Good therapist, bad therapist, indifferent therapist-how to tell from the outside?

March 10, 2012 9:15 AM

How do you assess a therapist when it's not you that's going through therapy?

My husband is bipolar. The mania is long in his past - I've never seen him manic in over a decade of marriage plus several years of friendship - it manifests exclusively as depression and anxiety. After many years of general stability, the past couple of years have involved a lot of medicine changes, a worsening of his depression and anxiety, and, in short, a lot of challenges. He is currently seeing a person who manages his medication, and a CBT therapist.

I'm his primary support and advocate, and I'm having a hard time working out whether or not his therapist is the right one for him, if they need more time (she's been seeing him for about a year). He's very emotional at their sessions, and frequently cries through them. For a time, he wasn't able to remember much of anything that happened at them, although this has improved slightly. He also tends to feel hopeless about whether or not the therapy is actually helping, although he does the homework when I nudge. (Left to his own devices, I think he'd abandon therapy. Deep down, he tends to think of his illness as something he can't really fight back against, or something that can only be helped with medication.) When I ask him if he thinks that he is getting something out of the therapy, he says he's not sure, and doesn't know if he should look for a different therapist or not. I've thought about DBT as an alternative to CBT (a suggestion that was made at one point), but finding one in our city might be a little difficult.

As the person not going through therapy, I'm not sure how to help. Perhaps he just needs more time, but perhaps this therapist isn't really helping all that much - I have no idea how to tell. He's improved, but he's nowhere near stable, although he has developed enough management of his anxiety that he hasn't had a panic attack in about a year which I look at as really concrete progress. The idea of failure and failing is a big issue with him right now, and I think he goes back and forth between thinking that therapy is failing him, or he is failing at therapy. Is there a way to know if his therapist is right for him, or is this a decision I need to leave with him? Are there things I can be doing to bolster his therapy at home? I've considered getting some of the anxiety workbooks and doing them at home with him, together - he'd be more likely to do it if I were involved, and as I suffer from (mild) anxiety myself, the idea of getting some good strategies for coping with it myself is not a bad thing. But I worry about butting into areas where trained professionals are working.

posted by anonymous to health & fitness (9 answers total)

Do you have the option of attending some therapy sessions with him, either with this therapist or an additional therapist?

He sounds like he's very lucky to be married to you.
posted by alphanerd at 9:27 AM on March 10, 2012 [7 favorites]

Have you met with the therapist for a joint session? Personally, I think when one part of a long term couple are in therapy the therapist should get everyone on the same page by meeting at least once a year. What about booking joint sessions with another therapist to explore the issues of what he should be looking for in therapy, how you can support him and how to keep your relationship healthy.
posted by saucysault at 9:44 AM on March 10, 2012

Most therapists in my experience would be open to a joint session with a patient and spouse.

I don't want to be all Armchair Diagnosis Bozo here, but "he can't remember anything from his CBT sessions" doesn't really sound like the usual experience of a patient whose only diagnosis is bipolar disorder, and whose only symptom is depression. Has he been evaluated by a psychiatrist recently? Or maybe a neurologist?
posted by Sidhedevil at 9:53 AM on March 10, 2012

What sticks out to me is all the medicine changes. It's not clear from your post if his symptoms precipitated the medicine changes, or vice-versa, so that is something to consider.

It sounds like you and your husband know what a good, stable run for him really looks like - maybe he has a hard time now communicating that to the therapist (or psychiatrist). Is he open to the idea of you joining him for a session? I would think that would be the place to start if he wants help from you in maximizing what he gets out of the therapy.
posted by stowaway at 10:01 AM on March 10, 2012

To unpack a bit on "has he been evaluated by a psychiatrist"--you say that he is seeing someone (presumably a psychiatrist) to "manage medication." In my experience, "medication management" sessions are really brief (mine are 15 minutes) and rely on patient self-reporting.

If your husband hasn't told his psychiatrist that he had such extreme difficulty remembering the content of his CBT sessions, I think that's an important datapoint for him to share, and one that might indicate the need for a re-evaluation.
posted by Sidhedevil at 10:04 AM on March 10, 2012

From the OP:

To clarify - when he says he can't remember what occurs during the sessions, it's not that he blacks out or is impaired, but that he's usually very emotional or crying to the point where he doesn't hear or retain much. His memory was slightly impaired by ECT, which stabilized him during the worst of the depression (and is why he really, really wants to avoid going down that road again) but this specific issue doesn't seem to be anything cognitive - he's just too distracted and upset to come away from the sessions with much. I think his therapist has been combating this with a lot of repetition (and written instructions that come home with him) but it looks like, from the outside, that they've been stuck covering the same ground for a long time. And maybe that's just what needs to happen. Sometimes it seems like the best thing that happens at the sessions is that he gets cuddle time with her two awesome therapy dogs.

The end of the period of stability was the result of his medication losing effectiveness after many years, and the struggle to find new ones that worked (combined with environmental stress of unemployment - he's now on disability, which helps us financially but doesn't do much for his sense of self-worth).  Looking back, we should have had him in therapy for all those years of stability, so he could work on stuff from a position of strength, but unfortunately neither of us recognized that at the time.

I've had one joint session with his therapist, and I think the idea to sit in on more sessions sounds like a good strategy.  

posted by jessamyn at 11:03 AM on March 10, 2012

There is just not enough information to get a handle on what is going on.
When was he diagnosed? How long has he been unemployed? What did he do? How old are you two? How long have you been married? What medication has he been on/is he on? What do you know about this therapist? MSW? Supportive therapy?
How I could go on.
posted by provoliminal at 12:25 PM on March 10, 2012

Two possibly unhelpful lines of thought to supplement some great thoughts above (especially RE: possible joint session and RE: the medication changes):

* What was his mania like in the past? How certain are you guys that your husband's "really" bipolar? (You could be very very certain in fact, I just don't know from this description!)... Theoretically, is there a differential diagnosis? It's interesting that he's bipolar but there's been no sign of any mania--major or hypomania--in over ten years... I'm not sure if this is typical or not for a bipolar I/II diagnosis as bipolar disorders aren't at all my specialty.

* If CBT-style therapy doesn't really seem to hack it for your husband, has your husband considered seeking another style of therapy (e.g., psychodynamic, interpersonal, emotion-focused/experiential; all of which have some evidence base for depression)?
posted by Keter at 3:53 PM on March 10, 2012

The thing about therapy is, it serves two totally different purposes:

1) It helps you make progress towards changing your patterns, emotional responses, and/or thoughts (but you have to do the work - like having a coach train you for a sport, the heavy lifting is on your end.)
2) It helps you "hang on" when you're in a crisis, provides a sense that you're being listened to, gives the medical community a chance to keep tabs on your current state of mind, etc.

For me, as a bipolar/anxious/etc. person, purpose #1 is only achievable if my medication is working effectively and I'm basically healthy. And purpose #1 sounds like most of what you're worried about right now.

For me, again, when I'm in the middle of a huge depressive episode, therapy can take the edge off the worst of my reactions, give me a little bit of a different perspective, help me remember that I am cared for and there are other options, etc. But it doesn't solve much of anything, because the real benefits of therapy as a solution-maker are simply not possible for me right then. The progress I make in therapy in the middle of a depressive episode is minor, transient, and hard for me to even notice - it's stuff like "I chose to get out of bed and sit on the couch feeling sad, rather than slept the whole day as I really desperately wanted to." Or, "I managed to stop pulling my eyebrows out after five minutes, a little after I realized I was doing it, instead of it taking till my skin was raw and bleeding and there were no hairs left to pull."

And that's not the fault of my therapy team at all. It's just the reality of what therapy - any kind of therapy - can actually accomplish.

I definitely think joint sessions are a good idea, but I do want to caution you about your expectations.

And I second the advice to get a few longer sessions with a psychiatrist - not a GP, not a nurse practitioner - until real progress is being made again. My psychiatrist ups my appointments from 15 minutes once a month to 30 minutes every other week when things are really not working (and before I was having to see her every 30 days for ADHD med refills, she would go from 15 minutes every two months to 30 minutes every two weeks, for a major depressive relapse.)

You also may want to look into participating in more outside support stuff - NAMI groups, DBSA groups, the Bipolar Bears, a local clubhouse, etc. The daily support of the partial hospitalization program was really helpful to me, even though there were days I seemed to get very little progress from it - the frequency of the contact with other people in recovery and with mental health providers was beneficial and kept me from going "down" between sessions. Almost everyone there agreed that things were "harder on the weekends," indicating this aspect of the program was helpful to them, too. If you're in the US, your state's department of vocational rehabilitation, NAMI, and your local branch of Mental Health America are all good places to try and find this kind of support organization. One of the people in my partial program was attending four different groups - one weekly, two monthly, and one somewhere between the two - and it really seemed to help him. He also really enjoyed the sense that he and his wife were able to help others, even though he was really badly off at the time - and he was inspired by the people who had "come so far" that still attended and tried to help/gain strength from others in the groups.

Oh, and there have totally been days where I was either too out of it or too emotionally worked up to be able to articulate what happened in therapy, even in a private journal and given plenty of time/space to figure it out. Therapy is hard work, and it gets harder the worse off you are chemically, in my experience. Therapist competency is sometimes a factor, but not that much.

(Feel free to MeMail me if you like. I was off work for two months for a major depressive episode last year and have some experience with the "is this therapy working for me" question. I'm also happy to email with your husband directly.)
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 2:19 PM on March 11, 2012 [1 favorite]