Therapy: How do you know when you’ve had enough?

by Thomas Ellis, PsyD, ABPP on August 19, 2010 · 3 comments

in therapy

“All those years, all that money….”

So begins “My Life in Therapy,” an autobiographical saga that appeared recently in The New York Times Magazine. Here, Daphne Merkin writes in great detail about her 40-plus years (!) in therapy, mostly psychoanalysis. Early in the piece, she starkly declares,

“To this day, I’m not sure that I am in possession of substantially greater self-knowledge than someone who has never been inside a therapist’s office.”

Oof.

At this writing, more than 600 comments to her article have been posted online, ranging from “Thank you for this eloquent and insightful account” to “Grow up and get a life!” By eyeball reckoning, the latter outnumber the former by at least 2 to 1.

What’s interesting (ironically) is that Ms. Merkin never quite comes out and says how she feels about her therapy experience – whether she is satisfied, frustrated about the time and money, enraged about the lack of results or grateful for having had the opportunity. Perhaps some of each.

Reading the article brings to mind a fairly common question raised by therapy patients: How do I know when it’s time to stop therapy? To the casual observer, this is a silly question: Obviously, you stop when the problem is resolved – the panic attacks stop or the depression lifts.

But as you know if you’ve been there, sometimes it’s not so simple:

If my problem is low self-esteem, how do I know when I have “enough” of it? Ditto for reducing one’s stress level or increasing assertiveness. Not to mention more nebulous objectives such as figuring out who I am or finding intimacy in relationships.

Sadly, therapists are often of little help here. Patients asking this question may be met with platitudes such as “Things take time,” or simply more questions, such as “What do you think it means that you ask this question?”

Well, as Freud famously commented, sometimes a cigar is just a cigar, and sometimes a question deserves an answer!

Here’s the short answer: Therapy should end when your goals have been reached or when it becomes apparent that it’s not helping.

Two qualifications: “Supportive” therapy may go on for extended periods of time without apparent progress in the sense that a “cure” is never achieved, but the individual needs help to prevent relapse or severe deterioration. Such therapy, while life-sustaining for some, is quite different from what Ms. Merkin describes.

Second, therapy for the purpose of personal growth and self-knowledge may not fit the framework presented here. I think this may be why Ms. Merkin isn’t more upset: Her therapy may have been more about the journey than the destination.

Fair enough. But it’s my impression that relatively few people enter therapy with the equivalent of a EuroRail pass, without limits on time or money, just traveling for the sake of the scenery. Most are interested in results – a destination, if you will – and most, in my experience, would opt for the quicker, rather than the scenic, route.

If this is where you are “coming from,” then your best bet is to talk frankly with your therapist, preferably early in the therapy process. Now not all therapists speak this “language” (important information, in my opinion), but many, perhaps most, will be more than happy to “go there” with you.

So, what should you discuss? There are actually two related questions here:

  1. What exactly are we trying to accomplish?

  2. Are we there yet?

You’ll notice right away that it’s difficult to answer the second question without a clear answer to the first. The first, in turn, requires “operationalized” goals. This means defining your objectives in ways that are specific and observable.

For example, “being better adjusted” is hard to measure and means different things to different people. But if you were asked, “What would we see if you were better adjusted?” you might list things like worrying less, socializing more and sleeping better, all of which can be measured.

Even an apparently straightforward goal like “overcoming my depression” is too vague, because it may mean one thing to you and something quite different to your therapist. But exploring this together with your therapist might help identify goals like crying less often, resuming sexual activity, reducing indecision and thinking better of yourself, all of which reflect recovery from depression. Such goals are observable and less impressionistic than simply wondering if you are “getting better.”

Another goal to consider (a given with many therapists) is the internalization of the therapeutic process, what some refer to as “becoming your own therapist.” This is important when it comes to relying on yourself rather than needing to re-enter therapy whenever life presents you with new challenges.

So, here’s the bottom line: It’s time to end therapy when you determine that your goals have been met (unless, of course, you want to set some new goals). On the other hand, it may also be time to stop (or make a change) if, after reasonable time and effort, your goals haven’t been achieved. The definition of “reasonable” is a matter of opinion, of course, but let’s hope that it’s well this side of 40 years.

Be Sociable, Share!

{ 3 comments… read them below or add one }

Elizabeth Doherty Thomas August 30, 2010 at 3:43 pm

I love this post. It gets to the heart of the matter. What IS therapy? What CHANGE is possible inside the therapy room? How do you measure squishy things like “self esteem?” As I embark on the journey towards becoming a therapy I’ve been reading books by many wise therapists. It’s very useful before I get pulled into the humdrum of graduate school, theories, modalities, techniques, to have spent all this time exploring the core of what the heck “it” even is! I think there is a huge missing link between what therapy is and how therapists market themselves. It is true that NYT article is going to scare a lot of people away and that is tragic.

Tom Ellis August 24, 2010 at 11:44 am

David,
Thanks for your comment. I suspect you are right, in that a bright person like this doesn’t keep investing so much time and money in something with no payoff. My greater concern, which motivated my commentary, were her disheartening statements that “Therapy…is never about finding a cure for what ails you…There is no absolute goal…it’s possible to stay in therapy forever without much real progress.” Extreme statements like this could deter untold numbers of people from getting the help that they need. I don’t fault Merkin for this so much as the NYT editors who apparently failed to get input from clinicians who might have been able to help get rid of some chaff while retaining the wheat.

David Ness August 23, 2010 at 11:31 am

I think that this article has been interpreted (e.g., in this week’s letters to the NYT Magazine) more negatively than it deserves, by and large. Perhaps the problem is that perhaps the best articulated outcome of her therapy comes at the very end — only after all of her harping on the shortcomings. Her conclusion is poignant and moving; it would be hard to find a more meaningful and humble assessment of what we therapists can realistically give to our patients in emotional need. She says,
“Therapy, you might say, became a kind of release valve for my life; it gave me a place to say the things I could say nowhere else, express the feelings that would be laughed at or frowned upon in the outside world — and in so doing helped to alleviate the insistent pressure of my darker thoughts. It buffered me as well as prodded me forward; above all, it provided a space for interior examination, an education in disillusioned realism that existed nowhere else on this cacophonous, frantic planet.”

Leave a Comment

Previous post:

Next post: