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Friday, October 16, 2009

Returning to Therapy

It's not unusual for people to return to psychotherapy, over the course of a lifetime, for a second or third treatment (or more) to deal with the same issues, often on a deeper level or in a different way. Many times, the first therapy might have been to develop coping skills to deal with a particular issue and subsequent treatments are for developing greater emotional insight into the problem.

Returning to Therapy

The following scenarios, which are composite accounts of actual cases (with all identifying information changed to protect confidentiality) are examples of clients returning to psychotherapy to deal with the same issues or emotional patterns in a different way:

Scenario 1:
When John attended psychotherapy sessions in his late 20s, his girlfriend of five years had just left him. After the breakup, John was highly anxious and depressed. He was also very isolated and lonely because his relationship with Jane had been everything to him. At that point, John had never participated in psychotherapy before. He had always thought that a person had to be "crazy" or "weak" to seek out the help of a psychotherapist. However, he did some research on his own and read that most people who attend psychotherapy were "normal" people who wanted to work on their problems with a mental health professional who could help them in ways that friends and family members could not.

Returning to Therapy

During the first psychotherapy session, John talked about the relationship, and about his anxiety and depression following the breakup. The psychotherapist explained how she worked and answered general questions about psychotherapy and her professional background, training and experience. John attended weekly sessions for about three months and, gradually, he began to feel better. He no longer felt anxious or depressed, and he was beginning to date again. At the point when he decided to leave therapy, he and his therapist were just beginning to deal with his codependent patterns in relationships. However, after his anxiety and depressive symptoms subsided, John no longer felt motivated to attend therapy.

His psychotherapist talked to John about remaining in psychotherapy so he could gain emotional insight into his patterns and he would not continue to repeat them in his next relationship, but John decided that he was "feeling good," he no longer felt anxious or depressed, and all of this talk about codependency was bringing him down, so he left therapy. He felt that as long as he knew that he behaved in ways that were codependent, he would "just stop" behaving in that way and it shouldn't be a problem. He told his therapist, "I know what to do now" and he left treatment.

After he left therapy, John began dating someone new, and they entered into a relationship almost immediately. A year later, his girlfriend broke up with him, telling him that she found him "too needy." John was upset, but he used the coping strategies that he learned in psychotherapy to deal with his depression and anxiety. Soon afterwards, he entered into another relationship with a woman who was an active alcoholic. He thought he could help Mary to overcome her alcoholism and, deep down, he felt that she would never leave him because he thought she needed him. Mary was unemployed and broke at the time. She moved in with John within a few weeks and John supported her. After several months, Mary began attending A.A., at the urging of her psychotherapist. She obtained a sponsor and began forming sober friendships in the program. Three months later, Mary found a good job and she decided that she wanted to be single again, so she broke up with John.

This time John was devastated. He never saw it coming. He tried to use the coping strategies that he learned in psychotherapy, but his self confidence plummeted after this last breakup. He bought self help books to try to understand what he was doing wrong and to bolster his confidence, but the self help books didn't help him. Reluctantly, he called his former therapist and returned to therapy. John began therapy again with the sole motivation that he wanted to "feel good" again. However, over time, he began to understand that while "feeling good" was important, psychotherapy was about more than just "feeling good" and he needed to look at some of the underlying issues involved with his codependency.

Over time, John developed an understanding that "knowing what to do" in an intellectual sense was not the same as having a deeper, emotional understanding and getting to the root of his problems so that he could change his patterns. So, when he began to feel better again and he was tempted to leave therapy, rather than giving in to this temptation, he stayed to do the deeper work to overcome his codependency.

When he entered into the next relationship with Susan, he was tempted to leave again because he felt that, for sure, this new woman was "the one." He felt happy for the first time in a long time. From his perspective, he thought, "Why should I stay in therapy? I feel very happy now." However, soon after they got together, John recognized the early signs of codependency in his relationship. He realized that he was falling into the same old patterns again, and he was able to work on these issues with his therapist. He learned to avoid the same codependent pitfalls from the past, and he gained a deeper emotional understanding of the origins of his problems.

With the help of his psychotherapist, his own diligence in going to his therapy sessions on a regular weekly basis, and applying what he learned, John's relationship began to flourish into a mature, stable, healthy relationship. He and Susan also began forming friendships outside the relationship so they were no longer solely dependent on their relationship for all of their emotional needs.

He worked through his family of origins issues that were at the root of his codependency problems; he no longer had the need for Susan to depend on him; and, he felt that he had grown as a person. At that point, he and his therapist talked about John terminating therapy. They spent about a month going through the termination process to help John consolidate the gains that he made in therapy, and then John and his psychotherapist mutually agreed that it was time for him to end treatment. His therapist told him that he could come back in the future. A couple of years later, John and Susan got married and they continued to have a stable and happy relationship.

Scenario 2:
Kathy, who was in her early 20s, began attending psychotherapy sessions to deal with the death of her grandmother. Kathy was close to her grandmother and she took the loss very hard. Several months before Kathy began psychotherapy, her grandmother was home recuperating from a heart attack and Kathy would come to see her everyday after work to check in on her. Over time, her grandmother got stronger and she was soon able to take care of herself and get back to her regular activities. At that point, assured that her grandmother no longer needed her help, Kathy decided to go on a week long vacation with her friends to the Bahamas.

Returning to Therapy

Kathy and her friends were having a wonderful time in the Bahamas when she got back to their hotel and found a message to call her mother immediately. When she called her mother, she found out that her grandmother had a massive heart attack that day, and she had died. Kathy was devastated. She blamed herself for going away and thought, "Maybe if I had been there, she might not have died."

After a couple of months of therapy, Kathy grieved the loss of her grandmother. She also came to understand, in an intellectual way, that there would have been nothing she could have done to save her grandmother from her massive heart attack and death. After all, she wasn't a doctor. Everything her psychotherapist told her made logical sense to her. Soon after that, she cancelled her appointments and she left treatment against her therapist's clinical advice.

Several years later, Kathy got married to Paul. They were both very happy in their marriage. One day, during the third year of her marriage, Paul began having chest pains. Kathy broke out into a cold sweat and felt panicky. She was afraid that Paul was having a massive heart attack, just like her grandmother. She could barely think straight, but she managed to call 911. After an extensive battery of tests, the doctor told Kathy and Paul that Paul's heart was very healthy and overall he was in good physical shape, but he had acid reflux and the symptoms were often similar to the symptoms of a heart attack. Paul was greatly relieved. Kathy was somewhat relieved, but she worried and feared that the doctors might be wrong.

After that, Kathy was afraid to go to work or to leave Paul, who worked from home, for any length of time. At first, Paul was understanding. He was taking his acid reflux medication and he told her that he was feeling fine. But nothing he said soothed Kathy's nerves. She called him at home numerous times from her job and would often come home early to check on him. She also refused to have sex with him because she was afraid that he would have a heart attack, even though the doctors had assured them that his symptoms had nothing to do with his heart. Finally, Paul told Kathy that he thought she needed to get help.

On the one hand, on an intellectual level, Kathy realized that her worrying and her behavior was excessive. But her feelings made her worried thoughts feel very real to her, and this was confusing. On the other hand, she didn't want to ruin her marriage with Paul, so she returned to see her former psychotherapist. She felt somewhat ashamed to return to therapy because she thought her problems "should have been fixed" after the first therapy. She was afraid that her therapist would think that she was "stupid." But she learned from her psychotherapist that returning to therapy to deal with the same issue, on a deeper level, was very common, and she felt relieved.

Kathy also discovered that her current worries were being "triggered" by the death of her grandmother. Even though she had grieved this loss during her first treatment, she had not dealt, on a deeper emotional level with the trauma of how helpless and guilty she felt while she was away and her grandmother died. She also realized that, during her first treatment, she went as far as she could at the time on an intellectual and logical level. But these other traumatic feelings had not surfaced in the first treatment.

When she realized this in her second psychotherapy treatment, Kathy was glad to know that she wasn't "going crazy" and that there was an explanation for her excessive worrying. It made sense to her. At that point, knowing this, she was about to leave therapy again, but her psychotherapist recommended that she stay to work on the trauma on an emotional level. Over time, Kathy learned the difference between intellectual insight and emotional insight. She realized that it was not enough to have intellectual insight. Her psychotherapist used a combination of clinical hypnosis and EMDR treatment to help Kathy process the original trauma. By the time Kathy and her psychotherapist mutually agreed that she had processed the original trauma, Kathy was no longer worrying about Paul's health. They began to have sex again, and they became closer than ever.

Over the course of a lifetime, old problems can resurface in new ways. Sometimes, there are residual issues that remain hidden and don't surface in the original psychotherapy treatment. Also, over time, as we mature and grow, we have a greater capacity for emotional insight (as opposed to only intellectual insight) and so we can approach old problems with a deeper understanding to resolve them.


Returning to Therapy

Returning to psychotherapy, whether you return to your original psychotherapist or you choose to see someone new who might have a different way of working, is not anything to feel ashamed about.

Returning to therapy doesn't mean that you failed in your original psychotherapy treatment or that you were inadequate in any way. Sometimes, it might mean that you left therapy prematurely. Usually, when this happens, people think that "feeling better" means that the problem has been resolved. But what it might really mean is that some of the worst symptoms have subsided, but that none of the underlying issues that caused the problem have changed. It might also mean that your psychotherapist or counselor was not skilled in the particular issue that you were dealing with at the time.

Also, often, as you mature and your life changes, it means that you now have the emotional capacity and you are ready to deal with a particular problem on a deeper level to resolve it.

I am a licensed psychotherapist, hypnotherapist and EMDR therapist in NYC.

To find out more about me, visit my web site: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (212) 726-1006.

Also, see article:  When Clients Leave Psychotherapy Prematurely

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