Richard  0:09  

Hello everybody out there hello therapy fans. Hello happy fans. Welcome to the therapy natters podcast. I am psychotherapist Richard Nicholls, pleased to meet you. And with me as ever is my co host here. Fiona Biddle psychotherapist also, hello to you. 

Fiona  0:28  

Hello and here is an interesting phrase, but I'm here anyway, yes.

Richard  0:36  

We record this on a Friday. And when you've had a week, you're kind of ready to chill out at the end of it. And I go a bit silly come the end of the week. I don't know about anybody else. 

Fiona  0:47  

I certainly do. And this is called therapy natters. We are here to natter. It's not intended to be overly serious, although there is a serious content to it. So I like the fact that we can be a bit silly. 

Richard  1:03  

Yes, I know. We're never, I think going to belittle the content, we're always going to be always going to take it seriously. But I think we all need to recognise that therapy, although it is a serious thing. I was gonna say it isn't life or death. But you know, sometimes it is. But most of the time it isn't. Most of the time it is about people wanting to explore how they think and feel and the things that they do and what makes them tick. And that can be light hearted. I've read plenty of academic stuff where people talk about the use of humour in therapy, and how important it is. I think I do that a little bit 

Fiona  1:40  

Before you said it's not life and death. I was thinking that it's like life in that humour helps. In that what whatever the situation is., However dire things are in the world, whether specifically or generally, humour has always been found to be helpful. So I think it's always a good thing.

Richard  2:03  

I think so even if we tend to be using it as a defence mechanism, defence mechanisms are there for a reason. And they are useful, sometimes they're not. And we'll talk about that in future episodes. But they're there for a reason. And they can serve a purpose that can be helpful. So we have a couple of questions today that merge quite nicely together. And I'll I'll read them out. I'll read them out, Fiona.

Fiona  2:29  

Go for it. 

Richard  2:29  

First one is from Hannah from Stoke. She says "I've been on antidepressants for three years in January. And I'm wondering how I will know when I'm ready to come off them. I understand I need a doctors support and that there will probably be side effects. But how will I know that I don't need them anymore? Is it safe to stay on them indefinitely?" And a similar or kind of related question came in from anonymous listener. Who says "How do I know when to end therapy? I've been seeing my counsellor for around three years now. And we have appointments every two weeks. I've improved a lot since we first started therapy, but we simply rebook for the same time in two weeks at the end of each appointment, will it be obvious that I don't need to see them anymore? Thank you."

Fiona  3:18  

The first word that comes to my mind when I hear these two questions is autonomy. That each of these Hannah and

Richard  3:30  

Anonymous 

Fiona  3:31  

Anonymous, I got the word autonomous in my head and couldn't shift back to anonymous. Hannah, and Anon. Both of these are questions about your autonomy. So I think Richard would agree with me that our basic question is, it's up to you. But I think we can give a little bit more help than that, as we go through a little bit more. Not a lot because it is up to you. And client autonomy is a really big deal. In the world of therapy. Maybe not so in medicine. Maybe it should be a little bit more in medicine than it might be. But it's still up to you.

Richard  4:18  

I think when it comes to medicine, there's a lot more advice needed. I think people go to a doctor or a psychiatrist and say, I need some help. What do you advise? And if they were to say, well, it's up to you. Well, no, Doc, it's up to you. Whereas with mental with, with talk therapy, it is slightly different because we do tend to know it seems as if our relationship our therapeutic relationship is strong enough that I can say "I think we've come to a natural conclusion in our treatment."

Fiona  4:54  

Yeah, I guess I wasn't saying that. It's up to the patient or the doctors to say exactly what they want. But the overarching thing is they can choose whether to accept a treatment or not, and with antidepressants, when to come off them, but definitely within the guidance of their medical practitioner. Absolutely,

Richard  5:21  

yeah, I've met people over the years, including therapists, let alone the clients that they've seen that are quite anti psychiatric medicine. And one of the things that they, they say they aim to do is get their clients off their antidepressants as soon as possible. And I don't like that. That sounds....that sounds a bit scary and a bit dangerous to me. I understand why a lot of therapists think that the antidepressants are the problem. But we've seen them save so many lives, that they're clearly useful. And I've had lots of clients who have said, my aim in therapy is to come off my antidepressants. They don't want to be on them, they see them as a problem. Now, there's a phrase, I always say, crops up everywhere. Nothing's a problem unless it causes problems. If the side effects of the medication that somebody's on, are worse than the issues that they had before, then yeah, that medicine isn't right for them. If they feel that they're well, that they're emotionally well, they feel quite stable, and they're still taking the antidepressants, but they're not causing any side effects. There's no weight gain or testosterone problems or problems with lactation or all these strange side effects that they sometimes claim that anything can happen when you take any, any medication, if it's not causing a problem. Is it okay, just to simply stay on it for the rest of their days?

Fiona  6:47  

And of course, we probably most people who are listening to this and certainly, Richard, you and I know of people who are on antidepressants long term, without any problem. This takes me back slightly to the question of whether the antidepressants are actually doing what they say they are doing. Because I don't know about you, but I've heard many people who are still, let's just make it really simple, still depressed when they're on antidepressants. So are they actually doing the job? The general thing that I see is that antidepressants are there to help people to overcome the issues that are resulting in them feeling depressed. But that's only when there are certain issues that are resulting in it, sometimes it feels much more vague than that. which case well maybe if they are doing the job, and the person is feeling fine, then well carry on.

Richard  7:53  

We know that antidepressants work. There's this myth, I think within a lot of talk therapy communities that say, oh, it's all placebo, they don't actually do anything. Nobody really knows how they work. And there is some truth in that nobody truthfully knows exactly why antidepressants work, we just know that they do. But we also know categorically research after research, study after study, they work better than a placebo does. If the GP, if the psychiatrist doesn't know which medication the patient is on, if the patient doesn't know which medication they're on, there is a considerable difference in those that have the placebo and those that have the antidepressant, or what gets people's back up, I think is the fact that people still benefit from the placebo. And they go well, clearly, it's all in the mind. But it's not all in the mind. And this kind of takes us this merges both of these questions together. Because when you're part of a study into testing, which antidepressant is going to be useful, you're going to get the same treatment from the psychiatrist no matter what. Now, some of that is going to include sitting with somebody telling them how you feel, talking about your problems, and have them listen to you and understand you. That's therapeutic, whether they're doing it as a psychiatrist, or they're doing it as a psychotherapist, that is therapeutic. And yes, they might take a placebo. And they get some benefit. But I think the benefit, some of it could come from, hey, I'm doing something that's gonna get me better every morning, I pop this pill, there could be a lot to that we're not we're not ignorant to that. But there's a lot of benefit that comes from sitting with another individual and feeling like a human being.

Fiona  9:38  

The whole placebo effect issue is an absolutely fascinating one. And whether something is placebo or whether it's partially placebo. It sort of doesn't does it really matter? As long as whatever it is, is working but it can be a mix it's not just necessarily it is a placebo or it's not? Well, obviously some things can be. But if you're given a dummy pill, for example, well, you know, that is technically placebo. But there can be a placebo effect from a genuine medication as well. So it's hard to pull things apart really. And of course, then you've got the individual differences. So just because a research study has shown that X, Y, and Z has such an such result, but doesn't mean that it does for you. And that's the same with any medication.

Richard  10:35  

Yeah, I think that's, that's really important that people recognise that just because somebody's brother or sister says, This is what I take, and it works for me. So go to the GP, that's the only one that works. Every brain is different. Every body is different, how our hormones interact with the bacteria in our gut compared to the different serotonin levels that we have, and the things that we produce there's so much that goes on in our brain and body that contributes to our mood. And unfortunately, that can mean a little bit of trial and error into what's the right one for you. But if something isn't working, that's when you speak to your GP or your psychiatrist or whoever is prescribing your medication and say "This isn't working for me" or you say, "I'm not sure if I need to be on these anymore, because I'm feeling pretty good. What do I do?"

Fiona  11:28  

So that brings us back to this, the basis of both of these questions is when do I know? And I guess the answer is, we probably don't absolutely know. But you get an inkling or a bit more of an inkling of my feeling, okay. Maybe I can try it, whether that's coming off antidepressants, or moving away from therapy. But it's important to recognise neither scenario is black and white. You don't have to stop absolutely cold turkey on either. In fact, that's probably not a good thing, certainly on the medication. Not a good thing. But you can try things out. So with Anon with the therapy, maybe move it to three weeks, or four weeks, or six weeks, and see how it goes. And if you've got a therapist who is insisting that you stay to a particular routine, I would seriously be saying challenge them as to why. Yeah. And if you don't get an answer that fits for you and your circumstances. I I know that you've got that wedding coming up this summer. And I think that that might be a bit of a challenge for you. And it feels important to me that you're supported through that. That might be a realistic answer to the why the therapist is saying every two weeks. If you don't get a valid answer to that one that works for you, then I'd question it.

Richard  13:14  

What we do tend to as therapists, what we do tend to do is after a certain amount of sessions, every now and again, maybe it's every 10th session or something, we'll have a review of where somebody was 10 sessions ago, and how far forward they are, how they think therapy is going how the relationship between the two of us is, and that needs checking in from time to time, it really really does. And no, no, no, not every therapist does that. And I think it would be important if we all do, because in that conversation can be. I'm doing okay, I'm doing okay. For somebody then to say, Well, how about, we end our therapy together? For a client to say that? Or to talk about spacing sessions further apart? If there is pushback that says, oh, no, that's not what I do from the therapist, or why don't do that, then that's a problem. Because that's not client focused. That's not person centred counselling. And that that might be that that therapist isn't a person centred counsellor that they are they work in a particular way where no you there are some psychodynamic therapists, and they're still around, that insist on seeing somebody twice a week, for years, because that's what I do. They

Fiona  14:32  

can be even up to five times a week, some of the analysts, and I remember when I was trying to find an existential psychotherapist, for a friend of mine, and I just felt that had a little bit of an existential crisis. And it would help to talk to somebody else thinking in my own mind. Not that I know but I was thinking three to four sessions, that sort of thing. And when I contact the person whose name I was given, it was right, well, we'll contract for every Monday at two o'clock or somesuch. And you can have four weeks off in the year where you don't have to pay. But when I'm on holiday, you do have to pay. And it was just Oh, que no, no, we don't want that. That's not what we're talking about. We don't want to commit to a year of therapy minimum, with those sorts of conditions on it, because not everything, some things, yeah, not everything needs that length of time. And another one I remember was one of our students who the students, as I think we mentioned in episode one, have to have therapy. And she'd gone to somebody was going to say the type, but it's a bit too narrow to name the type because a little bit too close to naming somebody. But anyway, the person when she said, I'm not getting anything from this, I'd like to stop. The therapist said it's a six session ending process.

Richard  16:06  

It takes six sessions to end their therapy.

Fiona  16:09  

Yes. Okay, she did not go back. No, can't force it. But that's the sort of thing to be wary of. If you're wanting, if you're wanting to end and you're with a therapist who's on your level in your corner, then when you say, I'm thinking that maybe it's coming time when they're going to be thrilled.

Richard  16:34  

We're in a position, I often say this to people that I'm in the sort of job where I'm trying to put myself out of work. That's, that's my aim is to put myself out of work. And if I can do that, and clients get better than I know that we're doing the right thing. That's the point. But I do wonder if sometimes, clients are embarrassed about saying, I don't want to do this anymore. It's costing me a lot of money every other week, I'm not sure I need it. I like it. And it's nice, but it's a bit of an indulgence that maybe I can put this towards other things instead. And there might be a bit embarrassed about doing that. So maybe the therapists, we need to bring that up from time to time. And we do I do, and we have to tread very carefully that those clients don't see that as a rejection and go, ah, He clearly doesn't want to see me anymore. I'd better Cancel all my sessions with him and never see him again. So we have to wait until the the therapeutic relationship that we've got is strong enough that you can cope with those sorts of questions.

Fiona  17:32  

The number of times that I'm saying to therapists who I supervise, have you talked to them about that? And if I could talk to the clients as well, which of course I can't, but if I could I'd be Have you talked to them about that? Exactly. Yeah. Because it's, it's remarkable a number of times. Oh, oh, yeah, I could talk to him about that. Good night. So yes, for a non talk show therapist, if you don't get a good response that tells you something, but chances are, it's going to be a conversation that is open and available. And you can do something like changing the frequency, or just moving away, but knowing you can come back, there's always options. And if there aren't, that's a problem. But it's not your

Richard  18:22  

how they ended. The question was, will it be obvious that I don't need to see them anymore. I'm not sure that it's always obvious, when we're doing something that we call it enjoy. Because therapy can be pleasant, it can be very nice. It can be the one time in the week, or that fortnight where somebody feels listened to and attuned to and valued. And if that's the case, then you might your mental health might be very, very good. But it might not be obvious that you don't need to see that therapist anymore, you might want to maybe comes down to cost.

Fiona  18:56  

It often does. I remember a client I had long time ago, he said to me, so I'm going to keep coming to see you until you tell me that I'm safe to go out in the streets again. And that sort of knocked me back in my chair because I was thinking, I don't see what the problem is you're safe to go in the streets right now. But he obviously felt was something and it was only a matter of a few sessions before he clearly did feel safe to go back in the streets again. But that just reminds me of for how the client may feel very unstable, and not sure of what they're doing. But again, that can be talked about. Talk to your therapist, about what do you think, what do you think I need? Where do you think I am? Because they've got a view? Yeah. I mean, they won't say it in judgmental terms of you're doing brilliantly. They will point out the this is where you were when you came and you said you couldn't do that. is all that you couldn't say this to that person, those sorts of things. And now you've done this or that, and you've said this or that, they'll be holding the whole picture. They can share it with you. I think

Richard  20:13  

it's hard to see our own improvement. It's easier as therapists to see it in others, because we see the expressions on their faces, we see that extra bit of confidence when they walk in the room, or they connect to us. We see the body language in them, and we hear those stories. So we see it. It's hard to see when somebody's growing, if you see them all the time. When you meet a family member, that I've not seen for a while and they'll look at my son and go, Oh, he's grown. Gosh, I can't believe how much he's grown. I've not seen him growing. He just grows is taller than me now. And I think, Oh, well, nevermind, I that was going to happen eventually. And he is taller than me. I noticed it again last night. But it happened gradually. It's like remember the twits the Roald Dahl book, The twits great story very, very clever man. Now, Mr. Twit, he played a trick on his wife by adding a teeny tiny little bit of stick a little bit of wood to the bottom of walkingstick. So the walking stick every day was getting that little bit bigger. And so she didn't realise that it was happening until eventually this walking sticks really huge for her. And he was playing a trick on her to say you've got the shrinks. That's what the problem is. It's you, you've shrunk. It's playing these silly jokes. Now. I think that happens in our development in our personal development, we just change very, very slowly and we don't see it. But somebody who only sees us every two weeks is going to see those leaps, because they're going to be noticeable

Fiona  21:41  

reminds me of when Greg was he went on very quick growth spurt. And he would constantly be saying to me, you shrunk, you shrunk. But that was how he saw it. But yeah, absolutely that clients very often don't see their own improvement. Because what they felt when they first came to us was normal. This is their normal, and then something changes. But it's still normal. It's a different normal, but they still feel normal. So unless the somebody outside saying that there's a difference. Now it can be us. It can be their friends and family of notice the differences. But they very often don't see the difference, because they just feel normal.

Richard  22:33  

What's going to be the case, when somebody takes medication as well, there will be changes, people will see their improvements. And also, when they consider coming off that medication. Other people are going to notice that any changes there if there are any which need monitoring, which need looking at because there's a process to follow when that happens.

Fiona  22:56  

Yeah, I was slightly concerned by Hannah's phrase of there will probably be side effects. Yeah, I'd like to change that around to possibly be side effects. Yeah, it seems like quite strong belief system going on there. And going back to what we said about placebo, if you believe there are going to be side effects, you could well find them

Richard  23:23  

the Nocebo. Yes,

Fiona  23:25  

yes. Just let's go on to another idea of going back to the idea of autonomy. And there's a concept that I think we're very likely to come to again in another episode of this, but it's from transactional analysis where they say that at any given moment, any person is either in parent, adult or child mode. So just a very brief way of looking at it parent can be somebody when you're in parent mode, you're looking after somebody or you're trying to control them. When you're in child mode, you're either freely behaving like a free child, you know, Joseph, jumping over the waves on the seashore or, or you're behaving properly, like a good child should. But the key for this place is the adult ego state, as it's called, where you're responding with the information that you have available to you. The rational processes, the thought, clear thought processes that you have, and making logical rational decisions and rational logical behaviour to go with that. The reason I'm bringing that up here is can be a very useful thing to just make sure that when you're making a decision, such as I'm not going to carry on with therapy or I'm going to move off My medication, that you're doing it from that adults position, and that you're not it, I can't see why you would be going to parent in it. But you could be going into child of doing what you're told doing what you're supposed to do. Or potentially even being too free and saying, Whoa, I don't care anymore. Keep in that adult mode, do it from their rational, logical thinking place. And then you'll be okay.

Richard  25:34  

Yeah, I think you've, you've hit the nail on the head there. That's the key to it. If you can recognise what state you're in, then you can see whether you're in the right position to make decisions in life. There's a phrase when somebody when somebody is unwell, where we say, you know, don't make big decisions, people will often talk in therapy about the depression, leading them to consider handing in the notice, leaving their partner making really big decisions. And it's driven out of fear, rather than anything else. And I wonder if that goes on with endings, whether it's the ending of therapy, or the ending of medication. People are scared about what might happen. I've heard people talk about particularly medication, when they're well, and they've been well for 20 years. And they'll they'll then maybe they talk about what tends to happen. It's often people talking about their family members, actually, for example, my mom's been on Prozac. She's been on it for 20 years, there's nothing wrong with it, she's absolutely fine. She's just scared to stop taking it because she started taking it when a husband passed away or something like that. And she's never considered the idea of stopping taking it. Because in her mind, it's a return then to the grief that she had before. Which then is a whole new subject of well, is the medication just masking somebody's grief, then is that what it is, and that's not always the case can be, of course, but the medication can give people permission, to look at things, to grieve to do what needs to be done. And maybe when that's done, maybe they don't need that medication anymore. But it's got to be done healthily, safely in a way that isn't going to damage them.

Fiona  27:19  

So that's the difference between reactive and clinical depression. So if it's reactive, so responding to a bereavement, for example, then the antidepressants, the idea is that they will give you space to be able to work, work on and through whatever it is that you're going through. Whereas clinical depression is the type which has got no perceived cause, that's then going to be harder to work on the causes. So with that, it might be more likely that people will continue taking it forever.

Richard  27:57  

Yeah, it's quite a big topic, this, and it's something that I think we'll probably end up revisiting at some point, because endings in therapy, particularly, they're a very contentious subject, they really are.

Fiona  28:09  

And people are very likely to play out their standard way of endings in therapy. So somebody who's let's say, they've, what they brought therapy, this is getting off the topic from Anolon Hannah, but if they if what they've come to therapy with is about relationships, not having successful relationships. If their modus operandi is to walk away, they're very likely to do that with the therapist as well. Paralleling the process from outside. Yeah. In therapy session.

Richard  28:45  

Yeah, yeah, that's very likely. And as therapists we need to be aware that people do that. Yes. So we can monitor it, monitor and

Fiona  28:53  

watch out for it. If that's the that's the process they're bringing. Yeah.

Richard  28:58  

Well, Fiona, we seem to have come to time already. Would you believe it? Half an hour is flown by yet again.

Fiona  29:06  

I just wanted to say one thing, extra, which is about avoiding becoming dependent on your therapist. So for Anon, about wanting to move away from therapy, to me, that's a good thing. Getting dependent on your therapist is not a good thing. And good therapist should be helping you not to do that. Yeah. If you feel it, that's not happening. Again. Talk about it.

Richard  29:37  

Yeah, simply talk about it. Talk to your therapist about it. Talk about it. Well, Fiona, let's leave it here for today. Okay. As always, we'll be back with another episode at some point very, very soon. And there are links in the show notes to our contact details where you can submit as a question, if there's anything you'd like us to discuss within reason, of course, make it about out therapy, and we will do our best to answer your question in as light hearted and sensible but genuine, helpful way as we can. So I'll leave you to it. You know where we are. Have a super time. See you soon. Bye