Do I have to go to therapy every week for the rest of my life?
May 27, 2021 10:41 AM   Subscribe

I have bipolar disorder and have been in therapy most of my adult life. I talked to my therapist today about starting to cut back on the frequency of my sessions now that I am very stabilized, and he said that the clinic requires weekly visits. I would not be able to receive psychiatric services without weekly therapy sessions. Is this a known model of practice?

I started going to this clinic over two years ago when I needed a medication adjustment because my bipolar symptoms were flaring up and I was in a bad place. I found a local clinic that offered both therapy and psychiatric treatment, and over time my meds have been adjusted very well and I've been quite stable for at least half a year (pandemic be damned).

My therapy sessions have gotten really unhelpful because I just have nothing to talk about. It feels like I'm struggling to make small talk because I have no pressing clinical needs. I spend the session talking about TV shows and what I read on the internet and funny things my cat does. I am not finding the sessions helpful anymore.

I brought up my desire to switch to an every other week schedule a few months ago, and my therapist basically told me that it would be too difficult for him to fill the alternate slots with another patient's appointments. I kind of didn't know what to say to that so I dropped it (even though I felt like his scheduling woes shouldn't impact my treatment schedule).

When I brought it up again today, that's when he told me that receiving psychiatric services from the clinic requires weekly visits. That there is absolutely no option for reducing appointment frequency while still getting my medications.

I recognize that with bipolar disorder I need lifetime monitoring of my meds, and should have a relationship with a therapist to draw upon if I ever start to backslide again, but I'm not trying to drop out of treatment forever. I just don't think weekly sessions are necessary any more. Am I just ignorant of best practices in mental health treatment? Should I really expect to have to maintain the same frequency of appointments when I'm stable as I needed when I was in crisis?

I'm very frustrated because I absolutely hate the idea of having to start from scratch in finding a new shrink and therapist. And I don't know that a new clinic/provider would start me off with biweekly sessions either.

I guess my question is, is it unreasonable to expect to be able to reduce the amount of therapy I receive after achieving stabilization? It sounds like they clinic is all or nothing so I don't have many options no matter what, but I'm curious whether I'm really off base in expecting to have that option in my treatment plan.
posted by Neely O'Hara to Health & Fitness (17 answers total) 3 users marked this as a favorite
Are they requiring weekly, full 50-minute therapy sessions? When I'm not in a therapy cycle, my psychiatrist does 15-minute maintenance appointments at regular intervals (that are presumably dictated by law and her insurance). She's in private practice in CA, for context.

From my experience as a patient, not as a clinician, regular maintenance appointments for medications would be expected, but forcing me into unwanted therapy sessions (that I'm financially responsible for!) seems like an unreasonable burden.
posted by ApathyGirl at 10:55 AM on May 27, 2021

Response by poster: Yes, I have to do weekly 50 minute sessions with a social worker, on top of monthly appointments with the psychiatrist. This has been unwavering since I began.
posted by Neely O'Hara at 11:09 AM on May 27, 2021

I’ve been in and out of therapy most of my adult life, and I’ve never had sessions more than once a month. (Mostly because that’s all any insurance would pay for, but only one therapist ever mentioned that as being unusual.)
posted by The Underpants Monster at 11:15 AM on May 27, 2021 [3 favorites]

Is this covered by insurance (or public healthcare, if not in the US, ie is it tied to funding in some way? Some publicly funded programs here [not in the US] do ask for commitments like that)?

I would say that the scheduling concern is valid, actually, I know people who’ve had to give up their time slot because of wanting to reduce frequency.

I would say that IF you aren’t paying out of pocket, might as well stick with it, even if you’ve got two sessions you’re not feeling you need (whether it’s best practice for your region/condition or not).

Because if you’re stable, that speaks to the med regime working. There’s no telling what would happen if you had to go to a different psychiatrist. Good ones are hard to find, and frankly many of them like to switch things up with a new patient even if they’re working, it’s like they have their preferred regime or just want to question a previous doctor’s rationale.

If you are paying out of pocket, sure you can take your chances with another psychiatrist. But you might not get everything you need that way, either (maybe there’d be no therapy available, or not as a package).

I kind of think if you’re doing well, that’s amazing and worth not messing with, though.
posted by cotton dress sock at 11:17 AM on May 27, 2021

Actually can you share your location (country)? Because the standard of care and accessibility is really different from place to place. (Like my bf who has BPD and BP would LOVE to have a monthly visit with a psychiatrist no matter what... where we are even for those conditions, most people get a one-off consultation with a hospital based psychiatrist, and the GP - if they’re lucky enough to have one - monitors things after that. They only get to see another psychiatrist if there’s a crisis - in 6-12 months by referral, a little less if they go through an ER (and then they have to be actively suicidal. So like monthly visits no matter what would be like a dream for him.)

Please also share if you’re paying for this OOP.
posted by cotton dress sock at 11:21 AM on May 27, 2021

Response by poster: Oh sorry to leave out that info! I'm in the US, in NYC. My insurance covers all five sessions a month and the copay is very reasonable. So the cost is not my concern, thankfully.

I almost want to just pay the copay every week but not attend the sessions every week. Or cut them down to half an hour a week.
posted by Neely O'Hara at 11:28 AM on May 27, 2021 [1 favorite]

To answer your first question, yes, this is a known practice model. It is especially common in clinics that treat a lot of patients who (for any number of reasons) tend to have poor treatment adherence and therefore a high risk of relapse. But to answer your second question, it is also reasonable to reduce your therapy frequency once you're stable. It sounds like that's not possible at this particular clinic though. In my experience, clinics set policies like this specifically to avoid having to make case by case decisions (as it would be difficult to set consistent criteria and difficult to enforce) so I doubt that you'd have much success asking them to make an exception for you. I think realistically you'll have to decide whether it's worth it to you to attend weekly therapy in order to be treated at this clinic, or look for care elsewhere.
posted by scalar_implicature at 11:30 AM on May 27, 2021 [11 favorites]

Are you particularly attached to your psychiatrist there? If so, it may be worth talking directly with them about your preferred plan. It’s realistic to imagine many patients will need/benefit from continued medication management services but not continue to need weekly talk therapy. Maybe your clinic has a very specialized model where they work with acute mental health conditions and refer patients out to other providers if/when they are more stable and no longer need weekly therapy. Maybe your therapist is mistaken about the specifics of the policy. Maybe the whole office is a bit wacky and all the providers expect the same level of care to be necessary and appropriate indefinitely. In any case, it’d be good to find out where your doctor stands and how much they can help you, whether that’s advocating for you within the office or referring you out to another prescriber/practice.
posted by theotherdurassister at 12:01 PM on May 27, 2021

For reference, I have bipolar disorder too, and I've never had a psychiatrist say "you need to be in weekly therapy at my clinic." I've often had a therapist elsewhere, because I like therapy and find it helpful, but it's never been the sort of package deal you describe.

Right now I'm stable and my baseline is a checkin with my psychiatrist every three months, though I'll make an appointment earlier if I'm starting to feel off. I see a therapist weekly because I like it that way, but I'm sure if I went down to biweekly or monthly, or even stopped entirely, my psychiatrist wouldn't mind at all.

I get that finding new providers is a huge pain in the ass, but your expectations are reasonable and, unless NYC has a very weird mental health ecosystem, I don't think you'll have any trouble finding a prescriber who's okay with this.
posted by nebulawindphone at 12:10 PM on May 27, 2021 [4 favorites]

This seems like a common treatment requirement that I've seen with certain disorders where a lack of insight into symptoms is one of the symptoms of the disorder. Sometimes that's true with bipolar, meaning, if you're starting to have an episode, you might not be able to tell that yourself whereas someone who sees you regularly and knows your baseline can identify issues sooner. It's also the case that 6 months of stability, while something to be very happy about, is still a bit on the shorter side when it comes to being stable on meds, particularly given that seasonal changes can trigger mood changes. However, weekly still sounds like a lot of monitoring.

I would personally be willing to stick this out for a year and if still stable after that, I'd move to another shrink.
posted by Rock 'em Sock 'em at 1:52 PM on May 27, 2021 [9 favorites]

I am a therapist at an agency and clients receiving medication are required to be in therapy, although they can attend once a month for 30 minutes if stabilized. There's no reason you need to be in therapy once a week probably, it's just a rule applied to everyone. If there's no flexibility possible, you may want to just look into going to another clinic. There are some clinics that are medication only as well. It also might be worth asking the psychiatrist though because sometimes they are able to over-ride rules like this more than therapists can (in the eyes of insurance companies).
posted by bearette at 3:36 PM on May 27, 2021 [2 favorites]

The therapist gave you two different reasons for why you couldn't adjust the frequency. I would seek confirmation that this is an actual policy.
posted by sm1tten at 7:04 PM on May 27, 2021 [1 favorite]

You say you are not finding the sessions helpful anymore. In your case, I would absolutely explore moving to a different clinic or situation if possible. In the meantime, if it were me, I would discuss with my therapist how to make the mandatory time useful. I would tell my therapist what you have told us, that you feel like you are forced to discuss TV shows and your cat because you can't think of anything more appropriate.

If you end up being stuck with this time, perhaps you can reframe it in a way that makes it more of an investment in your future than an obligation you resent. For some of us, having time with a therapist when we are not in crisis is a kind of luxury. It's a time to consider longer-term issues, or goals, or dreams and get help working to resolve or realize those things. In my experience, therapists genuinely want to be helpful. That doesn't mean they're all good at their jobs, but it might be possible to enlist your therapist to help come up with ideas for issues to tackle over the next six months, for example, that will help make your life better now that your condition is stabile. Also, congratulations! That is a wonderful place to be. I wish you didn't have to deal with this frustrating situation.
posted by Bella Donna at 1:39 AM on May 28, 2021 [2 favorites]

PS: I am suggesting the possibility of reframing your therapy if it turns out that the insurance situation makes it too challenging to switch to a different provider.
posted by Bella Donna at 1:42 AM on May 28, 2021

Your expectation is not unreasonable and you are not going against best practice in wanting to reduce frequency of sessions. I would seek out another clinic, while this is a model of treatment, it’s not the most popular one—lots of people get prescribed meds for bipolar without seeing a therapist at all. Not saying that’s what you should do, just that there are a range of options out there. Finding someone who is willing to go at least biweekly shouldn’t be hard.
posted by brook horse at 6:12 AM on May 28, 2021

You know, Rock 'em Sock 'em raises a good point. It sounds like you've had this diagnosis for a while and it isn't your first rodeo, but even still, missing a mood change that would have been obvious from the outside is a super real thing. I'd say that in particular, the fewer people you have in your life (a) who would notice, (b) who would tell you, and (c) who you would believe if your mood started to go haywire, the more important it is to keep having a therapist who talks to your psych.
posted by nebulawindphone at 8:52 AM on May 28, 2021 [1 favorite]

I’m not at all batting an eye at the clinic’s requirements for you to have weekly sessions. It sounds reasonable from a business perspective and from a mental health perspective for this kind of establishment to exist, but it’s also eminently reasonable for their business/care model to not fit your needs.

If you like your providers and can afford it financially, I agree with trying to keep a continuity of care. Chat with your social worker about keeping your weekly slot, but being flexible about the format your sessions take. Could you do a 15 minute phone check in for half of your monthly sessions (and still pay your copay)? Or do an informed no-show (and still pay your co-pay)? Can you structure things so some of your sessions are “study hall” instead of active talking?

Hopefully you can have productive conversations about this with your counselor and/or the care manager at the clinic. If ALL you get from them is “you must attend and participate in 50 minutes of talking per week” without accommodation or nuance... it might be time to find a new provider. (I personally react poorly to systems that treat me like a cookie-cutter patient/cog/invoice rather than an individual. Not that I’m happy to cause headaches with paperwork, but since I’m *paying* for the counselor’s time, I want to have input about how the time is used. As long as I’m stable and checking in to report on symptoms, why can’t I use that time to hold myself accountable to write a few postcards each week?)
posted by itesser at 4:41 PM on May 28, 2021

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