On therapy


When do you stop going to therapy?  An x-ray can tell you that a broken bone is mended and that you can walk on it. But you aren’t a bone.  Here are some ideas to help you decide when you are done with therapy.

All of this assumes that you are working with a therapist who is a good fit for you. You feel you can trust them, you are in agreement on how to address your issues, and on what you are basically doing there. If you are there to understand your marriage and your therapist thinks you are there to feel less anxious, you have a mismatch and need to sort this out right away.  If you want to learn better coping skills and your therapist thinks you are there to understand your dreams… get on the same page.  If you can’t, find someone else.

Ideally you will leave therapy when you’ve accomplished the goals you’ve set for yourself.  When you started, you should have had some sense how you wanted things (you)  to be different when therapy is complete.   You can and should check in from time to time with your therapist about how you are doing and where therapy is going.  I like it when my clients do this.  I like looking for signs of progress, and sharing our insights. You should see signs of progress within one to three months. It might take longer to resolve, but you should not be waiting years to see something happen.

Some issues resolve pretty quickly, others can take a long time. Part of this depends on what level of work you are doing.  If  you are trying to find strategies to deal with  a specific life problem or make a decision, you probably won’t need to go for long.  Changing a specific behaviour might not take that long either,  depending on what it is. If  you are trying to change a part of your personality, this can take quite a while – minimum six months, and it could be years.  Trauma work generally takes a while, and the earlier it began and the longer it lasted, the more time it will usually take. Generally, short-term issues lead to short-term therapy. Long term issues, especially those that began in childhood, generally mean longer therapy to be resolved.

Other clues that you might be done are:

  • When you have made or resolved the life transition that brought you to therapy and you are getting on with life.
  • When you feel that you know how to deal with your feelings and relationships, and the problems life throws at you.
  • When you feel confident in who you are, what you feel, and what you want and you can stand up for these.
  • When you are able to make free, smart, and responsible choices for  yourself out of love and not fear.
  • When you are able to love as freely as you would like, and let others love you.
  • When you have good boundaries with others. You can let them in… or not. You can go along with them… or not.
  • When you are able to feel your feelings and you don’t take your feelings out on others.
  • When you are not in the power of an addiction.
  • When you are not haunted by past events any more.
  • When you have some sense what you want from life and are able to go for your dreams.
  • When you are able to work effectively, but also to have fun, play and relax.
  • When you feel that you now thoroughly know yourself.  You understand the sources of your happiness and unhappiness and know what to do about these.
  • When the problem that brought you to therapy is solved and you have worked through the other issues that came up along the way.

It’s usually not a good idea to stop just because you start to touch uncomfortably strong feelings or issues. Or you get scared of your feelings or impulses that are coming up.   It can be tempting at this point to think that therapy is not working or just making you worse. Strong feelings, including those about the therapy, are actually a great reason to continue. You are now getting ready to do some of the real work, discovery and healing.  The deeper problems are now within reach and are available to be explored.

However, if you are not learning any more, this is a clue that you  could either end therapy or else increase the heat. If you are just chatting session after session, there is something missing. Maybe you are not going deep enough, or maybe you are done and don’t realize it.  Discuss this with therapist. It’s not criticism. Even if it were, the therapist should be able to take it.

I appreciate it when I know we are near the end, and the client doesn’t just stop coming without telling me.  When I know we have just a session or two to go, I have a different focus, and use the sessions accordingly.  There might be a specific piece of work I want to suggest or a skill I’d still like to teach, and if I don’t have warning, this gets lost. An end date might be next week, it might be in 5 months. Some of my long-term clients like to taper off – checking in less often and spreading out the appointments.

If you feel that you’ve accomplished what you wanted to, but your therapist hasn’t said anything, it’s up to you to tell him or her that you are ready to leave therapy.  Then you can discuss it. The therapist may agree and be really pleased for you.  Remember that the therapist’s job is to make him or herself unncessary. Or he or she might be able to point out a possible next step that you overlooked. Then you discuss whether you want to do that piece of work or not.

If you are a bit scared about leaving therapy, remember that you can always go back if you need to.  And it can be nice and affirming to check in some time later, even if it is no longer a necessity.  Because you now know it is not a necessity!

Brian Grady, Ph.D. Registered Psychologist

23 Marchh 2009

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I recently came across this article by Dr. Kevin Grold.  Here are some extracts.

————————–

A good therapist for one person is not necessarily the right therapist for another person. You have to find a good match for your personality.

[snip]

THE PROCESS

First, and most importantly, start by finding three therapists to interview for the position of “your therapist.” [snip]

If you have a close friend who … is seeing a therapist who is being helpful, what better recommendation could you receive for the beginning of your search? I would say, “Start with THAT therapist.” [snip]

Let’s say you decide to ask your family doctor for a recommendation. Your doctor probably has one licensed therapist in the office building who he or she uses for cross-referrals.[snip]

Another way to develop your list of three interviewees is to call a referral service.
[snip]

MAKING THE CALL

Next, call your three therapists and say, “I am considering becoming a new client of yours, is there a time we could discuss this for five minutes?” The therapist may be busy at the time you call but this allows him or her to set up another time to have a short phone call with you. Do not expect a full counseling session on the phone, but do expect to be able to say, “Here are the issues I have been facing–do you have any experience in this area?–How would you approach such issues?–What would you consider your therapeutic approach to be?” These questions will help you prioritize your list of three therapists from most to least favorite. If a therapist is not willing to take 5 minutes of time to talk with you over the phone, then you have an easy decision to cross that name off the list.

Next, make an appointment with the therapist with whom you felt most comfortable on the phone. If after the first session, you feel you may have not chosen wisely, do not continue.  Instead, go to the second therapist on your list. Remember that you are making a choice for a life-long companion and guide. Do not take this decision lightly.

the full text is avaiable online at
http://www.1-800-therapist.com/how_not_to_choose_a_therapist.htm

A recent dream:

I am with a homeless man. I take pity on him, and I buy a lottery ticket for him, thinking that if it wins, I’ll give him the winnings. It turns out that the ticket wins $1 million. I give it all to him, but it comes in the form of water. I pour this into a mixing bowl of his. He lets it all slowly run away out of the bowl until there is nothing left. I can’t believe that he’s just let $1 million of water go away.

He tells me, “But it is flowing freely from the sky at all times, in all places, on all people.”  And I am shown an image of rain.

He has no need for me to give this water to him.

Brian Grady, Ph.D.

The new issue of *Journal of Consulting & Clinical Psychology* (Vol. 76,
No. 6) includes an article: “Psychotherapy for Depression in Adults: A
Meta-Analysis of Comparative Outcome Studies.”

The authors are Pim Cuijpers, Annemieke van Straten, Gerhard Andersson,
& Patricia van Oppen.

Here’s how the article opens: “Whether all psychotherapies are equally
efficacious for the same disorder has been studied and debated for more
than 3 decades (Cuijpers, 1998; Luborsky, 1995; Luborsky, Singer, &
Luborsky, 1975; Shadish & Sweeney, 1991; Stiles, Shapiro, & Elliott,
1986), and no definite answer has yet been found in empirical research.
Early meta-analyses indicated that different types of psychotherapy were
equally efficacious (Smith & Glass, 1977; Smith, Glass & Miller, 1980).
One possible explanation for this finding is that most effects of
psychological treatments are caused by common, nonspecific factors and
not by particular techniques (Cuijpers, 1998). These common factors
include the therapeutic alliance between therapist and client, belief in
the treatment, and a clear rationale explaining why the client has
developed the problems (Lambert, 2004; Spielmans, Pasek & McFall, 2007).
Another possible explanation is that the effects of psychotherapy are
realized by various therapy-specific mechanisms (Butler & Strupp, 1986)
and that the number of possible mediators and moderators is so large
that small differences between treatments in specific groups of patients
remain unnoticed owing to insufficient statistical power or because
research methods are not sensitive enough (Kazdin, 1998).”

Here’s the abstract: “Although the subject has been debated and examined
for more than 3 decades, it is still not clear whether all
psychotherapies are equally efficacious. The authors conducted 7 meta-
analyses (with a total of 53 studies) in which 7 major types of
psychological treatment for mild to moderate adult depression (cognitive-
behavior therapy, nondirective supportive treatment, behavioral
activation treatment, psychodynamic treatment, problem-solving therapy,
interpersonal psychotherapy, and social skills training) were directly
compared with other psychological treatments. Each major type of
treatment had been examined in at least 5 randomized comparative trials.
There was no indication that 1 of the treatments was more or less
efficacious, with the exception of interpersonal psychotherapy (which
was somewhat more efficacious; d = 0.20) and nondirective supportive
treatment (which was somewhat less efficacious than the other
treatments; d = 0.13). The drop-out rate was significantly higher in
cognitive-behavior therapy than in the other therapies, whereas it was
significantly lower in problem-solving therapy. This study suggests that
there are no large differences in efficacy between the major
psychotherapies for mild to moderate depression.”

Here’s how the article ends: “Despite the limitations of our study, it
seems safe to conclude that there are few significant differences in
efficacy between most major types of treatments of mild to moderate
depression, including cognitive-behavior therapy. Interpersonal
psychotherapy may be somewhat more efficacious and nondirective
supportive therapy somewhat less efficacious. They all should have
prizes, but not all should have the same prize.”

The author note states that correspondence concerning this article
should be addressed to Pim Cuijpers, Department of Clinical Psychology,
VU University Amsterdam, Van der Boechorststraat 1, 1081 BT Amsterdam,
the Netherlands
Email: <P . C u i j p e r s @ p s y . v u . n l>.

——

Comment:

One of the important implications of this study has to do with cognitive-behavioural therapy (CBT), which is given special mention in this study.  Many agencies and institutions ask that psychologists provide ‘evidence based’ methods; that is, methods that are shown to be effective. Often, in my practice, this has meant that I am asked to provide CBT. My impression is that that CBT has been a highly researched form of therapy, which means that that there is evidence for it. My clinical experience has been that other approaches can also be effective, and this study bears this out.

I commented to a colleague the other day that perhaps it’s most important that we as therapists use an approach that we feel comfortable with – which allows us to really use the method and, crucially, to be who we really are in the therapist’s chair.  We know that the relationship in therapy is the biggest predictor of its outcome, and I for one cannot create a strong and positive relationship when I am being inauthentic, not myself. Over the last several years, I have been learning more and more to “show up” more fully, and for me this has meant using methods that fit my temperament and interests as well as the needs of the client. Sometimes that looks like CBT, sometimes not.

Learning psychotherapy, like learning how to be in relationship, is such an art. One that I am still learning after all these years and will probably continue to learn my whole professional life.

Brian Grady, Ph.D.

How to Figure Out When Therapy Is Over
By RICHARD A. FRIEDMAN, M.D.
Published: October 30, 2007 New York Times

If you think it’s hard to end a relationship with a lover or spouse, try breaking up with your psychotherapist.

A writer friend of mine recently tried and found it surprisingly difficult. Several months after landing a book contract, she realized she was in trouble.

“I was completely paralyzed and couldn’t write,” she said, as I recall. “I had to do something right away, so I decided to get myself into psychotherapy.”

(more…)

New York Times 6/12/2007 included an interesting article: “‘Been There?’
Sometimes That Isn’t the Point” by Sally Satel.

Here’s the article:

During our first year as psychiatric residents at a veterans’ hospital,
any patient could reliably stump my colleagues and me by asking one
simple question: “If you weren’t in Vietnam, how can you possibly help me?”

We hadn’t been to Vietnam. We were in high school during the worst years
of the war. And no, we had never been ambushed, cradled a dying buddy in
our arms or dodged land mines. It was a mocking question, really — “Were
you in Vietnam?” — and it left us tongue-tied and apologetic.

(more…)

The New York Times (5/22/2007) included an article: “This Is Your Life
(and How You Tell It)” by Benedict Carey.

Here’s the article:

For more than a century, researchers have been trying to work out the
raw ingredients that account for personality, the sweetness and neuroses
that make Anna Anna, the sluggishness and sensitivity that make Andrew
Andrew. They have largely ignored the first-person explanation — the
life story that people themselves tell about who they are, and why.

Stories are stories, after all. The attractive stranger at the airport
bar hears one version, the parole officer another, and the P.T.A. board
gets something entirely different. Moreover, the tone, the lessons, even
the facts in a life story can all shift in the changing light of a
person’s mood, its major notes turning minor, its depths appearing shallow.

(more…)

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