CHAPTER
17

Are You Out of Your Mind?

In This Chapter

In 1973, psychologist Dr. David Rosenhan and seven other sane individuals faked mental illness to gain admission to 12 different psychiatric hospitals. It wasn’t hard; they just complained of hearing voices that said “empty, hollow, thud.” Other than this symptom, they answered every question honestly. Once in the hospital, they behaved normally—just as they would have outside the hospital. When asked about the voices, they said they no longer heard them.

Strangely, the only people who suspected anything were other patients, who thought the seven might be reporters doing research. Not only did the staff continue to view the fakers as mentally ill, normal behavior was often described in hospital notes as symptoms of emotional instability. For example, each pseudo-patient kept a journal of his experiences. No one on staff asked the “patients” about it, but they made notes on the patients’ charts about “excessive writing.”

The material in this chapter explains how psychiatric labels are determined—what psychologists define as abnormal, how diagnoses are classified, and the pros and cons of our current classification system. You’ll also become acquainted with weapons against mental dysfunction, what drugs work best for what illness, and how psychotherapy works.

Defining Abnormal

Have you ever worried excessively, felt depressed for no apparent reason, or felt afraid of something you knew couldn’t really hurt you?

Most of us have from time to time experienced thoughts and feelings that seemed strange and unusual for us. Maybe we even wondered if they were abnormal. But what exactly is abnormal? A few irrational fears and occasional periods of worry or sadness seem to be part of life. The challenge is in knowing how many are too many and how long is too long.

This is no easy task; it’s hard to determine at what point eccentric or free-spirited behavior becomes a marker of mental illness. But when a person begins to behave in a way that causes significant personal distress and disrupts his ability to function effectively at work or at home, there’s a legitimate cause for concern. So mental health professionals designate a point at which a person’s behavior crosses the sometimes fine line between health and illness. This cutoff point is called a psychological diagnosis.

DEFINITION

A psychological diagnosis is a label used to identify and describe a mental disorder, based on information collected by observation, testing, and analysis. It is also a judgment about a person’s current level of functioning.

In order for someone to receive a psychological diagnosis, that person must have had the problem for an extended time—to make certain that it’s not just a temporary state. For some diagnoses, such as clinical depression, the minimum time period could be as short as two weeks; for personality disorders, the time frame must be at least two years.

In addition to a consistent pattern of symptoms, the person’s problems must be bad enough to disrupt normal daily activities. Maybe you’ve been waking up in the middle of the night and can’t go back to sleep. Maybe you’re calling in sick at work quite often, or maybe you’re drinking too much. Whatever the problem is, to warrant a psychological diagnosis, it must be severe enough that you’d function much better without it.

BRAIN BUSTER

A major National Institute of Mental Health study found that, in any given month, about 15 percent of the population is suffering from a diagnosable mental health problem and almost one out of every three people will suffer from one in the course of a lifetime.

How Psychologists Use MUUDI

Clinical psychologists generally evaluate a person’s behavior according to five basic criteria: whether it is maladaptive, unpredictable, unconventional, distressing, or irrational. If at least two of these criteria are present, a warning bell alerts the psychologist to look more closely at the person’s symptoms. Mental health professionals use these criteria to diagnose abnormal behavior.

Maladaptive. The person fails to adapt to the demands of everyday life, either by acting counter to his own well-being or against the goals and needs of society. For example, avoiding situations that cause anxiety might lead to social isolation and career problems.

Unpredictable. The person loses control or acts erratically from one situation to another. For example, the child who suddenly smashes a toy for no apparent reason is behaving unpredictably.

Unconventional. Behavior psychologists define unconventional as both rare and undesirable. Geniuses may be eccentric, but a psychologist wouldn’t apply the term unconventional unless their behavior violates social standards of what is morally acceptable or desirable.

Distressing. The person is suffering from severe personal distress or intensely negative emotions. If a person is nervous before an exam, that’s normal; if he throws up, can’t concentrate, and eventually gets up and walks out, that’s abnormal.

Irrational. The person acts in ways that are incomprehensible to others. Hearing voices or believing that you’re overweight at 95 pounds are examples of irrational behavior.

Sick Societies

For hundreds of years, most societies saw abnormal behavior as a sign of evil. Throughout the Middle Ages, for example, concepts of mental illness were intertwined with superstition and religion, and one “treatment” involved drilling holes in the afflicted person’s head to let the evil spirits out.

In fact, until the end of the eighteenth century, the mentally ill in Western cultures were viewed as mindless beasts who could only be controlled with chains and physical discipline. “Psychiatric hospitals” were nothing more than jails. And curious visitors could sometimes pay to view the mentally ill as they would animals in a zoo.

INSIGHT

Of course, there’s another factor involved in any psychological diagnosis—the level of discomfort in the people making the judgments as well as the society in which they live. A person who hears voices in the United States is much more likely to be labeled “mentally ill” than someone who lives in a culture that views hallucinations as a form of spiritual guidance.

In the 1700s, however, Phillipe Pinel began preaching that disorders of thought, mood, and behavior were similar to physical illnesses. He also developed the first system to classify psychological disorders. His classifications were a huge step forward because they made it easier for clinicians to identify and design treatments for common mental illnesses.

In 1896, German psychiatrist Emil Kraeplin created the first truly comprehensive system of classifying psychological disorders. Even today, when psychiatrists speak of “mental illness” and talk of treating “patients,” they are borrowing from Kraeplin’s medical view of the origins of mental illness. While Kraeplin’s medical approach helped reduce the stigma of mental illness, it also slowed down the discovery of the psychological, social, and environmental influences on mental-health problems.

Psychology Today

While today’s psychologists have ruled out evil spirits as the source of mental illness, we still have a ways to go. The search for the causes of mental illness is still alive and well and is currently carried out by two groups: the biological team and the psychological team, each with very different ideas of what causes them.

Walking the Biological Beat

The biological team assumes that psychological problems are directly attributable to underlying brain or nervous system disorders. Subtle alterations in the brain’s tissue or its chemical messengers can have a dramatic influence on a person’s mental health. In fact, tumors in certain areas of the brain can cause extreme changes in behavior. An autopsy of Charles Joseph Whitman, the “Texas tower” sniper who gunned down 45 people before being killed by two police officers, revealed such a tumor. And having too little or too much of even one neurotransmitter can mean the difference between happiness and despair.

The biological approach to mental illness is responsible for developing the powerful psychiatric medications that are available today, some of which enable people to live normal, satisfying lives. Years ago, these same people would have spent their lives chained to the wall of an insane asylum.

Pulling for the Psychological Team

The psychological team focuses on the causal role of social or psychological factors in the development of psychopathology. They search for the personal experiences, traumas, conflicts, parenting styles, and so forth that lead to psychological disorders; what environmental factors they focus on often depends on the therapist’s theoretical orientation.

A therapist relying on the psychodynamic perspective, for example, might focus on a person’s past actions and relationships and the conflicts in these. Behaviorists would examine the conditions in the environment that reinforce a client’s problem behaviors, while a cognitive therapist might investigate irrational thinking or poor problem-solving skills and their impact on a person’s life.

DEFINITION

Psychopathology is the clinical term for an abnormality or disorder in thought, emotion, or behavior.

However, both teams are becoming increasingly aware that psychopathology is often the product of a complex interaction between biology and psychology. This diathesis-stress model of mental illness says that an individual who has a biological predisposition to a certain mental disorder will tend to develop it when under stress. For instance, a person might have a genetic susceptibility for depression (biology) but doesn’t get depressed until his divorce (psychology). In fact, many mental illnesses seem to work this way; a person is vulnerable to a mental illness because of faulty hormones or neurotransmitters, but certain stresses or maladaptive coping strategies are necessary for the illness to fully develop.

Of course, it’s pretty useless to argue about what causes mental illness unless you are in agreement about what it is. To create greater consistency among clinicians, mental health professionals have developed a system of diagnosis and classification that attempts to provide an objective framework for evaluating a person’s behavior and picking the most effective treatment.

DSM-5: The Mental Health Catalog

Without an agreed-upon system to identify people whose disorders are similar to each other, the accumulation of knowledge about causes and effective treatments would be impossible. In 2013, the DSM-5 was released. “DSM” stands for Diagnostic and Statistical Manual of Mental Disorders, and the “5” means this is the fifth edition since the first version was published in 1952. This revision took 19 years and involved more than 160 world-renowned clinicians and researchers.

PSYCHOBABBLE

The ICD-10 is the European version of our DSM-5, which means your diagnosis could shift with a move across the ocean.

The DSM-5 Catalog

The DSM-5 lists close to 300 mental illnesses, grouped under 17 diagnostic categories, summarized as follows.

Anxiety disorders. In this group of disorders either fear or anxiety is a major symptom. Examples include panic disorder, social anxiety disorder, and separation anxiety disorder.

Depressive disorders. Examples include major depression, dysthymia (chronic but less severe depression), premenstrual dysphoric disorder, and disruptive mood dysregulation disorder (mood swings in children up to age 18).

Somatic symptom and related disorders. In these disorders physical symptoms arise from psychological problems. Examples include hypochondriasis, somatization disorder, and pain disorder.

Substance-related and addictive disorders. Disorders are caused by drugs, alcohol, or compulsive behaviors. Examples include substance dependence, caffeine withdrawal, and gambling disorder.

Dissociative disorders. Disorders occur when a part of one’s experience is separated from one’s conscious memory or identity. Examples include dissociative fugue, dissociative identity disorder, and depersonalization/derealization disorder (a feeling of unreality).

Schizophrenia spectrum and other psychotic disorders. Disorders are characterized by a loss of contact with reality, either through hallucinations, delusions, or inappropriate emotions. Examples include schizophrenia, delusional disorder, and schizoaffective disorder.

Sexual disorders. Sexual disorders are gender-specific disorders of sexual functioning, including lack of arousal/pain during sex (for women) or inability to perform (for men).

Gender dsyphoria. This disorder involves not only a persistent desire to be, or appear to be, a member of the opposite sex, but also a sense of distress over the confusion the sufferer feels in attempting to reconcile his biological gender with his psychological one.

Feeding and eating disorders. Disorders are marked by unusual relationships with food. Examples include pica (eating bizarre substances), binge eating disorder, and anorexia nervosa.

Sleep-wake disorders. Disorders involve disrupted sleep, sleepwalking, and/or fear of nightmares. Examples include insomnia, narcolepsy, and hypersomnolence (excessive sleepiness).

Disruptive, impulse-control, and conduct disorders. Disorders that result in impulsive behaviors that harm the self or others. Examples include oppositional defiant disorder, intermittent explosive disorder, kleptomania, and pathological gambling.

Neurodevelopmental disorders. This range of disorders, usually first diagnosed in infancy, childhood, or adolescence, includes aberrations in normal cognitive or social development. Examples include intellectual development disorder, autism spectrum disorder, or communication disorders.

Personality disorders. These long-term disorders are characterized by rigid, maladaptive personality traits. Examples include antisocial personality disorder, histrionic personality disorder, and narcissistic personality disorder.

Neurocognitive disorders. This group of disorders ranges from mild to severe impairment of memory and cognition and includes Alzheimer’s disease, intellectual impairment due to a stroke or head injury, and delirium (changes in consciousness) as a result of drug overdose.

Bipolar and related disorders. This group is characterized by swings in mood, activity level, and energy. Examples include bipolar 1, bipolar 2, and others variations of mania and depression that either coexist or alternate.

Obsessive-compulsive and related disorders. The previous diagnostic manual linked OCD to the anxiety disorders but the new DSM-5 focuses more on the role irrational beliefs and compulsive behavior play in these disorders. As a result, OCD is included with body dysmorphic disorder, excoriation (skin picking), and hoarding.

Trauma and stressor-related disorders. Similarly, while post-traumatic stress disorder was formally classified as an anxiety disorder, DSM-5 authors put more emphasis on the triggering event and linked PTSD with other stressor-related illnesses including reactive attachment disorder, acute stress disorder, and adjustment disorders.

INSIGHT

In order for a diagnostic decision to be made, classification systems must designate a cutoff point; below that point a person doesn’t have a disorder, and above it he does. In real life, though, mental health and emotional challenges exist on a continuum.

Warning: Labels Can Be Hazardous

Diagnosing and labeling may be essential for the scientific study of mental illness. Insurance companies often require them. However, we should use them with caution because they can blind us to the person’s qualities that aren’t captured by the label. For example, if we know that our new acquaintance, Jan, has been treated for depression, we may be less likely to notice her sense of humor or generosity. This tunnel vision isn’t limited to the layperson; as we saw at the beginning of this chapter, mental-health professionals can also develop tunnel vision.

The Gender Politics of Mental Illness

In the 1970s, a study asked a number of mental-health professionals to describe a mentally healthy man. They used adjectives like assertive and confident. Then these same people were asked to describe a mentally healthy woman. This time words like warm, sensitive, and nurturing appeared. Then came the biggest challenge: describe a mentally healthy person. And the mentally healthy person had the same traits as the mentally healthy man. So where does that leave those of us of the female persuasion?

Gender differences in mental health diagnoses exist and are still being debated. Although little difference is found between men and women in the overall prevalence of mental illness, large gender differences are found for specific disorders. For example, women are much more likely to be diagnosed with anxiety and mood disorders, and men are more likely than women to be diagnosed with substance-abuse problems and antisocial personality disorder.

It’s possible that such discrepancies come from biological differences between the sexes. It is also plausible that sociocultural factors, such as self-reporting differences, biased observers, and role expectations for men and women, account for these differences.

Studies suggest that because some diagnoses occur more frequently in men or women, clinicians may expect to find them and, not surprisingly, find what they are looking for! These preconceptions can also influence treatment decisions; just being female ups the likelihood that your psychiatrist will prescribe medication.

INSIGHT

A 2002 NIMH study revealed that the demographic group with the biggest mistrust of the mental health care system and the least likely to seek help from it is white, non-Hispanic males. They are also the group most likely to stigmatize mental illness and mental health concerns.

Are You Insane?

On March 30, 1981, John W. Hinckley Jr. shot President Ronald Reagan. His defense attorneys did not dispute that he had planned and committed the act. Instead, they argued he was not guilty by reason of insanity. Specifically, they argued that Hinckley’s life was controlled by his pathological obsession with the movie Taxi Driver, in which a woman is terrorized by a stalker who eventually gets into a shootout. The defense attorney argued that Hinckley was schizophrenic and that the movie caused his attempt to assassinate the president. The jury believed it.

Mental Illness vs. Insanity

Mental illness is a medical decision. Insanity, on the other hand, is a legal one. The insanity defense is based on the principle that punishment is justified only if the defendant is capable of understanding and controlling his behavior. Because some people suffering from a mental disorder are not capable of knowing or choosing right from wrong, the insanity defense prevents them from going to prison.

INSIGHT

Despite popular belief, the insanity defense is not the easy way out. Less than 1 percent of all criminal defendants plead “not guilty by reason of insanity” and the vast majority of them (between 75 and 85 percent) are unsuccessful. And “successful” defendants often spend more time in a mental institution than they would have served in prison.

Weapons Against Mental Dysfunction

Once we’ve figured out what’s wrong, we have to fix it. Just as we’ve looked at both the biological and psychological explanations for mental illness, we can follow the same process when developing treatments for psychological disorders.

Better Living Through Chemistry

In the 1950s, French psychiatrists Jean Delay and Pierre Deniker broke new therapeutic ground when they used chlorpromazine to successfully treat the symptoms of schizophrenia. As a result, a whole new treatment era was born. Today, the right dose of the right medication can dissolve hallucinations, douse depression, level out moods, and soothe anxiety. In fact, people who years ago might have spent many years in mental hospitals may now go in only for brief treatment or might receive all their treatment at an outpatient clinic.

Another benefit from these medications is an increased understanding of the causes of mental illness. Scientists have learned a great deal more about the workings of the brain as a result of their investigations into how psychotherapeutic medications relieve disorders such as psychosis, depression, anxiety, obsessive-compulsive disorder, and panic disorder.

INSIGHT

Psychotherapeutic medications also may make other kinds of treatment more effective. Someone who is too depressed to talk, for instance, can’t get much benefit from psychotherapy or counseling; the right medication might relieve his symptoms to the point that he can benefit from therapy, too.

Choosing Your Drugs Carefully

Before we move along to other biological treatments of psychological disorders, let’s nail down some basic information to help keep all these drugs straight. Medications used to treat psychological disorders are classified according to their clinical class, chemical class, and action:

Cures for Kids

About 15 percent of children in the United States below age 18—about 9 million—have a mental health problem severe enough to interfere with their ability to function. Mental health treatment—including psychotropic medication—can be a lifesaver for these children as long as we take the risks as seriously as the rewards.

PSYCHOBABBLE

When it comes to mental health treatment for children, parents may need to be most vigilant about practitioners using combinations of prescription drugs and unproven, and often unsupported, therapeutic approaches.

In the late 1990s and early 2000s, there were reports of an increased risk of suicide among children and adolescents who were prescribed some of the newer antidepressants (the SSRIs). As a result, in 2004, the U.S. Food and Drug Administration issued public warnings and required a “black box” warning be added to package inserts for antidepressants.

Antidepressant prescriptions for children have dropped 20 percent since this warning went into effect. Ironically, however, the suicide rate among children over 10 years of age has continued to climb. Furthermore, a 2014 study found no increased suicide rate among children and teens who were prescribed older versus newer antidepressants. It seems that the unintentional result of the FDA’s warning may be that some kids who truly need pharmacological help may not be getting it.

BRAIN BUSTER

Anyone who talks about suicide should be closely monitored by a mental health professional. And don’t count on Prozac to stifle the urge to self-injure; a review of more than 71,000 patients in clinical trials of 52 psychotropic medications found an equal risk of suicide among those given medication and those taking placebos.

The Facts About ECT

Electroconvulsive therapy or ECT, commonly known as electric shock therapy, has split the psychiatric community since it was pioneered more than 50 years ago. Before modern procedures were invented, the seizure induced by the electric shock was so violent that the muscular contractions would break bones.

Today ECT is painless and quite safe. Patients are given drugs to block muscle and nerve activity so that no pain or muscular contractions occur. Doctors may disagree about when, or whether, to use ECT, but all agree the technology has improved.

Still, some patients complain of lifelong memory lapses after ECT even though brain studies show no evidence of permanent memory loss or chemical or structural changes after repeated ECT shocks. Until this discrepancy between science and personal anecdote is resolved, ECT will continue to be seen as a last-ditch treatment alternative.

PSYCHOBABBLE

About 70 percent of people who suffer from major depression and have not responded to other treatments get better with ECT. Sometimes the depression goes away for good; other times it reoccurs after several months.

When the Cure Is Worse Than the Disease

From the late 1930s to the early 1950s, thousands of men and women were subjected to a prefrontal lobotomy, in which the front portions of their frontal lobes were surgically separated from the rest of their brain. This operation was prescribed for people with severe cases of schizophrenia, bipolar disorder, depression, obsessive-compulsive disorder, and pathological violence. During their heyday, lobotomies were so highly regarded that in 1949, the Portuguese neurosurgeon who pioneered the technique, Antonio Egas Moniz, was awarded the Nobel Prize.

Sadly, while lobotomies did relieve patients of their incapacitating emotions, it also left them with lifelong deficits in memory and the ability to make plans and follow through with them; they often became ghosts of their former selves.

Although lobotomies are no longer performed, a rare few individuals are helped by a new kind of psychosurgery known as cingulotomy. With this treatment, the cingulum, a small structure in the limbic system involved in emotionality, is partially destroyed with radio-frequency current applied through fine wire electrodes temporarily implanted in the brain. Follow-up studies suggest these operations most often reduce or abolish major depression and obsessive-compulsive disorder and have rarely left the patient worse off than before.

Cingulotomy, like the earlier lobotomy, is still controversial, but to someone who has been seriously depressed for many years has gotten no relief from ECT and every antidepressant medication on the market, it’s something to consider. Blessedly, this degree of treatment failure rarely happens. And no matter how you feel about it, cingulotomy does help.

INSIGHT

Keeping a journal or diary, talking things over with a friend, or meditating on a problem all are ways we label our thoughts and feelings. Not only does this labeling productively shift our perspective from tunnel vision to the big picture, it also gives some much-needed distance from the emotional turmoil that upsetting thoughts and feelings create.

Winning the Battle with Talking Cures

Not everyone needs—or benefits—from medication. In fact, for many psychological disorders, psychotherapy works as well as pharmacology. And just as individuals’ symptoms will guide what medication they receive, the kinds of psychological problems people face will determine what kind of therapy they will receive.

For instance, some problems are short-lived but intense, such as a loss or a divorce. Some are mild but persistent and energy draining over time, such as dysthymia or chronic worrying. And some problems are frustratingly repetitive, like realizing you’re dating another loser. What all these problems have in common is that the person dealing with them feels they exceed his coping skills. For whatever reason, he just can’t see the light at the end of the tunnel.

PSYCHOBABBLE

While the drop-out rate for face-to-face therapy is nearly 50 percent, less than 8 percent of patients receiving phone therapy for depression dropped out of treatment prematurely.

A Team of Professionals

When our informal counselors—our best friend, our mom, or our minister—can’t help, there’s something to be said for the skills and knowledge that formal psychological training provides. These five kinds of mental health professionals can help us deal with problems when our support system can’t:

Counseling psychologists specialize in the problems of daily living. They often work in community settings such as schools, clinics, and businesses and deal with challenges like relationship conflicts, choosing a vocation, school problems, and stress.

PSYCHOBABBLE

Psychiatrists are increasingly becoming the medication dispensers, leaving psychologists, social workers, and counselors to do the psychotherapy. In fact, between 1996 and 2007, the number of psychiatrists providing psychotherapy to all their patients decreased from 19.1 percent to 10.8 percent.

Clinical psychologists are trained to treat individuals who suffer from more severe conditions, such as clinical depression, eating disorders, and anxiety.

Psychiatrists are medical doctors who specialize in the treatment of emotional and mental disorders. These physicians generally treat more severe conditions and, in these days of managed care, are most likely to prescribe medication for psychiatric disorders.

Clinical social workers are mental health professionals with specialized training in the social context of people’s problems. Clinical social workers often work with family problems, like child abuse, and their work often involves entire families in the therapy.

Counselors or therapists are mental health professionals covering a wide range of specializations and expertise. Pastoral counselors are members of a religious group or ministry trained to specialize in the treatment of psychological disorders. Marital and family therapists are often master’s-degreed professionals who have chosen to focus on family/couple problems, while drug and alcohol counselors often have specialized training in the addictions.

INSIGHT

A good fit between a therapist and client is a unique and somewhat mysterious chemistry that develops between the two. However, all good therapists seem to share certain traits: they listen more than they talk, keep their own problems to themselves, pay attention to what you’re saying, own up to their mistakes, and keep what you say confidential.

Finding Your Therapy Match

It isn’t always easy to find a good therapist. Your first therapy session is like a blind date; you never know for sure what you’re going to get. However, there are some guidelines you can use to improve the odds that your first encounter with a therapist will turn into a trusting relationship:

Get personal referrals, particularly from a friend or colleague who has had a problem similar to yours. If you can’t find a therapist this way, then check with your doctor or hospital’s social work department.

Interview the therapist over the phone. Remember, you are hiring this person to be your therapist, and you need to make sure she is qualified.

Ask questions. Be sure to ask what her specialties are, how many people she’s seen with the same problem as yours, and what her treatment philosophy is. One person may be a fabulous therapist for substance-abuse problems but have no experience with depression.

Trust your instincts. If you don’t like the person or don’t feel comfortable after three sessions, switch therapists.

Talking It Out

While medications have helped people solve mental problems by acting on the brain, psycho-therapy works on the mind. There are four major types of “talk” or psychotherapy: psycho-dynamic, behavioral, cognitive, and “group” therapies. Though different in approach and process, each has the same goals: to provide people with a rational explanation of their problem; to offer a very real basis for very real hope; and to achieve their success through a positive, one-on-one relationship between the client and her therapist.

A psychotherapist is, in effect, like your driving instructor. He can give advice—talk about how traffic lights work, discuss the importance of a properly executed U-turn, and explain how to merge correctly—but ultimately the patient must drive her own car.

INSIGHT

In the past, mental health specialists tended to choose a certain theoretical orientation and treat all patients under this umbrella. A new, Evidence Based Therapy (EBT), says the kind of treatment you get should be based on the problem you have—not on the expertise of your therapist. For example, if research shows that cognitive behavioral therapy works best for anxiety disorders, that’s what your therapist should start with.

One “instructor” might concentrate on helping a student unlearn reckless driving habits, while a second might tackle fears of getting behind the wheel. Yet a third might bring new drivers together so that they can support each other. But no matter what, all therapists have the same purpose: to bring forth their patient’s inner Dale Earnhardt and point them down the road.

To help you narrow down and understand your options, this table compares and contrasts the four primary types of therapies:

No matter which kind of therapy you choose, always remember you can do numerous things to enhance the odds your therapy will work, including working with your therapist to set clear treatment goals, deciding on how progress will be evaluated, monitoring progress carefully, and revising treatment plans.

Short and Sweet or Long and Slow?

Many therapists are now utilizing recently developed therapeutic techniques that focus less on the therapeutic process and more on results. They concentrate less on their patient’s childhood and more on his current life experiences and relationships. They provide more directive guidance and feedback—and will often even prescribe homework to speed up the process!

For people who don’t need more intensive treatment, these sort of “McTherapies” can prove very satisfactory indeed; for example, a review of more than 30 years of short-term (between 7 and 40 sessions) psychodynamic therapies found that 92 percent of the treated adults were better off than similar individuals who received no treatment. Many people, with many common mental-health concerns, begin experiencing positive gains in therapy in as little as 6 to 12 sessions. At one session per week, that translates into feeling better in between two to three months.

However, according to a recent meta-analysis of 23 studies, longer-duration psychotherapy (lasting for at least a year or 50 sessions) appears to be more beneficial for treatment of complex mental health problems such as personality disorders, multiple diagnoses, and chronic psychiatric illnesses. In this review, long-term psychotherapy was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning.

PSYCHOBABBLE

A recent study found that 60 percent of therapy clients felt their therapy either lasted too long (23 percent) or ended too soon (37 percent). However, clients who reported that termination was a mutual agreement between both parties and that termination focused on the positive gains in therapy, i.e., a mutual agreement between both parties, were more satisfied with their therapy. Part of the problem may be that therapists are trained to focus on the emotionally painful aspects of saying goodbye; celebrating the success of the therapeutic relationship and the positive gains in therapy may make a satisfactory ending.

Getting Wired

It’s only natural that modern technology would influence and modify the work of therapists. While the use of the Internet and other communication technologies for the purposes of therapeutic counseling is new, it’s surely here to stay: already, 70–80 percent of psychologists say they rely on “telephone therapy” for at least some of their patients. Increasingly, therapists are delivering clinical services on the Internet or via satellite.

While the jury is still out on how effective online therapy is, preliminary evidence suggests that “telehealth” may provide new opportunities for effective low-cost treatment, especially for people who are harder to reach by traditional means. Recent studies have found that improvement in depression was comparable for patients receiving in-person therapy and those receiving it online and that the number of psychiatric admissions fell 25 percent for patients receiving 6 months of psychotherapy via remote videoconferencing.

INSIGHT

How do you know when you have a good alliance with your therapist? You look forward to your sessions; you leave them feeling as if you’ve done good work and made progress; and you feel like your therapist really gets you.

But Does It Work?

Of course therapy works! Why else would I be writing this book? Don’t take my word for it, though; thousands of studies have been done, and here’s what they have to say:

Psychotherapy works. About 75 to 80 percent of people in therapy show greater improvement than the average person in a control group.

The outcomes of therapy tend to be maintained. Numerous follow-up studies have tracked patients after leaving treatment for periods ranging from six months to over five years. These studies are fairly consistent in demonstrating that treatment effects are enduring.

Some therapies work better for some problems. Fear and anxiety seem to respond best to behavioral and cognitive therapies, while humanistic therapies do wonders for self-esteem, and psychodynamic therapy can help underachievers.

Therapy is for better and worse. Despite overall favorable results, about 5 to 10 percent of patients get worse during treatment, and an additional 15 to 25 percent show no benefit.

So there you have it: the mechanistic (drugs, ECT, psychosurgery) and the idealistic (using therapy to change thoughts, behavior, and feelings). Both can be useful, and both have their pros and cons. Both use different means to get to the same goal—leading a better, happier, and more productive life. In the next chapter, we’ll go from our general overview of mental-health help to tackling—and treating—two of the most common and most painful disorders that can dampen the light of even the brightest psyche—depression and anxiety.

INSIGHT

No matter what problem brought you to the therapist’s office, you can expect to work on figuring out what’s wrong, what caused the problem and why, how to get rid of it and/or making it better, and predict what will happen in the future.

The Least You Need to Know