Into Every Life A Little Rain Must Fall–Some Thoughts On Being Prepared

One of the expectations that I have for patients I work is that they are connected with a therapist.  My role has been to evaluate for the need for medicine and to periodically assess how well that medicine is working.  Medicine is rarely THE answer to behavioral health needs, especially when a patient first arrives on my doorstep.  That is why all patients are expected to meet with a therapist first.  That therapist ensures that all of the appropriate paperwork is done (sorry, business and insurance crap is just a fact of life)  More importantly, the therapist screens for the presence of emotional issues that could potentially benefit from medication.  But even MORE importantly, the therapist will help develop a treatment plan that includes looking at past and present life events and how the patient deals with them.  It is a well established fact that good quality therapy delivered in a safe environment with a patient who is motivated and active in that therapy is as good as throwing someone on medicine.  In my ideal world, anyone who initially presents off psychiatric medication would be referred for a medication evaluation only after they have spent some time actively working with a therapist.

Let’s suppose that a patient did do the hard work of active therapy and STILL had considerable symptoms of anxiety and depression.  That patient is seen by a psychiatrist or nurse practitioner and is placed on medicine and does, indeed, get much better.  Sometime so much better that therapy seems superfluous.  “I don ‘t have anything to talk about” is a common refrain.  “I don’t see the point in spending the money . . . I’m fine!!!”  So, in those cases, is therapy really necessary?  Does it have a role to play in the preservation of ongoing health?


Let’s look at two general scenarios, both of which are very common.  First, the patient who has a lot of life crap going on that genuinely does not involve them behaving badly.  For example, the person who was very depressed and anxious because their parents are aging and increasingly dependent on them for emotional and physical support at the same time they are trying to juggle work responsibilities and a spouse and children who are demanding and needy.  Sound familiar?  With a brief course of therapy and some medicine, the patient gets better . . . meaning that they no longer have symptoms of depression and are not having panic attacks anymore.  Do they really NEED therapy?  They sure could benefit from it!  Once we get back on track and are taking care of the 10,000 things that need to be taken care of, we still need to make sure we keep ourselves healthy and take the time to attend to our own needs.  Ongoing regular therapy can help us keep some of our focus on ourselves so that the risk of a return of significant symptoms is lessened.  The frequency of that therapy does not need to be as often as it was during the height of the troubles, but, in the above example, I would suggest not less than one time per month.  More than that, you spend the whole session catching up and not actually doing any work.

How about a second scenario.  In this scenario, the person is stable and really has minimal work, school, family or relationship stress.  Things are good . . . life is good . . . all good!!  What is the point of meeting with a therapist in this situation?

. . . time for a brief poetic interlude . . .

The day is cold, and dark, and dreary;
It rains, and the wind is never weary;
The vine still clings to the mouldering wall,
But at every gust the dead leaves fall,
And the day is dark and dreary.

My life is cold, and dark, and dreary;
It rains, and the wind is never weary;
My thoughts still cling to the mouldering Past,
But the hopes of youth fall thick in the blast,
And the days are dark and dreary.

Be still, sad heart! and cease repining;
Behind the clouds is the sun still shining;
Thy fate is the common fate of all,
Into each life some rain must fall,
Some days must be dark and dreary.

Thank you, Longfellow.

Yes, unfortunately, “into each life some rain must fall”.

No matter how good things are.  No matter how calm the seas of your life seem to be . . . something is bound to stir the waters of your heart and cause it to ache.  If someone has had behavioral health symptoms significant enough to be on medicine, they are at risk of a worsening of symptoms if life throws them reasons to get worse.  And sometimes, symptoms get worse for no reason at all.  If you suffer a stressful life event and you are not connected with a therapist, you have to start all over again in the midst of emotional turmoil.  If, instead, you have a connection with a therapist, you can jump right in and work on the issue at hand and not have to put it in context of the past.  This allows you to work on issues more quickly and more effectively and in a space that you have previously determined is safe for you.  That is golden.  That connection with a therapist can be maintained with relatively infrequent contact with the therapist.  Many people that I see are stable and only see their therapist every three months or so.  It is not therapy.  It is more like case-management.  But even those infrequent visits with someone you know . . . and knows you . . . allows for the space to be safe when you need it to be.

There are, of course, more than a couple scenarios where an ongoing connection with a therapist would prove valuable.  The above are just two that are common.  If you have had behavioral health issues I encourage you to make a connection with a therapist and keep that connection going, even when life is going well.  You never know when a little rain might fall.


–Dan Hartman, MD



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