When I wrote my first article years ago about the power of psychotherapy, I was stunned by the reaction. Seventy-five percent was positive, but a very vocal minority attacked me viciously for either not having cured the patient or promoting a pathological dependence. They reasoned that had the patient received proper therapy she would not have needed anyone to solve her problems.
I was treating a woman for bipolar disorder with mood-stabilizing medication and monthly to bi-monthly psychotherapy. Her cognitive-behavioral psychotherapist referred her because she couldn’t get out of bed. She didn’t want to need medication. The psychologist didn’t want her to need medication. I didn’t want her to need medication, either; however, although not suicidal, the woman could barely function. The family of origin was loaded with depression and bipolar disorder; several uncles either killed themselves outright, or drank themselves to death.
It took months, but we found a workable medication regimen that elevated her mood and protected it from plunging when stressors occurred. The woman found our meetings educational, helping differentiate depression from the loneliness and alienation from her husband that pervaded her life. She felt our sessions complemented treatment with the psychologist.
During a particularly bleak period, she called asking for a medication change. During the ensuing session, we addressed her depressed mood psychotherapeutically and it improved immediately. The point of the article was that psychotherapy is a powerful biological treatment for depression. It often works immediately, as opposed to the days-to-weeks medication changes require to take effect.
The dictionary definition of the word dependence is “relying on or needing someone or something for aid, support, i.e. reliance; confidence, trust.” So why all the flak?
The word dependence as a term of art in medicine, psychiatry and clinical psychology is really a suffix. There are many prefixes: independence, counter-dependence, interdependence (that is a healthy reliance on an other benefitting both), overdependence, co-dependence, and hostile dependence. When unstated or ill-defined, the word dependence itself, and those purported to be responsible for the state, tend to be viewed negatively and judgmentally. Just as mental illness itself has fought hard against stigmatization, so must mental illness therapy.
Therapists serve multiple functions for their patients: advisers, educators, counselors, cheerleaders, behavior-modelers, reality-checkers, affirmers, disabusers, interpreters of the unconscious mind, and medication prescribers, to name only a few. Since no two patients or clinical situations are the same, each therapy requires a different mixture of therapist interaction.
In the best circumstances with the optimal outcome, therapy leads to independence: the doctor operates on a broken bone or cancer. After physical therapy or chemotherapy, the patient no longer is dependent on the doctor’s intervention.
Even then, assuming the patient follows up periodically, the patient relies on the doctor’s expertise to affirm that the disease is in remission. At some point the patient is discharged from care, usually with the understanding that he can return for reevaluation and treatment if the condition warrants. Given that the doctor receives remuneration and gratification from his work, and the patient receives comfort and affirmation that he is well, the relationship is in actuality interdependent.
In less than optimal circumstances, a doctor or therapist knows he can help his patient but the patient eschews help with the counterdependent declaration “I don’t need help from anyone.” Or the patient resents his need for help with a hostile-dependent attitude which often manifests in nonadherence to therapy.
The same holds with treatment for depression and anxiety: some patients who receive extensive and effective therapy during the active treatment phase derive great solace and affirmation from checking in with their therapist periodically. Is that overdependence? No. Is the patient emotionally weak because he counts on his or her therapist for affirmation? No. Or for reevaluation of prescription medication that is essential to maintain remission? No.
The crutch analogy to mental illness therapy remains pervasive and stigmatizing. It connotes that periodic or time-extended contact between patients and therapists after the acute phase of treatment is evidence of pathological overdependence on therapy. The therapist may be seen to be exploiting his patient by making him or her codependent on therapy.
Our brains are wired to connect. Even the most independent thinkers are interdependent on their fellow men and institutions to share and nourish their ideas. Performers need an audience. Writers need editors and a readership. Competitive athletes need events in which to showcase and develop their skills. Teachers need students and sometimes tutor them one on one if necessary. Research shows that continuing education is essential to keep the aging brain healthy. And companionship needs for loving connections to family and friends increase as we progress through the life cycle.
Certainly, therapists want patients to unconsciously incorporate what they learn in therapy. But the human mind needs continuing education and some life skills cannot be self-taught. The need for a continuing relationship with one’s therapist helps sustain healthy connectedness and interdependence.
Therapy session photo available from Shutterstock