More therapy?

Sometimes it can feel like we have been in therapy for years. Maybe you have had thoughts like "shouldn't I be healed by now?" or "Is this even working?". Or maybe you are trying to decided if it makes sense to slow down and space out appointments. Maybe you did stop therapy or slowed down and it feels like you need therapy again. That can come along with other thoughts and feelings. And then there could be the ADHD of it all, which could look like wanting an appointment but forgetting to book in. Maybe it feels like you figured out one quadrant of your life, but then there's another quadrant that asks for attention. I think something a lot of people (clients and therapists) can struggle with is when to space out, increase, or stop therapy.

Starting off

When I start working with an individual or couple, I prefer to meet them weekly for the first 4-ish weeks. It helps us to build the therapeutic rapport and working alliance. It helps to identify therapy goals and builds a trajectory around working towards those goals. Sometimes weekly sessions will continue to make sense. For example, a couple in distress, or an individual who has a lot to unpack may continue to find weekly sessions helpful. Sometimes it makes more sense to space out. I work with my clients to determine what makes sense for them. Depending on what we are working on, it actually might make more sense for them to space out therapy.

When Have I suggested that we space out?

1. When we have met therapy goals, but clients still want support. Sometimes clients meet their therapy goals. They might have worked through the thing that brought them to therapy in the first place. When their case notes start to say things like: Increased ability to sit with uncomfortable feelings; has built a compassionate voice; Is identifying and meeting needs; has integrated new attachment patterns and is building secure bonds; etc. When these things show up consistently I know it's time to think about spacing out or ending therapy. But sometimes the changes are still new and the client want support maintaining these changes.

2. Therapy itself has become distressing. This sounds counter-intuitive but it can happen. Sometimes frequency of sessions can be overwhelming to people's schedules. Or sometimes exploring parts of ourselves can be difficult and emotionally activating which can be energetically draining. Sometimes people need more recovery between sessions. Kind of how our muscles need to repair after a difficult gym day. It's okay to and even celebrated to identify that a client may need more space between sessions so they are not overloading themselves. It's a win that they can identify their needs and then work to meet them.

3. When regularly scheduled therapy gets in the way of therapeutic goals. If therapeutic goals include things like increasing socialization, increasing engaging with hobbies, connecting with their partner, etc. sometimes it makes more sense to take that hour (and money) and put it towards something else. It may make more sense to spend that hour in the gym or with a hobby. Or it may make more sense to spend the $150.00 on a date night or a massage therapy appointment. People have limited resources and it's okay to work therapy into your self-care program that includes other self care activities. In fact a good therapist should want you to have a full self care routine.

When Have I Suggested Therapy Increase?

1. If clients have identified subsequent goals that need more time and attention. Sometimes clients might want to explore a new part of them, or go deeper. It's hard to do that if sessions stay spaced out too far.

2. If something big has happened in their life and they need more support. Life is unpredictable, sometimes even when we are very mentally healthy life can catch us off guard. There could be things like loosing a loved one, receiving a diagnosis, job loss, increased work stress, life transition, among others. It's okay to need extra support during these times.

3. Low feelings/ low mood return. Sometimes it happens, everything seems normal, nothing big has changed and yet clients might feel more distress than usual. Critical self talk can re-immerge, relational patterns might shift, adaptive strategies might fall away. It's okay when that happens because good mental health is a practice not something you achieve once and set and forget. We wouldn't expect people to only go to the gym for 6-8 weeks of their life and then be magically fit the rest of their life.

Some ADHD Considerations

1. Sometimes ADHDers can take longer to learn new skills. That can happen for a few reasons. Emotional distress can make it harder to access executive functioning like working memory and self monitoring. That means we might need more practice than other people when we are learning a new coping skill or changing a relational pattern.

2. The nature of ADHD is that our executive functioning, including emotion regulation can be unreliable. It is a dynamic disability. What felt easy one day may feel really taxing the next. We may need therapy as part of our regular self-care routine to help us practice and find solutions that makes sense along the way and to maintain a compassionate inner-voice. It's hard not to be self-critical when ableist and captialist scripts try to frame our ideas of self-worth.

3. What works in what quadrant of our life doesn't always work in another. We might need different kinds of therapies for different parts of our lives. Maybe a solution focused approach works really well for work dynamics. But we have to do psychodynamic work or attachment work for relationship distress. Maybe we have to work on self-compassion and narrative therapy for our critical inner-voice and our relationship to self. Maybe one therapist can help with this or maybe it takes a few different therapists.

Sometimes unavoidable but not good reasons to stop or space out therapy

1. Finances. Sometimes the cost of therapy can be too much for people, especially if they don't have insurance coverage with work. Some therapists offer sliding scales, and intern therapists or new therapists typically work at lower cost fees to help with accessibility to their services. Even then, therapy can feel like a luxury. I have a method I use to determine if someone meets the criteria for access to my sliding scale. For other people, I am upfront. I explain the limitations that can occur if we are spacing out therapy before it makes sense to. As long as the person understands and is able to consent, I will generally meet that client where they are at and see them with the frequency they are comfortable with. There's some research that shows any therapy is better than no therapy. I just work with those clients on determining what they want to get from therapy and make sure we are always collaborating and I am getting informed consent.

2. Burnout or Scheduling issues. Sometimes clients may have so much going on that they can't fit therapy into their schedule (I have been there as a client myself). Sometimes it's those times we could benefit from therapy the most. But we all have to make decisions that work best for us in the moment. Sometimes though this can actually highlight some avoidance tendencies or habits of sidelining needs and could be really good to talk about in therapy when there is a chance.

Can you tell when you need to space our, increase, stop, or re-start therapy?