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Set specific goals. Keep up on your meds. Sometimes the best approach to treating depression is both medication and talk therapy. What you say is confidential. Let honesty rule. Therapists who are early in their careers may be surprised by what comes out during sessions, but a seasoned therapist will never show surprise, Dr.


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Bea says. Ilardi says people with depression typically want to get better. Rather than simply telling people to exercise because physical exercise has profound antidepressant effects , the team sets them up with a personal trainer. You may need extra pushes like these from a therapist or loved ones. You may have to make your own conclusions. Without much happening—with no real intensity or vitality—ease eventually turns to boredom, at least for the therapist.

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So why do therapists tend to get stuck in clinical relationships where we spend session after session spinning our wheels? One reason is that these sessions ensure a predictable, paying slot in our schedule. We reserve supervision or consultation for more compelling crises or direct conflicts in the clinical relationship. Groundhog Day cases, where no one is threatening divorce or suicide, lack the drama of standard consultation cases. But when I stepped back and asked the couple to evaluate the progress of their overall relationship, they concurred with me that nothing much had shifted.

In fact, a mentor once told me that two-thirds of the records he reviewed for mental health hospitals reported progress, even for patients who never got better overall. So what do you do when you find yourself with a Groundhog Day case? One form of lurching is shifting abruptly from a therapeutic posture of empathic support to one of hard-nosed challenge. Either the client forgives the unexpected rudeness and therapeutic homeostasis is restored, or the therapeutic relationship spirals downhill until the client fires us.

Another form of lurching is trying out a different, more dramatic type of therapy without preparing the client. The therapist, familiar with the current trendiness of traumatology in the field and having just taken an introductory course in Eye Movement Desensitization and Reprocessing therapy, jumped to initiate two trauma treatment sessions with the husband.

Both of these sessions failed, and the therapist gave up on the couple. In pulling a new technique out of her hat, this therapist failed to ask herself something basic: how could she uncover what might be causing the husband to cling to his grief and anger? In a sense, she skirted the very heart of talk therapy. These days, many of us are overly focused on the flashy public-workshop intervention in which the proponent of some new attachment-based, body-oriented, Buddhist-inspired, or neurophysiological-leaning approach enthralls us with a new method.

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When we throw all our energy into the latest fads in the field, we stop working at the essence of what we do: the routine conversational practices of psychotherapy—the skills that keep therapy moving from minute to minute and session to session. The key to dealing constructively with stuck cases is to treat the clinical relationship pattern first, and only then to consider alternative treatment strategies. Set time to evaluate progress together. I do this in a matter-of-fact way, not assuming a challenging mode, but letting the client know this will be an important conversation.

Assess where you are in the course of therapy. Are we in the winding-down phase, the middle phase, past the middle phase? Generally, I accept whatever the client offers as an appraisal of our current stage of work. I sometimes even say that I prefer to work intensively with people and take breaks from therapy, rather than stay on plateaus for too long.

Of course, they had marital issues as well, including difficulty with emotional intimacy, which they were trying to tackle. But that phase of the therapy was slow going.

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Despite my best efforts to have them reflect on what might be blocking the energy for intimacy, therapy was bogging down. I said that a plateau in therapy after good initial work is common, and that it gives us a chance to decide what to do next, including ending our work for now. Earlier in my career, I might have increased my efforts to avoid failure and, as a result, bestowed a sense of failure on them. Instead, after one more session, we finished up with our heads held high. Gradually, however, I began to get the sense that I was serving more as a trusted confidant than a therapist.

She mostly wanted to talk about the ups and downs of her week, along with routine complaints about her ex-husband. After we reflected on her progress and the plateau in our work together, she said she had more issues to focus on and wanted to continue our therapy to work on them. What do you feel a sense of urgency about? Fortunately, the emergence of these emotions can allow real therapy work to begin again, providing a new focus on issues of loss and autonomy. Other times when trying to move from a plateau, it takes a while for the conversation to play out and a conclusion to be reached.

My attitude is like that of a music instructor whose client has learned the basic scales and a few songs and is satisfied with that progress for the time being.


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Another form of stuck clinical relationships involves the client who keeps making self-destructive choices, ones the therapist is on record as having repeatedly warned against. In my own clinical experience, Cindy stands out. She enjoyed therapy and had inherited enough money to work or not as she pleased.

Each time, she worked in therapy to extricate herself from the relationship, but whenever a new questionable character came along, she was impervious to my fervent attempts to get her to pay attention to the multiple red flags whipping in the wind. These are our Dr.


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  6. Acting like disapproving parents. Assigning pejorative clinical interpretations. Threatening to end therapy. Coming on too strong. Instead, I imagine that the therapist was sick of seeing no movement, but lacked a more skillful way of dealing with the impasse. Listening too closely to the negativity of our consultation group.

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    So how do we effectively shift gears with stuck clients who repeatedly make unfortunate choices? Virginia Satir used to talk about the two universal drives operating simultaneously in people in distress: the desire for growth, which means change, and the desire for stability. As therapists, we have to address both drives. An important value for you is to bring yourself fresh to each new relationship and not assume this guy must be a jerk because some other guys have been jerks.

    Bookend major challenges with autonomy-granting comments. Each time this happens, you seem to go deeper into a pit of despair.

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    Step 1: I respect you as an adult. Step 2: I care about you and am worried for you. She knew well my concerns about her pattern and shared them. After a particularly challenging session in which my conversational craft had slipped into badgering, I knew I needed to do repair work.

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    How are you feeling now about the stance I took in our last session? We then processed the clear reality that I was skeptical about a choice she was making and talked about how we could live with that tension and still do good work together. Stop pushing for change, and wait for another opening when life teaches lessons.

    Cindy and I moved on to work on ways she could keep as healthy an emotional balance as possible in a relationship I thought was basically unhealthy. At some point, one of us would be proven right by the outcome of the episode. Not having to defend her decision allowed Cindy to appraise the relationship realistically as it developed. With my support, she dug in her heels on this one. Overall, experienced therapists have no better success than newbies.