© (1994) by Thomas A. Grugle, M.D.
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| Thomas A. Grugle, M.D. |
Psychotherapy is a psychological treatment intended to help the patient resolve emotional difficulties through a relationship with a professional, the psychotherapist. The psychotherapist is specially trained and (we hope)
gifted in establishing and maintaining healthy, therapeutic relationships with people. However, psychotherapists are not all well trained, and some are just plain sick themselves. It is important, therefore, for the patient to have a pretty good idea of what kind of treatment to expect when beginning psychotherapy.
Psychotherapy occurs one to three times per week in a therapist's office in a face to face seating arrangement. Sessions usually last forty five minutes to an hour. Psychoanalysis is a more intense form of psychotherapy and occurs four to five times per week over several years. A patient in psychoanalysis will usually lie on a coach so he or she cannot easily see the psychoanalyst. Patients in psychotherapy should never be asked to lie on a couch.
What kinds of psychotherapy are there?
The therapeutic relationship can take place in a variety of settings. Most familiar to the public is individual psychotherapy, where the patient and therapist sit facing one another and talk about the patient's problems. Group
psychotherapy involves a therapist (sometimes two) and a group of patients, usually from five to eight per group. Family psychotherapy (including marital psychotherapy) involves the therapist with the entire family or couple, all
sitting face to face.
What other kinds of psychiatric treatments are there?
Distinct from psychotherapy, medication management by a psychiatrist involves the prescribing and supervision of medication. This may be done in conjunction with psychotherapy or done separate from it. Medication is almost always more effective when combined with psychotherapy, so if your psychiatrist is only prescribing medication and hasn't recommended psychotherapy you should find out why. Medication management sessions are usually much shorter and less frequent than psychotherapy, usually lasting fifteen to thirty minutes and occurring every two to twelve weeks, depending on the patient's symptoms. The rating system below does not generally apply to psychiatrists who only prescribe medication, although many of the points will be important to observe.
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The Rating Scales
Circle the choice that most closely matches your experience with your
therapist.
The First Contact
1. When I called for me first appointment, the therapist called me back the same day, asked briefly about my problems, then offered to set up a first appointment.
2. When I called for me first appointment I spoke with a secretary who asked me for insurance information, then gave me my appointment time.
3. When I called for me first appointment I got an answering machine, the therapist didn't call me back for several days, and never asked me what was bothering me.
4. When I called for me first appointment the therapist told me about his own problems and how he'd resolved them, then offered to see me for therapy.
The First Session
The waiting Room
1. The waiting room was private, quiet and tastefully furnished. I was alone until my therapist came for me.
2. The waiting room was basically neat. I waited with other patients, but it still felt comfortable and private.
3. The waiting room was a bit cluttered. The receptionist engaged me in a conversation while I was waiting. I could hear some talking behind the door to the offices.
4. There really wasn't a waiting room, I had to wait in a public area with other people. Business was being conducted in my view and I was bothered by noises from within and without the office.
The wait
1. My therapist was right on time to get me.
2. My therapist was a few minutes late.
3. My therapist was more than five minutes late.
4. My therapist was more than fifteen minutes late.
The therapist
1. When my therapist came to get me, he greeted me kindly and showed me to his office. He shook my hand briefly and did not call me by name if other people were in the area. We walked in silence to the office.
2. When my therapist came to get me he called my name out loud, then escorted me back to his office. He chatted with me on the way back.
3. My therapist offered me something to eat or drink before we went into the office.
4. A secretary called me back to the therapist's office, or I saw a nurse or assistant before I talked to the therapist.
The session
1. During the first session, my therapist listened carefully and helped me to discuss almost all of the major problems I'd been having.
2. My therapist took notes during the whole first session.
3. I felt disorganized and confused, and my therapist didn't help me straighten things out
4. My therapist told me things about himself and his struggles during the first session.
The close
1. For the last ten minutes of our first session, the therapist briefly summarized my problems and told me what she thought she could do to help. If psychotherapy was recommended it was recommended unequivocally. She told me
how to reach her in an emergency.
2. The therapist said she thought therapy might help and offered to meet again.
3. The end of the session seemed abrupt and I wasn't quite clear what the therapist thought I needed.
4. The therapist gave me a hug at the end and said we should meet again. She said to call anytime if I wanted to talk on the phone.
The Ground Rules
Financial
Financial
1. I am totally financially responsible for all charges and my therapist expects me to keep my bill current.
2. Someone else, or an insurance company, pays part of my bill, but my therapist holds me responsible for my portion.
3. My therapist allows me to leave my bill unpaid for several months.
4. My therapist offered to creatively bill my sessions to my insurance company so that I wouldn't have any out of pocket expense.
Appointments
1. I have a regularly scheduled time to meet for therapy, the same time each week.
2. I have sessions every other week and schedule as my time allows.
3. I often have extra sessions if I'm having a rough week.
4. It's hard to get regular appointments because of my therapist's schedule.
Missed Sessions
1. If I miss an appointment, no matter what the reason, I am still charged for that time.
2. If I cancel more than twenty four hours in advance I am not charged.
3. If I miss a session my therapist still bills the insurance company.
4. I'm not sure what happens if I miss.
Therapy Goals
1. I have a clear understanding of what my goals are and how long it might take to achieve them.
2. I basically understand what I'm working on, but we've never discussed treatment length.
3. My therapist told me we would finish within ten to thirty sessions.
4. My therapist says I will need her forever.
Confidentiality
1. If someone calls about me without my prior consent, my therapist doesn't return the call and tells me about it at the next session.
2. My therapist has called someone in my family to discuss me.
3. My therapist has written an article about our sessions without my consent.
4. My therapist has videotaped our sessions and I'm not sure what he does with the tapes.
Therapist Activity
1. My therapist sits quietly during most of the session, speaking only to help me keep going if I get stuck or to observe something I was about to see myself anyway.
2. My therapist talks about half the time.
3. My therapist talks more than half the time.
4. Sometimes my therapist talks the whole session.
Material
1. I talk about whatever comes to my mind without censoring or changing it in any way. My therapist encourages me to do so, especially if I am having thoughts or feelings about her.
2. I talk mainly about my current life and almost never mention dreams or
fantasies.
3. I talk about current events and politics.
4. I talk about my therapist almost all the time (when I get to talk).
Fringe Techniques
1. My therapist has never suggested hypnosis, sodium amytal, or anything other than talking in the office.
2. We occasionally take walks outside the office to talk or we meet some other neutral place.
3. My therapist suggested hypnosis, age regression, sodium amytal, channeling, or body work.
4. My therapist actually did hypnosis, age regression, sodium amytal, channeling, or body work.
Boundary Violations
The Setting
1. We never meet anywhere but the office.
2. We have taken a walk or met in some other office.
3. We have met in my therapist's home.
4. We have met in my home.
Physical Contact
1. My therapist never touches me at all.
2. We shake hands after each session.
3. We hug after each session.
4. We have had sex together.
Personal Information
1. I know nothing about my therapist except his professional credentials and marital status.
2. I know where my therapist lives and how many kids he has.
3. My therapist has told me about his marriage or childhood.
4. My therapist has shared a great deal about his own personal struggles.
Time Management
1. We always start on time and end on time.
2. We occasionally start five or ten minutes late, but still end after the allotted time.
3. We sometimes start thirty to sixty minutes late and often run over more than five minutes.
4. Its hard to know when we'll start or finish-it could be off by a much asan hour or two.
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Scoring
Add up the points for each question to arrive at your total score.
IMPORTANT NOTE- If you scored any question as a 4 you are in potential danger from this therapist and it is highly recommended that you seek immediate consultation from a board certified psychiatrist.
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18 - 27
Congratulations! You have selected a psychotherapist who seems well trained and competent. There are no serious problems that should worry you and if issues do arise they are probably talked about openly.
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28 - 45
Your therapist is basically doing a good job, but occasionally engages in activities or behavior that might impede your progress in psychotherapy. If you are concerned, seek consultation from another qualified professional about your psychotherapy and how its going.
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46 - 63
This score indicates a seriously impaired psychotherapy. It is doubtful that any therapy is going on at all. You are strongly encouraged to consider seeking consultation from a board certified psychiatrist and ending your treatment with your current therapist.
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64 - 72
You may be in serious danger from this relationship. Boundary violations and errors in technique abound. You are advised to seek immediate consultation from a board certified psychiatrist and seriously consider not returning to
your current psychotherapist at all.
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Psychotherapy is an effective and safe treatment when properly administered. There is much room for differences in style, but no room for errors in technique. The issues that have been presented in this article address errors in technique. Most competent psychotherapists do occasionally engage in behaviors or techniques that have been rated a "2" in this article. When they do, they always have clear and well thought out reasons for doing so and can explain why these minor variations in technique are in the patient's best interest.
One of the most important indicators of a good therapeutic relationship is your own feelings. If you don't feel quite right about what's happening in your therapy, get a consultation. You may wind up spending time and money only to find out things are going the way they are supposed to, but you may also save yourself from continuing in a damaging therapy relationship.
