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Type of therapy affects conclusion

There's no single way to decide how, when and why to wrap up talk treatment. But doing it well may solidify gains.

October 08, 2007|Janet Cromley | Times Staff Writer

You've been in psychotherapy for awhile, and you're feeling better. Much better. Is it time to quit?

The answer is based, in large part, on the type of treatment. "When to end therapy depends on context and diagnosis," says Dr. Gary Kennedy, director of geriatric psychiatry at Montefiore Medical Center in New York.

Certain types of treatment, such as cognitive behavior therapy, are designed to relieve disorders such as mild depression or anxiety in a short period, and the end is almost predetermined. The therapist lays out a plan with the client, sometimes with goals set by the client, and executes the plan over a few months.

These therapists may even use questionnaires for measuring progress on particular concerns, such as levels of anxiety or depression.

With this type of therapy, the treatment is done when symptoms have been reduced, based on the client's own assessment that he or she is feeling better and coping better.

"Cognitive behavior therapy is focused and goal-oriented," says Emanuel Maidenberg, a UCLA associate clinical professor of psychiatry who uses cognitive behavior therapy to treat anxiety and depression.

"From the very beginning, my client and I have developed specific goals that are measurable by definition," Maidenberg says.

"We're done when both of us know that we've achieved most or all of these goals -- when you believe that you can cope with whatever life is going to present you with."

The end point is less clear cut with more explorative types of approaches, such as psychodynamic therapy, in which the goal is to examine unconscious motivations and get to the "why" of the feelings and behavior. This type of therapy tends to be open-ended and the decision to end is more subjective.

Nevertheless, a natural end point for the patient "is when their issues are resolved, their relationships are better, they have their lives under better control," says Dr. Marcia Kraft Goin, a professor of clinical psychiatry at USC's Keck School of Medicine and past president of the American Psychiatric Assn.

Sometimes the patient will initiate the conversation about it and sometimes the therapist will, she says.

In addition, there's no shame in reevaluating therapy, whatever the kind, if it clearly isn't working, writes psychotherapist Barry Reynolds, executive director of USC's Psychology Services Center, in an e-mail.

"Psychologists and other therapists are obligated by their ethics codes to talk with clients about an apparent lack of progress after six months or so," he says. "The therapist should consider a change in the therapy procedures or a referral to an alternative therapist."

Some therapists will wean the patient off therapy slowly. "I might suggest that we not meet the next week," Kennedy says, "and then perhaps suggest that we meet in a month, and maybe in the next two or three months, then maybe call as needed."

Terminating therapy is particularly problematic for patients with certain types of mental illness -- such as repeated bouts of clinical depression -- that require extensive therapy.

"If you have a chronic relapsing illness," Kennedy says, "the likelihood is that you're going to need some form of ongoing psychotherapy -- that could be in the form of counseling or a supportive relationship."

"If you think about it," he says, "we don't think of diabetes or hypertension or congestive heart failure as illnesses where you're going to take medication episodically. We think of these as illnesses where you need treatment for the long run."

Goin believes that handling the termination properly may be key to sustaining gains made in therapy.

"In psychodynamic therapy, we believe the beginning, middle and the end" are all part of the process, she says. "It's very important not to suddenly one day come in and say 'goodbye,' but to spend a little time talking about the leaving, the saying goodbye, in order to consolidate the gains."

For some, saying goodbye might require scaling back their dreams of a miracle recovery.

"There are hopes and expectations that people have when they come to therapy that in many cases don't happen," Goin says. "So we talk about limitations and disappointments as well as the positive things that have happened in therapy. That way it doesn't go underground and sabotage the good work the patient has done."

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janet.c romley@latimes.com

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