Should Depression Be Treated as a Chronic Condition?

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. 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 around 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.

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 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.

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.

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.

This blog is excerpted from “Cure or Control?” The full version is available in the Nov/Dec 2014 issue. To subscribe, click here. >>

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