4 Big Reasons Why Treatment Falls Short
What can we do when it isn't going the way we hope?
Posted Jan 31, 2019
Dedicating some time to meditation is a meaningful expression of caring for yourself that can help you move through the mire of feeling unworthy of recovery. As your mind grows quieter and more spacious, you can begin to see self-defeating thought patterns for what they are, and open up to other, more positive options. — Sharon Salzberg
Getting better can be challenging. Evidence on the treatment of mental health conditions shows that while many people recover fully, and many emotional complaints are normal or part of adjusting to change, a decent proportion of people seeking treatment don't get better or show slow, limited improvement. Some folks suffer chronically, sometimes trying everything possible. But sometimes they have not tried treatments that stand a good chance of helping.
Try, and try again
In the famous Star-D Study, 30 percent of people treated for recurring depression recovered fully with first-line medication prescription and 10 to 15 percent more had a partial response. The rest required several more treatment attempts, and many still did not get better. The more tries they made with additional medication strategies, the lower and lower their chances of recovery became, until by four tries, the chance of responding to medication was less than 10 percent.
Psychotherapies (there are so many), and non-clinical approaches such as exercise, sleep cycle control, light therapy, meditation, yoga and breath practice, and others can help. But we are often left with inadequate responses, or we have great difficulty doing what we know will help — or we do it half-prepared to succeed and let it fall by the wayside — often increasing self-reproach and enhancing hopelessness and helplessness. Getting set up to succeed ought to be built into any approach, with attention to interfering factors as part of the process. It doesn't help that there is a lack of consensus within the field about what works best, and a lot of disinformation and conflict that confuses patients seeking help.
Four reasons why treatment may get bogged down
These are a couple of big issues I see a fair amount of, unfortunately, as a psychiatrist. My intention is to provide useful perspectives, encourage constructive exploration and conversation, foster collaboration, and sidestep unnecessarily destructive or defeating emotions and responses — opening a window if you will, to let in fresh air.
1. The diagnosis may be wrong. According to basic medical principles, making an accurate diagnosis is the first step in developing a rational, evidence-based and personalized treatment plan. Because psychiatric diagnosis is not yet based on clear biotypes (though this is beginning to change) and is based largely on clinical presentation, there are many reasons why diagnosis may be delayed or inaccurate.
One reason is inadequate history. Getting a good clinical history requires a lot of time and a connection between clinician and patient. Time may be limited because of managed care in the case of insurance-based care, or because of difficulty committing financial resources. Gathering a patient's history can also include obtaining prior medical records as well as, at times, speaking with family members or reviewing school records to get accurate information. Many times providers don't have the time and unfortunately patients often have difficulty with a comprehensive evaluation, and understandably may want to start immediate treatment. However, failing to do a thorough job often leads to long delays in proper diagnosis and care.
Clinicians may thus be inclined to make rapid diagnoses based on insufficient history, leading to errors in diagnosis, especially if the decision is not reviewed periodically, either as a matter of routine good care or when treatment is not working. When a particular diagnosis is popular, as ADHD currently is, clinicians may be quick to notice difficulties consistent with ADHD and fail to recognize other issues. Many conditions are associated with distractibility, agitation and inattention, including post-traumatic conditions, bipolar disorder, depression, anxiety, and others. Patients may find a quick online diagnosis like ADHD seems to fit. On the other hand, ADHD is underdiagnosed for different reasons, and often treatment is delayed as well. When diagnosis is unclear, or treatment isn’t helping after a reasonable period of time, getting a second opinion and obtaining formal psychological testing may be useful. It's about accuracy and completeness, without undue delay but without rushing.
Furthermore, there are important factors that people may not want to talk about, or may not understand are important, including substance and alcohol use and developmental adversity. There may be experiences that people don't mention because they are unremarkable, a good example being hypomanic episodes that feel good and aren’t necessarily seen as problematic by patients if they haven’t caused problems. Hypomanic episodes would suggest a diagnosis of bipolar disorder, rather than major depressive disorder, and the approach to care is very different. Issues like this lead to delays in diagnosis and effective care.
Post-traumatic consequences can present with complex symptoms as well, and may appear to be a basic anxiety disorder, like generalized anxiety disorder or panic disorder, a mood disorder, or anger management issues, and may also present with alcohol and substance use, eating and interpersonal issues. When trauma hasn’t been identified, people may end up with multiple diagnoses and treatments that don’t seem to be working. On top of all this, people often have more than one condition, including both medical and psychiatric disorders that present with emotional and psychological problems. In addition, the diagnostic system itself is evolving. As we understand the brain better, and the relationship among various biological and social factors, the way we view diagnosis may change almost completely in the future.
2. Important diagnostic discussions may not yet have taken place. For many different reasons, some more understandable than others, clinicians may not share their diagnostic thinking with patients. Discussing diagnosis can be challenging because patients may have negative reactions, either not agreeing with the diagnosis, reacting defensively, or both. This is often the case with alcohol and substance use disorders, where denial is a common element and addiction makes people want to avoid treatment because it would mean decreasing or stopping use.
Sometimes clinicians are unsure of a diagnosis and want to wait until they are more certain. Sometimes, clinicians may not discuss difficulty or stigmatizing diagnoses in order to spare patients’ feelings, or may be working toward a time when they are able to discuss more difficulty diagnoses more constructively. In my experience this is often the case with personality disorders, including Borderline and Narcissistic Personality Disorders, for instance. We don't want to hear emotionally challenging information, typically, even when we have to be prepared to make use of it.
Diagnoses can be a tremendous relief, providing an explanation for long-standing struggles and avenues for care. At other times, people may recoil from diagnoses that feel threatening or too dire, placing greater demand on the clinician’s communication skills to constructively navigate the discussion.
So, while clinicians may be able to discuss diagnoses sooner, especially if they are skilled in having difficult conversations, patients may also react negatively. In some cases, patients will go from clinician to clinician for years, staying only with those who agree with the that person’s view. Clinicians, in turn, may avoid confronting issues that are too emotionally distressing to tolerate. If more sophisticated issues are too disruptive to address in treatment, focusing on basic building blocks—such as emotional awareness and fluency, emotional tolerance and regulation, and capacity for self-awareness—is the way to go. This can help address the underlying experiential avoidance and unconscious habits of avoiding recovery.
3. There may be a problem that we aren't aware of. There are many situations where we can't really pinpoint why we are having difficulty moving forward. These include un- or misdiagnosed conditions, maladaptive belief systems that haven't been fully elucidated, developmental hang-ups, including unresolved distressing early experiences, deep negative convictions about oneself that must be overcome, and a range of other issues. Sometimes there seems to be nothing wrong, except for the strong and uncertain conviction that something must be or is wrong. Then the question becomes difficult, as there may be no answer, other than to put aside such questions and get on with the business of changing. When "why" gets in the way of "how," it's a good idea to slow down and get a bit meta, asking: How am I approaching this problem, how am I working with other people to optimize change, what are my underlying associations and beliefs about healing, what is my relationship with myself, what haven't we thought of that may be helpful, and related questions.
4. We are trying too hard. I think this is an easy one to understand intellectually, but a hard one for people to really grasp when it comes to their own experience. Sometimes we have to make a change in order to get it, like riding a bike. What is it like to ride a bike? Hard to describe, but learn to do it and you'll see. Then we can talk about it together in a different way. This kind of metaphor applies to the experience of recovering, of feeling well, of tending to oneself properly. People who didn't absorb these things non-verbally growing up may have more trouble because they can't imagine what a different way of being would be like. Here's a true story, which illustrates stuckness and escape from stuckness.
I was a surgical resident for two years before psychiatry residency. It was a great experience. It was brutal. Weeks were up to 110, even 120 hours long, on call overnight every other day in the intensive care unit for months on end, and a variety of experiences, challenges and triumphs, which shaped me as a mental health doc. We woke up early, we hit the ground running, and would routinely pop out of bed and be on rounds in 10 minutes. This sets the stage.
One morning I woke up, showered fast, pulled on my scrubs, and was in the kitchen. I heard a ruckus in the bedroom and went in to see what it was. A beautiful spring morning, sunny, I'd left the window open several inches to get fresh air, and a visitor had inadvertently entered the room.
This squirrel found itself in an unfamiliar and hostile environment. It was ricocheting around the room like a real-life cartoon character, careening off the furniture and wreaking havoc. The room was trashed. The squirrel was stuck, wanting a major change, but not knowing what to do. I for my part wanted to help him without getting injured in the process. Thinking on my feet, I reached over, opened the window up wide, and backing out of the room, closed the door. The smashing continued briefly, and to my the squirrel found its way out, somehow. In its stochastic, bouncing-randomly-around panic it just randomly shot out through the window. Back into a bright, familiar reality — and I made it on time to rounds, avoiding the certain wrath of my senior resident that lateness would have evoked.
The moral of the story is about the mammalian brain. To keep it simple, let's just say there's a lot in common between squirrel's brain and the human brain. Though there's a lot not in common (where did I put my keys?). When in a state of fear, there's not much room to think. Absent the over-practicing of desirable alternative responses (think fire drill), we revert to automatic patterns. In many cases, these are response habits that were formed in the past, but no longer apply today. Someone who learned to throw water on a wood fire may pick up a bucket and throw water on an electrical fire.
The squirrel was unable to pause and think, but I was. Opening the window, I knew, would lead to the squirrel eventually finding the new way out. Luckily for me, it did it within a minute, and I made it to rounds that morning on time (with a good story). The squirrel was trying too hard, making it impossible to respond adaptively. When we are trying to be effective, sometimes we try too hard to see the viable paths. Freud knew this, too. In one of his early papers, Recommendations to Physicians Practising Psycho-Analysis, along with many other sage observations and instructions, he strongly cautions against "excessive therapeutic zeal." While diligence and persistence pay off, trying too hard just ties us up in knots.
Trying too hard comes from many sources. It comes from obsession, and it can come from perfectionism. "Perfect," pioneering pediatric surgeon Alberto Peña would gently repeat, "is the enemy of good." My psych reinterpretation of this is, "Perfect is the enemy of good-enough." Psychoanalyst and pediatrician Donald Winnicott recognized that what kids need is "good-enough" mothering. Perfectionistic mother may be counter-productive. Good-enough is good.
Sometimes with therapy, knowing when to capitalize on major gains, wrap up, and move on — not to stop, necessarily, but to transition to a different phase of growth — sometimes means letting go of trying and simply getting on with living.
Other considerations when contemplating treatment response
There are other considerations better saved for another time: For example, some people suffer from treatment-resistant conditions, such as treatment-resistant depression (TRD), without having tried effective alternatives. These might include new classes of medications (if you have taken more than a couple of SSRIs, for example, what about other classes of antidepressants?), treatments like transcranial magnetic stimulation and other emerging therapeutics, major lifestyle and diet overhauls, and so on.
There can also be a problem with the therapist-patient fit. Sometimes it isn't a matter of training or what kind of therapy, but a personality clash. One analyst talked about this as an "interlock." It isn't anyone's fault, but if the therapeutic pair doesn't address what is happening on a relational level, it's a no-go. It is possible that the therapist isn't skillful for what a given person needs and may be treating outside of their range. If that is the case, it's appropriate to acknowledge and discuss it, so the patient can get proper guidance if they are to remain involved in care (e.g., training and supervision, second opinions) or be referred to another clinician.
Last, it may be that there isn't really anything wrong. This is tricky because it's circular, and if someone feels so strongly that something is off, even if "nothing's really wrong," by definition the powerful belief of wrongness itself is a legit issue. It's a tough one to deal with. In other cases, though, it may be a belief which, when explored, leads to the recognition that we have more going for us than we thought—and taking certain risks will allow us to prove our own self-efficacy to ourselves.