Mismanagement of Psychotherapy
Stephen Barrett, M.D.
Psychotherapy can be defined as any type of persuasive or conversational approach designed to help patients. Although there are hundreds of techniques and schools of thought, most have in common a wish to understand the patient and help the patient change emotional or behavioral patterns. Unfortunately, explosive progress in the neurosciences and psychopharmacology and the rise of managed care during have been accompanied by decreased access to highly qualified psychotherapists and minimization of psychotherapy in psychiatric training programs.
Psychodynamic treatments are based on the premise that childhood experiences exert an unconscious influence that actively shapes people's current feelings and behavior. In analytically oriented psychotherapy, also called exploratory therapy, patients say what comes to mind (free association) and are helped to understand their feelings, mental mechanisms, and relationships with people. Insights are used to help patients develop healthier ways of dealing with feelings and life situations. This type of therapy typically involves one or two 50-minute sessions per week for a few months (short-term therapy) or years (long-term therapy). It is especially appropriate for people who communicate well and are motivated to change. Psychoanalysis is a more intensive form of psychodynamic therapy in which free association is done while lying on a couch. It usually requires three to five sessions per week for several years. Few people can afford its high cost. Interpersonal therapy focuses on current relationships in order to help people deal with unrecognized needs and feelings and improve their interpersonal and communication skills. Used mainly for depression, it typically involves 12 to 16 sessions.
Supportive therapy is a conversational approach intended to maintain or restore an individual's highest level of functioning. Therapists give advice and reassurance, make suggestions, and discuss alternative behaviors and problem-solving techniques. Depending on the nature of the problem, treatment ranges from a single session, or a few sessions over a period of weeks or months, to long-term care over many years.
Cognitive therapy, which typically involves 15 to 25 weekly sessions, is aimed at relieving symptoms rather than resolving underlying conflicts. It is used for the treatment of depression, anxiety disorders (mainly panic and phobias), anger management, personality disorders, and marital therapy. Therapeutic efforts center on decreasing faulty perceptions and negative attitudes. This is done by identifying how the patient reacts to life situations and helping the patient test the validity of these reactions. For example, someone who assumes that bad things never happen to good people might feel intensely unworthy in the face of an adverse event. The therapist attempts to modify this tendency by persuading the patient that adverse events occur for many reasons, most of which have nothing to do with the worth of the person.
Behavioral therapy (also called behavior modification) aims to replace maladaptive patterns with healthier ways of behaving. The therapist first analyzes the behaviors that cause stress, limit satisfaction, and affect important areas of the patient's life. Treatment techniques can include: (a) systematic desensitization (mastery of fears through gradual exposure to circumstances that provoke anxiety), (b) relaxation training, (c) exposure (gradual exposure to a feared object or situation without use of a relaxation technique), (d) flooding (maintaining exposure to feared situations until the anxiety dissipates), (e) reinforcement (rewarding behavior that is more mature), (f) modeling (copying a behavior demonstrated by the therapist), (f) social skills training, (g) paradoxical intention (temporary encouragement of behavior the patient wishes to stop), and (h) aversive therapy (associating an unpleasant stimulus with undesirable behavior). Behavioral therapy usually involves fewer than 25 sessions.
A deep understanding of a patient's dynamics may enable a therapist to give beneficial advice. But sometimes therapists give advice without considering the complexity of the patient's situation. Such ill-conceived action may be the result of inadequate training, poor therapeutic technique, or an emotional problem of the therapist. The following composite cases illustrate this point.
A 60-year-old businessman complained of insomnia and depression. Worry about his business was keeping him awake. The physician advised him to take a vacation to "get away from it all so you can stop worrying." The man went to a seaside resort but found he could not relax. He thought that his business would suffer from his absence, and idleness merely served to intensify his worrying.
A 35-year-old junior executive sought treatment for headaches and abdominal fullness. The physician correctly diagnosed that these were bodily reactions to tension, which was generated primarily at work. The patient believed he was being asked to do more than his share but was afraid to speak up about it. The physician encouraged the man to express his resentment, but failed to discuss how to do this in a constructive manner. The patient "told off" his boss and quit in a huff-a decision he later regretted.
A middle-aged couple who consulted a counselor spent the first two sessions berating each other for one thing after another. Seeing only the hostility in the relationship, the counselor advised them to get a divorce. A more qualified therapist would have realized that they could not have remained together for many years without a positive side to their relationship. The therapist should have terminated the verbal slugfest, explored the positive aspects of the relationship, identified the issues in conflict, and tried to help the couple resolve them.
A 30-year-old housewife sought help to understand why she became angry with important people in her life, particularly her husband. The therapist encouraged discussion of her childhood, analyzed similarities between her father and her husband, and said: "You get angry with your husband when he reminds you of your father." Feeling that this information justified her resentment, the patient acted more nastily toward her husband, and their relationship deteriorated. Actually, the marital situation had been far more complex than the therapist realized. He should have explored the patient's contribution to the marital friction and helped her learn better ways to handle her feelings. Joint sessions with the patient and her husband might have helped the therapist understand the situation better.
Psychotherapy should not only help patients resolve problems but, in most cases, should also help foster independence from the therapist. Just as children must learn to handle situations without always running to their mother, patients must learn to handle upset feelings between sessions without the direct help of the therapist. Therapists who permit or encourage frequent telephone calls encourage overdependence. Therapists who receive many such calls from many patients are likely to have an underlying problem, such as a neurotic need to have people depend on them, which impairs their ability to treat patients.
A more subtle example of this problem is the therapist who cannot adhere to a schedule. Patients are scheduled for particular times, but sessions are allowed to run considerably overtime when patients are upset or appear to be talking about particularly meaningful material. Although an occasional brief extension may be justified, a general policy of this type encourages patients to manipulate the therapist to gain more attention. Other signs that a therapist is improperly crossing the patient-therapist boundary include:
- Repeatedly touching or hugging the patient
- Nontherapeutic contact outside of the therapist's office
- Hiring the patient or using the patient as an unpaid volunteer
- Talking about other patients
- Disclosing personal problems or intimate details of personal life, such as sexual experience
- Giving or accepting a valuable gift or loan
- Addressing the patients with a pet name
- Dressing seductively
- Ignoring mounting unpaid bills for treatment
- Offering not to charge or to greatly reduce the fee for sessions, even when the patient can afford the cost
- Permitting a patient to run errands or do other small favors for the therapist
- Using data from a therapy session (such as inside knowledge of a good investment) for personal gain
- Spending time—and wasting the patient's money—talking about the therapist's problems
- Promoting the therapist's religious belief system
- Promoting involvement in a social or political cause that the therapist is fond of
- Joining the therapist in an investment or business venture
- Encouraging patients to engage in cultlike behavior with the therapist as a guru.
You should also be wary of therapists who promote simplistic notions about the cause of their patient's problems. Some therapists, for example, conclude—regardless of the presenting problem—that most or all of their patients are suffering from repressed memories of sexual abuse or are suffering from multiple personality disorder. Another simplistic notion is the idea—commonly portrayed in the media—that childhood traumas are an excuse for antisocial behavior.
The most malignant type of therapist behavior is probably sexual exploitation. Although it is not unusual for therapist and patient to feel a personal or physical attraction toward each other, acting on such feelings is not therapeutic. A composite case history illustrates what can happen:
An unmarried 27-year-old woman entered therapy to overcome shyness, feelings of inadequacy, and fear of involvement with men. Few men had seemed interested in her, and she had rarely dated. As therapy proceeded, she developed an intense fondness for the therapist, based largely on the fact that he was the first man who had spent time with her on a regular basis. At this point, instead of helping her learn how to attract suitable dates, the therapist suggested that sex with him would help her become more comfortable with men. She consented, hoping that marriage to the therapist would result. Her eventual disillusionment was a shattering experience that led to suicide.
Nearly all psychiatrists believe that sexual contact with a patient is inappropriate and usually harmful. Several states have laws forbidding such contact. In some states it is a criminal offense, while in others it is considered malpractice and can lead to a loss of license. In 1990, a California jury awarded $1.5 million to a woman who said she had been exploited by a psychiatrist who had treated her. Testimony during the trial indicated that they had begun dating after almost two years of treatment. The patient said that although she was extremely happy during the beginning of their affair, she became severely depressed when it ended. In 1993, the American Psychiatric Association's board of trustees declared that "sexual activity with a current or former patient is unethical." [1-3] However, boundary violations do not have to involve sex [4-7].
In 2013, the Pennsylvania State Board of Psychology revoked the licencse of R. Scott Lenhardt, Ph.D. after concluding that he had sexually exploited two female patients, one for nearly seven years and the other for fifteen years. The case illustrates the extent to which sexual exploitation claimed to be "therapy" can develop.
- The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. Washington DC: American Psychiatric Association, 2009.
- Legal sanctions for mental health professional-patient sex. American Psychiatric Association, 1993
- Patient/therapist sexual contact. American Psychiatric Association fact sheet, 1995.
- Sexual misconduct in the physician-patient relationship. Council of the College of Physicians and Surgeons of Nova Scotia. December 2010.
- Spero and Associates Web site, accessed July 22, 2011.
- Professional conduct: Sexual Impropriety. Royal College of Physicians Canada Web site, accessed Aug 8, 2000.
- Procci WR. A cautionary tale about boundary violations in psychodynamic psychotherapy and psychoanalysis. Focus 5:407-411, 2007.
- Barrett S. R. Scott Lenhart, Ph.D., loses psychology license due to sexually exploiting patients. Casewatch, May 12, 2013.
Portions of this article have appeared in Consumer Health: A Guide to Intelligent Decisions. Additional information was developed with help from psychiatrist Eric Goranson, M.D., of Portland, Oregon.
This article was revised on May 12, 2013.