Some things never change: A question about the effectiveness of therapy
December 2, 2018 10:46 AM   Subscribe

Lately I’ve been reflecting on old questions that I’ve asked the MeFi community when I’ve been depressed, namely this one and this one. I’m finding that a lot of the behaviors that I mentioned, unfortunately, have stuck. Do some things really never change?

A few examples of the negative behaviors that have stuck are: a really shitty, negative attitude most of the time; severe reclusiveness; an inability to mobilize; poor health; etcetera, etcetera.

After a full decade of depression and anxiety, and an especially rough past four years, things are finally starting to look up. However, a lot of the negative behaviors, attitudes, and lifestyle choices have yet to be changed. I’ve been in therapy weekly for a just over a year and started seeing my psychiatrist again monthly as of six months ago. My psychiatrist switched me from Abilify to Vraylar which has been a literal life saver for me, but I feel like being in therapy hasn’t done a damn thing for me.

My therapist tries to assure me that I’m better off than I was when I started seeing him, but aside from a very few external things ive changed I still feel like the same unfortunate soul I’ve been for the three years prior to seeing him. He often tells me that I’m being impatient with life changes and the therapy process, but I feel like a year is long enough to see some change. Basically, while I definitely am trying to change external circumstances, I’m more-so trying to change who I am, and I feel like he just isn’t helping in these areas. This often leaves me feeling even more frustrated with myself for not making these changes, as well as with him for not helping me make these changes. I have vocalized this with him several times before, but nothing seems to change.

So what exactly is going on here? Does some behavior never really change, or am I truly being too impatient as he suggests? Really, I’m just wanting some classic “breakthrough sessions”, and that just isn’t happening.

Also, I’ve invested a lot of time and money into this particular therapist and would rather not need to find a new one unless absolutely necessary.

Demographic info for reference: 28 year old straight, white male.
posted by omgkinky to Human Relations (14 answers total) 9 users marked this as a favorite
It took me a good 2 years with the same therapist before I felt real changes. If your rapport is good, I say stick with it a while longer.
posted by 8603 at 10:53 AM on December 2, 2018 [1 favorite]

I can confirm 8603's experience (tho of course everyone is different). I was in therapy for 2.5 years. The first few months I felt I was discovering a lot about myself. Then I felt quite stuck for aaaages and wanted to give up a few times. The two year mark I think was where I really saw things looking up, and we finally wrapped it up half a year later.

Before that, I was a depressed alcoholic for 8 years. Now, I've been a happy, balanced person with mostly healthy habits for 6 years. So it's certainly possible! You need to decide for yourself whether you want to switch therapists. If you're not getting what you want out of it, then surely you're just wasting more money. But you can also bring it up again and ask to make a plan / goals to stick to etc. I did this a few times with mine, and if it all fizzled out it was mostly my fault. I mean, the work in therapy should mostly come from you. They're just a facilitator, they're not going to "fix" you.
posted by ClarissaWAM at 11:02 AM on December 2, 2018 [2 favorites]

I know it doesn’t seem that way to you, but 28 is *extremely* young, especially for a man. And really, I think being in your 20s sucks. It’s just a hard time for everyone, especially if you’re prone to depression and sadness, because you’re still trying to figure out relationships, work, etc.

Just to give you my own experience: I was in therapy with the same person for 14 years beginning when was I was a lot older than you — 37, to be exact. I was really pretty messed up and had very serious psych issues, so he sent me to a psychopharmacologist for those, but I was in talk therapy the entire time. It took a lot of time and a lot of hard, dirty, and scary work, but I’m so much better now that I sometimes can’t believe I’m the same person I was 15 years ago. It takes a long time to change.

But I also believe for therapy to be effective, you really have to get with the right person. If you feel like your therapist isn’t working for you, don’t become a victim to the sunk costs fallacy, especially for something this important.
posted by holborne at 1:21 PM on December 2, 2018 [4 favorites]

What type of therapy are you in? I’m just a layperson but I think of talk therapy (like psychodynamic) as helping with personal insights while CBT is better for behavioral change.
posted by JenMarie at 2:21 PM on December 2, 2018 [2 favorites]

There are studies showing that external changes tend to happen more quickly than internal changes in therapy. As a therapist, I tend to assume that when I start seeing behavioral changes, that's the first step, and it's likely to take six months to a year of continued progress for the client to really feel the changes.

That said, "I’m more-so trying to change who I am" is a HUGE goal, and I would counsel a client that such a big goal would require six to eight years of weekly therapy. I don't know if you're overstating for effect here, but if you're not, you need to recognize that your goal is larger than a lot of therapy clients'. Which doesn't mean it's unattainable, just that it will take some time.
posted by lazuli at 6:53 PM on December 2, 2018 [1 favorite]

In my therapy it took a few years.

Looking back I think of it like year one was about looking at what other people had constructed in Lego pieces and deciding if they were okay or not okay and taking them apart. Year two was about sorting all the little bits and categorizing them. Year three was about starting to build things with the pieces I had.

Maybe what you need is to test out your changes by tackling one thing you can measure. Out of what you've listed above, I wonder if setting some goals around being reclusive would help, since that's something that is both kind of internal and how you feel/think, but also involves tracking how often you go out, reach out to people, put yourselves in social situations, etc. In other words, pick something to build and see how the Lego pieces you have so far stack up.
posted by warriorqueen at 7:10 PM on December 2, 2018 [1 favorite]

This question resonates with me. I've been seeing my current therapist for four months, and I'm starting to feel resentment over the cult of therapy and my lack of progress.

And it's expensive! This is not cheap. There are real opportunity costs. I could have hired a personal trainer. I could have hired an escort - multiple escorts. I could have gone on my first adult vacation. I shared things that are deeply personal and painful.

The therapist says that I'm getting better. I don't think that's true, I think that's something they all say. Going in, I experienced extreme daily mental torment at work, shame, anxiety, low self-esteem, no friends, no social circle and no sexual history. All of that is still true four months later.

I'm already introspective. I don't need help looking inward. I've done that for decades.

To be fair, I'm a gay forty-something man with a unique set of problems. It's not the therapist's fault, I know that. I understand how foreign and unintelligible these problems are to other people.

But I'm really starting to get pissed off - at the rate of hundreds of dollars per hour (lol).
posted by beigeness at 7:11 PM on December 2, 2018 [1 favorite]

When assessing if things have changed, accept that some problems will never go away. What can change is:
1. frequency
2. intensity
3. duration
If your episodes are further apart, less intense, or shorter lasting, that's progress. If none of those things have happened, I'd look into what isn't working - but it sounds to me like your therapist is right and some of this is you wanting things to move way faster than they can.

At the beginning progress is slow because you're shoving this huge mountain and then slowly bits start to shave away and you don't really notice because god, so much shoving, and then at some point you realize the mountain actually shrank significantly and also you've built up some really nice arm muscles and you're doing some very nice terraforming. (but also you'll wonder why the hell is there still a mountain. And there will always be a mountain. Might eventually sort of segue into a pleasant rolling hill but sometimes that hill will just feel like the while damn mountain all over again.)
posted by Cozybee at 7:41 PM on December 2, 2018 [7 favorites]

Start journaling.

For me therapy has always been a huge spiral where I come back around to the same things again and again but each time I’ve made a little more progress. I can tell you that after years of work I’m still very mean to myself — but about 1/5th as mean and 1/5th as often as when I started.

There’s no way I would know that without a record of my day to day thoughts. I can’t, and I don’t think anyone can, evaluate my own progress without a real picture of where I was.

With regards to the long term I wouldn’t bet on this behavior (or others) vanishing entirely, but at this point I’m fairly confident that it will continue to get better.
posted by Tell Me No Lies at 7:41 PM on December 2, 2018 [2 favorites]

Therapist person here. Here’s my two cents...which may buy you a lollipop somewhere cheaper than the East Coast:

1) Change is hard. Certain kinds of change are nearly impossible. Also: No one wants to change. Your therapist cannot change you or fix you. You go to the therapist, you do the changing. The stuff you see in the movies is dramatized for your pleasure. If you want drama in therapy, do a genogram. You will be utterly horrified at how little changes over multiple generations in a family.

2) Different therapists provide a different fit. If the one you have isn’t cutting it, go find someone else. If they only believe in one thing (coughCBTcough), run the other way. Eclectic work is powerful. Things like mindfulness, yoga, and EMDR can be powerful adjuncts.

3) There are ups and downs and plateaus—these can be months. Years. Good therapy takes years to make tiny incremental changes that help break injurious cycles of behavior: You sign up for therapy, get inspired to eat right, throw out the oreos, join a gym, fall in love with the girl on the treadmill, date, move in, break up, feel depressed, quit the gym, gorge on oreos. A good therapist ain’t gonna try to stop the perpetual cycle of oreos—we know it’s coming. A good therapist will hopefully say:
“Huh, the oreos again, eh? What will come after oreos now? Maybe a nice walk on the treadmill?”

4) Family of origin is unbelievably powerful. I don’t put much faith in classic psychodynamics—but the Neofreudians got one thing right: the ways we view the world and ourselves starts in our interactions with family.

5) You mention poor health. Get that checked out. Certain illnesses cause an inflammatory response that leads to depression. If there’s chronic pain involved, do not just pass up on the alternative modalities because they don’t come in pill form. I speak from personal experience and working with many people who deal with intolerable pain...that isn’t bad enough to try acupuncture just bloody once. Chronic pain and depression and anxiety are bffs. Please try the acupuncture/reiki/yoga/meditation once before you shove it off as a load of baloney.

6) Maybe it’s OCD, not oreos. Maybe it’s the death of a loved one, not a breakup.

At the end of the day, the power of therapy is helping you learn who you are, who all these other people are, and what you intend to do during your time on Earth.

It’s not going to make you better like *poof* depresso disappearo! You are gonna wake up some days and be just as depressed as you were pre-therapy—even after a decade of hard work. The difference is you have a particular set of tools you are practicing to keep it from being worse than it has to be. Or you are learning to exercise your strengths. The cool trick is the depression (or whatever it is) can feel smaller and weaker as you occupy more mindful spaces and assemble a good set of tools.
posted by executive_dysfuncti0n at 9:32 PM on December 2, 2018 [8 favorites]

A few pieces.
It took several years of therapy before I even told my therapist the major piece of my history that made a lot of things fit together (and you may not know what that is, yourself - I didn't.) It also took many med trials for something to work, because no one knows how to predict which will.
External changes often need to happen before you can change who you are. We are in large part what is around us anyway (see above re: family).
Going through the process of treatment is very different from putting in the work for treatment.
My therapist has said that the passive suicidality will probably stick around for life - in psychiatric terms dysthymia, I guess. But there is a difference between baseline and abnormal.
posted by ahundredjarsofsky at 11:09 PM on December 2, 2018 [1 favorite]

How are you doing with pain and health? Pain makes everything darker, difficult, absorbs so much energy. If your health is still seriously impaired, you may need a rehabilitation counselor who can help you adjust to a new normal.

Change is difficult, growth is difficult. Is your therapist helping you see what's going on in your life so that you can grow the way you want to? Not all therapists are highly skilled, not all therapists are a good match.

It sounds like you need someone who can help you develop/ recover good habits; this isn't an emotional thing, it's a task. A star chart works. Don't use an app, use a calendar. Define some specific goals, break them down into small components. Every time you accomplish a task, you put an X on that date. 4 Xs gets a small star. 4 stars gets a sticker and a reward. Maybe a nice gel pen, maybe a book from the used bookstore. Small rewards are as effective as larger rewards, and the reward must be physical. Rewards, reinforcing desired behaviors, are the most effective way to change habits and behaviors (possibly excepting pathological behaviors like addictions). A good goal is taking a walk. That requires you to get dressed and washed, put on shoes, leave the house, and at least get around the block. If you decide to walk farther, great, but you get a reward. If you are really stuck, you get a reward (x on the calendar) for getting washed and dressed.

Talk to your therapist and define goals for your therapy. Talk about your frustration. I have been helped by Playing Ball on Running Water, by David Reynolds. It's based on Morita Therapy. Your feelings matter, but changing your actions and habits can be very effective at helping you feel better.

Goo dluck, you've had a rotten time, you odn't deserve it, but yo have to deal with it. You really can rebuild your life, and it will feel so good.
posted by theora55 at 5:15 AM on December 3, 2018 [1 favorite]

I have been in therapy many times, and while each therapist has helped (or not) in their own way, this most recent one has been the most productive. I'm a year in with about 20 sessions completed, and expecting another 6 to 12 months.

Here's some thoughts on what's made me feel like I'm making unusual progress this time around:
1. Deeply understanding that the therapist just a facilitator, they're not going to "fix" you. (thanks ClarissaWAM for wording) I used to think by just going to a therapist, that was "doing the work," but no. The therapist is a guide to help you discover your path. Akin to the Sherpa guides for Everest climbers: hiring the Sherpa does not equal attaining the summit. You still must climb the mountain yourself.
2. Informal Journalling: scribbling notes to myself about my thoughts when ruminating. Sending an email to my therapist recounting events of the past week. Anything that documents where I'm at mentally. Going back at a later point to review, I can really "see" progress.
3. Recording my therapy sessions, and replaying them later. I personally can get so emotional during a session that it's hard for me to grasp, comprehend, and remember the discussion. When I record the session and play it back later, it often solidifies the ideas discussed in session.
4. Listening to audiobooks on adjacent subjects helped - such topics as marital self-help, parenting techniques, biographies of inspirational people, Buddhist principles, the surprising effectiveness of Meditation (10% Happier by Dan Harris!) - bits and pieces from all these books reinforced the techniques and discussion from therapy.
5. Addressing the physical and social, as well as the mental & emotional: exercising regularly, eating healthier, getting engaged in social activities - all took a lot of the pressure off and served as a distraction from endless rumination.

It's like building fiberglass: tiny threads overlaid one on top of another, over and over, at different angles and directions until they all start to weave together into a coherence and fuse.

As far as a "breakthrough" session - I've had only one of the 20 sessions that was revelatory; it didn't "cure me" or dispel my issue, but instead illuminated some old, deeply rooted connections laid down when I was I child, that up until that session I'd been unaware of these connections' importance and impact on my life and outlook.

To sum, if you feel like you're making small progress, you're probably doing better than you are capable of recognizing right now. Keep at it.
posted by Ardea alba at 1:46 PM on December 3, 2018 [5 favorites]

You also might want to consider tracking your progress in therapy over time to get more data and inform your next steps.

Therapist here. My clients know concretely whether they are experiencing positive movement towards their goals because we track this using a very quick and simple measure.

It's a valid and reliable indicator called the Outcome Rating Scale, or ORS for short. It was created by Barry Duncan and Scott Miller and you can find enough information about it online to either ask your therapist* to start using it with you, or for you to use it yourself as a way of seeing whether therapy is helping you achieve your goals.

IMO, and in client self-reports (both mine and studies in the field), there is almost always some positive, incremental change within the first 6-8 sessions. I'm not talking about an major "I'm cured!" epiphany, just some shift in a positive direction. Tracking the ORS over time gives a picture of your progress from your perspective (which is the only one that matters).

*If he refuses, that would be a moderate-to-significant red flag to me, since you've already expressed your dissatisfaction to him.

"Classic breakthrough sessions" aren't a very frequent phenomenon over a course of therapy. I haven't tracked this explicitly (the term 'breakthrough' is a bit ambiguous), but would guestimate that my clients generally give me feedback that shows about 1 in every 4-8 sessions is significantly and noticeably helpful.

I have a sense that in the case of trying to shift temperament/characterological traits, breakthroughs might be less common, especially if they are based more on habitual behaviors than faulty beliefs.

Another thing studies consistently show is that the "fit" between client and therapist is the single biggest predictor of a successful course of therapy. If the fit isn't great now, it can be improved, if your current therapist is willing.

Good luck to you. I admire your persistence and self-advocacy.
posted by dancing leaves at 4:03 PM on December 3, 2018 [4 favorites]

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