Starting and Stopping Therapy

One of the guiding principles of conventional therapy is that it’s always the patient who makes the first call. It's hard to imagine the reverse being true:

"Hello. I'm Dr. Gunner. I understand you need therapy."
"I do?"
"You're depressed."
"I am?"
"So, you're anxious."
"Not really."
"Maybe mood swings?"
"Don't think so."
"Perhaps seeing things?"
"Where?"
"I know you're hearing things."
"What's that?"
"You're overeating."
"I'm on a diet."
"You're under eating."
"I weigh the same."
"We'd better meet."
"Hold on a moment, I'll just grab my keys."

It's hard to imagine this conversation taking place because therapy only works if the patient initiates. When the patient makes the call, it means he wants help. It means he is looking for some kind of change. It means he is unhappy about the status quo.

Sometimes other people want the patient to change. Husbands want their wives to change. Wives want their husbands. Parents want their kids to change. Kids want their parents. No matter what the reason, this never works. Change only comes if the patient really wants it.

Take Ben Kingsley, for example, in the movie You Kill Me (2007). He's a hit man who can't shoot because of his drinking. In a moment of uncharacteristically therapeutic thinking, the mob sends him to rehab to deal with his alcoholism. At first he resists, but eventually he relents. He realizes that his drinking is getting in the way of the one thing he loves to do most in his life. He goes on the wagon to become a better killer. At the end of the movie he's a happy hit man once more.

If this character were my patient, I could help him stop drinking, but I wouldn’t be able to help him stop killing for a living (other than by reporting him as “a danger to others"). He enjoys his profession and likes doing it well. He has absolutely no conflict about pulling the trigger.

Fortunately, most people intuitively understand that therapy is only possible if the patient wants help. This is the starting point for everything that follows.

When therapy is working the patient and therapist join forces to think about the patient's experience. The patient tells the therapist what he is feeling, and the therapist listens closely and tries to figure out why. They may agree or disagree about what the experience means, but only the patient knows for sure how it actually feels. Even the most empathic of therapists is guessing. It's up to the patient to confirm or correct.

Sometimes the challenge of dealing with one's feelings makes coming to therapy less than appealing. At these times, it's common for patients to conclude that the therapist isn't helping, that there's no hope for change, or that he's suddenly recovered and is feeling very happy. It's important for the patient and therapist to remember how scary and painful certain feelings can be. It's easy to be tricked into despair or delight if one doesn't respect the great difficulty of growth. Real growth takes hard work, resilience, and patience. It's tough to change the patterns that have governed our lives.

As long as the patient is feeling unhappy, is hoping for change, and is looking for help, there's a very good chance that the therapy will succeed. Over time, if the treatment works, the patient's life will improve. He will be more able to deal skillfully with the difficulties of being human and will be less dependent on the therapist to process his experience. When the patient can manage well enough his own, the progress of therapy has come to a close. This is a true victory for both the patient and therapist. A confirmation that change is really possible, after all. And a source of great hope about the quality of life to come.