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Resolving 100 Years of Psychotherapeutic Stalemate--Non-Directive Psychotherapy

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Psychological research on the effectiveness of psychotherapy indicates that psychotherapy may be helpful for a broad range of psychological problems. A wide-ranging, extensive 2013 study of psychotherapy from the Department of Psychology, University of Ottawa indicates that various psychotherapies can be helpful in approximately 25-50% of cases. The problem is that psychotherapy does not work across the board.

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Psychotherapists have struggled for over a century with the problem that many patients are resistant to change. The struggle to overcome patients’ psychological resistance has been a major stumbling block to psychotherapeutic success. To cope with this problem, for over a century most psychotherapists insisted on the paradigm that their patients be psychologically motivated for their treatments to work. Patients who were chemically dependent (alcohol 27%, drug abuse 10%), psychotic (1%), or character-disordered (i.e., rebellious, 15%), making a total of approximately 53% of the population, were typically excluded from psychotherapeutic treatment. This situation lead to this old joke:

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          Q: “How many psychotherapists does it take to change a light bulb?”

          A: “One, but the psychotherapist has to be motivated!”

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All too often, patients’ psychological resistance leads to a psychotherapeutic stalemate, where the patient did not get better despite continued efforts by the psychotherapist. It is at the stage of stalemate where many psychotherapies still flounder. This conundrum leads psychotherapists to search for decades for ways to overcome this all too human a problem.

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Fortunately, in the mid-twentieth century, psychotherapist Carl Rogers, PhD., formulated a new paradigm regarding the responsibility for conducting psychotherapy: The psychotherapist, rather than the patient, is 100% responsible for the psychotherapy. Dr. Rogers found that it was the psychotherapist, not the patient, who needed to be motivated for the psychotherapy to be effective.

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With this new view, psychotherapy achieved a dramatic power shift. The psychotherapist, rather than the patient, became responsible and empowered for the cure. This new approach to the psychotherapist-patient relationship put the psychotherapist back into the mainstream of medicine—e.g., cardiology, surgery, dermatology--where this same paradigm of medical responsibility holds: In medical treatment, it is the cardiologist, surgeon or dermatologist who is responsible for the treatment, not the patient. Only psychotherapists argued that their patients had to be motivated and, paradoxically, thereby be responsible for their own cure.

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How can a psychotherapist be 100% responsible for the psychotherapy? Dr. Rogers discovered that if psychotherapists neither directed their patients nor required them to do anything at all, there could no longer be any psychotherapeutic resistance. Since there is no psychotherapeutic direction for the psychotherapy patient to resist, the problem of psychotherapeutic resistance becomes moot. This is non-directive psychotherapy.

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With non-directive psychotherapy, resistance is thereby eliminated: When there are no directives from the psychotherapist, then there is nothing to resist. The patients’ resistance is no longer in control of the psychotherapy, placing the psychotherapists (and not the patients’ resistance) 100% in control of the treatment. Psychotherapists are thereby free to conduct psychotherapy, unencumbered by patients’ resistance.

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Non-directive psychotherapy can be frustrating for psychotherapists to learn and patients to accept. Most psychotherapists and patients are brought up in our culture that emphasizes an obsessive-compulsive attitude towards life: “Work harder! Confront your emotions! Change your cognitions! Stop distorting! Stop drinking! Give up drugs! Get along with your relationships!” Many psychotherapists find it counter-intuitive and emotionally difficult to give up being directive. Unfortunately, it turns out that only about 1/3 of patients will follow well-meaning advice. The rest of the patients resist getting well.

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As abstract a discipline as the practice of psychotherapy is, non-directive psychotherapy is even more abstract. The mere idea let alone the practice, of non-directive psychotherapy, can be anxiety-provoking to the psychotherapist. It means putting aside the psychotherapists’ crutches of their obsessive-compulsive character structure, avoid telling their patients what to do, and, instead, relate openly, genuinely, and acceptingly to them in as non-authoritarian and non-directive a manner as possible. 

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Non-directive psychotherapy requires the psychotherapist to have confidence in, trust about, and knowledge of the paradox of gaining control of the psychotherapy by giving up efforts to direct, advise, exhort, or otherwise control the (resistant) patient, thereby solving the resolving the riddle of 100 years of psychotherapeutic stalemate.

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The Number 1 Misdiagnosis in American Psychiatry

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In 1967, when I began my first year of medical school at USC, the professor of psychiatry asked our class of medical students, "What is the most misdiagnosed illness in American psychiatry?" None of us knew the answer, so we all remained silent. The professor seemed to be very pleased with our silence. In the most self-assured manner typical of medical school professors, he informed us that it was a manic-depressive illness, now called Bipolar Disorder. Today, over 5 decades later, the situation is thought to have remained virtually unchanged: According to the psychiatric literature, American psychiatrists all too frequently miss the diagnosis of bipolar disorder.  Astoundingly, the literature indicates that it can take an average psychiatrist 8-10 years to make this correct diagnosis.

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Since the psychiatric literature also indicates that bipolar disorder is rather prevalent and may affect up to one out every 16 people in the population, I thought it might be useful for all of us to become more familiar with this illness, because it is highly likely to have touched all of our lives in one way or another--with possibly devastating effects on our families, friends, business associates, communities, government, and/or the economy.

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So, what is bipolar disorder? The diagnostic "bible" of psychiatry is the Diagnostic and Statistical Manual V published by the American Psychiatric Association, otherwise known as the DSM-V. The DSM-V indicates that Bipolar Disorder is a mood disorder. A mood is "a pervasive and sustained emotion that colors our perception of the world." Bipolar Disorder is manifested by any of three abnormal manic moods--euphoria, irritability, or expansiveness--with or without depression. The presence of mania or hypomania, what may appear to be a milder and more subtle form of mania, makes the diagnosis of Bipolar Disorder. Surprisingly, hypomania is more lethal than mania, as it is much more difficult to diagnose and therefore it often does not get treated. The mood of euphoria is an exaggerated feeling of well-being--in other words, feeling high, up in the clouds, or on top of the world. The mood of irritability is being easily annoyed or provoked to anger. And the mood of expansiveness is the lack of restraint in the expression of one's impulses (i.e., feelings, thoughts, behaviors).

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Associated symptoms of mania and hypomania include grandiosity, inflated self-esteem, poor sleep, pressured speech, talkativeness, fast speech, racing thoughts which jump from topic to topic, distractibility, very high goal-directed activity, and excessive involvement in pleasurable activities that have a high potential for painful consequences--such as gambling, sexual indiscretions, alcoholism, drug abuse, and/or poor financial or business judgment.

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Typically, people who suffer from Bipolar Disorder can be found among populations that include those who suffer from alcoholism, drug addiction including chronic use of illicitly obtained or physician-prescribed tranquilizers, gambling, large business losses, large stock losses, engaging in sexual indiscretions, or having multiple divorces. The medical literature indicates that about a third of attendees at Alcoholics Anonymous suffers from Bipolar Disorder.

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Bipolar disorder is a spectrum disease, like diabetes. The spectrum includes mild, moderate, and extreme cases. Mania is divided into both mania and hypomania. Exaggerated forms of Bipolar Disorder (mania) are easier to recognize; but the milder and more subtle forms (hypomania) are also very important because they also can cause a lot of misery, are difficult to detect and are deadlier. People who are manic suffer their mania interfering with social and occupational functioning. Hypomania means "below mania", i.e., someone who has a mood that is higher than normal, more irritable than normal, or more expansive than normal, which does not significantly interfere with social or occupational functioning.

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Determining whether depressed patients have a history of mania or hypomania is crucial to the successful treatment of depression. Unipolar Depression--that is, depression in a person who was never hypomanic or manic--tends to improve with anti-depressants, such as Prozac, Zoloft, Effexor, Lexapro, Wellbutrin, or Cymbalta. However, bipolar depressions tend not to get better, or even get worse, with anti-depressants. That's because anti-depressants work. Antidepressants have been conceptualized as "rocket fuel to the brain." Thus, they may not only boost the bipolar depression but also the bipolar hypomania or mania, which can be very dangerous. By contrast, in bipolar depression, a mood stabilizer is typically required, not an anti-depressant. Mood stabilizers are safer than antidepressants, as they tend not to boost mania or hypomania. In Bipolar depression, anti-depressants are relatively contraindicated. Thus, one vital key to avoiding the treatment failure of depression and to achieve its successful outcome is to definitively determine whether the depressed patient has ever suffered a manic or hypomanic mood, which makes the diagnosis of Bipolar Depression and rules out the diagnosis of Bipolar Depression.

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Unfortunately, what is surprising, if not mind-boggling, is that Bipolar Disorder--suffering from both mania or hypomania and perhaps depression--is often not recognized, even by experienced psychiatrists. The "Journal of Clinical Psychiatry" indicates that it takes the typical psychiatrist 6-10 years from the onset of the bipolar illness of a patient to make the correct diagnosis of Bipolar Disorder. The recognition of Bipolar Disorder by non-psychiatrists is likely to be even more abysmal. The "Journal of Clinical Psychiatry" further indicates that in 37% of cases of depression, the typical psychiatrist erroneously diagnoses and erroneously treats the depressed patient for Unipolar Depression with an anti-depressant, when the correct diagnosis and treatment should have been for Bipolar Depression with a mood stabilizer. Doing the math on the US population of 350 million people, 6.7% of whom suffer or have suffered from major depression, makes for a whopping 8 2/3 million Americans who are apparently wrongly diagnosed and wrongfully treated for Unipolar Depression rather than Bipolar Depression. This represents an enormous cost of needless human suffering and enormous economic waste.

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Even more astounding is that the bipolar mood of expansiveness--lacking restraint in the expression of one's impulses--is, in my opinion, the least understood of the three manic moods. Over several decades, I have attended many lectures about Bipolar Disorder given by many psychiatrists who were reputed to be experts in Bipolar Disorder from many of the top medical schools around the country. I have repeatedly asked these professors to define the mood of expansiveness. Incredibly, none were able to accurately state to me the DSM definition. This suggests to me that, if these experts cannot accurately define an expansive mood, there are very likely to be myriad cases of expansive mania that remain unrecognized in the community.

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As a psychiatrist, I am fascinated by the bipolar mood of expansiveness--lacking restraint in the expression of one's feelings. I believe that the covert presence of the abnormal mood of expansiveness may be responsible for many treatment failures in virtually all the medical specialties. Expansiveness is like a turbocharger in a race car. A turbocharger makes the car go faster by hyper-oxygenating the gasoline. The mood of expansiveness can "turbo-charge", if you will, virtually all other medical problems. The bipolar mood of expansiveness can "expand" the medical symptoms in orthopedics of chronic back and neck pain; in urology of urinary frequency, in otolaryngology of ringing of the ears; in dentistry of grinding the teeth; in neurology of muscular weakness; in internal medicine of obesity, or chronic fatigue syndrome; in cardiology of palpitations, chest pain, and hypertension; in gastroenterology of nausea, diarrhea, constipation, or irritable bowel; in pulmonology of chronic insomnia or shortness of breath; in rheumatology of fibromyalgia or arthritis; in psychiatry of chronic anxiety, obsessions, alcoholism, drug abuse, relationship conflicts, and/or depression.

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Many patients who suffer from chronic medical symptoms of any nature may suffer from their medical symptoms, not only due to their medical problems per se but because they suffer from the covert, untreated, hypomanic expansiveness of their medical problems. From the point of view of the mood disorder of expansiveness, the treatment of many chronic medical problems may require "de-turbocharging" the unrecognized hypomanic patient with a mood stabilizer--in other words, treating the chronic patient's bipolar expansiveness along with the chronic medical problem. I believe that all physicians who treat and all patients who suffer from chronic illness should consider the possibility that covert expansiveness is aggravating the chronic illness. I believe that adopting the strategy of routinely adding a work-up for the possibility of an expansive mood disorder to all chronic medical cases would improve chronic patient care and reduce medical costs in virtually every medical specialty.

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Further compelling, correcting the 37% error rate regarding the diagnosis of Bipolar Disorder is important because in untreated Bipolar Disorder there can be significant mortality. Worrisomely, the psychiatric literature indicates that Bipolar Disorder carries an 8% risk of death. 50% of those with bipolar disorder make a suicide attempt sometime in their life. And 16% of those suicide attempts are successful (making for approximately 3/4 million Bipolar Americans killing themselves).

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Bipolar Disorder also carries very significant morbidity--a lot of suffering and emotional pain for patients and their families, business associates, and the country. Undiagnosed and untreated Bipolar Disorder is responsible for very high rates of medical over-utilization and very high costs of medical care that might otherwise be unnecessary. Undiagnosed Bipolar Disorder typically results in large medical workups for myriad medical symptoms, which typically turn out negative.

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Notwithstanding the counterproductive social stigma against the diagnosis of Bipolar Disorder, as a psychiatrist, what I find hopeful is that Bipolar Disorder is often a very treatable condition. Psychiatry has many good mood stabilizers from which to choose. However, there is a well-known tendency for bipolar patients to go off their medication, as some bipolar patients miss their "highs." A mood stabilizer has the potential for dramatically improving a bipolar patient's life. Because Bipolar Disorder--mania and depression--affects so much of a patient's mind, behavior, thinking, feelings, judgment, insight, reasoning, and relationships, it is crucial for virtually all bipolar patients to engage in concomitant psychotherapy along with taking their medication.

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