Sacramento Street Psychiatry

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"I Don't Want to be in Therapy Forever!"

When is enough therapy enough?

In this age of managed care it may seem surprising, perhaps even suspicious, that traditional psychodynamic therapy is designed to be open-ended, with no fixed number of sessions or duration. This can be anxiety-provoking both to third-party payers, e.g., insurance companies, who prefer to know from the start how much a treatment will cost, and to the patient, who also invests money, time, and emotional commitment into treatment. In addition, many patients find themselves uncomfortable with a growing sense of reliance or dependence upon the therapist, a feeling intensified by the lack of a defined stopping point. Part-way through the process many patients muster the courage to ask: "How will I know when to stop? I don't want to be in therapy forever!"

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In contrast to traditional open-ended, exploratory psychotherapy, shorter-term manualized therapies have gained prominence in recent decades. Based on psychodynamic, cognitive-behavioral, or other schools of thought, these treatments, often 12 to 16 sessions in length and with a defined beginning, middle, and end, appeal both to third-party payers and to many patients. Solid research evidence supports these shorter-term therapies as effective treatment for depression, anxiety, and other common symptoms. They are particularly suited for addressing well-defined fears (flying, spiders, public speaking, etc.), shyness in dating or other social situations, depression after a recent loss, and the confusing squirl of chaotic feelings after a relationship ends. The advantages of time-limited treatment are fairly self-evident; one sensibly wonders why anyone would choose the older open-ended alternative.

In contrast to time-limited therapies, traditional exploratory treatment invites wide-ranging discussion of thoughts and feelings; it is not limited to a specific topic or concern. It also has a timeless quality: If a topic doesn't arise today, it may arise next week or next month. A person avoids talking about troubling issues for only so long; eventually even the most shameful or ineffable topics are broached, detoxified, and worked through. Thus, open-ended therapy excels when problems are ill-defined or hard to talk about; when one is vaguely yet pervasively dissatisfied or frustrated with career, relationships, self-identity, or other central aspects of life.

Open-ended treatment tends to be less directive — steered less by the therapist — and thus more conducive to promoting and observing transference. And since transference interpretation is one of the best ways to bring unconscious thoughts and feelings into consciousness, open-ended therapy is well-suited for problems that originate outside the patient's conscious awareness.

Open-ended therapy can be more anxiety provoking than time-limited varieties. There is no set agenda, no obvious protocol or series of treatment steps. It is hard to know how "far along" one is, and sometimes it isn't clear whether any real change is taking place. The "active ingredient" that makes therapy work is less a matter of technique and more a result of a certain type of human relationship.

In the midst of all this murkiness, patients note subtle progress over time. Relationships gradually feel less frustrating, career decisions less intractable. But when does this process stop? The answer is simple and complex at the same time. On the one hand, therapy naturally ends when a patient "got what they came for." Feeling fundamentally satisfied with life is a good indication. Since this is subjective, no one can say except the patient him or herself, who often takes further investment of time and money into account as well. On the other hand, dynamic therapists consider a therapy complete when all major areas and conflicts of life have been discussed, explored, and resolved in some manner. As many of these conflicts are unconscious, this assessment is made by the therapist, not patient, and can be quite complex.

Neither the patient nor the therapist wants therapy to last forever. Ultimately our job as therapists is to make ourselves obsolete. Nonetheless, the nature of open-ended dynamic treatment provokes concerns about dependency and "getting too comfortable" with therapy, and often elicits a reactive fear that therapy might last forever if the patient isn't careful. These feelings are themselves well worth discussing in therapy; their resolution brings the patient a big step closer to an ending both parties can endorse. For more on this topic, see here and here.

Copyright Steven Reidbord MD.

Steven Reidbord, M.D., is a psychiatrist and psychiatric educator, and chairs the Continuing Medical Education Committee at California Pacific Medical Center.

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