Diminishing returns in therapy, and ‘work’ to drive treatment forward

I have been in therapy since I was sixteen years old. I am thirty-four years old now, a psyçhotherapist and mental health advocate. I’ve taught students and young practitioners how to execute psychotherapy, troubleshoot issues, and drive treatment forward with limitless passion and calculated precision. I am sharing this because I want to talk about getting the most out of treatment, specifically, therapy, to treat a mental health disorder. I will cite mistakes I’ve made as a patient passively letting the ‘work’ slip past me in treatment and lose ground because I didn’t have an active enough voice in my own medicine.

I will also talk about cases I’ve treated, folks that I sat with within the course of group therapy for our mental health, and ultimately, why we all need to be mindful of ‘diminishing’ gains. I hear it all the time from social work students and young students practicing therapy. Students ask: ‘was I effective there?’ or ‘how could I have been more effective?’. This question brings many moving parts into the conversation, which we will table for a moment. These elements include essential engagement, the therapeutic alliance, and generally, skill and technique. All of these elements push back against the response of the patient. However, these moving parts aside. The prevailing moving part of the therapeutic process has the most momentum and is hands down the most significant player in treatment.

The energy created by its inertia is what truly drives treatment in the right direction: work. I am not facetious. The ‘work’ or doing ‘work’ in therapy makes the difference in treatment every time. On the level of physics, the measure of energy transfer (in therapeutic/clinical language, the ‘change’ or ‘corrective force’ occurs when an object (the issue at hand) is moved over a distance by an external force (the counselor or therapist). On the level of physics, all of this makes perfect sense. So, why does it seem like such a farse when translated into clinical terms. I will be brutally honest. Because aside from ‘burnout’ and ‘compassion fatigue’, there aren’t many clinical terms that evaluate the sheer energy a therapist must invest into the work and be matched by the patient to expect meaningful gains in treatment.

As a therapist executing the work, it requires just as much energy and as is required of a patient to produce actual results. Why is this the case? Let’s break it down on both sides. Have you ever met with a therapist that is dull, unmotivating, and low energy? Sleep apnea aside, I still would have fallen asleep in session. People don’t make progress in therapy when they are sleeping in session. Patients must be awake, attentive, and actively responding to a highly energized therapeutic probe. Pushing against this probe and learning where he or she stands in the wake of the therapeutic distress invoked by the therapist to learn new limits, insights, and awareness. This back and forth pushback creates the energy transfer and release of negative energies, or cultivation of positive reframe, to understand ourselves and the world more healthily.

I have observed people sitting beside me in group therapy working on the same issues ad infinite. Now, there is something to be said about working on problems chronic in treatment. That’s fine if the issue is genuinely chronic and needs weekly or monthly maintenance. What is chronic and what is acute, in my opinion, and in most cases, is not in the eye of the beholder. Sometimes, for one reason or another (maybe a lazy therapist who doesn’t want to refer out) or an ambitious and overzealous clinician more interested in finally correcting a historically problematic issue instead of shifting the therapeutic focus to more meaningful and more considerable roadblocks in his or her patient’s life. I will provide a case example. After ten years, my groupmate is still actively grieving the loss of her husband. Sure, I feel for this groupmate. She loved her husband. However, the more significant issue and the more chronic issue isn’t the loss of her husband. Her crippling anxiety and the real problem is the therapist’s unwillingness to shift the therapeutic focus away from her difficulty passing through the bereavement process.

Look, folks, I’ve made mistakes myself with this stuff. It is effortless to let the real work slip past us in therapy. It is easy to sit back and complain about death and issues we cant control. The real work will always be the work itself. Investing ourselves means investing energy into the therapeutic process. And, like all work and investments in our health, eventually, we will get back less and less in terms of therapeutic gains even if we invest the same amount of energy into the process. What we gain are diminishing returns. Most of the time, it means moving on to a new therapist or trying a new therapeutic modality. I am going to take a slightly different approach to this issue and stay on message. When you begin to benefit less from the energy you invest into the work. Invest even more until you get the results you are looking for or walk away knowing you did all you could to move forward in your healing.

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