Josh, a 32-year-old electrician in Brooklyn, started going to therapy about a year ago for the same reasons many people do. He was hung up on his ex and his friends were sick of hearing about it, so he decided to pay a professional to listen instead.
In many ways, Josh was lucky. He found a therapist available on Saturdays who took his insurance and had an affordable copay. And so, he really threw himself into the process, hoping to “get it all out there the first few weeks.” Through therapy, he learned that his problems had nothing to do with the person he was pining for, but how he felt about himself, and how quickly he was attaching to women. Yet no matter how much his therapist emphasized that therapy was a gradual process and there weren’t any quick fixes, he found it harder and harder to keep up with appointments once the breakup wasn’t bothering him as much.
“I was able to control my emotions a lot better and do more things for myself,” Josh tells me. “So when I went after feeling better, it felt more like a catchup than trying to figure out what I would have to do.” Josh tapered to bi-weekly appointments, then monthly, then when his therapist stopped following up to schedule, he assumed it was because he was doing so well and moved on with his life.
Research shows that nearly half of the people who begin psychotherapy will stop it prematurely, citing a variety of reasons that range from a lack of confidence in the therapist, to a disagreement about what the problem is, to a general unwillingness to open up. But getting people to keep coming in after they start feeling better is a common and under-researched obstacle in terms of client retention. “The question of why someone should come to therapy when they’re having a good day is a frequent one,” clinical psychologist Michael Wusik says. It’s a reasonable premise, given that mental health is an extension of physical health. After all, you wouldn’t keep a cast on your leg after it heals, so why would you continue with therapy after improving emotionally?
Wusik, however, stresses that we should still show up to therapy when we’re happy and healthy for a number of reasons. To start, sticking with commitments is an underrated way of generating self-esteem. “Follow-through shows us that we’re reliable and that we matter enough to do what we said we were going to do,” Wusik explains. But on a broader level, the false notion that you should only go to therapy when you feel terrible is a systemic issue that clinicians like Wusik have been trying to correct for decades. “Mental-health therapy has been gradually trying to work away from a weakness- or illness-focused model and more toward a strength or growth model,” Wusik tells me.
Historically, therapy has been a very reactionary process designed to get people “back to normal.” Or as Wusik puts it, “If you have a crisis, you talk to someone. If you aren’t in a crisis, you move on.” By now, though, it’s pretty clear that doesn’t work, and we only seem to be getting sicker. Anxiety and depression rates were approximately four times higher between April 2021 and August 2021 than they were in 2019, per the American Psychological Association. Obviously, COVID had something to do with that, but long before the pandemic, Wusik and others had been trying to treat therapy as a long-term, “cumulative process that’s working toward making lasting changes,” he says. And that means going on bad days.
The challenge for therapists is getting this logic to trickle down to their clients. Like for Mike, a 32-year-old teacher in Chicago, who has been going to therapy off and on since he was 12. He accepts that therapy is a long-term process to help him live a happy and healthy life. At the same time, he admits, “I’ve definitely canceled and also fired therapists because I was feeling good. I felt as if I was in a good place and needed to kind of loosen the reins.” He’s also bailed to watch soccer: “I’m not proud of that, but those tiny men across the ocean needed me spiritually.”
Although he opted for a “something suddenly came up” type of excuse the last time he canceled, Mike acknowledges that the truth was he just didn’t want to feel bad that day. To therapist Brooke Bralove, that’s precisely the problem — i.e., the fallacy that therapy inherently encourages negative feelings and you should cancel it if you want to avoid them. “In my 18 years in private practice, some of my absolute best sessions occur when patients say that things are good and they don’t know what to talk about,” Bralove says.
When you’re in a state of crisis, therapists spend a lot of time slowing you down and focusing the conversation on aspects of your life they can triage. But when you’re having a good day, therapists can “circle back to areas that we may have touched on but haven’t gotten the depth they deserve,” Bralove notes. Sometimes she’ll redirect a patient to their initial reason for coming to therapy and take time to revisit their goals. “I also tend to use those sessions to ask the patient if there’s something they’ve been avoiding discussing with me as now would be a great opportunity,” she adds.
For his part, Wusik has found that people tend to short-change themselves when they fail to show up on good days, because they don’t get the chance to examine what’s working. “It’s easy for somebody to chalk up feeling good to luck or other factors outside themselves,” he points out. In these sessions, he tries to focus on choices clients are making, as well as how they might behave differently on good days. “We can learn a wealth of information from the good days that we would otherwise totally miss if we only met during crises,” he continues.
That said, while it would be great if everyone could go to therapy weekly for the rest of their lives, forcing such a schedule on people violates a core ethical principle clinicians have — client autonomy. To Wusik, a non-negotiable part of the job is letting people leave prematurely if they chose to and offering the support of “booster appointments,” or even phone or email check-ins. If time allows, Wusik prefers to taper off sessions, like you would with medication, but if people need to stop going before that’s possible, his goal is to meet them where they’re at, offering resources and options without being too pushy. “I would hope my intention comes across as me trying to continue being helpful to the best of my ability,” he says.
Although Mike has canceled sessions over the years because he felt fine, the significant breaks he took from therapy were usually related to work, money and health insurance. And when those issues came up, his therapists were understanding and helpful, which has made it easier for him to go back. It’s also a two-way street, as “chronic cancellations can wreak havoc on a therapist’s ability to make a living,” Bralove says. To that end, Wusik has a waitlist at his private practice, so when people cancel repeatedly, it not only makes it harder for him to do his job, it potentially takes therapeutic time away from people who need it. “It’s frustrating to sit with an open spot knowing that there’s somebody patiently waiting to come do some work,” he says.
As for Josh, after more than six months away from therapy, he is planning on returning, but is overwhelmed by having to restart the process. When Hurricane Ida hit New York at the end of August, his Queens apartment and a majority of his belongings were destroyed in a flood that also nearly killed his cat. Since then, he’s relocated to Brooklyn, where he has roommates for the first time in years, which doesn’t make it easy to start opening up on Zoom with a therapist. “I don’t know if anything would’ve been different if I stuck with it, at least with the flood stuff,” he tells me. “I plan on going back soon, I just don’t know when. I sorta feel like it can only do so much.”
In fairness to Josh, a therapist can’t keep your apartment from flooding or any other living nightmare from happening, but they can do a lot more than just helping us through a single crisis if we give them the time. Perhaps that’s what will keep Josh going to his appointments next time — no matter how good he might feel.