Why Does Psychotherapy Take So Long--Part 2

An important part of the psychotherapy process, as I understand, and have practiced it, involves constructing a narrative of one’s life.

This may seem like a curious task given that we all know, or should know, the story of our lives. We’ve been imagining the movie to be made from that story, forever, right?

Well, that may be true of some us, but a surprising number of people actually don’t have a coherent story, something that hangs together, makes sense, and has some internal consistency to it.

There is some compelling evidence that the coherence of one’s story is a key component of sound mental health. I derive this from solid research findings that the quality of one’s attachment to one’s off spring is strongly influenced by said coherence. What researcher’s found was that the strongest predictor of stable, secure attachment in babies was the caretaker’s (read mom’s) ability to recount a coherent story of her own life. That story didn’t need to be historically accurate. It didn’t need to be positive. It was not necessary for her to have had a happy childhood. She just needed to be able to narrate the story to herself and the interviewer, of course, in a manner that hung together.

A baby’s “attachment” status reflects the ability of the young infant to bond with their parents, an important, maybe the most important, measure of their emotional well being.

Given the robustness of this research finding, frankly, I don’t understand why everyone who wants to be a parent, or is a parent doesn’t run to their nearest therapist. It would seem to be the best argument for undertaking this admittedly arduous and expensive process.

So back to what we do in therapy. We construct a story. This is the story of the client/patient. Its not mom’s story, dad’s story, or the story of the siblings, its not the therapist’s story, it’s the patient’s story.

So many of us have accepted, wholesale, someone else’s version of our lives. If you have been told forever that your childhood was idyllic you might be tempted to go along and not validate some of your own memories, or even weak suspicions that things were not always perfect. If you were always told that you were an overly sensitive child you might buy this wholesale. Never mind your own observations that people were actually pretty mean to you

This is tantamount to not being on your own side. Empathy for others, those adults who did the best for us growing up is a positive thing. But not if it’s prioritized over empathy for the self.

It is truly amazing how much fog, depression, confusion, and anxiety begins to lift when the story one narrates starts to be one’s own. It needn’t be a pretty story or even a wholly accurate story—just one’s own.

Sometimes the story is there but it is self-condemnatory and unfair. A woman who was raped at the age of 16 has told herself forever that she consented to sex with a man much older than her that she barely knew and was therefore a slut. All the adults in her family would agree (if they knew the story): a 16 year old is a grown up and responsible for her actions.

I had her look up the definition of “statutory rape.”

It took years for her to empathize with her frightened and confused 16 year old self and for her to re-structure the story to reflect her naiveté, her fear, her helplessness and her isolation at the time.

Story construction is central to the project of psychotherapy. Coherent stories evolve only slowly.

Why Does Psychotherapy Treatment Take So Long?

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

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.