[pachyderm]

http://www.cnn.com/2008/HEALTH/condi...apy/index.html

[sunrise]

Thanks for bringing that article, pachy. I wanted to comment on a couple of things from the article:

</font><blockquote><div id="quote"><font class="small">Quote:</font>
"It's unrealistic to expect a cure for depression symptoms after four to six weeks of therapy... But if there's no improvement during that time, we need to evaluate whether you're in the right treatment for you."

</div></font></blockquote><font class="post">That's interesting to me. So if 4-6 weeks with a therapist is not helping, then perhaps it is time to seek out another therapist who uses a different approach? For example, CBT instead of psychodynamic, or existential instead of CBT, etc.? Or perhaps it is just the relationship with the T that is not clicking, so give it 4-6 weeks, then move on to someone else you can get on with better? Or if you are not taking anti-depressants, and 4-6 weeks therapy does not help, then turn to meds? That short time frame is very interesting to me. I know here on PC people often post about not really getting on with their therapist and wondering if they should switch, but often they have given the T more than a 4-6 week trial. The article's implication seems to be that longer than that is beating a dead horse? I know with my first therapist, who was CBT, and would not treat me if I took ADs, we worked together for 5 months, and then, I guess perceiving that her efforts were ineffective, she suggested I go get drugs after all. So she waited a lot longer than 4-6 weeks.

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"I had a patient in long-term analysis, she just wanted to go, but she felt like she had to be angry in order to leave," Bloch says. "She felt the only way to leave is to just set the date and leave being angry. It's not that different than the process of leaving home-often kids leave their parents feeling they have to rebel."

</div></font></blockquote><font class="post">That's an interesting client approach to termination. It makes me wonder if I am doing that now. I have been feeling let down and a bit pissed at my T, and I feel a strong impulse to withdraw from him. I want to cancel our session next week, and since we don't have a standing appointment, I would have no further appointments with him. And I would just let it slide, and drift off, and I would be on my own. Am I being the rebellious teenager and trying to terminate in this immature way?

</font><blockquote><div id="quote"><font class="small">Quote:</font>
Many patients with chronic depression hope to keep their relationship with their therapist for as long as possible. Lisa, 42, from Huntington, New York., likens talk therapy to "going to the gym."

</div></font></blockquote><font class="post">I wonder how many therapists would allow that? I always have in the back of my mind that my T says he does not do longterm therapy, which he defines as greater than 3 years. I always feel like that clock is ticking. I have been with him 20 months.

[splitimage]

I've been thinking about terminating or at least cutting back on therapy for a while now. I've been going to the same therapist for 9 years now, and I feel like I've been making progress throughout that time. We've focussed on very different things over the years, from dealing with childhood trauma, to dealing with current crisis, my depression and cutting, my self image, and now what feels like the final hurdle to me, over coming my social phobia. It's been incredibly expensive but worth it. I guess now I'm starting to feel like I have more social supports outside of therapy and that the incremental value of therapy is starting to diminish. I'm not going to make any changes over the summer, but it is in the back of my head.

The one thing I didn't agree with, was that if after 4-6 weeks you're not seeing improvement, then maybe it's time to change to approaches. It can easily take that long to build up trust with a therapist and much longer to doing any really hard work. To me it smacks of HMO's pushing for quick results based outcomes.

--splitimage

[chaotic13]

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sunrise said:

</font><blockquote><div id="quote"><font class="small">Quote:</font>
Many patients with chronic depression hope to keep their relationship with their therapist for as long as possible. Lisa, 42, from Huntington, New York., likens talk therapy to "going to the gym."

</div></font></blockquote><font class="post">I wonder how many therapists would allow that? I always have in the back of my mind that my T says he does not do longterm therapy, which he defines as greater than 3 years. I always feel like that clock is ticking. I have been with him 20 months.

</div></font></blockquote><font class="post">

I had a similar thought about this one. I guess it re-raised in me the issue of want vs need and who is paying. I find my sessions with my T very helpful and therefore keep going. However, a lot of my initial therapy goals have been met or at least insight has been given to get me started. I obviously still have a lot of other issues that have surfaced, but I wonder if I really NEED help or just want it.

In one recent session I finally asked my T what my diagnosis was. I have avoided asking for what my pathology label is partly out of fear and partly because I knew I would immediately search for all available information on "it" and the various treatment approaches, etc. However in this session I was having a really very bad day and asked my T what technically was wrong with me. She said the code she is using for insurance purposes is the "Adjustment Disorder" code. Of course I didn't listen to anything else she said after that point and immediately after the session started looking it up. The first web source I pulled up defined it and said most patients are usually done with therapy in 6 months. Of course I immediately slammed the laptop closed and concluded that I was a slow adjuster and that my T was looking to kick me out any minute. Obviously these negative thoughts were still lingering in the back of my mind 2 weeks later, 'cause the next session I tapered my session back to 1 every 3wks.

[(JD)]

While I agree that most do try to keep the therapy relationship as long as possible, there is a natural sense of when to terminate when it's no longer needed. If you have to question yourself, you probably aren't there yet.

The fear that T will abandon you (the patient) is natural, and with that comes the desire to keep the T for as long as possible. There's nothing wrong with that (in spite of what the HMOs say.) Having assurance that the T will be there for the long haul is a good foundation for not feeling rushed. Often it's the slowing down of therapy that allows you to accomplish more, and often more quickly.

If your dx usually necessitates long term therapy, or your natural ways of healing do, it's best to find a T that will be there with you, to the end if possible. Ask!

[ECHOES]

Oh, this one's easy. Never.

[chaotic13]

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Sky said:
The fear that T will abandon you (the patient) is natural, and with that comes the desire to keep the T for as long as possible. There's nothing wrong with that (in spite of what the HMOs say.)

</div></font></blockquote><font class="post">
It doesn't feel very natural or that there is nothing wrong with it. At least to me anyway. I (the patient) should not be worried about being abandoned by a health care provider! But I do... and I'm not feeling OK with at present....#$*@!!! ...I'm attached and I don't want to be...I think I just developed another adjustment disorder. Wonder how many disorders my insurance will cover?

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Often it's the slowing down of therapy that allows you to accomplish more, and often more quickly.

</div></font></blockquote><font class="post">
I think I have a different view on this. I think slowing down therapy is a T's way of saying to themselves, "Holyshit did I help open up a can of worms today! I better give him/her an extra week to dig themselves out of that smelly pile of pooh and regain their composure before I have to deal with them again." While telling the patient,"Wow, your getting soooo much better. Lets see how much you can accomplish on your own for a while."

[ECHOES]

I'm thinking Sky meant slowing down the pace of therapy? Getting used to the pace was an adjustment for me. Now that I'm comfortable there, I love the pace that seemed slow when I started. I used to feel like I didn't 'accomplish' much because I was trying to rush things, and to be a 'good' patient and show results.. instead of just going to session, being there, and letting it go where it goes. I love T's "instructions".. "Say anything."

When I 'interviewed' my T, I asked her about personality disorders because a previous T mentioned one to me. When I asked my T about it, she said "Well, really what ISN'T about personality?" and that really put me at ease. We also arrived at another diagnosis, besides depression and anxiety, and we've discussed it several times. She says she doesn't want me to get hung up on the diagnosis. (She didn't provide the diagnosis, I had been reading and I asked her if she thought it applied. She readily agreed, and had thought for some time that it fit me. Or I fit it?)

Adjustment disorder can mean so many things. And I believe it's probably a nice, broad diagnosis to use to keep the insurance company from bugging her with "Are you done yet?" type queries.

Why not ask her to talk to you about Adjustment disorder and why she thinks it applies to you. I'll bet it will be relieving for you.

The attachment is okay. Hang in there and it will feel better. Instead of panic at the thought of losing her, when you can hang on to the good feelings of therapy, of being there with her, you may begin to feel comforted instead that she is there for you. It feels so good.

[chaotic13]

AH...I get the pacing concept. TY

I'm feeling a bit down tonight so give most of my comments a hint of sarcasm. During the session I described, I did later realized that my initial interpretation of what she was telling me and what she actually said were VERY different. I still felt the effects of my interpretation for a while, though... guess that's why I have 2-3 weeks between sessions to figure out what was actually said and what I am supposed to get from it. Guess that's the how much YOU can accomplish part.

I also notice I have a tendency to skip the ASK comments. I wouldn't be able to feed my ego if I did that

[ECHOES]

</font><blockquote><div id="quote"><font class="small">Quote:</font>
I also notice I have a tendency to skip the ASK comments.

</div></font></blockquote><font class="post">

Oh, me too! I used to get so upset about it, it would be part of my tearful call to her after session "I didn't ask you things I wanted to ask you!!". When she called back she would say it's okay and we can talk about it next time; anything can be talked about again at any time." Along with "Say anything." her instructions include "Start where you are." and "Whatever is on your mind at the moment.".

I still struggle with asking questions. I have a tendency to report rather than engage, but that's getting better with practice I've been going for about 16 months weekly and I really think it would be even better to go twice weekly, to keep the momentum going, to not be close then distanced then close again.

Asking is like stating a need. It's so so hard for me to do.

[(JD)]

Sometimes therapy gets rolling too fast, and things are uncovered and too raw to do much with...and the patient is reeling from the exposure... then the next several weeks or sessions are spent trying to restabilize the patient rather than progressing on track. That therapy time is lost doing something important (stabilizing) but if the original pace had been slower, then breakage would never have occurred or not been so violent at least, and could have been handled in the normal week to week therapy (that's normal progress.) This is what I meant by going slower is often faster in the long run.

[ECHOES]

Thanks for expanding on that, Sky.
I did experience that at first. I think when patient and T are new to one another and getting to know one another, it's a time of discovery and adjusting the pace as needed.

[sunrise]

</font><blockquote><div id="quote"><font class="small">Quote:</font>
chaotic13 said:
I still felt the effects of my interpretation for a while, though... guess that's why I have 2-3 weeks between sessions to figure out what was actually said and what I am supposed to get from it.

</div></font></blockquote><font class="post">Have you considered having weekly therapy sesions? Then you don't have to stew in your interpretations for so long and can get a reality check from your T. You can share your thoughts from the last session and she can clarify anything you misinterpreted.

</font><blockquote><div id="quote"><font class="small">Quote:</font>
I wonder if I really NEED help or just want it.

</div></font></blockquote><font class="post">Does that matter in terms of whether you continue with therapy or not? Is it only OK to continue with therapy if you need therapy but not if you want it? Plus, who defines "need"? Something can be helpful, empowering, or even life-changing without it being "necessary." Is therapy necessary for your survival? Perhaps not. Is it necessary for your continued growth and ability to reach your full potential? Perhaps. It's just a different kind of need. I think you owe yourself more than you are willing to give yourself, chaotic13. If you want to continue therapy and it is indeed helping you, then I hope you will give yourself the "gift of therapy."

[chaotic13]

</font><blockquote><div id="quote"><font class="small">Quote:</font>
I hope you will give yourself the "gift of therapy."

</div></font></blockquote><font class="post">
This shouldn't be so difficult should it.

</font><blockquote><div id="quote"><font class="small">Quote:</font>
Have you considered having weekly therapy sessions?

</div></font></blockquote><font class="post">
Yes, I was really struggling in Feb and went weekly for the month of March. I liked this a lot but felt guilty about liking it. I don't like to appear needy or dependent on therapy. In Feb I was miserable and emailing a lot. My T said something like, 'When would you like to come in again? I have openings next week or do you want to stick with 2 weeks.' I say, "next week is good for me." In April it was, 'Would you like to go back to 2 weeks?'. I said, "Yes I'd like to move back, probably more appropriate." Then last week it was do you want to shoot for the 25th or 2nd?" I then say, " Ah, the 2nd will work OK. ." I figure her suggestions mean something so I go with them. Not very assertive on my part, I guess.

I guess I will be done with therapy when she says, " Do you want to schedule for 3 weeks or wait and schedule when you need to see me." At this point I will know that I am officially abandoned and officially considered to be adjusted.

[red8326]

Frankly, I'm somewhat scared to quit therapy. I'm bipolar II and compared to where I have been I'm doing great BUT the idea of not having that support system scares me. She has said that I can come back anytime I want to but without that security of a set appointment I don't feel that great. Right now we are doing every other week and that feels pretty good. I have always had a VERY hard time talking in therapy so going every other week is a little bit of an issue. The longer I go without talking the less I will say because I stop trusting her. It's kind of a double edge sword. The way I'm trying to get around all of this is to write to her in a journal, just like i'm talking to her, and then taking my journal with me to the session.

</font><blockquote><div id="quote"><font class="small">Quote:</font>
sunrise said:

</font><blockquote><div id="quote"><font class="small">Quote:</font>
Many patients with chronic depression hope to keep their relationship with their therapist for as long as possible. Lisa, 42, from Huntington, New York., likens talk therapy to "going to the gym."

</div></font></blockquote><font class="post">I wonder how many therapists would allow that? I always have in the back of my mind that my T says he does not do longterm therapy, which he defines as greater than 3 years. I always feel like that clock is ticking. I have been with him 20 months.

</div></font></blockquote><font class="post">

My T has given me "permission" to be in therapy with him for as long as I want. Most recently, he has said that we can work together "for 50 more years." He doesn't really believe in the need for termination. He is of the belief that self-examination can go on forever.

[Brian37]

insurance companies are starting to crack down on therapy now.....Anthem Blue Cross Blue Shield is trying to cap all therapy at six months.....after that they wont pay for outpatient

</font><blockquote><div id="quote"><font class="small">Quote:</font>
"It's unrealistic to expect a cure for depression symptoms after four to six weeks of therapy... But if there's no improvement during that time, we need to evaluate whether you're in the right treatment for you."

</div></font></blockquote><font class="post">

i'm sorry.. i actually laughed when i read this.. and not a funny-haha laugh. Anyone who knows me, IRL or not.. anyone who has paid even a fraction of attention to me knows that i have changed in positive ways... IRL people have asked me what's up.. they say they see such growth in me, they say it's really obvious. So.. that took how long? Try 16 months. Am i done yet? Nope.

i dont see this as a stop and go thing. i see it as a continuing process and it took forever to feel that... like i dont have to really ever decide that it's tout fini. i can always choose to move in and out of the process as i need it. Until he retires, i can always choose to see him. i don't think that is the same as saying i want it to go on as long as possible. i'm not looking to get stuck in therapy, unable to move.. just to hang on to him. But i do want his consistency to go on forever... obviously, the amount of time and attention from him would decrease to zero in the times when i am not active in therapy, but i dont think his feelings towards me will. He is human, and i don't care less about people i dont see often. i am there and so are they... and so is he. He has said as much. i like this approach... even if the doubts and fears haven;t gone away completely.

and as far as 4 to 6 weeks.... again, isn't that dependent on a lot of different things? My state of mind didn't change quickly... my precipitating circumstances didn't change.. so how could my state? Even with non-situational depressions, depression isn't the freaking measles! True change, winning the war and not the battle needs time.

[sidony]

I sometimes feel I'm in the minority, but I don't worry about termination in the slightest. I suppose I'll terminate when T retires. It's unlikely that I'll leave before then. Hopefully that's years away. I guess I just don't see the need to quit something that is helpful. Even if I were so well-adjusted that I was only going for some vague reason such as "living a fuller life," I'd be fine with that. I might be like the patient who likens therapy to going to the gym. It's just an ongoing part of my life that makes me healthier and happier. I have no intention of giving it up. I don't even worry about that.

Sidony

</font><blockquote><div id="quote"><font class="small">Quote:</font>
sidony said:
I sometimes feel I'm in the minority, but I don't worry about termination in the slightest. I suppose I'll terminate when T retires. It's unlikely that I'll leave before then. Hopefully that's years away. I guess I just don't see the need to quit something that is helpful. Even if I were so well-adjusted that I was only going for some vague reason such as "living a fuller life," I'd be fine with that. I might be like the patient who likens therapy to going to the gym. It's just an ongoing part of my life that makes me healthier and happier. I have no intention of giving it up. I don't even worry about that.

Sidony

</div></font></blockquote><font class="post">

I'm exactly that way, too, Sid. My worries are more of the catastrophic, "what if," abandonment-type: What if he moves away? What if he drops dead? As far as termination, that is not a concern.

I know that for me, I have always had the desire to self-examine. I am very attuned to myself intellectually, emotinally, relationally, etc. Why would I stop going somewhere that serves my ability to do this? There is so much you can do on your own in the way of writing, thinking, creating, etc... but when you find someone who can be on that journey with you, it is so much more powerful.

I never saw therapy as a "fix" for a specific problem. While I am working on some serious issues with him, it is also a part of my life.

[sunrise]

</font><blockquote><div id="quote"><font class="small">Quote:</font>
sidony said:
I sometimes feel I'm in the minority, but I don't worry about termination in the slightest.

</div></font></blockquote><font class="post">That could be because your T will allow you to see him as long as you need/want to. I don't worry about termination because it's something I want to do but because my T told me early on he doesn't do longterm therapy (greater than 3 years). So the worry comes from what he said. If he did therapy with clients indefinitely, I wouldn't give termination a second thought. I would let it happen on its own timetable (if it happened at all). I think many Ts don't do longterm therapy, so I suspect this is where a lot of the tension over the topic comes from. You're lucky, Sid, to have a T who will see you until he retires. I guess one approach would be to see one T for 3 years, or whatever his limit was, then terminate, then start with another T for 3 years, etc. But I don't want to do that. I truly cannot picture doing therapy with anyone but my T.

At some point, I will probably become unable to pay for therapy, so that is another problem lurking. Insurance doesn't cover it and I have a family to support.

now there is the biggest reason, outside of abandonment fears possibly, for fears about termination. i haven't heard anyone say that they fear not knowing what to do with the extra money. Most of us struggle with the costs in some way. i have to pay out of pocket for all but $200 (dont even go there). It's crushing.. but the alternative is frequent hospitalization or death. Hardly a choice. What would be the cost of not being able to function? But yeah, i worry a LOT about being able to pay for it. It has happened more than a few times that i have worried about starting a topic because i didnt want to just open a fresh can of worms and be left alone with it.

sunrise

[nageshrao]

i am not sure when you should stop going to the therapist but i have stopped going to mine because it wasnt working for me .