Martha is terminating therapy again. This woman, who’s dealt with depression throughout her life, has been my client on and off for 10 years. Her pattern has been to work with me for a year or more and then take a break as she feels better. Then life will throw something at her that she can’t quite manage without despair—her beloved dog dies, her spouse is diagnosed with cancer, her finances take a plunge—and she’ll be back to find ways to get out of the pit she’s fallen into.
She’s not the only one with this pattern. Ric has been back three times. He has generalized anxiety disorder, and over the course of seven years he’s returned to therapy as life has hit him with overwhelming changes. The first time was when he and his new wife had bought a house and he was frantic that he’d made an irreparable mistake. Then they had a baby. Then the boss at his new job started asking him to cut corners in ways that Ric thought were unethical. The worry that plagued him would be unmanageable, but each time in therapy he learned more about how to make it abate.
As they return for another round of couples counseling, Jill and Mike tell people that working with me keeps them “maintaining.” But they’ve been in and out of treatment about four times since Mike needed help with addiction eight years ago. This time, they’re back because they can’t resolve their conflicts parenting their first adolescent. But they believe that together we’ll chart a course that will put them back on track—which is what they’ve done each time, beginning with Mike’s sobriety.
At this stage of my career, this list of returning clients has started to get quite long. And it’s certainly challenged my idea that my practice is primarily about offering lifelong cures to all the clients that I see. Especially with clients who come in with serious anxiety and depression problems, I’ve begun to put aside my idealized view that unless people overcome their difficulties once and for all, therapy is somehow a failure. More and more, that perspective seems simplistic and disconnected from the realities of what psychotherapy, no matter how skillful the clinician may be, can actually provide. In fact, evidence continues to accumulate that many people who have anxiety and depression suffer bouts of it all their lives, even after a good response to therapy.
So what if we start to think differently about this? What if we view anxiety and depression—especially generalized anxiety and dysphoric states of mild and moderate depressions—not as disorders that will be cured, but as chronic, relapsing, remitting disorders? Reflecting on Mike’s journey actually prompted me to think more about this. As an addict, he’s never recovered, but is continuously in recovery. He does daily activities that keep his mind, emotions, and lifestyle focused, not only on preventing a relapse, but on overall healthy living as a goal. What if we look at certain types of anxiety and depression in a similar way?
The Long-Range View
As someone who’s been in the field for almost 40 years, I’ve seen a lot of changes in the attitudes, therapeutic trends, and models that shape the direction of practice at any given moment. I was initially trained to believe that therapy was a long-term proposition and that clients needed to come for years to benefit from it. Making progress in therapy was inherently a slow, somewhat mysterious process, revolving around working through transference, countertransference, and other intrapsychic subtleties. Then, beginning in the 1980s, short-term therapies became all the rage, and the field grew enamored with powerful, new techniques that offered the prospect of fast recovery for all. When pharmaceutical companies got on the bandwagon, convincing insurers and consumers alike that medication could fix mental health, the pressure mounted to think about “curing” our clients. Economic pressure pushed us to think even more short term, and everything that promised fast progress got a lot of attention. Stepping back now, we see that the emphasis on short-term change seemed natural, even inevitable, in a fast-paced culture preoccupied with productivity and bottom-line outcomes.
But the more experience I’ve acquired in short-term models of treatment, the more skeptical I’ve become about offering permanent solutions to life’s complex issues. As I watch how clients typically respond to treatment, even with all the range of tools I’ve mastered over the years, I find that while they can certainly learn things that make them feel better quickly, they often forget these strategies when life is going well, and then can’t remember to do them when it isn’t. More and more, I’ve come to view complex conditions like anxiety and depression as chronic, remitting, and relapsing disorders, rather than simple behavioral problems that can be cured over the course of a few sessions. And I’ve become more and more impressed with the importance of the therapeutic relationship as the key ingredient in psychotherapy. Advances in neuroscience have underscored how our ability to maintain balance in life is closely connected to our ability to coregulate our emotional states through relationships of trust and intimacy with the key people in our lives. Being ongoing, trusted sources of support and guidance is an essential part of what we therapists can offer clients over the long haul, even those we see only occasionally over the years.
This is a perspective that our colleagues in the addictions world have long embraced. They talk about people as being in recovery for life, with the expectation that they’ll stay in the state of recovery, applying every day what they’ve learned in therapy. Whatever the ups or downs of their lives at any particular moment, they aren’t considered treatment failures if they go through a rough stretch. Instead, they remain successful by following their relapse-prevention plan through whatever challenges and obstacles arise.
It would be a relief if, when educating our clients about what we see in them and what we can do about it, we could confidently tell them that they can gain significant control over their symptoms and achieve long-term remission and make probable relapses brief. They can expect life to be filled with the unexpected—and they might unexpectedly have symptoms of anxiety and depression in the future—but we can give them tools to prevent and manage relapse for life.
I wish I’d approached Ric that way. When I first met him, I was enthusiastic that if he mastered cognitive tools to control worry and made sure to keep lifestyle changes in place, like exercising regularly, he’d be done with debilitating worry. He left his first round of therapy seemingly a changed man. We both thought it was permanent. When anxiety slapped him down after the birth of a child, he felt he’d failed. He also thought maybe I hadn’t given him enough tools to withstand all of life’s curveballs. After trying a different therapist, he came back to see me. I talked to him about my own failure to prepare him for relapse, and he gradually saw that he hadn’t applied to the new situation what he’d learned in therapy. He forgave me and himself, and then we planned for what to do if anxiety came back. He trusts me now, and I know being able to return without shame makes him more secure.
Addiction-treatment professionals have operated this way for years. They make an assessment of all the complications of people’s individual situations, and educate them about the chronic nature of the disorder and what it takes to stay sober. Then they provide individualized care and create a customized lifelong program that fits the general model of ongoing support from a group and an individual (a sponsor), necessary psychotherapy for concurrent mental health problems, medications if needed, tools (including social support) to cope with unexpected changes, a daily program of meditation and spiritual connection, and daily optimistic reminders of the chronicity of their condition and how they’re managing it. While no part of that model says people can expect to be permanently rid of addiction, there’s no reason that they can’t live contented, purposeful, valuable lives.
Such an approach to therapy would make it clear that some problems can’t be permanently banished by therapy alone. In treatment, we’d do some of what we already do: listen to our clients and assess their problems, know what it’ll take to minimize their distress, teach them the skills they need to learn, perhaps weave medication into the plan, and schedule follow-up sessions or check-ins. But we would add the piece about lifelong recovery, placing relapse planning—and the prime responsibility that a client bears for executing the plan—at the center of the therapy process.
I’m by no means a pessimist about the possibility of change in psychotherapy. As a big fan of symptom management, I believe people can feel much better for the rest of their lives by managing their symptoms—and at times those symptoms can be eliminated. In Gerald’s case, for example, his panic was triggered by heavy doses of steroids to manage a life-threatening medical problem. At the time I met him, he had no idea the original panic was a side effect of the medications. He thought he was inexplicably falling apart emotionally. He’d began avoiding anything he thought could cause panic, which meant staying home most of the time. He was nearly agoraphobic when he came for help. But he had no life history of anxiety or depression, and basic cognitive behavioral therapy (CBT) relieved that panic in about five sessions, with homework in between.
I believe symptoms management can change the brains of people with anxiety and depression so that their symptoms diminish or are eliminated. But this perspective, which seems like a CBT, brief-therapy stance, makes me more comfortable with the idea of that these disorders can be chronic, remitting, and relapsing ones. If therapists adopt that view, we’ll pay attention to the client’s personality, temperament, locus of control, learning style, and so on to find the kinds of methods that can be sustained effectively as a relapse-prevention plan. For example, passive clients who are forgetful and not persistent will need to develop a set of external cues and reminders that will focus their attention on what to do when they need it. They might want to set up an app on their phones that delivers a daily message of encouragement and a “skill of the day” as a way to keep their attention on the process. They may also need more frequent booster sessions than clients who are more persistent and disciplined. In addition, a client who’s especially active and health conscious may embrace the physical regimens that we know help both anxiety and depression—such as regular, rigorous exercise, plenty of omega-3, and good sleep patterns—whereas the quieter, more introverted client might more easily embrace meditation, a proven pathway to mental and emotional well-being.
Therapists who adopt a mindset that these disorders may be relapsing and remitting will need an array of symptom-management techniques, many of which we already have from CBT, acceptance and commitment therapy, and emotionally focused therapy, among others. But most of us will want to develop our resource lists, so that if our client can benefit from a treatment we don’t practice, we’ll be quick to provide it via another therapist, much in the way that an endocrinologist might refer a diabetic to a nutritionist. We’ll want referral sources for practitioners who can manage medication, supplements, acupuncture, neurofeedback, and other nonpsychotherapeutic modalities. We’ll want a list of technological tools clients can use on their own, such as apps that guide breathing, meditation, relaxation, or positive-messages practices, or apps that help people declutter their homes, exercise regularly, deliver light therapy, and so on. In these ways, we can individualize relapse-prevention plans exactly as we do for people with addictions—with a wide variety of helpful tools.
We’ll do away with the expectation that therapy will one day be over. Instead, we’ll see clearly when it’s time to decrease the frequency of sessions as clients are successfully using their methods, and then set up regular check-ins. As with medical conditions, those check-ins might be annual or more frequent, and will always include the addition of new tools if symptoms or circumstances change.
Martha is finishing up her current round of therapy with me in a new way. She’s creating a plan to remember the important lessons she’s learned to manage her depression. Together, we’re reviewing what’s been most meaningful and useful, and she’s compiling reminders for herself: photos, songs, sayings, and a list of books whose main characters demonstrate the attitudes she wants to embrace. She’ll probably reread particular books when she’s in a slump. If all this means I won’t see her again in therapy, then that’s fine; if she returns, it won’t be a failure, but rather, another stage in her ongoing recovery.
Ric knows he’ll be back when something triggers his insidious worry. He’s so health conscious he won’t need reminders to exercise and eat right, but he knows those are part of his process to relieve tension. And in the meantime, he’s remembering the tools to stop worrying, and gets daily reminders of optimistic thinking delivered to his computer.
Mike and Jill each have their relapse-prevention plan in place for addiction, and they’re consciously using therapy to resolve conflicts and improve their skills for parenting, as well as for resilience in the face of stress.
Giving up the idea of cure and opting for the idea of management might change the course of treatment for client and therapist alike. By forging an alliance that can stretch over time, we set the stage for the relationship to do its work of healing. We eliminate the discouraging idea that returning to therapy is failure, and open the door to allow both therapist and client to adapt to a changing life with new insights, skills, and understanding.
Illustration © Dave Cutler
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