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.