Effective therapists

With regard to the February Monitor article on the characteristics of effective therapists ("The Therapist Effect"), I wasn't surprised to see omitted the key characteristic that is so frequently overlooked — a good set of boundaries. This quality enables a therapist to be helpful while being empathic, reflective while being accepting, focused without getting lost, and ethical without being cruel. Most often, the question of boundaries is brought up only in connection with real or potential transgressions, but in fact boundaries are at the core of the psychologist's most effective interventions and most productive listening. It will be most helpful if this area of research is included in any study of the qualities of an effective therapist.

Arthur S. Brickman, PhD
Ann Arbor, Mich.

Treating ADHD

I read with great interest the February article "Easing ADHD without meds." The article's enthusiasm for non-pharmacological approaches to ease ADHD symptoms is noteworthy but not yet supported by rigorous data. I have always been a strong proponent of non-pharmacological interventions for treatment of ADHD, especially for children, but I make it a point to also disclose that research to date does not support these interventions unequivocally. A new study in the American Journal of Psychiatry conducted by Sonuga-Barke et al. (2013), found little evidence to support a reduction in ADHD symptoms when using non-pharmacological interventions. More specifically, the results of this meta-analysis of non-pharmacological interventions for children with ADHD found that treatments were rated more effective in the unblinded tests (when using behavioral interventions, cognitive training and neurofeedback). When analyses were restricted to those studies that used blinded tests (to eliminate bias), the results invalidated the unblinded tests.

It is my hope that future research will lend support to the benefits of using non-pharmacological approaches to ADHD. In the meantime, I urge parents to talk to their child's therapist or psychiatrist to find interventions that are appropriate for their child's situation.

Faith Galliano Desai, PhD

A recent New York Times article highlighted issues in the diagnosis and treatment of attention-deficit hyperactivity disorder, such as the danger of becoming addicted to attention deficit stimulants as growing numbers of youths are faking symptoms to obtain steady prescriptions for these stimulants. In light of such news, I want to applaud the Monitor for its February article "Easing ADHD without meds" on the behavioral treatment of ADHD. Thank you for reminding us all that at the heart of treatment lies a human connection that has the potential to be more powerful than any drug.

Rachel Manes
City University of New York

Quantifying our work

The November Monitor article "Psychotherapy works!" discusses an initiative focused on attempting to educate consumers. A significant hurdle for psychotherapists is that we are not recognized as scientifically informed, highly trained professionals. The impact of our work is difficult to quantify. Improvements in productivity, health, longevity, relationships and well-being may all resonate from changes occurring within the privacy of one's soul. It is elusive to conceptualize because of the complexity of human suffering. Therapy is much more than teaching and much deeper than a simple conversation. We are an essential element on the front line of treatment. We witness the intimate details of pain and the torturous conflicts with self and others, both phantom and reality. We see and feel the relentless pounding of overwhelming waves of emotion. Beneath all this, we strive to maintain clarity. We try to discern truth and meaning while fueling the warmth of hope and the strength of purpose.

Perhaps the true value of therapy may be fully understood only by experience. Unfortunately the stigma of mental illness remains a deterrent, and the myth of medical certainty provides false reassurance. Psychotherapy should be a primary intervention for mental health concerns, not a supplement or second-choice alternative to medication. In some cases, medication may be beneficial, but effectiveness will be limited if there is not a core therapeutic process addressing insight, awareness and coping. I hope that physicians will also consider educating and referring patients with mental health concerns. 

Henry Benson, PhD
Jacksonville, Fla.

Seniors don't have enough access to psychologists

I was dismayed by the sentence in the January Monitor news item "More older adults with depression referred to medication — not psychotherapy — for treatment": "But until more mental health providers are trained to treat an aging population, other clinicians may continue to overlook psychotherapy as a treatment for older patients."I believe that last sentence is reductionistic and inaccurate. I believe that the two biggest reasons that older adults do not get referred for psychotherapy as often as they get prescribed medications are related to each other: Few psychologists accept Medicare, and Medicare payment rates are abysmal.

I have been a practicing psychologist since 1996, and Medicare reimbursement for psychotherapy has dropped by almost 20 percent over my career. Public hospitals and medical centers have allowed their staff to refuse to see Medicare patients. Thus, the pool of psychologists who accept Medicare rates has shrunk and many seniors cannot get appointments if they intend to use their Medicare insurance. I lose money on every Medicare patient I see because Congress continues to balance the budget on the backs of medical providers, and especially mental health providers. But I refuse to disenroll as a Medicare provider because I believe that seniors and adults with medical disabilities are entitled to quality psychological care — but I can't provide it to all the people who need it by myself.

Susan G. Rosenzweig, PsyD
Portland, Ore.

Please send letters to Sara Martin, Monitor  Editor. Letters should be no more than 250 words and may be edited for space and clarity.


In the March article "A champion of change," Edelgard Wulfert, PhD, should have been referred to as "she."