Therapists may need to learn how to be more explicit about endings from the start. “In my beginning is my end” may be the mantra to be adopted, with a focus on self-management from the start and an emphasis on endings. One could imagine conversations at the early stage of an intervention along the lines of “My job is to try and help as much as I can, but the focus is really on you finding ways to draw on your own strengths to manage your own life and finding a balance that is right for you.” Or “Given the difficulties you are experiencing and your context, you have a x% chance of being completely better (or completely meeting your goals) and a y% chance of being much improved (or partially meeting your goals.” Or “I would expect x change on measure y by z date. It is important to note that research shows that even without help a specific percentage of people will get better with time anyway. We can discuss the pros and cons of different types of help, and also agree when it looks like you may be better off managing things yourself, or if there is nothing else I can usefully suggest.” Or “Not everyone is helped by this treatment, but people do find ways to live with these difficulties. If what we have agreed to try first doesn’t seem to help you, then you might try x and y, but even if that does not help we find that people can live with these difficulties using strategies such as a and b.” It might be that one way to discuss these issues is to talk about the way people manage to live positively with ongoing difficulties: “Some of our most productive members of society live with ongoing challenges of bipolar disorder, obsessive-compulsive disorder, self-harm, and anorexia, for example. Some would even argue that it provides them with a wisdom and perspective they might otherwise not have.
”I believe that there is an ethical imperative to be more explicit in our communal recognition of the limits of treatment, and on the definition of treatment failure and appropriate response to it. Being unrealistic with service users about possibilities of treatment failure may mean that all too many are left feeling to blame for not having succeeded in therapy. Remaining silent on the levels of treatment failure stops service-level discussion of what should be done for these individuals. It reduces rational use of resources, stunts service development, and might contribute to forms of both therapist-blaming and patient-blaming. For these reasons, I would argue that there is a pressing need for greater research into and discussion of the limits of treatment and treatment failure, which I hope this Essay might play some part in stimulating. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(16)30075-X/fulltext