of those who went to mental-health specialists. And almost half the people whose doctors gave them drugs received medication without the benefit of much counseling.

The people who relied on their family doctors for help were less distraught at the outset than those who saw mental-health providers; people with severe emotional problems apparently get themselves to a specialist. Even so, only half were highly satisfied with their family doctor’s treatment (compared with 62 percent who were highly satisfied with their mental-health provider). A significant minority felt their doctor had neither the time nor temperament to address emotional issues. In general, family doctors did help people get back on their feet-but longer treatment with a specialist was more effective.

However, if you begin treatment with your family doctor, that’s where you’re likely to stay. Family doctors referred their patients to a mental-health specialist in only one out of four cases, even when psychotherapy might have made a big difference. Only half of those who were severely distressed were sent on, and 60 percent of patients with panic disorder or phobias were never referred, even though specific therapies are known to work for those problems.

Other research has shown that many family doctors have a poor track record when it comes to mental health. They fail to diagnose some 50 to 80 percent of psychological problems, and sometimes prescribe psychiatric drugs for too short a time or at doses too low to work.

The power of groups

It was 60 years ago that a businessman and a physician, both struggling with alcoholism, realized they could stay sober by talking to one another. They talked to other alcoholics, too, and eventually worked out the system of long-term recovery known as Alcoholics Anonymous, or AA. Today there are over a million active AA members in the U.S., and attending an AA group is often recommended as part of professional treatment. The AA format has also been adopted by dozens of other self-help groups representing a wide spectrum of dysfunctional behavior, from Gamblers Anonymous to Sex and Love Addicts Anon. Support groups also bring together people who are dealing with medical illness or other trials.

One-third of our survey respondents went to a group, often in addition to individual psychotherapy. Overall, they told us, the groups seemed to help.

Readers who went to AA voiced overwhelming approval. Virtually all endorsed AA’s approach to treatment, and most said their struggle with addiction had been largely successful. In keeping with AA’s principle that recovery is a lifelong process, three quarters of our readers had been in the group for more than two years, and most were still attending. Most of those who had dropped out said they’d moved on because their problems had improved.

Certainly, not everyone who goes to AA does as well; our sampling method probably over-represented long term, and thus successful, AA members. AA’s own surveys suggest that about half of those who come to the program are gone within three months. Studies that follow people who have undergone treatment for alcoholism find that AA is no more or less effective than other programs: A year after entering treatment about half the participants are still in trouble.

Nevertheless, AA has several components that may maximize the chance of success. In general, most alcoholics do well while they are being actively treated. In AA, members are supposed to attend 90 meetings. In the first 90 days, followed by three meetings a week for life.

Drugs, pro and con

For decades, drug therapy to treat problems such as depression carried a raft of unpleasant, sometimes dangerous side effects. Then came Prozac (fluoxetine), launched in 1998. Safer and easier to take than previous anti-depressants, Prozac and other drugs in its class – including sertraline (zoloft) and paroxetine (Paxil)–have radically changed the treatment of depression. Along the way, people have claimed that Prozac seems to relieve a growing list of other complaints from eating disorders to shyness to, most recently, premenstrual syndrome.

In our survey, 40 percent of readers who sought professional help received psychiatric drugs. And overall, about 60 percent of readers who took drugs said the medication helped a lot.

However, many of our readers did well with psychotherapy alone; in fact, people who received only psychotherapy improved as much as those who got therapy plus drugs.

For many people, having the option of talk therapy is important because every psychiatric drug has potential side effects that some individuals find hard to tolerate. Almost half of all our respondents on medication reported problems with the drug. Drowsiness and a feeling of disorientation were the most common complaints, especially among people taking the older anti-depressants such as amitriptyline (Elavil).

Although the problems associated with psychiatric drugs are well known, 20 percent of readers said their provider never discussed them – a disturbing lapse in communication. Equally disturbing was the finding that 40 percent of the people taking anti-anxiety drugs had done so for more than a year – 25 percent for more than two years – even though long-term use results in habituation, requiring larger and larger doses.

Anti-anxiety medications such as Xanax and Valium can provide relief if used for a short time during a particularly stressful period, such as the death of a parent. But they haven’t been well tested for generalized anxiety – a kind of chronic, excessive worrying combined with physical and emotional symptoms — and therapists have found them only erratically effective.

Xanax is approved by the U.S. Food and Drug Administration for panic disorder, which causes repeated bouts of unbearable anxiety; studies show that it acts quickly to reduce panic attacks. But after two months, Xanax apparently performs little better than a placebo. (See CONSUMER REPORT, January 1993.) The reason many people take anti-anxiety drugs for so long is that they’re extremely hard to kick; if the drug is stopped, symptoms return in full force.

How long will it take?

When a person needs psychotherapy, how much do they need? That has become a critical question both for clinicians and for the insurers that pay for therapy. And it’s a hard one to answer.

Nationally, most people who get therapy go for a relatively short time — an average of four to eight sessions. It’s not clear, however, whether people stop going because they have been helped enough, because they don’t think the therapy is working or because they’ve run out of money. Controlled studies of specific kinds of therapy usually cover only 12 to 20 visits. While brief therapy often helps, there’s no way to tell from such studies whether 30 or 40 sessions, or even more, would be even more effective.

For the people in our survey, longer psychotherapy was associated with better outcomes. Among people who entered therapy with similar levels of emotional distress, those who stayed in treatment for more than six months reported greater gains than those who left earlier. Our data suggest that for many people, even a year’s worth of therapy with a mental-health specialist may be very worthwhile. People who stayed in treatment for more than two years reported the best outcomes of all. However, these people tended to have started out with more serious problems.

We also found that people got better in three distinct ways, and that all three kinds of improvement increased with additional treatment. First, therapy eased the problems that brought people to treatment. Second, it helped them to function better, improving their ability to relate well to others, to be productive at work, and to cope with everyday stress. And it enhanced what can be called “personal growth.” People in therapy had more confidence and self-esteem, understood themselves better, and enjoyed life more.

Despite the potential benefit of long-term therapy, many insurance plans limit mental-health coverage to “medically necessary” services which typically means short-term treatment aimed at symptom relief. If you want to stay in therapy longer, you may have to pay for it yourself.

Our findings complement recent work by psychologist Kenneth Howard of Northwestern University. By following the progress of 854 psychotherapy patients, Howard and his associates found that recovery followed a “dose-response” curve, with the greatest response occurring early on. On average, 50 percent of people recovered after 11 weekly therapy sessions, and 75 percent got better after about a year.

Recommendations

Emotional distress may not always require professional help. But when problems threaten to become overwhelming or interfere with everyday life, there’s no need to feel defeated.

Our survey shows there’s real help available from every quarter – family doctors, psychotherapists, and self-help groups. Both talk therapy and medication, when warranted, can bring relief to people with a wide range of problems and deep despair.

With such clear benefits to be had, the strict Emits on insurance coverage for mental-health care are cause for concern. As the debate over health care continues, we believe that improving mental-health coverage is important.

If you want to see a therapist, you should approach therapy as an active consumer. In our survey, the more diligently a person “shopped” for a therapist – consulting with several candidates, checking their experience and qualifications, and speaking to previous clients –the more they ultimately improved. Once in treatment those who formed a real partnership with their therapist – by being open, even with painful subjects, and by working on issues between sessions – were more likely to progress.

When you look for a therapist, competence and personal chemistry should be your priorities. You’ll be sharing your most intimate thoughts and feelings, so it’s important to choose someone who puts you at ease.

Many people first consult their family doctor, who has already won their confidence and trust. If you decide to stay with your physician for treatment, bear in mind that the approach will probably be medically based and relatively short.

If you would prefer to work with a therapist ask your doctor for a referral. Other good referral sources are national professional associations or their local or state chapters. For information or referrals you can call the American Psychiatric Association, at (202) 682-6220; the American Psychological Association, (202) 336-5800; the National Association of Social Workers, (800) 638-8799, ext. 291; the American Association for Marriage and Family Therapy, (800) 374-2638; and the American Psychiatric Nurses Association, (202) 857-1133. Also contact local universities, hospitals, and psychotherapy and psychoanalytic training institutes. For general information on mental illness, call the National Alliance for the Mentally IN, (800) 950-6264.

Family and friends may also know of reputable therapists; try to get several names to consider. Our readers who located therapists through personal or professional references felt better served than those who relied on ads, their managed care company’s roster, or local clinics.

THE RIGHT TREATMENTS FOR YOUR TROUBLES

Until a decade or so ago, any evidence that psychotherapy worked came from the testimonials of therapists and their patients. But today, controlled studies have shown that psychotherapy does make a difference: People with a broad range of problems can usually benefit from psychological treatment. More important, for certain conditions researchers have homed in on specific therapies and drugs that can bring swift improvement for the majority of sufferers.

Here is a summary of the top treatment options for four common problems. It was compiled from the scientific literature by psychologist Martin Seligman and reviewed by psychiatrists Stewart Agras of Stanford University and Jesse Schomer of Cornell University, and by social worker Eleanor Bromberg of The Hunter School of Social Work in New York. (For a comprehensive look at treatments that work, see Seligman’s book, “What You Can Change & What You Can’t,” Ballantine Books, New York, 1995.)

Depression

More than the passing blues, depression can sap you of pleasure, hope, and vitality, upend your eating and sleeping habits, and draw a veil of despair that lasts for months or years. In bipolar depression, also called manic depression, the lows alternate with excessive, frenetic highs, Most of the time, depression can be cut short and considerably relieved.

With cognitive therapy, you learn to recognize and change the negative assumptions and beliefs that color your emotions and shape your world view. If for example, you react to small setbacks by thinking you can’t do anything right, you’ll learn to focus on evidence to the contrary – your recent promotion at work, for instance. Cognitive therapy brings considerable relief to about 70 percent of depressed people. It takes about a month to start working, and typically involves a few months of weekly sessions.

Interpersonal therapy is just as effective and runs about as long, but focuses instead on the difficulties of personal relationships. You’ll examine current conflicts and disappointments, learn how they sow depression, and work on successful ways of relating to other people.

Drug therapy is about as effective as these psychotherapies. Each of the three major classes of anti-depressant drugs works equally well. People who don’t respond to one type of drug may respond to another; overall, 60 percent to 80 percent of depressed people get marked relief within three to six weeks. However, the classes differ significantly in their adverse effects: Fluoxetine (Prozac) and related drugs tend to be better tolerated, though they frequently produce insomnia, restlessness, and sexual problems. The older, “tricyclic” antidepressants such as amitriptyline (Elavil) can cause drowsiness, tremor, weight gain, and heart-rhythm changes. For people with manic-depression, treatment with the drug lithium carbonate (Escalith, Lithane) is clearly the best route.

Electroconvulsive therapy is used for severely depressed people who can’t take, or don’t respond to, antidepressant drugs. Electrodes placed on the head transmit bursts of electricity believed to affect many of the same brain chemicals as antidepressant drugs. The “dosage” has been greatly reduced from the jolts used in the past. Repeated several times over the course of a week, ECT quickly relieves severe depression about 75 percent of the time. The downside is the risk of anesthesia and the side effects temporary but disturbing of memory loss and confusion.

Anxiety

Unlike ordinary worrying, clinical anxiety is irrational, freezes you into inaction, or dominates your life.

Tranquilizers such as diazepam (Valium) and alprazolam (Xanax) can provide quick relief, but the benefit ends when the drug is stopped. Extended use may result in tolerance, which diminishes the benefit, and also produces dependency, making it hard to quit.

Everyday anxiety often yields to self-help techniques. Simple forms of meditation can be useful. So can various forms of relaxation, such as progressive relaxation. Some therapists teach these techniques, or you can check a local YMCA, community hospital, or yoga institute for courses.

If your anxiety is intense and unyielding, it may need professional attention. Cognitive Behavioral therapy is often helpful; you’ll learn to counter the irrational thoughts that provoke anxiety and to overcome fears.

Panic

A panic attack isn’t easily forgotten. It produces chest pain, sweating, nausea, dizziness and a feeling of overwhelming dread. Millions of people suffer such episodes repeatedly and unexpectedly.

Antidepressant drugs and the anti-anxiety drug Xanax can dampen or even prevent panic attacks in the majority of people. But the side effects include drowsiness and lethargy, and panic rebounds about half the time when therapy is stopped.

An alternative approach is cognitive therapy, which provides relief to almost all panic sufferers. Treatment is based on the idea that panic occurs when a person mistakes normal symptoms of anxiety for symptoms of a heart attack, going crazy, or dying. The fear that something is wrong can escalate into a full fledged panic attack. In cognitive therapy you’ll learn to short circuit that reaction by interpreting anxiety symptoms for what they are.

Phobias

Strong, irrational fears affect more than 10 percent of American adults. Some fear specific objects, such as animals, snakes, or insects; even more can’t bear crowded places or open spaces, a condition called agoraphobia. Still others with social phobia recoil from situations involving other people.

Two behavior therapies are now used, with considerable success, to treat phobias. In both, you’ll have to confront what you most fear. The more gradual technique is systematic desensitization: After learning progressive relaxation, you’ll construct a fear hierarchy with the most terror-inducing situation at the top. In the first of a series of steps, you’ll go into a relaxed state, then vividly imagine the least fearsome situation – or face it in real life. Gradually you’ll move up the hierarchy and face more frightening situations.

During flooding, the other therapy, you’re thrown in immediately with the thing that scares you; a cat phobic, for instance, will sit in a room full of cats. The goal is to stay for an agreed-upon length of time while the anxiety ebbs.

Behavior therapy is most successful with object and social phobias, producing lasting results in the majority of cases in a matter of weeks or months. In agoraphobia, behavior therapy is best combined with an antidepressant drug to control panic.

MENTAL HEALTH INSURANCE

WHO PAYS – AND HOW MUCH?

Private insurers have always covered mental disorders and substance abuse more grudgingly than medical illness, either by building in limits or by interposing a case manager between you and your benefit. And very few plans deal well with the lifelong needs of people with chronic, severe mental illness. On the whole, says Kathleen Kelso, executive director of the Mental Health Association of Minnesota, “insurers would just as soon cover us from the neck down.”

Almost all traditional fee for service plans pay 80 percent or more of the fee when you visit the doctor with a medical problem. But for outpatient therapy, the majority pay just 50 percent, and frequently that’s after “capping” bills at well below the therapists’ actual fees – which range on average from $80 to $120 according to Psychotherapy Finances, an industry newsletter. Most insurance plans also impose one or more other limits on mental-health coverage, such as the number of out-patient visits and hospital days they will pay for. In addition, many plans have annual or lifetime dollar maximums; for out-patient care, it can be as low as $1000 and $10,000, respectively. In recent years consumer advocates have lobbied for state laws that would equalize coverage for psychiatric and other illnesses. So far, just six states Maine, Maryland, Minnesota, New Hampshire, Rhode Island, and Texas – have passed so called “parity” laws. Consumers Union supports such laws, and has actively worked for their passage.

Health maintenance organizations (HMOs) also limit access to psychiatric services, typically providing a maximum of 20 outpatient visits and 30 hospital days a year. Patients usually have to go through their family physician or another gatekeeper to gain access to those benefits, and may get less than the maximum.

In our survey of mental-health care, respondents whose coverage limited the length and frequency of therapy, and the type of therapist, reported poorer outcomes. (However, we found no clear difference in outcome between people with fee for service coverage and those in HMOs’ and preferred provider plans.) Paying for therapy on their own was clearly a hardship for many: Twenty-one percent cited the cost of therapy as a reason for quitting.

To hold down spending, increasing numbers of employers, HMOs, and fee for service plans are turning to specialized managed care companies to run their mental health benefit. These specialty firms refer patients to a network of clinicians who must adhere to strict treatment guidelines. And they have reined in spending, saving some employers as much as 30 percent in the cost of mental health care.

But many patients and their therapists feel they’re being shortchanged. Psychiatrists complain about the difficulty of extending a hospital stay for patients considered too sick to leave and the challenge of getting approval for more than brief outpatient care.

Although many plans ran by managed-care firms nominally have generous benefits, reality may fall somewhat short. All services must be authorized by a case manager. To get approval for additional sessions, therapists must provide details about a patient’s problems and the course of treatment.

With scores of managed-care companies nationwide, there’s great variability in how they tend to the needs of their subscribers. Even critics acknowledge that some plans are quite accommodating, and that some overly stringent practices have been curbed. But concern about heavy-handed practices has prompted several states to enact laws regulating managed care services.

How to choose a plan

If you’re picking a health care plan and are concerned about mental health coverage, you should ask some pointed questions:

• What are the stated benefits? Pay close attention to the benefit limits, including co-payments, limits on the number of hospital days and outpatient sessions, and annual or lifetime dollar maximums. A typical plan with limits covers 30 days of inpatient care and 50 or fewer outpatient visits. But the cap it sets on covered charges may be low, and the copayments high.
• If the benefits cover only “medically necessary” treatment, who makes that determination? It’s best if that decision is left to you and your therapist But in many managed-care plans it’s a case manager who decides whether you need therapy or hospitalization, and how long it should last.
• What are your rights of appeal if coverage is denied or cut short? In many plans the grievance process consists of a single appeal.
• In a managed-care plan, how large is the provider panel? The more therapists in your area, the more likely you’ll find one whose personality and expertise are a good match for you.
• Will the plan add new providers to its panel? This can be important if you’re already seeing a therapist who’s not part of the plan but is willing to join.
• Which facilities are approved by the plan? Be sure there’s a hospital that’s convenient and that offers a broad spectrum of mental-health and substance abuse services. Also look for transitional and intermediate-care programs, such as mental-health day centers.

THE TYPES OF THERAPIES AND THERAPISTS

If you’re considering mental-health treatment, you’re facing a wide choice of therapies and practitioners. Many therapists favor a particular theoretical approach, though often they use a combination.

In psychoanalysis, Freud’s classical technique employing a couch and free association, patients explore and confront troubling childhood experiences. In psychodynamic therapy, the emphasis is on discovering unconscious conflicts and defense mechanisms that hinder adult behavior. The goal of Interpersonal therapy is to enhance relationships and communication skills. Cognitive therapy is aimed at helping people recognize and change distorted ways of thinking. Behavioral therapy seeks to replace harmful behaviors with useful ones.

As for choosing a therapist, be careful. Anyone can legally be called a psychotherapist, whether or not he or she has received the training and supervision needed to competently practice. Look for someone licensed or certified in one of the following fields:

• Psychiatrists are physicians who have completed three years of residency training in psychiatry following four years of medical school and a one year internship. All are trained in psychiatric diagnosis and psychopharmacology, but only some residency programs provide extensive experience in outpatient psychotherapy.
• Psychoanalysts have a professional degree in psychiatry, psychology, or social work, plus at least two years of extensive supervised training at a psychoanalytic institute.
• Psychologists with the credential Ph.D., Psy.D., or Ed.D. are licensed professionals with doctoral-level training, typically including a year of clinical internship in a mental-health facility and a year of supervised post-doctoral experience.
• Social workers typically train in a two-year master’s degree program that involves fieldwork in a wide range of human services, including mental health settings. Those who seek state certification or licensing as a clinical social worker need two years of supervised post-grad experience and must pass a statewide exam.
• Marriage and family therapists may have a master’s or doctoral degree from an accredited graduate training program in the field, or may have another professional degree with supervised experience in the specialty.
• Psychiatric nurses are registered nurses who work in mental health settings, often as part of a therapeutic team. Advanced practice nurses have a master’s degree and can provide psychotherapy.

Can you get medication and psychotherapy?

Since everyone is different, there is no one correct approach. Research suggests that the use of medication and psychotherapy in combination can be very helpful. The medication offers relief from severe symptoms, while psychotherapy enables you to gain knowledge about, and control of, yourself and your life. The usual result is enhancement of your quality of life.

Is everything confidential?

Confidentiality is basic to therapy and the patient has the legal right to control access to information about their treatment. You should be aware however, that some insurance companies require certain information from the therapist as a condition for payment. If this is a major area of concern, it should be one of the subjects covered when you meet your therapist for the first time so that you are clear about your therapist’s policies and procedures regarding confidentiality and what information insurance companies require.

How long will therapy take?

Because each of us is unique, there is no single answer to this question. The length of therapy depends on factors such as the types of issues you are working on, how long you have been struggling with your problems, the complexity of your situation, and what you are looking to accomplish. Sometimes brief interventions are very helpful. In other cases, months and years of work are invested in an in-depth exploration of your personal conflicts. The choice is yours and it can always be discussed with your therapist.

Does psychotherapy always work?

The greatest benefit of psychotherapy over other treatment options is that you are an active and vital participant in your own healing process. Because of this, and myriad other factors that may impede or accelerate your progress, there is no demonstrable way to guarantee success in therapy for everyone. However, with the right therapist, many people have changed their lives dramatically through psychotherapy.

I can talk to a friend for free, why would I go to a therapist?

If you have a patient, wise and understanding friend who will listen to your problems, you are very lucky indeed. But often, a shoulder to lean on is not enough. A professionally trained therapist has the objectivity and skills to help you uncover the issues that are really bothering you, see the patterns in your life that led to your unhappiness, and help you recognize and change those patterns.

Psychotherapy is a process that focuses on growth and change. Talking about our issues, assessing and understanding our feelings, makes it possible to become more aware of the source of our problems. This awareness enables us to make the most out of the options we have available to us. It also helps us to find ways to deal more effectively with our feelings and to choose the way we behave in every aspect of our lives. A good friend will offer understanding, love and comfort – nothing to sneeze at, but not enough.

I don’t like to bother other people with my problems. Shouldn’t I be able to help myself?

Sadly, seeing a therapist is often associated with dependency and weakness. Nothing is further from the truth. In fact, it takes great courage and humility to face your problems head on. Therapy is a journey of change and self discovery and you are in charge of that journey. The therapist will assist you in clarifying your thoughts and feelings and provide you with helpful tools and feedback, but you will make your own choices. The goal of therapy is to help you gain independence and decision making power over yourself and your behavior.