Friday, July 30, 2010

Why Does Psychotherapy Treatment Take So Long?

This is a question I have heard, in one form or another, many times from my

Sometimes the question is not posed explicitly, but the client assumes at the opening of our work together that he/she will be in and out in six weeks (said client having just told me that she has a long history of failed relationships, periodic dark depressions, and an eating disorder).

There are of course treatments that are shorter, but I tend to think in terms of years, if a client is suffering a great deal and has for some time.

Explaining why psychotherapy treatments are not generally brief affairs is complicated. My model of therapy is of course not everyone’s model. Models of short term therapy exist. I am not a practitioner, although I am aware of these modalities and have read their literature.

I think of the realtor’s motto—there are three things important in the sale of a home “location, location, and location.” In the kind of psychotherapy treatment that I practice, those three important things are : “relationship, relationship, and relationship.” What happens between therapist and patient is the cornerstone for effective change with and for the patient. The relationship is the crucible for change. Obviously building a trustworthy resilient (if not perfect), mostly predictable relationship takes time. If there has been a major betrayal at the heart of a person’s life experience, building trust can take a very, very long time.

In the ordinary course of events the relationship stumbles, there are crises, loss of faith, mistakes made, failures of understanding and empathy. As in life, so in therapy, it is in the repair of those rents in the fabric of the connection that hold the real promise of lasting change in the structure of the self. This is a basic tenet in many theories of therapeutic change.

Within the context of the mostly safe relationship, our clients have the opportunity to develop new skills. Most of us developed our coping skills early in life. We adapted to whatever conditions we faced with the best tools available to us at the time, that time being childhood. Checking out (dissociation), cheerful denial, taking care of others, distancing ourselves from others, controlling others, numbing ourselves, living in a fantasy world are only a few of the popular choices.

As circumstances in our life change we fail to update the toolkit. We go on automatic. This is true for all of us. If you have always been cheerfully unaware of thunderclouds on the horizon you will probably continue to be so, even if the consequences are dire. It takes a lot to get us to reconsider our choices or even to become aware that we are making choices(!) and to re-evaluate the appropriateness of our adaptations.

That’s where the therapist comes in. Its their job to identify those automatic choices and to help the client evaluate them. Dissociation, to take an obvious example, is wonderfully adaptive for a child trapped in an abusive family. Why not check out, if there’s nothing you can do to remediate the situation? Obviously this is not so adaptive for an adult who needs to find the wherewithal to get out of an abusive marriage, a heinous job situation, a sadomasochistic friendship. But now the dissociation is ingrained and it takes real work and real time (!) to turn that around.

So the blood, sweat, and tears that it takes to build a relationship and the difficulties of learning new tricks are two important factors contributing to the long term investment involved in change.

These are only two of several factors that make therapy very hard work. I will leave more commentary for another post.

Tuesday, July 6, 2010

CHOICE AND CONSEQUENCE: Terry Gross and One Life to Live

We went to hear terry gross of NPR fame a few weeks past. It was wonderful. She is wonderful.

There was an interesting moment when she answered a question in the q & a period that was never asked by this particular audience. Undoubtedly she had been asked the question at some other time.

She never had children. It was a deliberate choice. She is probably 60 or close to it. But I guess she knew early on that her life as a journalist, whether it was on her current show “Fresh Air” or not, was going to be all consuming. What she said was (and of course I am paraphrasing as best I can), “I never could figure out how I could do it—do my job and have a child and raise that child well. I know other people do it, but I couldn’t figure out how I could do it.”

For those who don’t know Terry Gross, she has a wonderful interview show on NPR, 5 days a week, interviewing novelists, biographers, historians, political analysts, pundits, musicians, movie and theatre people, etc., etc. The level of conversation she promotes is unusually high for radio and other media. This requires intensive preparation, she reads and understands the books, she listens and understands the music, the theatre, the geopolitical situation under discussion. She facilitates conversation at a very high level. Her job is terrifically demanding.

What struck me about her disclosure was her humility, her maturity. She accepted, probably at a fairly young age, that she was a limited human being, that she could do this or should could do that but she couldn’t do both and she needed to choose.

Elizabeth Gilbert whose book “Committed” I just finished, said something similar about her own choice to remain childless.

This post is not about the decision to remain childless. Both Gilbert and Terry Gross helped me think about the omnipresent work life/balance struggle that so many, maybe all young parents struggle with; women maybe more than men. I certainly struggled with it.   Coming to terms with the push/pull of career choices and family life style choices for those who indeed do have a choice (a privileged class, those who have a choice to work or not), requires humility.

We can neither do everything or have everything. Every decision has consequences: to have a child, to not have a child, to work full time, or to not work full time, to forego the career, to pursue the career full tilt, to have one child, or two, or many.

This is an obvious point I’m making, perhaps, but I have a sneaking suspicion that there is a barely acknowledged assumption buried in the heart of young parents, that if one does it just right, there will be no great pain or sacrifice. The children will not suffer, our careers will not suffer, our spouse will not suffer, our marriages will not suffer, we will not suffer.

I think there is always sacrifice, at the very least there is always consequence, and we can’t always forsee what that will be when we make our choices, or how we will feel on the other end. What’s important in my estimation is an acceptance of that truth.

Terry Gross struck me as surpassingly wise and humble when she decided she couldn’t have it all.