Everyone who has been in psychotherapy has had the question arise: When am I done here?
This question is a good one, as there is no obvious ending point for psychotherapy – it isn’t like a course of antibiotics, or a broken bone, when the ending of treatment can be prescribed. With psychotherapy, the ending has to do with 1. the goals of the therapy (which can grow and change), 2. the ability of the therapist to adequately address those goals and 3. the ability and/or willingness of the patient to do the work necessary to complete the goals.
Let’s address each of those questions individually.
1. Have I achieved the goal(s)?
This question is an interesting one. Often, people come into therapy with acute problems which tend to improve after a while, sometimes within several months. If the goal was to address these acute problems, there can be a perception on the part of the patient that therapy has done its work and they are therefore done. That is certainly one way of looking at it but is it a good enough reason to end therapy?
Often the improvement someone experiences is because they have been able to identify the problem, learn new communication skills, and experience being heard through nonjudgmental inquiry and feedback from the therapist. They learned their part in their problem and/or the psychological impact of the problem and have been able to begin to talk freely about the problem.
However, several months, or even a year, is usually not long enough to address the underlying vulnerabilities that led to the acute problems in the first place. This makes the person highly vulnerable to repeating the acute problems in the future. It is also not typically long enough to create a lasting change, so that the person may find that they are coping better but they have not made the deeper changes that address their orientation to life, work, or relationships. If the goal is to have fewer symptoms and feel generally better, that goal might have been met, but if the goal is to have a broader understanding of themselves and a shift of perception enough to implement lasting change, they may not be.
Take, for example, the case of Marty: Marty came to therapy to try to figure out why she was so burnt out in her chosen field as a creative director in an advertising agency. Her goal for therapy was to get back her passion and excitement about her work. Through therapy she discovered that it wasn’t really her work that was the problem. She and her husband were parenting three teenagers and had very little time for themselves and each other. Her therapist came to feel that an underlying issue was Marty’s lack of self-care, and began to work with Marty on it. Marty discovered it wasn’t that easy. It was easy to support her husband to go swimming and get back to his passion for woodshop. But for some reason she couldn’t seem to sign up for yoga, painting and ask her kids to pitch in more. Slowly her therapist suggested that perhaps they needed to look a little more closely at her childhood growing up with an alcoholic mother and father. Marty was willing to consider adding this to her goals and realized that she was never very good at taking care of herself, she was good at surviving in an out of control alcoholic family. After a few months she was able to sign up for yoga and a few months after that she signed up for weekend painting class.
As in the example above, deeper work often means a revision of the goals. Sometimes it means that the therapist and patient do not have shared goals – the therapist may see the potential for greater change and the patient may not be interested (see #3). But often as the patient and therapist work together they come to see that there are goals that were not initially apparent.
2. Is my therapist capable of helping me achieve my goals?
This is also a very important question and one that can be difficult to assess. Sometimes people encounter frustration with their therapist and feel they must leave – that they are not done with therapy but done with that therapist. This very well may be an accurate assessment on the part of the patient: even if people seek specialists for their particular problem, or they get a recommendation from someone who they know, not every therapist can work well with every person – there needs to be a “fit” for the therapy to work. Additionally, some therapists are more skilled than others.
However, often people underestimate their therapist and leave instead of working with their therapist to see if the frustration can be resolved.
Take, for example, the case of Sue and Dave: Sue and her husband Dave brought their child to a therapist because they had reports from school that he wasn’t doing well academically and were concerned that their son had an emotional issue that was causing him to lose concentration. Sue and Dave luckily saw an adult & child psychologist, Dr. Lee, who not only specialized in mood disorders but also in learning disorders. After an initial evaluation the psychologist told them that he felt their son didn’t have mood based learning problems, rather he suspected the neurological based learning disorder dyslexia. Initially Sue and Dave were upset by this thought, and felt Dr. Lee was the wrong therapist for their son. However, after discussing it further with Dr. Lee they agreed to testing and discovered Dr. Lee had been correct. Dr. Lee was able to work with the family to help them accept the diagnosis, including the depressed feelings Dave initially experienced as a result. Dr. Lee was able to support Dave to work on all his feelings and now both Sue and Dave are involved parents and advocates for their son, and their son was able to receive the help that he needed.
Often, the therapist and patient can work through the impasse together and the process itself can be a very effective part of the therapy.
3. Am I willing and/or able to do the work necessary?
This final question is crucial. The process of therapy is intense and powerful. Often when people find their symptoms are (temporarily) alleviated, they feel incredible relief, and this feeling of relief allows them to feel the possibility of wellness. Typically, as they continue in therapy, they then begin to feel uncomfortable. The therapy process begins to take a deeper look into the person and his or her life. Unpleasant feelings can emerge, such as feelings of dependency, or a deeper unhappiness. More subtle thought distortions, relationship patterns, or acting out can begin to be revealed, and all of this can be frightening or make the patient feel worse. This is a common time when people have the urge to leave.
Take, for example, the case of Tony: Tony came to therapy after his partner discovered Tony’s compulsive sexual behavior involving internet pornography, multiple affairs and frequent encounters with prostitutes. His partner had told Tony if he didn’t get help to stop his behaviors, she would leave and take their three kids with her. Tony was motivated to change, got into an intensive outpatient treatment program, joined a twelve step program and his wife joined a support group. Tony was hugely relieved that things started to calm down at home and he and his wife were finally able to communicate without painful arguments. Six months into the therapy, Tony had a very deep session with his therapist acknowledging he thought he’d been depressed since his mom died when he was eleven years old. A week later Tony came to therapy stating he was confident he was over his problems and decided after six months of no longer acting-out in his sexual compulsivity he was done. His therapist asked him if he thought he’d touched on something very painful when he had brought up his mother and that he had more work to do to grieve her loss and look at the corresponding depression he’d had since that time. Tony disagreed and in a couple of days sent her an email stating he would not return. His therapist called him back and told him that her door was always open to him and encouraged him to consider a final session for closure. Two months later he returned to therapy and said his wife had caught him again on an internet pornography site. His twelve step sponsor said he was still in his addiction and he needed to get additional help of therapy to get and stay sober. He acknowledged he wasn’t done and indeed was really just getting started. Tony later learned that when he had been in so much pain remembering his mother, it wasn’t his sober adult mind doing the thinking and acting, it was the addict defensive part of his mind that was telling him to run and hide from therapy. That was a part of his mind that had developed to help him survive a traumatic event when he was young but it was no longer helpful – it was self-destructive.
People spend a large portion of their lives acting without knowing really why or where the action is coming from. Part of the goal of therapy is to develop a mind that can think “real thoughts” versus automatic responses, awareness of feelings and ability to tolerate them, so that conscious decisions can be made and intimacy can be created. The discomfort – experienced as frustration, irritability, restlessness, sadness, pain, anger, unhappiness, etc – can be an indication that the real work can begin – the work of discovery and healing. The deeper problems are now within reach and are available to be explored and resolved.
Samantha Smithstein, Psy.D. & Elizabeth Corsale, MFT
Pathways Institute for Impulse Control
www.pathwaysinstitute.net
help@pathwaysinstitute.net
415.267.6916