Stabilization Over Termination Written by Josh McManus

Last week, I sat with a teen client during our first therapy session together. Several minutes into the session, he asked me outright: “how long am I going to be doing this before everything feels good again?”

I get versions of that question constantly. Almost without fail, in the initial consultation parents ask about their child's neurofeedback protocol: "How many sessions until he stops having meltdowns?" Adults ask it about their own anxiety, their marriage, their grief: "How long until I feel normal again?" And every time, I feel the same small pull in my chest, because I know I'm about to disappoint someone who came in hoping for a quick fix up and is instead going to leave with a toolkit.

To be fair, I completely understand the fantasy. Therapy and neurofeedback are both marketed, at times, in ways that lean into it. This includes sleek before-and-afters, promises of "rewiring" the brain, testimonials that sound like miracles. While these testimonies may be accurate, oftentimes people arrive expecting something closer to surgery than training. They want the problem evaporated, not managed. They want the anxious thoughts to stop showing up, not to get better at responding to them when they do.

I had a client two years ago who, after doing neurofeedback for anxiety after 10 sessions, told me she was "still having anxious thoughts so it is not working." What had actually happened was that not just her objective brainwave numbers but her anxiety and all her reported symptoms had dropped by an average of 40%. By any clinical measure, that's a significant win. By her measure though, the total elimination of anxious thoughts, it was a failure. We weren't disagreeing about her progress. We were disagreeing about what "working" was ever supposed to mean.

Once I noticed how often this played out, I looked into what the research says about expectations, and it turns out this is one of the more studied dynamics in therapy.

Client expectations about what therapy or neurofeedback will do are considered one of the "common factors" that shape outcomes across virtually every therapeutic approach, and researchers estimate that expectancy effects alone account for a pretty meaningful share of therapeutic progress. But the flip side of that same research is a tough pill to swallow: when a client's expectations and their actual experience of treatment don't match up, that mismatch is one of the most consistently cited reasons people quit therapy early. Qualitative interviews with people who dropped out of therapy too early identified unmet expectations as a central theme, right alongside relationship problems with the therapist and simple logistical barriers (Dew & Bickman, 2005). 

The scale of this problem is bigger than most people realize. Across studies involving tens of thousands of patients, roughly one in five terminates treatment after a single session, and depending on the setting, somewhere between 30 and 50 percent leave before a full course of treatment is complete (Swift & Callahan, 2011). Older research on the "expectation-reality discrepancy" found this gap between what people thought therapy would deliver and what it actually delivered predicted premature dropout decades before anyone was using the term "common factors."

Interestingly, one clinical trial found something that speaks directly to the fantasy of the quick fix: clients who were simply given accurate information up front about how long meaningful change typically takes stayed in treatment significantly longer and were far more likely to complete it than clients who weren't told (Swift & Callahan, 2011). In other words, correcting the expectation itself before a single "real" session even happened changed the entire trajectory of care. 

Now I've started addressing this head-on, usually within the initial consult. I tell people plainly that my job isn't to entirely remove anxiety, grief, anger, focus issues or whatever brought them in. Those things are, for the most part, permanent features of being a person with a nervous system and a life that includes loss and uncertainty. That being said, what I can do is help someone tolerate that level of distress without being flattened by it, and respond to old triggers with something other than the automatic reaction causing them the pain that they came into the office to resolve. 

With neurofeedback in particular, I explain that we're training the brain toward more flexible, regulated patterns, not fully erasing the capacity to feel stressed. A well-regulated nervous system still reacts to real threats and real stressors, and thank God for that. It just recovers faster and doesn't stay stuck in overdrive. That's a different promise than "you'll never feel anxious ever again," and it's not as flashy of one to sell, but it's the honest one.

Here's what I've come to believe, both from the research and from years of watching people engage with seeking mental healthcare: the clients who do best aren't the ones who stopped struggling. They're the ones who got faster and better at handling the struggle when it showed up again, because in some shape or form it always shows up again: it is the human condition.

The woman with anxiety eventually came to understand this. Around session 20, she stated that she had come to notice that her overall anxiety had lessened, and when it did appear, she was able to regulate and control that emotion better. That shift, from fearing her own nervous system to working with it, was an incredible therapeutic outcome. It just didn't look like the reset button she originally wanted.

If you're going into therapy or neurofeedback hoping the finish line is a life with no more hard feelings, I would recommend against that. This is not to discourage you, but to protect you from quitting the moment real, meaningful progress doesn't look like a perfect cure. The goal was never to hand you a life without storms, but to give you the proper ship and rigging to sail through it.