The ethics of “crisis-management” therapy

What kind of support do you need on your path?
What kind of support do you need on your path?

I was thinking about practicing psychotherapy.   Okay, I think about that a lot, and discuss it with my colleagues, and read about it and of course I also spend a bit of time actually practicing.  I recently heard Randy Patterson talking about processes in therapy, and one of his thought-provoking questions was about therapy drop-out.  What proportion of clients leave therapy before attaining their goals?

Apparently most practitioners will estimate about 20-25% but they will be wrong.  The actual, documented typical drop out rate is more like 75-80%.  So that includes the people who come once and don’t like you or the process, and also the people who work hard in therapy, start to feel better, but leave before actually accomplishing their goals.

I was just like the rest of the herd: roughly estimated that about 20 percent of people who come to therapy drop out.  Upon reflection, I can see that the drop-out rate is a lot higher.   Many people in therapy accomplish a lot even though they may not meet their goals, such as to no longer be depressed, or to get through a difficult situation.    So even without meeting a goal, it isn’t therapy wasted.   In fact, even for people who only come once or twice,  the time, money, and energy are likely not  wasted.  When the client leaves, it may be that  the process wasn’t meeting some need at that particular time, or that competing needs pushed therapy out.  And in reality, the client’s goals might never actually be discussed, or defined.   So the entire process, therapy, outcomes, termination, all of that might be very murky for both client and therapist.

But all that talk is  just prelude to my title thought.   People do leave therapy in various ways;   leave angry, leave silently, leave with congratulations and great hurrahs for accomplishments    They also return, and they return in various ways.   If they leave in a way that feels okay to them, it makes it easier to return.   And the other circumstance that makes a return to therapy easier is extreme distress.

It is not uncommon for clients to come to therapy in distress, get some relief, and, just as the therapist thinks it is time to really begin the actual THERAPY, the client leaves.  Well, she got what she came for, which was relief.   The problem is that if the underlying behaviour or thought pattern hasn’t changed, or maybe even hasn’t come into her awareness, she’ll likely be in a very similar distress again.   So she returns to therapy and has a few sessions;  feels quite a lot better, either due to the intervention, or to a change in external circumstances, or to that old placebo, time.   So she leaves again…..only to return another time.  Lasting change hasn’t happened;   there has been, perhaps, a series of band-aids, or (better image) a step-wise movement that may be more lateral than progressive.

Is it okay to keep using band-aids when therapy might actually generate some real change ?   Who makes that call?   What does the ethical therapist do with this?

Day breaks, the crisis abates...
Day breaks, the crisis abates…

I don’t have an answer.  Part of me thinks that it is disingenuous to just keep on with supportive counseling when I believe that a deeper, more focused type of work will be helpful in the long term.  But another part of me acknowledges that  for many people, symptom relief is a good thing and is sufficient.  So whose goals are important here?  It doesn’t make sense that my goals for your therapy should supersede YOUR goals for your therapy.  But you also have less experience with therapy than I do, and you might not know what is possible.

Reflection tells me that I probably have to be honest with clients and tell them how I see it….that there is hope beyond just immediate relief from distress…but that the immediate gratification may not be there.   Longer term therapies, like bioenergetic analysis which helps to restructure personality, or trauma treatments which heals through restructuring of distorted memories, can have outcomes that make a huge difference to the person.  The path to those outcomes isn’t a smooth one, though, and often the courage it requires to take that path is hard to come by.  So I can understand why someone might decide to use counseling as a symptom relief measure.

So ….. whose agenda, whose goals?  Is feeling better a good enough goal for therapy?   or do we have a better chance of getting change when we set goals that are more clearly defined??

These are some of the things I ponder.  If I don’t find an answer, I usually look for chocolate.   Which, in its way, performs the same soothing and comforting role as supportive counseling.  Chocolate for everyone!   Then back to pondering the deep thoughts.

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