When Therapy Hits a Wall: Ten Suggestions for Getting Back on Track

If you’re currently participating in psychotherapy to address depression or a related illness, and you’ve invested time and energy in developing a good working relationship with a trained, experienced psychotherapist, you are to be congratulated. Chances are you’re already seeing or will soon see benefits in your symptoms, outlook, mood and coping skills.

But what if that’s not your experience? What if you’re feeling stuck?  What if you sense that you are covering the same information over and over again, without gaining new insights?  What if you get the feeling that you and your therapist are on two different channels?

The connection between therapist and patient is unlike that found in any other relationship. When for some reason that connection weakens or breaks down, the relationship between the patient and the therapist can suffer, and progress can grind to a standstill.

Statistics aren’t available to illustrate how often this happens, but experienced therapists will tell you, it’s not an uncommon occurrence. Unfortunately, there is also no formula for determining when the effectiveness of therapy is waning. Nevertheless, in this article we’ll offer up a few suggestions for how to assess your situation and course-correct if needed, based on the real-world experiences of therapists working at the University of Michigan Depression Center.

1. Don’t just give up. 

A whole host of issues could be impeding your progress in therapy.  Rushing to judgment or assigning blame without some serious investigation undermines the process – and therapy is a process, not an instant fix – and undervalues you both. Take the time and do the work together to determine exactly what’s going on. Chances are, you can get back on track.

2. Share your concerns.

Talk about it, whatever “it” may be.  That’s the whole idea behind therapy.  Be as direct about your concerns as possible.  Because this can be a challenging conversation, it’s wise to do some preparation.  Write down your issues and questions in advance.  You might find our “Preparing for Your Appointment” tool to be helpful. Ask yourself how you feel in the relationship.  Do you feel comfortable sharing?  Do you feel you are being heard and respected?  Now, ask your therapist the same questions.  You may both be surprised by the answers. Studies show that patients and therapists commonly see their relationship differently.  And don’t hold back for fear of hurting your therapist’s feelings. Therapists are trained not to take what is said personally.  (If yours does, you have real cause to look for another therapist.)  

3. Revisit the method of therapy in use.

The different psychotherapeutic techniques available for use by mental health professionals today have been developed and tested extensively over many years.  Each technique is designed to address a specific diagnosis or grouping of symptoms or intended outcome.  Have you and your therapist discussed the method of psychotherapy you are engaged in?  If you don’t know whether your therapy is Cognitive Behavioral Therapy, Interpersonal Therapy, or some other method, don’t be surprised.  It’s not unusual for therapy to proceed – and proceed successfully – without the therapist and the patient ever reviewing the name of or the technical aspects of how a given therapy works.  Nonetheless, it is good practice to know which kind of psychotherapy is being employed, why that approach was chosen, and its objectives. Don’t hesitate to ask about your current therapy, as well as about what other psychotherapy alternatives might be appropriate. You may discover that your situation has evolved since beginning therapy, and that perhaps a different approach is needed for the issues you face now.  Making a change in therapy may or may not require working with a new therapist. 

4. Map out your expectations.

What do you expect to gain from therapy? What does your therapist expect to accomplish?  Differing expectations can cause a disconnect.  For example, you may have entered the relationship for a safe and stable place to be heard.  Your therapist may be expecting to guide you through making significant life changes.  You’ll get the best result when you both put your expectations on the table from day one.  But if that didn’t happen, it’s not too late to make a course correction.

5. Be honest about your motivations.

Have you entered into therapy out of a desire to feel and function better?  Or are you simply complying with the recommendation of your healthcare provider, spouse or friend to give it a try?  If you’ve come willingly, your motivation and your chances of success are much greater than if you are there out of a sense of obligation.  Your reasons for staying in therapy should be examined honestly, too. At times, a therapist may feel that the goals of therapy have been met for a patient, while the patient may be reluctant to end the therapy.  This is fairly common when a patient lacks the proper support system outside of therapy, and feels he/she has no one with which to share except the therapist.  

6. Be honest about your symptoms.

Patients tend to minimize their symptoms, especially those who may have a less than 100% commitment to the therapy process. It’s extremely important for your therapist to understand the full extent of your symptoms, and how they change over time.  You may find it helpful to keep a log of your daily activities and symptoms to review with your therapist during your appointment.   

7. Share the details about your medication.

Every part of your treatment plan – medication, psychotherapy, self-care -- is interrelated. Regardless of whether your prescriptions for antidepressants or other medications are written by your therapist or another healthcare provider, it’s vital that your therapist be made aware of all of the medications you are taking, and your reaction to them.  Only then will he or she have a clear picture of how to proceed.  For example, if your symptoms are very severe, or you are still adjusting to a new medication, you may not yet feel well enough to fully engage in therapy.  If side effects are causing or worsening cognitive or sleep problems, it may not be the appropriate moment to try to do the hard work required to make progress in therapy.  It’s a good idea to keep a log of your medications, and to bring it with you to each therapy appointment.

8. Uncover the barriers to progress.

Are there obstacles that are keeping you from working on your goals?  For example, are you avoiding keeping a journal for fear someone in the family will discover and read it?  Do you skip your medication dose at lunchtime because you are embarrassed to take meds in front of coworkers?  If you are encountering obstacles, identify them with your therapist, and work together to develop an action plan.

9. Inventory your stressors and triggers.

Pinpoint all of the elements of your environment at home, at work and even in therapy that may be bringing on stress, triggering anxiety or keeping you from making progress. Consider devoting an entire session to identifying stressors and triggers – it could prove incredibly valuable.

10. Don’t blow off your homework.

What happens outside of therapy is every bit as critical to making progress as what transpires in the appointment itself. “Homework,” which includes recommended exercises to practice during the week, is assigned for a reason. Unlike school assignments, there are no right or wrong answers; the objective is simply to engage with the activity and see what you learn.  When a patient is reluctant to complete assignments given in therapy, he or she builds a huge barrier to progress.   Make sure you are giving your all to your homework, and that you review your assignments with your therapist regularly. If you are unable to work on homework for any reason, it is important to share this with your therapist.

What do these ten suggestions have in common? First, each requires an honest look in the mirror.  Therapy can at times be scary; many times patients call the effectiveness of therapy into question as a way to avoid facing tough issues.  Second, each is undertaken in partnership with – not independent of – the therapist. Remember that successful psychotherapy is a team effort.  Working together, you and your therapist can identify the issues that may be hindering your progress and determine a course of action to help you reach your objectives.

Contributions to this article were provided by Julie Kuebler, M.S., A.P.R.N., B.C., a Psychiatric Nurse Practitioner at the University of Michigan Health System.

 

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