New Science for Psychotherapy

Can we predict how therapy will progress?

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From the May/June 1997 issue

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We break one another’s hearts, we’re heartsick, our hearts take flight. The idea that the heart is the seat of our emotions predates written literature. In this technological age, people have taken to studying the heart to find the connection between emotions and disease.

Researchers have known for years that depression and heart disease are connected. Approximately one out of six people in the United States has had an episode of major depression, but among people with heart disease, it’s almost one out of two. Anywhere from 11/2 to 3 percent of the population is afflicted with less severe, but still diagnosable, depression at any given time, but among patients with heart disease, says medical psychologist Robert Carney, it’s closer to 18 percent.

The question has always been whether heart disease leads to depression or depression to heart disease. The January/February Archives of Family Medicine reports a study from the National Center for Health Statistics, a division of the Centers for Disease Control, in which 3,000 men and women were tracked for 7 to 16 years. None of them had high blood pressure at the beginning of the study, but 60 percent of those with intermediate levels of anxiety or depression later developed hypertension, which leads to heart disease or stroke. According to an article in January’s New York Times by Gina Kolata, the latest thinking seems to align with the identification of depression as the precursor of heart disease.

The link between the two may be the stress hormone norepinephrine, which increases the blood pressure and heartbeat; depressed people have levels of norepinephrine that are up to 30 percent higher. Further, because of the vicious paradox of depression–while the overt symptoms are of listlessness, internally the stress level is elevated–signs of hypertension usually go undiagnosed and untreated until the condition becomes evident in heart disease.

The ancient poets were apparently right: people sometimes do die of broken hearts.


Knock, Knock . . .

Psychologists are knocking at the door of two of the previously exclusive mental health domains of psychiatrists. California recently became the first state to require that hospitals consider applications from clinical psychologists for medical staff membership. Psychologists will have admitting privileges for patients and will be able to participate in decisions concerning hospital practices and non-medical treatments. This is a significant step forward in both prestige and power. According to Russ Newman, the executive director of professional practice of the American Psychological Association (APA), similar measures are being considered in 16 other states, including Florida, Michigan and Nebraska.

Another development has even broader implications, not only for psychologists but for their clients. Approximately half of the state psychological associations have set up task forces on obtaining prescription-writing privileges for psychologists. Actual legislative pushes are planned within the year in California, Hawaii, Louisiana and Missouri. Elsewhere, state associations are actively working on establishing training programs for their members on prescribing medications.

The powerful managed care industry is supportive of the APA initiatives, since psychologists command lower fees than psychiatrists.


A Running Start

Clients who get the most out of family therapy are apparently the ones who begin with a good running start. A study of 200 families seeking treatment at Utah State University’s family therapy clinic, conducted by psychologist Scot Allgood of the University’s Department of Family and Human Development, shows that those who report positive change between the time they arrange their first appointment and their actual first session are the least likely to terminate therapy prematurely. Therapists know it’s not uncommon for clients to feel better just because they made that first phone call, but Allgood’s study confirms that tendency toward improvement; 30 percent of respondents experienced positive change between the first contact and first session. The study also underscores the importance of that preliminary change. Based upon clients’ self-reported pretherapy positive developments, Allgood and his colleagues were able to predict with 76 percent accuracy whether the client’s subsequent termination of therapy was planned with the therapist.

Allgood theorizes that clients who make preliminary changes are already in a state of flux and are thus ripe for more significant changes. “If the therapist builds on these preliminary changes,” says Allgood, “the client is more likely to follow through and less likely to drop out of therapy.” The study reinforces the all-too-frequently-forgotten concept that therapy begins at the moment of first contact, not first appointment, and that the initial phone call presents an opportunity for therapists to start pointing clients toward positive change.


New Markets for Therapists

Therapists trying to find ways to increase their practices should keep a basic marketing idea in mind: determine where the need for services is. Two of the fastest-growing segments of our society are the geriatric population and divorced or divorcing couples. Three therapists who have reconceptualized their practices to fit these areas have found ways to significantly increase their incomes, while avoiding the managed care squeeze.

Annapolis, Maryland, psychologists Maureen Vernon and Tom Muha, realizing that half of all new marriages and 60 percent of second marriages end in divorce, decided to target not only divorcing couples but also attorneys, therapists and judges. Vernon had been doing divorce mediation and court evaluations for years and, like anyone connected with the system, saw the stresses, the inefficiency and the ways in which the entire adversarial process takes on a life of its own, breeding antagonism and running up financial and emotional costs. In response, Vernon and Muha developed SOLVE, a conflict-resolution program of videotapes, workbooks, training manuals and exercises that encourages and educates divorcing couples to resolve their disputes before they become too enmeshed in the legal machinery. “SOLVE has built-in referrals all over it,” says Muha. “People going through divorce are reluctant to go into therapy–they’re afraid they might be seen as unstable. But they’ll go into a psycho-educational program because it carries less stigma, and after they get through the divorce and think about doing some deeper individual work, they remember you.”

In 1995, according to the U.S. Department of Health and Human Services’ Administration on Aging, 12.8 percent of the U.S. population–33.5 million people–were 65 and over. By 2030, the figure will jump to 70 million. Meanwhile, in 1988, Dallas therapist Constance Kilgore’s practice was inexorably dying. “I spent a couple of years grieving,” she recalls, “and then I finally decided to do something about it.” Kilgore became an independent geriatric care manager. “I didn’t want to form an agency and get caught up in administration,” she says. “With my background in psychotherapy, I was more comfortable providing direct service.” Kilgore began contracting with family members who needed help caring for an aging and ailing member. Sometimes the family members lived too far away, and sometimes they were just too overwhelmed by the pressures of family dynamics, the demands of their own lives and the confusing tangles of Medicare and Medicaid, nursing homes and medical and legal decisions.

Kilgore functions as a kind of therapist/ombudsperson. Depending upon her clients’ needs, she walks families through nursing homes to help them decide on a placement, advocates for insurance and medical decisions, helps people through the grieving process and arranges and monitors the quality of home health care. “One of my clients once asked me to make her funeral arrangements,” says Kilgore. “I helped pick out the casket, write the service, make the music selections and arrange for the obituary.”

Kilgore bills hourly and has no trouble collecting, both from relatives and from long-term care insurance policies, which are rapidly proliferating and seem to pay with less paperwork and fewer hassles than other medical insurance policies. Her practice has kept her so busy that Kilgore has had to start charging consulting fees to other therapists who have started calling her for information on geriatric care management.


Schizophrenia Research

About 35 years ago, psychiatrist R.D. Laing published his brilliant book, The Divided Self , which explicated the etiology of schizophrenia in terms of double binds, parental projections and other false communications and experiences between parents and children. Today, it would be difficult to find anyone in the Western world who explains schizophrenia’s basic onset in terms other than biomedical. Now, two recent discoveries announced in the same month seem to push Laing’s theories even closer to the realm of fable and metaphor.

The February 13 issue of the journal Nature describes a study by Japanese researchers, led by Yoshiro Okubo of the Tokyo Medical and Dental University School of Medicine, which shows that people with schizophrenia have an unusually low number of specific dopamine receptors called D1. Using Positron-Emission Tomography (PET) scans to study 17 people with schizophrenia and 18 people without, the researchers report that the fewer D1 dopamine receptors, the more withdrawn and apathetic the patients. Commenting on the study, Eric Nestler from the Yale University School of Medicine points out that it’s impossible to determine whether the reduced D1 receptors are the cause of schizophrenia or a reaction to it.

Meanwhile, a study of 36 people with schizophrenia and more than 100 of their family members, reported in the February proceedings of the National Academy of Sciences, has brought scientists closer to identifying the gene that may be responsible for fewer dopamine receptors. Psychiatrist Robert Freedman of the Department of Veterans Affairs Medical Center in Denver used tones to stimulate brain-wave patterns. When normal people hear tones twice, their brain-wave response to the second is less intense, but the second response of people with schizophrenia is almost as powerful as the first. This could explain why they have so much difficulty filtering sensory input and why stimuli that might be minor distractions to others become unbearable to them. Healthy family members of schizophrenics showed a response range to the second tone that was higher than the normal population but lower than their schizophrenic relatives’, leading Freedman to speculate that an additional gene defect or a past trauma may also contribute to the development of schizophrenia.

The receptor that Freedman believes is responsible for this second tone anomaly is known to respond to nicotine. Freedman thinks that this may explain why people with schizophrenia smoke so heavily: nicotine may afford temporary relief from sensory overload.


When Is Enmeshment Not Enmeshment?

Psychologists Robert-Jay Green and Paul D. Werner of the California School of Professional Psychology insist that family therapists who don’t rethink their notions of enmeshment are likely to mislabel some kinds of intimacy as pathology. Writing in Family Process , Green and Werner propose replacing Salvador Minuchin’s landmark continuum of boundaries that placed intimacy on one continuum, stretching from enmeshment to disengagement. The main problem with that continuum, they say, is that intimacy is too complex to fit on it. According to Green and Werner, family therapy has been “haunted” by Minuchin’s blending of two distinct dimensions of intimacy–Closeness/Caregiving and Intrusiveness.

To better evaluate the complexities of intimacy, Green and Werner have designed the California Inventory for Family Assessment (CIFA), which measures components of the two dimensions. CIFA breaks Closeness/Caregiving into such components as warmth, nurturance, time spent together and physical intimacy, and Intrusiveness into parts such as separation anxiety and possessiveness. Under this model, a family may be atypically close but not intrusive. In addition, by reconfiguring Minuchin’s continuum into separate constructs, therapists will be able to make more sophisticated analyses of families’ communication patterns and design more appropriate interventions.

The old continuum–an evolution of the earlier concept of symbiosis–tends not only to pathologize certain kinds of intimacy, they contend, but may also be biased against female-female relationships and ethnic minorities. They speculate that “family therapy’s tendency to equate Closeness/Caregiving with enmeshment may have been fueled by European-American, middle-class, ethnocentric models of mental health.” Hispanics, for example, might tend to be labeled as enmeshed and Asians as disengaged. Likewise, early literature on lesbian couples often described them as “suffering” from fusion or merger, when, in fact, they may have been expressing forms of feminine intimacy that male-dominated theory often has labeled as smothering or overprotective.


Cancer as Punishment

More than a decade ago, Susan Sontag pointed out in her now-classic book, Illness as Metaphor, the terrible psychological burden of cancer–that in addition to the pain, side effects of medications and fear, cancer patients were haunted by the shame that they must have done something wrong to contract such a disease. Cancer was seen in part as a deficiency, a consequence of not eating healthy foods or taking care of oneself, a spiritual and moral failing. Now a survey of 1,225 Orange County, California, women aged 18 and older, funded by the National Cancer Institute, has come up with a similar finding. The study’s aim was to determine why Hispanic women underutilize preventive services for breast and cervical cancer–two cancers with a high early-detection cure rate. Nearly 25 percent of the women surveyed believe that cervical cancer is God’s punishment for an immoral life-style. Among first-generation Hispanic immigrants, the figure jumps to 43 percent. Physician F. Allan Hubbell, who participated in the study, points out that people who attempt to educate Hispanic women about the sexual causes of cervical cancer and the need for pap smears may actually drive patients away, if they are not aware of the shame-laden perception.


Empathy Makes a Comeback

Several recent studies suggest that the best predictor of success in therapy is the perceived empathy of the therapist. A study of 28 therapists treating 250 depressed people, funded by the National Institute of Mental Health (NIMH), showed that no matter which treatment was used–two forms of psychotherapy, antidepressants (with and without psychotherapy) and placebos–those therapists who established the strongest therapeutic alliances with their clients experienced the greatest success. The most effective therapists combined empathy with a focus on the psychological components of depression, such as feelings of helplessness and distorted thinking, rather than on the biomedical aspect. They also expected therapy to take longer than did the less effective therapists. Clients who perceived their therapists as empathic even reported the most success with antidepressants.

Reporting on the study, January’s Science News quotes Vanderbilt University psychologist Hans H. Strupp: “The NIMH study indicates that the therapeutic alliance is more critical than the techniques a therapist employs or the drugs that may be prescribed. This is not a popular view among many researchers, and it isn’t what health care insurers want to hear, either.”

Although, as Strupp implies, empathy has not historically been a byword in the world of managed care, two managed care organizations are at least taking note of the importance of good communication among providers and clients. Kaiser Permanente, the country’s largest nonprofit HMO, announced that it will begin basing its providers’ compensation system not just on productivity, but on how well its providers interact with patients. And last June’s issue of the Psychotherapy Letter reported that Merit Behavioral Care Corporation, after surveying its network, concluded that its care managers and providers need a more personal touch. Merit has issued them workbooks and guides with techniques for communicating empathically. (One wonders why trained therapists would need such a guide.)

A study in February’s Journal of the American Medical Association

supports empathy from a slightly different angle. Apparently, the most important determining factor in whether a patient sues a doctor for malpractice is not a lack of quality care or a lapse in medical judgment, but how well the patient perceives the doctor is communicating. After listening to tapes of doctors interacting with patients, researchers were able to predict with 75 percent accuracy which doctors were likely to get hit with malpractice claims. Listening to patients, it seems, makes sense, not simply as a matter of politeness, but from the standpoint of better treatment outcome and economics, too. 

Garry Cooper

Garry Cooper, LCSW, is a therapist in Oak Park, Illinois.