Sunday, February 10, 2013

Why Am I Still Here?


It's a question I hear from time to time: "I've been in therapy for years.  How come I'm not better by now?"  

Okay, so psychiatric conditions are not like infections, at least not for some people; you can take a week of antibiotics and your urinary tract infection is all gone.   Your bipolar disorder may take a wee bit longer to stabilize.

~ Not only that, but this is something that's different for everyone, some people seek treatment for a single episode of depression, for a help coping with a stressful life event, or for help to change a maladaptive pattern, and they come for a short time, figure out what they want to figure out, and they're done.  In this case, it is kind of like a taking a round of antibiotics.

~Some people have intermittent problems and come to treatment for a while then stop, then return when the problem comes back.  It's kind of like seasonal allergies.  Or maybe like the infectious disease model, but the infection recurs.

~Some people have chronic psychiatric problems, along the line of "think of it like diabetes or another illness" and treatment continues for a very long time. For some, there's chronic titration of both medication and therapy to cope with life's issues when the psychiatric condition waxes and wanes but never totally recedes, or at least not for long.

~Some people have a chronic problem that requires medication, but they find they just do better if they keep up with some degree of regular therapy.  Therapy either gives them an outlet or a degree of support that makes it so the psychiatric problems don't relapse, or the relapses are more manageable.

~And finally, some people, whether or not they need medication, find that it's helpful to have someplace to process what goes on in their emotional lives.  If the patient doesn't have a psychiatric disorder, then you're welcome to raise questions such as to whether this is an appropriate use of treatment or whether it should be reimbursed by insurance, but I would contend that if having a place to process one's stuff makes it so that someone is a more productive, less distressed member of society, then should a decision to see a therapist be judged by others?  A variant of Socrates' thought that "The unexamined life is not worth living." (This is not to say everyone needs a shrink to examine their life in a thoughtful manner.)

Ah, you might say that our resources are scarce, that no treatment should be offered without "medical necessity" whatever that may mean -- it's a term invented by insurers to justify denying payment for a problem.  So let me put it this way: our sickest members are often our least productive members, even with treatment.  They take the most expensive medications, often get government disability payments, and may require expensive hospitalizations repeatedly, not to mention case managers and placement in day programsThey are clearly ill and one would would deny them careSo what about a rocket scientist or a neurosurgeon or a school teacher, who simply finds that talking to someone once a week or once a month, or whenever a problem arises,  enables them to be more emotionally comfortable, to understand and manage their interpersonal motivations in a way that gives them more control and makes life smoother and more productive -- might it be okay for therapy to continue without a definite endpoint?  What if insurance is paying?  Is this really "medically necessary?" and do we ask "medically necessary for what?" For optimal functioning and emotional comfort? What if the patient is paying out of pocket?  Or should psychiatric care go only to the sickest members of our society, a form of rationing to make sure the needs of our sickest members get met?

No, I don't encourage patients to stay forever, but I do believe that most people talk with their feet.  If they want to come less often, or call when there is an issue, I'm usually good with that unless there is a reason not to be, for example if they are still in the middle of an episode and notably symptomatic or having trouble functioning.  If they're well but want to stay in treatment and feel they are getting something out of it, I'm good with that, too. And I end most sessions with "When should we meet again?" just to be sure that the agenda belongs to the patient, and not the doctor.

23 comments:

Plain Anon said...

I am in psychoanalysis and take meds. Insurance pays for meds but not psychoanalysis, which is a significant about of money. It took me a long time to find what would support me to keep me out of the hospital and not living my life in a suicidal depression. I am successful at my job so the money I need isn't much of a problem, but I worry sometimes what would happen if I didn't have the money or insurance.

SlečnaLíná said...

What do you think about pacients, who are well now, but do not want to quit the therapy? Is it a sign of a excessive dependence or a sign that they still need some care?

gringard said...

This is very similar to Clink's post of Aug 2010 that referenced the Daphne Merkin article in the Times.

Katherine said...

What do you do when you have a patient who you feel is still in the middle of a mood episode but the patient feels he no longer wants to be in treatment?

Dinah said...

--gringard: I'm glad someone is paying attention.

Katherine: I would tell the patient why I thought they still needed to be in treatment.

SlecnaLina: What does "excessive dependence" mean? We don't want patients to use therapy instead of having other close relationships, or to call so much with minor concerns that it's disruptive to us, but I'm not sure what else that might mean?

SlečnaLíná said...

I am sorry for my bad English, I looked it up in the Czech-English dictionary :-/ I wanted to know, what do you do with pacients, who do not need therapy any more (from your point of view) but they still want to continue.

Alison Cummins said...

There's also the possibility that the person is still in therapy because therapy is ineffective or damaging and the client doesn't trust their own judgement enough to talk with their feet.

It seems you started with a question from a patient - I've been in therapy for a while now, how come I'm not any better? - and answered it with an unrelated question from a shrink - Why shouldn't well-paid, productive people have occasional sessions with me covered by insurance?

I fail to see the link.

jessa said...

I'm with Alison on this. As a patient, I didn't "talk with my feet" when the therapy was infective for a number of reasons: I believed I was sicker than I was so I didn't trust my instincts that the therapy wasn't working, I desperately needed the help and had nowhere else to go for it. There is also trying therapy of various sorts, going from practitioner to practitioner, where the answer may be that the patient hasn't found anything effective yet.

All your answers seem more to answer the question, "Why am I still here if I am significantly better than I started?" Less, "why am I not better?" than "why am I not as much better as I think I should be or want to be?" It seems like a strange group of possible answers that are rather disconnected from the question.

JJ said...

I take meds but my latest mood episode and eating disorder relapse are over and it is hard for me now to know how long to continue therapy. I still feel I am benefiting from it, and my therapist says that is criteria enough. But I secretly feel like she thinks I'm well and shouldn't be there. I'm constantly giving myself timeframes and justifying why I'm still going in my head. Since no one in casual society talks about this sort of thing it can feel like I'm trying to navigate a dark hole. But then again, perhaps it's an opportunity to not conduct my life based on polling others or what I perceive as normal, and to actually figure out what is best for me apart from labels.

whizkidfloyd said...

I'm actually in the same boat as Allison. I'm not sure what the link was. Was there supposed to be one? Or was this more like two posts in one? "Why am I not better" and "Who deserves care" combined?

Sabre said...

Alison,
Incisive, as always. I am always impressed by your ability to cut through and to express yourself.

Katherine said...

Agree 100% with Alison.

That said, you didn't really answer my question, either. What if the patient wants to terminate therapy and you feel he is still in the middle of a mood episode? Obviously you've expressed your opinion. The patient still disagrees.

Anonymous said...

I agree with Alison. The therapist should be able (and willing) to recognize when they are not helping the patient or are no longer helping the patient, as the patient may not have the knowledge or strength to do this on his/her own.

Unfortunately, with my first therapist I didn't have any experience at all with therapy so I didn't realize how bad the treatment was, I stayed way too long and continually got worse --I know now I should not have accepted his response that it gets worse before it gets better. Like another person mentioned, the first therapist I had kept telling me how sick I was (to justify why I wasn't improving), and I believed it and stayed put until a family member said, "I'm not sure he knows what he is doing, because you have been a lot worse since you started seeing him."

With my second therapist I steadily improved and always came away from a session feeling better than I went in.

We pay too much for therapy to be ineffective, if it's not working (or is no longer working) the therapist should be the first to realize it and refer the patient to someone else, because the patient may not be able to see it.

My sister & brother-in-law saw a therapist for marriage counseling, and the therapist was the one to say, ok, you're both doing great. Call me again if you ever need anything. He didn't keep them hanging on until they said something, he was the one who said, well done, see you in the future if you need me. I was pretty impressed with that. He honored their progress, and he set them free.

Laura1019 said...

Hi Dinah,

Thanks again for another post that feels validating and supportive! I’ve gone through a tough time personally in the past 3 months with the cpt coding changes and really doing some soul searching about what I do as a psychiatrist and whether it has any validity.

I’ve been thinking about this a lot, and I came to some of the same conclusions you voiced in your post. There are many ways to think about “being in therapy”, whether it’s to try to heal deep wounds from a traumatic past, cope with a serious mood or psychotic disorder or to allow a space for exploring existential issues.

I agree that patients talk with their feet, and I also am known to refer people to other practitioners who have certain therapy skills I don’t have or for a second opinion on meds. My goal is always to strive to understand my patient and do what I can to help them progress. Unfortunately, in this field, that isn’t easy to figure out or make happen quickly. When people are suffering, they want to feel better asap, and there is a lot of pressure to do something NOW, like give a pill. Don’t get me wrong, I think meds are helpful but are only part of the answer most of the time. It can take a good deal of time, to really understand what has caused a person’s difficulty and to do the psychological work it takes to “rewire” (as Dan Siegel would say).

My second choice for what specialty I wanted to go into after medical school was surgery. Sometimes I wish I had chosen something like that where the problem and the solution is more straightforward, but I also love what I do, especially when I’m rested, and confident. I’ve been far from both in the past few months. I’m glad I found your website, it has been very helpful to me as I’ve wrestled with working through the changes we are going through in the profession of psychiatry.

I’m also happy I’ve made the choice to get off the insurance panels, though I still feel worried about how this is impacting some of my patients. Mostly, I think we will be able to work out how to continue together, but I know it has caused stress for them too. It will be good, however, to think less about whether what I’m doing is “medically necessary” and think more about what’s good for the patient.

Sarebear said...

I have stuff to say, but I'm bed-ridden sick these last few days and I just can't pull it together.

If I can sometime soon, I'll comment, otherwise I'll post it on my blog.

Been out of sorts since last fall and hard to interact when my core, my center of where I operate keeps shifting and some days I have contempt for a particular place I operated from with complete confidence the day or week before. I hate this.

Anyway, so I'm kind of under a floorboard, for awhile, hanging back on purpose.

Dinah said...

I guess this is two posts in one.

Katherine, my experience is that anyone who doesn't want to come simply doesn't make another appointment, or if they have one, they leave a voicemail canceling and say they'll call when they want to come in and then don't call. Or call years later. I only treat voluntary outpatients, so anyone who wants to stop is free to do so.

Laura, hang in there. The CPT code stuff will sort out with time. I'm glad Shrink Rap has been helpful to you.

Alison: yes, I agree. I hope people would tell me if they feel they are getting worse.

JJ: if someone feels they are still getting something out of therapy, then that seems like an answer.

SiecnaLina (I apologize for what I've done to your name!): I don't make anyone quit who wants to come. I sometimes suggest more time between appointments.

Usually the question of Why Am I still in Therapy is posed by people who have episodes of mood disorder and they had hoped to get the tools to prevent such episodes. That doesn't always happen, and sometimes the biology of the event just overwhelms their ability to prevent future episodes.

Not everyone gets better (or not all the way), but if someone is getting worse, then a change in treatment, a new therapist, a second opinion or consultation are definitely called for.

I hope that helps.

Anonymous said...

I spoke up finally to my psychiatrist and said that I was no longer going to be on meds for life as they had outlived their purpose. I should have done this years ago as I wasted years of my life.

Personally, I think it is criminal that many of your colleagues take this approach and don't review periodically with patients the need for the med. Yes, I am responsible for not speaking up but what is unconscionable is if I hadn't said anything, I would still be on them.

Oh and by the way, since that time, I have been diagnosed with a medical condition that in my opinion led me to the psych med route. Sadly, if I was still on the meds, I don't think that would have been picked up.

AA

Adolescent Psychiatrist said...

As a psychiatrist, my goal for every single one of my clients is positive change, but the length of time it will take to achieve this positive change totally depends on the client. You've hit on a difficult issue - that wellness can take longer to achieve than a client might expect or wish. It requires patience, cooperation, and discipline to keep working for change. As you've pointed out, there is no quick fix for the issues that bring people to psychiatrists - but we do hope for the quickest (and most holistic) healing possible for our clients.

Anonymous said...

I don't agree with the adolescent psychiatrist that the amount of time it takes to achieve positive change depends upon the patient. I had an ineffective therapist, and I doubt seriously that many clients achieved positive change under his care -- he encouraged dependency and helplessness and looking back on it I suspect he was himself depressed. I wasted too much time (and money) seeing him. The second therapist was mentally stable, goal directed, and no surprise, I improved.

I also think some therapists are too nice and maybe patients aren't challenged as much to change under their care. Super nice doesn't always equal helpful.

Sometimes it's just not a good fit between the patient and therapist. Whatever the reason, though, the therapist should know when to refer them -- and I think continuing to take their money when it's not helping isn't doing the patient any favors. Give them the opportunity to find someone who is a better fit for them and can better help them. I think sometimes patients stay with ineffective therapists because the therapist is nice, but that's not enough. They should expect to improve.

Anonymous said...

I don't agree with the adolescent psychiatrist that the amount of time it takes to achieve positive change depends upon the patient. I had an ineffective therapist, and I doubt seriously that many clients achieved positive change under his care -- he encouraged dependency and helplessness and looking back on it I suspect he was himself depressed. I wasted too much time (and money) seeing him. The second therapist was mentally stable, goal directed, and no surprise, I improved.

I also think some therapists are too nice and maybe patients aren't challenged as much to change under their care. Super nice doesn't always equal helpful.

Sometimes it's just not a good fit between the patient and therapist. Whatever the reason, though, the therapist should know when to refer them -- and I think continuing to take their money when it's not helping isn't doing the patient any favors. Give them the opportunity to find someone who is a better fit for them and can better help them. I think sometimes patients stay with ineffective therapists because the therapist is nice, but that's not enough. They should expect to improve.

Adolescent Psychiatrist said...

Anonymous, thanks for your response to my comment. You bring up a good point in recognizing that ineffective therapy is a factor in treatment length. Of course, this is true.
I used the word "totally," and I realize now it might be misleading.
What I meant in my earlier comment is that differences in situation, history, willingness to be in therapy, and mental state will dramatically differ the length of time a patient spends in therapy.
But if patients and therapists have decided they're a good fit, and progress seems possible, it's worth hanging in there - even if change isn't immediate. The article did contain a good reminder that change is often slow to come by.
You're also right in noting sometimes patients and therapists need to part ways. It's certainly important for therapists to determine whether or not they are the best fit for the patient. Thanks for bringing this up.

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Anonymous said...

I walked away from psychiatry after 10 years on SSRIs and Xanax, after my shrink dismissed my increasing anxiety, insomnia and restlessness as part of my "disease" and not a possible side effect.
He upped my dosages and added more drugs, and when I asked for a referral to a therapist, told me that I was "not a good candidate" for therapy and that all I needed were drugs- for life. Yes, even the benzos, for life, in spite of everything written about the hazards of long term benzo use.
I finally confronted him after going manic on these pills and told him what he could do with his drugs. I looked up discontinuation info on the web and weaned myself, painfully, off of all meds and feel better than I have for years.
My shrink did not take insurance and charged 160 dollars monthly for 10 minute med checks so losing just a few patients would cost him thousands in annual income. That's probably why he was so defensive. But I decided to stop my contribution. let him take his expensive vacations on someone else's dime. And if I need to talk to someone I will find a counselor. No more drugs for me, thank you.