Friday, January 30, 2009

Long Term or Short Term Therapy

I woke up today embarrassed and stressed that I opened up so much in therapy yesterday. Still I stand by my decision to do so. It was important for me to share my feelings for many reasons. One of the big reasons is I have a sort of "magical thinking" that if I tell someone I care for them they will disappear, or the relationship will end. For this reason I avoid telling many people I care about how much I care for them. Yesterday was my brave attempt to believe that speaking my truth will not affect my relationship with Dr. X. Today I feel the fallout and fear of that decision, but I think sometimes I need to challenge these beliefs, despite feeling the terror of impending loss...

On another note:
In my post yesterday, cbtish said...
"Yes, good therapists recognize the feelings on both sides in a therapeutic relationship.But it has to be said that few good therapists now believe therapy lasting many years, or involving the kind of feelings you describe, is likely to have a positive outcome.So it frightens me, too, that you feel you depend on him so much.The thing is, support, kindness and compassion do not actually promote change — instead, they maintain the status quo. Therapy is meant to be about healing. Things actually happen. Tomorrow is different from yesterday."

I would like to discuss my feelings about the benefits for me, of long term, versus short term therapy.

First thank you cbtish for taking the time to comment. I always enjoy hearing other people's opinions. On some level I agree with cbtish. I think for some people, some of the time, short term Cognitive Behavioural Therapy (CBT) may be the most effective treatment. However, I think we need to be careful that our dogmatic beliefs about a particular therapy do not mean we blanket all people with the same kind of therapy, especially if there are times when it is clear that a particular type of treatment may not be what the patient needs in that moment.

I think for me, during the early years of my illness (17-25) when I had had only a few Major Depressive Episodes CBT worked well for me. By the time I was 25 I had been depressed several times at 25 I saw a Counsellor for 6 sessions of CBT and I remained well for approximately two years. It really helped me. The difference is that at that point my illness was less severe and I was able to do the activities I needed to do to help myself become well again.

However, there were a few things every therapist, counsellor, psychologist and the pdoc I saw before Dr. X missed, or misinformed me about, or neglected to inform me about:

  1. That there are medications that can help people. Not a single counsellor/therapist discussed this with me. I discovered this on my own after reading a book about depression. Personally, I think it is negligent to encounter a patient like me, who has had numerous MDE's, and understand that for the most part each seems to last longer and become more severe, yet not inform the patient that medications help some people.

  2. Until Dr. X every Counsellor/Therapist I saw was very rigid in the type of therapy they practiced. One believed in CBT, one believed in Eye Movement Desensitization and Reprocessing. (EMDR), another was Jungian, another Psychodynamic etc. I do not believe for me that a particular therapy is necessarily the best approach. My mood disorder is such that my mood cycles between complete inability to even get out bed sometimes, to highly agitated and anxious, to feeling disconnected from everything, to how I feel right now: extremely motivated, content and relaxed. When I am fatigued and extremely depressed short term CBT, or even the ideas of challenging negative thinking does not help me. I do not have the ability to do the actions I need to do to challenge my negative thinking or to change my behaviour. During these times I need supportive therapy. Therapy that helps me understand it is not my fault I am unable to change, or get better. I need help understanding that guilt about how I am is unproductive. I need to know I am cared for no matter how I feel.

  3. I need different approaches in therapy depending on how my mood is, and what kind of cycle I am in. When anxious I need someone to help me relax, and learn relaxation techniques. I often also need medications to calm me down. When I am high I need someone who is familiar with CBT and can help me set goals and activate my life, because during these times I have the energy and power to change, when I am agitated and depressed I need to have a therapist who is not rattled by my intense suicidal thoughts, someone I know will listen and not judge me, someone who allows me to speak my truth, When I am severely depressed I need someone who understands and helps me learn to participate in activities outside my house; someone who knows I am struggling, but believes I can do things anyways. Sometimes, I just need someone I feel connected to; someone who I believe accepts and cares for me no matter what.

  4. My depression has been treatment resistant believe it is unconscionable to treat a patient for 12-16 sessions, see they were not well still, and end therapy despite the patient remaoning ill. Basically this is what would have happened to me, and happened to me, numerous times. The therapists would treat me, I seemed a bit better, or even much better, but I continuously slipped back into depression. I did not need short term therapy. I needed (and need) long term support to change huge areas of my life, to learn how to make healthier decisions and choices, to learn what kinds of activities drive me forward and which hold me back. My lifestyle has had to change dramatically for me to survive and thrive with and in spite of having this illness. Dramatically changing ones life cannot be done in short term therapy. Personally, for me, I often see that small changes take a very long time. In long term therapy I am able to practice my changes and polish them. I am able to find who I truly am, who I want to be, and how I want to live my life. Before seeing Dr. X I was lead to almost every decision by fear; fear of ending up homeless, jobless, loveless. I am not certain I made any decisions based on what I wanted and enjoyed doing. Long term therapy has allowed me to work through my fear and work towards what stimulates me. I feel I am working towards having a life based on Joy.

I guess what I am saying is there is a time and a place for short term therapy, but to be dogmatic about either short term, or long term therapy is to miss an opportunity to really help a patient change the outline, or structure of their life to one that supports ongoing wellness and resiliency. Patients like me may need ongoing support indefinitely. If I discontinue therapy, it will not be with an eye towards never going back. If I need help again I will return. For me long term therapy, and different types of therapy within my sessions has been extraordinarily effective and helpful . I really believe it is the relationship between the patient and therapist that leads to lasting positive change.

Relationships, trust, and the ability to be truthful and open about all aspects of my life in order that I have the opportunity to address those aspects, can take a long time. The relationship between myself and Dr. X. is strong and I feel safe to make the changes I need to make. I am grateful I have a therapist who understands the psyche may take time to adapt, change, and grow. For me, long term therapy has led to a great deal of positive change; not just surface change, but change that is becoming embedded in my character. This is a great thing.


Dr Shock said...

A very good and long post, will not go in to every detail, just let me tell you I fully agree.
Long term therapy is not about the therapy but very often about politics and money and insurances. Moreover, the possibility for patients to have these kind of therapies as history shows, waxes and wanes. I think we hit the bottom and now were in the up again. Research is showing the benefits of these kind of therapies.

Kind regards Dr Shock

cbtish said...

I agree with almost everything you write here. I particularly agree with the points you make about dogmatism, negligence, rigidity, and blanketing everyone with the same kind of therapy.

However, just one thing you write (in 4.) is itself a dogma:

"Dramatically changing ones life cannot be done in short term therapy."

I understand well that that may be true for you, but it is not generally true. In this CBT practice, and in others I know, dramatic and permanent changes in patients' lives are commonplace.

I would not want to deny the possibility of a life based on joy soon, not sometime in the far future, to all those people who could have it within their grasp, and especially not to those who later say, "For all those years, when I was with that other therapist, I thought I was resistant to treatment."

Handsome B. Wonderful said...

I agree that there isn't one therapy that works for everyone. Some people with short term mental health issues don't need long term therapy.

However, many others need long-term work. Especially if they show a history of suicidality such as myself.

Harriet said...

I originally thought that I wouldn't need to be in therapy for very long, because previous therapies have been short - ie; for fear of flying.

However, now I am dealing with deep seated issues that have taken a long time to develop, and I'm sure will take a long time to work through. I am not happy about this, because I find therapy terrifying. Every week I want to quit. Just the fact that I keep going is therapeutic, regardless of what we talk about.

Aqua said...

Thank you for your comments. You are right cbtish. That statement was dogmatic. Thanks for pointing that out. I have to say in 2nd year university I did see a CBT therapist for 6 sessions and it did dramatically help me for an extended period. So it is possible. On the other hand as my depression became worse CBT was unable to help me. I know I am with the right therapist now. While change has taken me, and is taking me, a long time, the change is deep and addressing issues I was never able to address for me in shorter therapies. Part of the reason chnage is happening is that I have the long term support I require to take the chances I need to change.

Lola Snow said...

This is a great post Aqua, and just goes to show how good a writer you are from a more thoeretical point of view. I think it comes down to what the patient feels works for them, but without disregarding the need at some point to detach and see if the skills we learn in therapy actually stick after therapy ceases.

Personally I still am unsure if the changes I am making now, so long after therapy finished, are due to myself, finally finding the right combination of drugs, or the legacy of therapy. I suspect a combination of all of those elements.

Lola x

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Polar Bear said...

Really good post, Aqua.

I do agree - some people may need long term supportive therapy indefinately. It gets complicated though sometimes when because of lack of resources, such things cannot be practically carried out, particularly for those depending on public services. Like I know that the moment I am considered "well enough" to function generally well, my therapy with V will end. It's possible it will also end once she's "taught" me all the skills I need to know. Alll I can hope for is that when that time comes, I will be OK about endning therapy.

Anonymous said...

your primary diagnosis is borderline personality disorder not MDD. The mood changes you describe are mood switches and common in BPD.

You are not alone. BPD looks similar to Bipolar II, bipolar spectrum disorders (i.e. not bipolar I).