Monday, September 12, 2011

Enough Already?

The radio station I listen to on the way to work has a segment every morning where people call or text in to vent (briefly) about what they've had enough of - tag line, you guessed it, "enough already!"

Something I've had enough of is clients asking for treatment, then backing out, or worse, disappearing after a few (or many) sessions. I understand that ambivalence and complicated lives are behind this phenomenon...but it's frustrating! I have open cases languishing because I'm not getting a response to outreach, I have half-completed charts because people only came once, or I have an unsettled feeling wondering what became of clients who came for awhile before disappearing without a trace.

Today, someone I was assigned as a new client in July, but never met because he didn't respond to any outreach, at the time, or after he left a message a month later, showed up unannounced wanting to be seen. I was suspicious, wondering why he keeps popping up sounding desperate, only to disappear when offered an appointment. The clinical director met with him to ask about this pattern, and learned that he has been having frequent flashbacks after seeing a triggering film. She told me that he does seem "desperate" as a result of these debilitating symptoms, and would probably come "every day if he could."

My (cynical) initial response was that he might come every day for a week, but then stop coming at all once he started feeling a little better. My feeling was, why bother starting treatment if he's going to drop out before we get to any "real" therapy?

But then I started thinking about it some more. Many therapists tend to see "real therapy" as longer-term work to resolve the core issues underlying whatever the presenting symptoms are - assuming that, even if the symptoms abate, the person may experience a relapse of the same or new symptoms if the core issues are left unresolved. In contrast, the theory behind "brief" therapies (and yes, there is theory rather than just insurance behind brief treatment!) contends that the most "work" in therapy happens in concentrated spurts, often fueled by some sort of crisis. People work through the crisis at hand, resolve or at least reorganize some issues, and when the acute discomfort has passed, lull into a less-fruitful use of therapy. So, since the work and the crises are episodic anyway, advocates of brief treatment recommend seeing people for a predetermined period of time, terminating, and then allowing them to return if they desire when another crisis occurs and they are ready to do another "piece" of the work.

This piecemeal approach to therapy isn't as pretty a theory as longer-term full therapy - but I do have to acknowledge that it may be just as useful. Having people come when there is an impetus for change, but not come once that impetus passes, could result in just as much progress as having them come consistently. Maybe the short span of treatment is "enough already" - or at least enough for now. It may leave some things up in the air, and I wouldn't get the pleasure of seeing how people are doing, and how their stories progress - but, it's not about me, anyway! And sometimes I think clients and clinicians continue therapy after the work is "done" because it's comfortable (but that's a topic for another post).

So, what do you think? Are short-term therapist just as useful, or more so, compared to long-term treatment? Or does the consistency and stability of a long-term therapy relationship matter more than momentum?

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