Wednesday, July 11, 2007

You're Supposed to Get Better

In the comment section of my last post, Let Me Tell You About Myself, an anonymous commenter asked the following great question:
If one is comfortable with their therapist and feels the therapist seems to know what they are doing, how much lack of improvement should one tolerate before deciding it's time for a change? I know it's impossible to talk about an exact time frame given different diagnoses and personalities and treatment progress, etc etc, but is there any indication?And if so, what should one do? Bring it up with one's therapist and see what happens, switch therapists, get a second opinion? ...I was in a situation where I made no progress after 40 sessions and 3 drugs, had no experience with other therapists, and didn't think the therapy was going anywhere, but my therapist seemed competent.

Wow, where do I begin? Our questioner uses the term "therapist", and I'm going to substitute "psychiatrist" while I think about this because I'm simply not qualified to answer this from the point of view of another mental health professional. For the sake of this particular question, the fact that I prescribe medications makes, I believe, a huge difference in both who seeks my services and how I view outcome. Oh, and if no one minds, I want to talk about this in a vacuum, free from the discussion of insurance, reimbursement, "medical necessity", and who deserves care.

People come to psychiatric treatment for a variety of reasons, but most commonly because they are having a constellation of symptoms which someone (the patient, a family member, their primary care physician) has identified as being indicative of a mental illness. In plain English: people come to see me because they're feeling badly or acting weirdly. The patient comes with, for example, a complaint of sadness, changes in sleep and/or appetite, hopelessness, decreased energy, thoughts of death or suicide, decreased interest and activity.

A second reason people seek treatment is because they have experienced an overwhelming stress and they feel they are not coping with it well: the stress has resulted in either subjective distress, an inability to function normally, or the stress has precipitated a full-blown psychiatric disorder (back to where we started). For the sake of discussion, we can lump these first two groups of people together as patients with specific symptoms they want resolved.

A third common reason for seeking psychiatric treatment is that the patient is unhappy with the course his life has taken and feels he has maladaptive patterns of behaving and/or interacting which interfere with his ability to love or to work to his full potential. Sometimes people in this situation have personality disorders. Generally, people do not seek psychiatric treatment if they are having normal reactions to bad events or if they have no symptoms and believe they didn't get their last promotion because of bad luck or something completely external to them.

Okay, so Patient Number One, with an acute onset of psychiatric disorder, wants his symptoms relieved. Often, medications are prescribed. Psychotherapy focuses on education about illness and support. People in a state of distress often feel an intense and powerful need to understand Why this has happened and want to talk about the precipitants of the episode, or if there are none obvious, their theories as to what may have gone wrong.

There is often a huge sense of relief simply in the telling of the story and the hopefulness of finding help. If the medications work, the patient often wants to end therapy or to come less often. People who are by nature a bit anxious often feel that regular therapy sessions keep them grounded and prevents recurrence. I don't know that they're right ( studies on Maintenance Psychotherapy, anyone?), however in those with repeated episodes of illness, if they are seen frequently it is easier to catch an episode and intervene early, and the patients who want to continue coming between episodes feel greatly comforted by psychotherapy for reasons that are sometimes difficult to articulate. One patient described therapy as a "safety net", and that's about as good as I've been able to get.

Let's move on to Patient Number Two: the person who is stuck in a bad place and thinks they should be getting more out of life. Sometimes people come to see me with a very specific concern: "I want to work on X" -- oh gosh, maybe feelings about a bad childhood, distress about a romantic relationship gone or going bad. These patients often talk for a few sessions, feel helped, and finish therapy quickly.

What about the patient with a personality disorder who repeatedly foils themselves or views life in a self-defeating way? These patients typically find me because they have a co-existing Axis I disorder -- meaning depression or anxiety or bipolar disorder, as in the last paragraph. But when their symptoms resolve with medications, their problems don't. These patients often continue with psychotherapy for a long time, and the therapy itself (and the therapist!) grow to have meaning above and beyond the issue of Fix the Problem, Doc. The end point becomes foggier, the treatment is more of a process, the goals may be clearly defined, but perhaps unattainable. And the treatment may start with the idea that progress will be slow and even painful. The relationship with the therapist may itself become a focus of attention, and this all gets muddled with what is going on with the illness and the meds and things are often just not so clear. Sometimes, it's not all that obvious exactly what is being worked on in psychotherapy and then, for lack of something that better describes what we do, therapy is deemed a "holding environment." I hate that term, and I like to know we're moving towards something, but that's just not always the case.

So How Long?

For someone seeing a psychiatrist with a psychiatric disorder, medications often provide relief. Medications take different amounts of time, not only to work, but to even tell if they are working. Typically, we say that antidepressants (just to use an example) take 3 to 6 weeks to work and they have to be given at high enough doses. If there is no improvement at all in a month, most psychiatrists will raise the dose or switch the medication. If there is partial response (some of the symptoms either resolved or lessened) then another medication -- an augmenting agent -- may be added. Sometimes it takes trying a bunch of medicines in a bunch of combinations, before results are seen, and this can take a while. If I start talking about antimanic agents and antipsychotics, we'll all be here for a while. As long as the patient is symptomatic and suffering, I believe this should be an active and aggressive process. Sometimes nothing works and all that's to be had for all the efforts are a lot of side effects.

For someone seeing a psychiatrist for an issue of dissatisfaction with their life, then it makes sense to stop and evaluate every few months. Are things getting better? Is there another way to go at the problem or something more or different that can be done? If the answer is repeatedly No Change at All, then it's reasonable to get another opinion or try something completely different.

Sometimes it's all very hard to quantify: even patients who don't get better, who continue to suffer or feel stuck, will identify therapy and the therapist as being helpful. Maybe they should get a second opinion, and often they don't want to.

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