I have been seeing a client in therapy for over six months. He was very depressed when he came in, and his depression has improved though he still scores in the mild range on the Beck Depression Inventory. I’m not sure what more to do to help him continue his improvement. It seems like therapy has reached a plateau.
The topic of the therapeutic relationship is covered in Chapter 11 of my book, which reviews different aspects of how therapy evolves over time. In this case, you report significant improvement followed by a period when the symptoms are remaining stable. I can recommend several things to consider at this point, to help you and the client understand the meaning of this plateau.
I would first suggest that you talk with the client about your perception that his symptoms have reached a plateau. He may be aware of subtle changes that aren’t reflected in his BDI score, indicating that change is still taking place during this period. If he does report that the pace of change has slowed, you can ask him how he understands this and engage in a collaborative discussion that may result in some insight into the next phase of therapy. Two specific areas for discussion would be his feelings about the changes that have occurred since he began therapy and an examination of the function his remaining symptoms may serve in his life.
Discussing your client’s feelings about the changes he has made may identify some ambivalence or some discomfort with what is unfamiliar to him. Although improvement in depression is desirable and is probably the primary goal you and he have worked toward, there are times when change can feel uncomfortable or even frightening. If he is handling situations differently, he may need some time to adjust to his new approach or a new way of thinking about himself and others. It’s possible you don’t need to do anything more; instead this pace may fit your client’s needs.
If your client indicates that he feels stuck or stalled in his progress, I would recommend that you reflect together on the function his symptoms may serve. In some cases, clients come to recognize that their identity is associated with being depressed or that they are repeating a pattern from their family of origin or that being free of depression may increase the expectations they and others hold for themselves. These factors are usually outside of awareness, so this examination may unfold over several sessions. The client’s history and current life circumstances may provide you with some ideas of how depression may serve a purpose. For example, he may feel closer to a depressed parent or sibling when he is also depressed or he may be avoiding the pursuit of a different job or entering into a new relationship.
It is possible that discussing these issues with your client will result in expanding or shifting the focus of therapy to incorporate your perspective on this plateau of symptoms. You might begin to talk more about the client’s sense of identity, his childhood experiences, or conflicts in his work or relationship life. You also might find that the client needs to learn and use different strategies for managing his symptoms in light of the new insight you and he develop together. This isn’t a matter of you figuring out what to do, but you and the client working together to discover what he needs to continue his healing.
I hope these ideas are helpful in understanding a period of slow change in therapy. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.