December 30, 2011

Psychotherapy for Normal People: Therapy Poll Results

Last month, a new friend told me about his therapy experience over dinner. I'm used to people telling me about their therapy, but the next day, my friend sent me a text to remind me to keep our conversation confidential. That got me wondering about how people perceive therapy--is seeing a mental health professional still stigmatized, or is psychotherapy accepted as normal these days? To find out, I decided to take a poll to see how many of my peers had been to therapy (and were willing to admit it).

Method: I posted the following as my Facebook status two or three times in one week: "Informal research project: Have you ever been in family, group, or individual therapy? Send me an email to say yes or no." The response rate was low (n = 8) so I created a Facebook event and invited all of my Facebook friends (n = 154). I sent two reminder emails within the following month.

Participants: I received 48 responses, 60% from women (n = 29) and 40% from men (n = 19); participants ranged in age from 25 to 48 years. Sixty-three percent of respondents lived in Montreal at the time of the poll (although a few others were former Montrealers), and 83% were Anglophone. Seventy-nine percent of respondents were white and urban, with post-secondary education; the other 21% were two of those three things.

Results: Fifty-eight percent of respondents (n = 28) reported that they had been to therapy. Most of those in the affirmative camp responded with a simple yes, but some further confided that they had sought therapy subsequent to a break-up or other crisis, had gone to couples therapy with their partner or former partner, or had been sent to therapy as a child during their parents' divorce. Interestingly, more than a few respondents in the no camp added that they maybe should seek therapy, or that they would like to.

The gender statistics revealed little. Of the respondents who said yes, 58% were women and 42% were men. Of those who said no, 65% were women and 35% were men. These numbers reflect the overall gender ratio in the sample of respondents, and don't suggest that one gender is more likely than the other to have been to therapy. Of the female respondents, 55% said yes and 45% said no. Of male respondents, 63% said yes and 37% said no. These numbers reflect the overall proportion of yes and no responses, and don't seem to suggest anything about gender and psychotherapy. 

Discussion: Nearly 60% of respondents acknowledged having gone to therapy at some point in their life. Although this seems like a pretty straightforward result, it's possible that the stats were falsely inflated by selection bias (i.e., I'm friends with the kind of people who go to therapy) and/or by self-selection bias (i.e., people with therapy experience were more likely to respond). Alternatively, it's possible that the actual statistics of therapy attendance are much higher, but that people who seek therapy don't want to admit to it, even anonymously (i.e., maybe every single one of the 106 non-respondents has been to therapy!). I also don't know whether or not the results indicate that it's common among my peers to seek therapy, because I don't know how many respondents independently sought psychotherapy in adulthood, and how many were sent to a therapist during their childhood. I wish I had been more specific with my question!

Conclusion: Even with the identified limitations to the research design, I feel comfortable concluding that psychotherapy is statistically normal among youngish white, urban, educated adults. I hope that this finding demonstrates that therapy is for normal people, and contributes to the destigmatization of psychotherapy.

What do you think? Are you surprised? Are you convinced?

December 22, 2011

Too Much Empathy

Judging from reactions to my two recent posts on the subject, most people believe that some form of empathy (cognitive or emotional; innate or learned) is a key characteristic for healthcare professionals such as doctors and psychologists. But is it possible to overempathize? A recent experience suggests that it is:

Last week at the chronic pain centre, I had the opportunity to see two therapists consecutively interact with the same patient, with two very different outcomes. The therapists were co-conducting a psychological assessment of a new patient who was extremely and visibly depressed. The patient walked into the office slowly and hunched over. He didn't make eye contact during the introductions, and slouched in his chair, tears falling unchecked even before the interview started.

The first therapist was shaken by the patient's appearance, and unsure that he was in a condition to answer three pages of questions about pain, mood, and functioning. She began the evaluation anyway, but the interview rapidly went nowhere. The patient spoke slowly, softly, and infrequently, and continued to cry. The therapist felt insensitive probing someone in such obvious distress, and spoke to him more and more slowly and softly. As palpable despair crept into the room, the therapist started fumbling her words, and within ten minutes, she too was slouched in her chair, feeling helpless.

The second therapist took over. She obtained the patient's consent to continue the evaluation and then, sitting up straight and speaking at a normal volume, she continued the interview. When the patient stumbled or got stuck, the therapist rephrased the question to make it easier. Her attitude and questions expressed empathy, but she maintained composure and didn't behave as though her questions were an imposition. 

How did the patient react? He sat up straighter. His tears gradually stopped. He raised his voice to a normal volume and made more eye contact. He joined the conversation and the second therapist was able to obtain the information necessary to formulate a treatment plan.

What happened here?

In a fit of unhelpful overempathy, the first therapist had fallen head first into the patient's emotional world, taking on his hopelessness and helplessness.  The second therapist didn't take on the patient's mood; instead, she maintained her own competent and upbeat manner, and her energy spread to the patient. Her composure conveyed a message of strength: whereas the first therapist's behaviour communicated "You (and I) are too fragile to complete this interview," the second therapist's attitude said to the patient something like "I see that you are in immense physical and emotional pain, but I believe that you have the strength to communicate your situation and participate actively in your treatment."
In the therapy room, part of the therapist's job is to be in control, to model competence and mental health, and to convey appropriate optimism to the patient. To do so effectively, the therapist needs to strike a balance between empathy and some degree of emotional separation. In this case, the first therapist's excessive emotional empathy maintained and propagated the patient's despair, and prevented the therapist from doing her job. The second therapist's appropriate empathy allowed her to maintain composure, do her job effectively, and propagate hope. The patient's reaction made it clear which attitude was more helpful!

December 18, 2011

Pain Psychology

In September, I started an internship at a chronic pain centre. The pain centre is a multidisciplinary hospital clinic that employs various types of healthcare professionals, including doctors (e.g., rheumatologists, anesthesiologists), nurses, a physiotherapist, and a team of psychologists. About two thirds of pain centre patients see one of the psychologists at some point during their treatment.

Why do chronic pain patients need psychological help?

Pain patients need psych help because chronic pain often impairs functioning significantly, creating considerable distress. Imagine not being able to go to work, walk around the block, or lift your child. Imagine going from playing competitive volleyball to walking with a cane, or from working construction to being unable to stand for more than fifteen minutes at a time. Imagine explaining to family, friends, and colleagues that you have constant pulsating pain shooting down both of your legs, or that you wake up every morning with what feels like a 100-pound weight pressing on your spinal cord. Then imagine years of this--sometimes without a clear diagnosis--and you can see why some pain patients need psychological help.

When pain centre doctors refer a patient to the psychology team, the first thing the psychologist does is a complete psych assessment. The goal of the assessment is to get a global portrait of the patient, and to answer the following questions:

a) What is the state of the patient's mental health? For example, the patient may be depressed, anxious, suffering from post-traumatic stress (e.g., pain onset subsequent to a work or car accident), or self-medicating with alcohol.

b) Did the patient's psychological problems develop before or after pain onset? For example, a depressed pain patient may have been psychologically healthy before pain onset; a patient with a personality disorder has probably had interpersonal problems all his or her life.

c) Do the patient's psychological problems exacerbate, maintain, or perpetuate the pain? For example, an extremely anxious patient may focus excessively on every tiny sensation in his body, fearing increased pain with every movement; his hypervigilance exacerbates the pain, reinforcing his fear of movement and creating a vicious cycle. A severely depressed patient may stay in bed all day for months; her decreased strength and flexibility maintains her pain.

d) Does the patient's psychological state present a barrier to treatment? For example, an extremely depressed patient may need to start taking an antidepressant before he would be able to benefit from therapy. The patient with a dependent personality may rely heavily on pain centre staff and, at some level, fear getting well enough to be discharged. The occasional patient is receiving good worker's compensation benefits or enjoying receiving care and attention from loved ones, and has little interest in getting better; this is a clear barrier to treatment and is important to assess.

We use this information, as well as information about pain history, family history, and work and relationship history, to formulate a treatment plan. The number one goal of psychological treatment at the pain centre is always to increase patients' functioning and improve their quality of life. In individual and group therapy, we help patients increase the number of pleasurable activities in their day, implement a healthy sleeping and eating schedule, and start exercising again if possible. We teach them how to manage stress, and how to communicate effectively with doctors and loved ones about their pain. Most patients' pain is only manageable, not curable, and many patients' pain isn't even diagnosable. Lack of diagnosis is understandably difficult to accept, and a big part of our job is helping patients adjust to this reality. We help them move from grieving their former activities and abilities ("I used to be able to...") to considering available adapted activities ("Now I can...").

Chronic pain eats away at quality of life, and our objective is to increase patients' functioning, restore some level of activity, and help them live better with their pain. When patients start to make some of the changes described above, they often find that their physical health improves and their mood lifts. Pain doesn't go away, but if fades somewhat or feels more manageable.

NB: Psychology is a key element of a multidisciplinary approach to pain, but psych treatment doesn't replace medical intervention--rather, most patients receive concurrent medical and psychological help.