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Common Problems in Time-limited Psychotherapy
There are no clear guidelines to determine the optimal next step for patients who fail to respond or do not respond fully to an initial course of psychotherapy. In the case of nonresponse to a given treatment, which may be defined as failure to achieve at least a 25% decrease in baseline symptoms over a 6- to 8-week time period (Nierenberg and DeCecco, 2001), the usual approach would be to stop the unhelpful therapy and consider alternatives. Patients who show no benefit from a TLP should be evaluated for the typical sources of treatment failure such as misdiagno-sis, the presence of a comorbid psychiatric disorder, or comorbid general medical conditions (Kornstein and Schneider, 2001), and referred for appropriate treatment. If the TLP psychotherapist is also a physician, it would be reasonable at this point to consider pharmacotherapy. If the clinician decides that it is in the best in-terest of the patient to abandon a course of TLP, it is importantthat the therapist help the patient understand that the “fault” lies with the TLP rather than the patient. The therapist should be cer-tain to offer the patient support during the transition to an alter-nate treatment, instilling hope that the new treatment will offer relief and making sure that continuity of care is preserved.
In most cases of partial response to a TLP, clinicians choose to add medication as their first strategy. Unless the thera-pist suspects that psychotherapy may have worsened the patient’s condition, continuing psychotherapy usually makes sense. The preexisting therapeutic relationship can provide a supportive holding environment for the patient while medication is initiated that may help the patient tolerate initial medication side effects and the delayed onset of action associated with antidepressant medication. Among depressed patients who fail to respond to an initial course of pharmacotherapy, response rates to a second antidepressant hover around 50% (Marangell, 2001). By contrast, in a sample of depressed women, the addition of an SSRI to IPT among those who failed to respond to IPT alone brought about remission in almost 80% of subjects (Frank et al., 2000). Thus, depressed patients who do not remit with psychotherapy alone may be excellent candidates for combination treatment with psy-chotherapy and medication.
If a patient refuses medications or prefers a trial of a differ-ent psychotherapy, it may be reasonable to change TLP modalities or consider an open-ended treatment. Issues to consider include whether it makes sense to switch therapists, the qualifications of the therapist to administer multiple types of psychotherapy, and the availability of alternate treatments in the patient’s geo-graphic area. Whereas psychopharmacologists can easily change prescriptions and proceed with a consistent therapeutic approach, a psychotherapist who suddenly begins acting differently may confuse an already uncomfortable patient.
In IPT, we make every effort to blame the treatment rather than the patient when symptoms persist beyond termination. Depressed patients are inclined to blame themselves, so it is important for therapists to maintain their objective stance, pointing out treat-ment successes (there are usually some) and underscoring the fact that not all patients respond to any single treatment. Patients with histories of chronic or recurrent depression who respond to an acute course of IPT are generally considered candidates for continuation and/or maintenance of IPT sessions (usually admin-istered at a reduced frequency) to help achieve a full remission and prevent relapse and/or recurrence (Frank, 1991; Markowitz, 1998).
During the course of any psychotherapy, unanticipated crises may occur in the patient’s life, temporarily derailing treatment. For instance, if the patient suddenly developed new, life-threatening symptoms such as active suicidal ideation or frank psychosis, the case formulation would be abandoned in order to attend to patient safety. Alternately, if the patient experienced an unexpected life crisis mid-treatment (i.e., the death of an important person, sig-nificant changes in socioeconomic status, etc.), it would be rea-sonable to reevaluate the treatment focus in order to attend to the patient’s pressing needs.
Regardless of treatment modality, patient safety super-sedes the treatment paradigm. In TLP, it is desirable to address the crisis as quickly as possible in order to return to the treat-ment focus and complete the treatment within the specified timeframe. If the therapist can address the crisis rapidly and resume the prior focus, it may be possible to regain the original treatment trajectory. If multiple sessions are required to address the crisis, the therapist must ask, “Is this TLP salvageable?” and “Can we meet our treatment goals within the remaining allotted time?” If not, the therapist should consider altering the treatment fo-cus or abandoning the current treatment approach entirely. As we have emphasized throughout, changes in treatment approach should be handled carefully, reassuring the patient that they are not to blame and providing support as the patient shifts to a new intervention.
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