What is success in therapy? How is that determined?
I read yesterday in Everyone Needs Therapy the following -- not being a resident of Illinois, I have no knowledge of the laws there regarding therapy and its practice --
"In the State of Illinois, after six months of treatment, if a patient isn't getting better under a social worker's care the social worker is legally mandated to punt to another therapist. I'm not sure how the other mental health professions handle this, but social workers can't let you malinger very long. "
Who decides that and how? A symptom checklist? What is "getting better"? What does this mean when applied to therapy modalities which assume a longer time frame for the work, like psychoanalysis or psychoanalytically oriented depth psychotherapy? Why would it be malingering for improvement to be slower in coming? What does this mean for and about patients who have benefited from rather long courses of therapy or analysis?
See -- more questions than answers. The law seems to operate on certain assumptions about therapy and about how much influence the therapist has over outcome. It also seems to assume that short-term or relatively short-term therapy is what defines therapy itself.
So how do we consider the therapy in the case of patients like Alex? This is a tough one. So much remained undealt with -- from the hostile attack Alex made against Paul to the fling with Laura to his relationship with his father to his return to flying that it is hard to assess. This is a therapy that was very much still beginning with the basic issues still emerging. And then Alex died.
It is common to imagine that it is therapy that transforms people's lives, that there is something in the process that makes change happen, rather like a medical procedure. But therapy is only a small part of the process. It is but an hour or so a week and it lies with the patient to reflect on and use what is learned, seen, or gained in that hour in the rest of his life. Unless insights gained in therapy lead to action in the patient's life, nothing will happen. The therapist can help with providing some of the insight, the means for which to view one's life differently, but it lies with the patient to take in the interpretations, observations, suggestions and digest them and then apply them. Therapy is not magic.
So with Alex, we have someone who started out quite resistant to the process, who only reluctantly yielded to it and that only in spurts. Under the 6 week rule, Paul would have had to refer Alex on to someone else before therapy even started! Does this mean the work he was doing with Alex was a failure? Or is it that little bit by little bit Alex was coming to trust what was happening in his time with Paul and might he, had he lived, decided eventually to actually commit himself to the therapy and really get down to work? We'll never know, of course, but that certainly is a possibility.
Ultimately only the patient can decide if therapy was successful because it is the patient's life to live. Any therapist has the experience of patients leaving before he or she felt the patient was ready or had finished. And also patients who have stayed after the initial complaint is resolved. Some of what it means for therapy to be a success is determined by how one conceives of therapy in the first place -- as a way to solve problems or relieve symptoms or as a way to learn more about oneself and gain greater understanding of the meaning of issues and events in one's life. There is no one size fits all definition of success here.
When a third party pays the bill in whole or in part for therapy, then it is reasonable to set some kind of standard for outcome. And insurance companies certainly lead the effort to do this. It is economics that set the agenda here though, make no mistake about it. But that is a topic for another day.