It appears that most people think that they can come to therapy whenever they want and return when they feel like it. As if therapy is an as-needed type of attendance when...
Symptoms Determine the Level of Care
Say what??? Yes you heard me ... clients do not determine how much therapy is needed, your level of symptoms determine it.
Remember this is my interpretation of this subject; each therapist has his/her own unique view.
1. Level "One" = As Needed Attendance for the Worried Well
This is when a client can come as needed. Basically clients will determine when they want to come. Level one is reserved for the worried well. These types of clients are functional, they go to school or work regularly. Their symptoms do not interfere with daily functioning except maybe during normal life events like death, divorce, breakups. They come to therapy for support, and maybe a skill here and there or some trauma work but not because they cannot function in daily life. It is mainly quality of life issues.
2. Level Two = Symptoms Interfering in Daily Living
At this point I get “bossy.” I will tell you what I think you need: skills, therapy, (weekly or bimonthly), and trauma processes. I will make learning skills mandatory. This is based on clients’ symptoms, when they are interfering with daily functioning creating distress. I may refer level two clients to a doctor for medication at this point.
Some clients who are at level two struggle with skill-building. Basically they are stuck in emotional reactions and negative coping cycles. Addressing these cemented reactions during a session is sometimes enough to bring awareness and break the cycle. Others times symptoms are too extreme and additional support is needed.
Most people at this level blame themselves, have negative self talk, and believe becasue it’s in their head then it’s their own fault. Wrong!!!
We are not responsible for what we think, but we are responsible for what we do with our thoughts. It is the same way with feelings. Feelings come and go like clouds in the sky. So we must allow our feelings and thoughts to exist as a stream flowing through us.
Sometimes I will see clients at level two until they know that they need additional support. My clients must know themselves and know what is impeding the process of “getting better”. This phase of awaking can take time. Working on pros and cons lists and examining negative coping patterns until you get better or "know" that you need additional support. Then I will make a referral for "more support".
Therapy is a place of learning.
Any good teacher is sure to convey this learning to their students -- otherwise that therapist is just the leader telling you what to do. That is not how therapy works. I am teaching you to see your own inner barriers and start your own process of healing when you come to see me. It starts with you, my clients, knowing where you are blocked.
3. Level Three = DBT Group + Therapy
Level three just means that you need more support. By this I mean you need a DBT group and individual skill-building every week to move through your symptoms. "Move through" means to develop new ways of addressing your inner world. I refer out for this level of support. Symptoms determine this referral.
4. Level Four = Hospitalization
This is the last level reserved for severe mental health issues like when someone is a threat to him/herself. Suicidal ideation is common in my office and most of the time it is not “lethal” which means the thoughts are occurring but the outcome is not truly what is desired. With that being said, sometimes it IS more serious and clients need to be hospitalized. For this type of hospitalization it is typical to go to a local emergency room or mental health hospital. This is merely for stabilization. I only suggest this when it is essential due to safety issues.
I prefer to send clients to facilities that specialize in your diagnosis. These facilities are always out of state. Programs can last two weeks to a few months for depression, anxiety, OCD, personality disorders, and trauma. These facilities are life changing with intensive therapeutic approaches to help stabilize and facilitate learning.
I hope this blog helps to explain that symptoms indeed determine level of care, not one’s individual desires. If you have a cold, you would not say, “I will just take my antibiotics when I feel like it.” It is the same way with therapy; following our recommendations is research-based and what has been proven as effective.