Synergies #4: Teaching The Patient To Swim

The goal of psychotherapy is wellness. For some, that includes “fixing a disorder.” For others, perhaps taking a medication for life. Either way wellness is the goal.

Wellness practice (WP) is prioritization of behaviors that put the individual’s basic physical and emotional needs first. This includes exercise and healthy nutritional habits, setting up boundaries that allow relaxation, creativity and play, social interaction and spirituality. These behaviors help to reduce the effects of stress over time on our mind and body, including cardiovascular, G.I., and immune systems. WP also includes learning to be present and future oriented, and nonjudgmental toward our self and others.

Many people have roadblocks and resistances to WP, such as low self-worth, and difficulty with boundaries. Psychotherapy can help. Wellness practice=relapse prevention=illness prevention (“Vaccination”).

Mardi Horowitz, M.D. at a recent talk on PTSD, described the need to treat “negative” psychology (trauma) as well as “positive” psychology (enhancing strengths, skills-training, self-confidence, life fulfillment). He and Dr. Walsh have described the “integrative psychology” model which teaches the patient to focus on the here and now, developing adaptive skills, and revising their narrative “schema” into a newer belief system that is more adaptive, functional, and fulfilling. I would only add that the concepts and practice of Mindfulness enhance all of these goals. Also, there are many good Mindfulness resources we can refer our patients to, which frees up valuable office time to focus on what can’t be learned in other places.

What is therapy? What is “complementary treatment?” Is “Skills Training” psychotherapy? Homework assignments? CBT and DBT are widely accepted therapies for certain diagnoses. DBT includes the cognitive-behavioral components and adds various skills-trainings such as Emotion Regulation. The core concept of Mindfulness pulls it all together. We should explain the concepts and practices to our patients, how learning them can help towards their goals, and give references they can work with at home. I refer my patients to resources such as Thick Nhat Hanh’s “The Art of Mindful Living” that they listen to outside session while we work in-session dealing with questions and resistances, including revising beliefs and time prioritization. See my website (Blog page) for books, CDs and tapes I’ve reviewed and recommend to patients.

The term “bibliotherapy” (from “papyrus”) has been widely used to describe homework as part of psychotherapy. This term is even more archaic today, as homework assignments come in many forms. An article in February 2009 CNS Spectrums reported a review of meta-analyses of self-help and Internet-guided interventions for depression and anxiety disorders. Results showed medium to large effect sizes compared with control conditions. Effects varied according to diagnosis, and also whether used alone or in conjunction with psychotherapy. While there are many limitations, there are also many advantages, including augmentation of psychotherapy, as well as lowering the threshold to get help for those less seriously ill.

I’m inviting readers to send me suggestions for a new term to describe homework assignments and applying what’s learned during sessions in everyday life.  This is indeed the most important part of “psychotherapy,” just as it is impossible to learn how to swim by talking about it and not getting in the pool. I’m thinking in the direction of “Self-Growth Practice” or “Lifework: Because you don’t just do it at home”.

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