DC Medical Malpractice & Patient Safety Blog

As one year ends and a new one begins, some people think about ways to start over. Be happier. Renew energy. Often, they turn to psychotherapy, and in many cases, it works, or at least provides a roadmap to a more satisfying life.

But mental health is like physical health—some things just don’t change. In an effort to help prospective patients understand what psychotherapy can and cannot do, a recent post on the Psychcentral.com website enumerates five things therapy won’t cure.

The advice isn’t just a reality-check; it’s an effort to help people save time, money and frustration. “Therapists, by their nature, tend to want to help every person who comes through their door,” writes John M. Grohol. “Even well-meaning therapists may not fully appreciate when they are largely going to be ineffectual in treatment because of the type of problem presented. After all, psychotherapy isn’t some magical elixir. Talking about some topics simply won’t do much to help the situation.”

Five Things Psychotherapy Won’t Change

1. Personality

Personality disorders are recognized as mental disorders. Typically, they’re more ingrained and more difficult to change than most other mental disorders. They begin in childhood and are shaped by experiences. “You can’t expect to undo decades of personality development in a few months’ worth of psychotherapy. (Years, maybe.)”

But psychotherapy can help mitigate some of the worst features of the problem. For instance, someone with narcissistic personality disorder may continue thinking he or she is better than everyone else, but awareness can help him or her tone it down in interpersonal relationships to become less of a social and work impediment. Another example: Introverted people will still be introverted, but can learn how to relax in social situations.

2. Childhood

No one can go back and fix a lousy childhood. It’s a piece of personal history.

But through therapy, someone can see how he or she interprets what happened in childhood affects behavior now. Then a choice can be made whether to indulge those issues, or grow through them by understanding their significance. A patient will still have had bad parents, rotten siblings, an unsafe childhood home or neighborhood. But those things are afforded a perspective that renders them less hurtful in the present.

3. Half a Relationship

A healthy relationship is a joint effort. Psychotherapy can help couples through rocky times, but only if both parties approach counseling with an open mind and a willingness to work on the relationship. Attendance counts, but work product is key.

That doesn’t mean it isn’t worthwhile if only one-half of a couple goes for therapy; often that helps the patient cope better with the situation or decide to end it. But if the goal is to maintain and sustain a relationship, it takes two to tango.

4. Broken Heart

The side effects of lost love can be long term. Professional counseling isn’t likely to help much, but talk therapy can if the listener is a close friend. Common activities and shared experiences make the painful time seem shorter.

Psychotherapy might help, however, in situations where someone is “stuck” ruminating over details of an old relationship, even years later. If someone can’t move on, talking to a professional might help bring perspective in the same way it does to childhood issues.

5. Bereavement

Typically, grief isn’t considered a mental illness in need of treatment, but its hallmark is depression. Despite popular common wisdom about the stages of grief, the reality is that everyone’s grief is unique.

Psychotherapy won’t help speed the natural processes of time and perspective. Like lost love, grief needs space for remembrance and reflection. It’s done best mindfully and with patience. And like love, it can help someone who cannot get over the loss, even years later. But for most people, “psychotherapy is both unnecessary and overkill for what is a normal process of life and living.”

Choosing a medical caregiver, like any good consumer behavior, involves comparison shopping.

Mindful of the restrictions of your health-care plan, cost, geography and/or time, choosing a psychological therapist is no different from choosing any other medical provider. In some ways, it’s even more important to have a good match between doctor and patient, because for most people, the mind is the most difficult body part to open to scrutiny.

Writing on PsychCentral.com, clinical psychologist Charles H. Elliott offers therapy shoppers several tips to ensure a good marriage between therapist and patient.

A range of factors can undermine the therapeutic relationship. Maybe the therapist reminds you of someone you dislike or with whom you have an uncomfortable history. Maybe you don’t even know why it just doesn’t feel right.

It doesn’t matter, Elliott advises, whether or not you can identify a reason for a rocky relationship. The fact that you’re uncomfortable is reason enough to question whether a practitioner is the right one for you. If he or she isn’t, you’re not getting the best care.

After a couple of sessions, ask yourself these questions in order to assess if the match seems to promise a successful outcome:

• Do I feel at ease in discussing almost anything with my therapist that I feel is important?


• Do I feel safe when I’m talking with my therapist?


• Does it seem like my therapist understands and truly hears what I have to say?


• Does my therapist look interested in what I have to say?


• Do my therapists’ reactions to what I say feel nonjudgmental and uncritical?


• Does it feel like my therapist cares about me and my problems?

If you’re uncertain about several answers, or if any one is a strong “no,” that’s a clue to discuss your concerns with your therapist. If he or she is defensive or evasive, if the discussion makes you feel uncomfortable, you probably need a different caregiver.

The one exception is if you have relationship problems in general, and struggle to feel safe talking even with close friends or family. That’s a tip that communication/relationship issues should be part of the therapy itself.

As reported in the journal Health Affairs, antidepressant drugs are the third most commonly prescribed class of medications in the U.S. Much of the growth of these drugs has been fueled by prescriptions written by nonpsychiatrist caregivers, and are not accompanied by a psychiatric diagnosis.

Between 1996 and 2007, the proportion of doctor visits at which antidepressants were prescribed but no psychiatric diagnoses were noted increased from 59.5% to 72.7%.

Researchers aren’t saying that this remarkable growth necessarily represents inappropriate use of antidepressants, and depression is underdiagnosed and undertreated in this country. But the rapid and marked increase of such prescribing habits have prompted researchers to call for scrutiny of the pattern to better understand the factors driving the trend and to develop “effective policy responses.”

Ramin Mojtabai, one of the study’s authors and a professor in the department of mental health at Johns Hopkins in Baltimore, said to WebMD, “What we are observing is that Americans are increasingly viewing psychiatric medications as a solution for a wide range of social and interpersonal problems and for dealing with daily stress [and] general medical providers appear to be going along with this trend. The irony is that many patients with major depression or anxiety disorders who could potentially benefit from treatment with antidepressant medications do not receive these treatments.”

Another source told WebMD that there may be another story line here. Doctors often get reimbursed at lower rates for treating psychiatric conditions, so they might be motivated to prescribe antidepressants but record them in patient charts as treatment for a nonpsychiatric problem. And there’s still a stigma attached to psychiatric illnesses, which could skew diagnoses.

The study authors suggest that if antidepressants are being prescribed for uses not supported by clinical evidence, there might be a need to improve providers’ prescribing practices, revamp drug formularies or vigorously pursue implementation of broad reforms of the health-care system. The point is to improve communication between primary care providers and mental health specialists.

An article by Jane Brody in the New York Times, "When Your Looks Take Over Your Life," draws attention to a tragic mental health issue called "body dysmorphic disorder."

These are people who are obsessed about a "flaw" in some aspect of their bodily appearance, and who sometimes subject themselves to repeated rounds of cosmetic surgery to "cure" this problem. And of course the surgery never works because the problem is much deeper than the skin. A malpractice lawsuit is not the answer for these patients, as I explained in a comment on the New York Times' "Well" blog:

As a malpractice attorney who represents patients, I have been consulted several times by potential clients whom I later realized had body dysmorphic disorder. When they called for the appointment, the story on the telephone was that they had been grotesquely disfigured by a cosmetic surgeon, often with repeat surgery. Then when I met them, I would not be able to see anything wrong with their appearance, even when they pointed it out to me.

One man in his mid-20s had had his nose operated on three times by the same surgeon. All I could see was that one nostril was slightly larger than the other. He was talking about needing to have yet another surgery. I politely urged him to see a psychiatrist first, and told him I could not represent him in any legal action against the surgeon.

My personal belief is that an ethical cosmetic surgeon would decline to operate on anyone with obvious signs of body dysmorphic disorder (if for no other reason than that this will be a hard-to-please patient), but a willing patient with the means to pay for the surgery can be persuasive for some surgeons, it seems. (Witness Michael Jackson.)

The legal system does not have good answers for these patients. A lawsuit would only perpetuate the patient's idea that their appearance can be "fixed" and that it's the doctor's fault for not doing so. Still, my heart goes out to people with this disorder especially when they subject themselves to a fruitless round of surgeries. They definitely need counseling.

Read more comments on the Well blog here.

A new study that concluded that two commonly prescribed antidepressant drugs don't work for people with mild depression has opened an interesting discussion about the quality of mental health care in America. The quality score: C-minus, for lots of reasons.

Judith Warner wrote in the New York Times that the news media reports about the new study (which really wasn't an original study but a number-crunching of selected older studies) were too simplistic. She noted many of the shortcomings of mental health treatment, starting with the fact that general practitioners do a lot of the medication prescribing and aren't as skilled as specialists in screening who really needs the medications.

Ms. Warner concluded: "The trouble is not that the drugs don't work, it's that the care is not very good."

She also said:

This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma and high prices; or finding care that is ineffective.

Her Op-Ed piece brought a round of thoughtful comments in the letters">letters to the editor column at the Times, including:

* Brown University psychiatry professor Lawrence Price writes:

Medications that work for depression are commonly misused, and types of psychotherapy that work for depression are commonly not used at all. The reasons for this state of affairs include mistrust of authority, stigma, big-stakes health care economics, cross-discipline rivalries and simplistic thinking (within the mental health care field as well as the general public).

* James Brush, a psychologist in Cincinnati, writes:

While researchers can investigate treatments in laboratory conditions, few clients fit into simple categories. Try applying an “evidence-based treatment” for a depressed, sexually abused child from a divorced family in which one parent is alcoholic and the child has a learning disability. Such clients do not tend to show up for laboratory studies and don’t tend to respond to simple bromides.

* Neil Brooks, former president of the American Academy of Family Practice, argues that family practitioners by necessity have to treat patients with depression who might be better off with a specialist. Dr. Brooks writes:

Many of those who need treatment have no access to psychiatrists because of geographical distribution, restrictive insurance coverage, cost or a perceived stigma to being cared for by a psychiatrist. Thus, distortion or misinterpretation of the evidence about the treatment of depression will result in those who desperately need help not obtaining it.

The Times also published a rebuttal to the new study by psychiatry professor Richard Friedman, M.D. of Cornell, who cited a number of caveats that limit the usefulness of the new study. He concluded:

Every once in a while, a landmark study comes along and overturns everyone’s cherished ideas about a particular treatment. But the current study is not one of them. So it would be a shame if it discouraged depressed patients from taking antidepressants.

Experts may disagree about what constitutes the best treatment for depression, and for whom. But there is no question that the safety and efficacy of antidepressants rest on solid scientific evidence.

Bottom line: Don't throw out your antidepressants just yet. But if they don't seem to be helping, do talk to a good therapist about trying another approach.