Tuesday, November 3, 2015

When Is Therapy Finished?

     What is the end result of therapy? I really struggle with this question. I think that different therapists with different orientations would, surely, have wildly different answers. Allow me to map this out so that I might better describe the issue later on. There would be a difference between what a directive and non-directive therapist would say. There would be a difference between what a therapist and a client would say. There would be a difference between what an insight and a more behaviorist clinician would say. Different venues would have different goals here. Diagnoses would entail different approaches and result in varied goals. A psychologist, a psychiatrist, and a therapist would describe different goals. A practitioner from the past would detail a different result from a therapist from more recent times. Similarly, a client from years ago and a client now would surely expect an end to therapy at different times.
     I think I will start this short essay with answering these questions/topics and, if I remember, go into my own ideas as to the result of therapy and knowing when therapist is "done."
     A directive therapist versus a non-directive therapist is the first topic I brought up. The locus of control for a true directive therapist would obviously be with that therapist, so the burden of result would be more with the clinician. Now, it must be said that most clinicians are not summarily directive, so this might be a moot point. A non-directive clinician, on an opposite note, will, at their core, leave the client to find the end of therapy. I think that the question here still stands: What is the end result for these two types of psychotherapy? Perhaps this is a confusing question. A better one could be: When does therapy end? or How does one know that therapy should be concluded? Referring back to the example of directive versus non-directive, I think that a directive clinician will halt therapy (if they think that a discharge is positive) when all goals on a treatment plan have been dealt with. This clinician is one that is doing more of the "executive functioning" of the dyad. On the other side of the equation is the non-directive therapist. When is therapy done in that situation? This is a much more difficult question. A client who is ready to release himself or herself from that type of therapy is one who has the skills, confidence, and reason to do it. Either that, or he'she just stops coming to therapy (which, while here being a jab at non-directionalism, is very true of most therapy types).
     What about a each person in the relationship? When would a clinician be able to say that a client is ready to leave therapy and when would a client know that they are done with it? I think that the first question is much easier to answer than the second, as I can speak through the lens of orientation or general counseling theory, while the latter has only a lens of personality or subjectivity. I would like to get into theoretical orientation later, if I remember, so I think that at this time I can speak from a more general viewpoint. In general, a counselor knows that a client is ready to leave if he'she shows a marked decrease in distress in their lives and can deal with situations in such a way that leads to minimal discomfort and no psychiatric disorders. As mentioned, it is difficult to adhere to an idea of an individual client (and his/her ideal self post-therapy) because each client is very different. To some degree, I think that the end result that a client is looking for is probably very similar to the generic counselor in his comparison. Frequently, in my short-lived experience, clients tend to disengage from therapy before their therapist intends. Barring bad match-ups and negative dialogue, clients seem to frequently want more instant gratification therapy; that is, clients want tools to help them decrease their stress immediately with minimal insight. In my opinion, it takes a special client who really wants to look deeply into themselves and reveal (as well as sometimes combat) what is there. These clients are looking for self-development and understanding and frequently only leave therapy when they have found that. Some want to undergo very intense therapy and frequently require little of the therapist outside a gentle nudge or permission/validation to continue their talk, needing more of a safe space to discuss themselves with themselves.
     Going on with this subject in a slightly different manner, an insight therapist and a more new-age symptoms-based therapist would have very different ideas as to what constitutes a "recovered" or "cured" client. I think that an insight- or depth-based therapist looks for a client, to some degree, to self-assess their own condition. This is in contrast to the more behavioral therapist who operates based on scaling and other more quantitative measures. It must be said that the former clinician will most likely have their client for longer than the latter therapist.
     It is important to look at where the client is being helped. If the client is at a clinic attached to a hospital, I think that the former scaling rules used would very much inform when a client is discharged or when they choose to leave treatment. Depending on the topic of treatment, a "cured" client is most likely one who shows minimal to no behaviors that plagued them before and pushed them to enter some kind of treatment to begin with. In a private-practice setting, it is possible that the client stays very long in that setting - which depends much on the client's identified concern(s) and/or the orientation or plan of the therapist. There are, of course, many different venues for therapy to occur, and each one has myriad different variables to take into account when this essay's question presents itself.
     I think that the next section is probably both the most interest academically, as well as the easiest one to talk about. Because this part has to do with diagnoses, there is an already set framework upon which to work, specifically symptoms and diagnostic criteria of the DSM 5. This section is easy because we are looking at set criteria. If these criteria dissipate, then we can easily make the case that the client should be discharged. Again, in my opinion, it is always good to check-in with the client to ascertain their viewpoint on the subject. Many venues, such as progressive private practices, might not diagnose or use diagnoses at all, so this venue cannot use symptoms, as such, as a criterion to discharge or recognize a client as able to leave treatment.
     Let us look at differences between what a psychologist, a psychiatrist, and a therapist would deem an appropriate as an end to therapy. I must preface this by saying that I am talking through my own lens and cannot completely see nor understand the intricacies of the other jobs (nor, indeed, all of them in my chosen field). A psychologist, in my opinion, uses many numerical measures. They might scale, as previously discussed, in order to ascertain whether a client is finished with therapy. There are many psychologists who act more like therapists and I would understand them more through the lens of a therapist. A psychiatrist, especially a more new-world one who is more interested in medication than true therapy, might see a reduction in certain symptoms as a basis for an end of therapy and a proclamation of a cured client. An unfortunate issue here has to do with the many medications from many psychiatrists being taken for a lifetime instead of being tapered off (when possible) and replaced with a strengths-based talk therapy regime. I believe that I already have revealed my own thoughts about how I see counselors acting in this frame and will ask the reader to refer back to those words rather than repeat them.
     The last two points have to do with the past: How would psychotherapists from the past know when/if a client is done with therapy? and How would a client from the past know this?  I will answer this in one paragraph as a I think that the latter question is very dependent on the former. It is my opinion that many clients in the further-flung past (early 1900s) held their therapists in such high esteem that their therapist was the one to end the relationship, frequently whether or not the client agreed. In Freudian terms, a client was in denial when resisting treatment, something he saw as a great step forward in treatment, as it signaled that the client was avoiding the clinician due to issues being uncovered that were uncomfortable and, therefore, important. These therapists (and I am speaking specifically of analysts) frequently kept clients for years, so an end to therapy was very infrequent for them.

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