Why Does Talk Therapy Take So Long?
The case for open-ended psychotherapy.
Posted Oct 18, 2019
I recently said goodbye to a patient I’d seen for six years in my psychotherapy practice.
“Doc,” he said, pointedly using the name he’d insisted on for the first two years of treatment, “all those times ... well, I’m glad I stuck with it. I definitely wouldn’t have Jackson,” referring to the adored child he’d sworn early in life never to have.
Circling back to using "Doc" in this instance was a gesture of intimacy, a private joke. But it had first been a distancing technique used with deference and then disparagement when he initially came to see me after his fiancée had left him at the altar, literally.
This educated man with a budding career might have seemed to some like he needed six sessions, maybe eight, to get him just well enough to hop back on Tinder. Yet over the course of those first two years, we probably spent at least six sessions, cumulatively-speaking, understanding the meaning of Doc. It became a metaphor for his fear of closeness: a desperately needed, if ineffective, defense that he clung to as a means to ward off dependency and loss, predating and contributing to his fiancée’s abandonment.
As a psychodynamic therapist—a therapist who uses psychoanalytic concepts and methods—for nearly 20 years, I’m often asked, "Why does talk therapy have to take so long?" Sometimes it’s asked with genuine curiosity, and sometimes it’s an indictment of an “outdated” approach to therapy (that somehow continues coming up for breath in a modern-day sea of quick fixes).
But it’s a valid question. I mean, how can I justify spending hours talking about the way a patient addresses me and expect to get paid for it?
Jonathan Shedler, a highly-regarded researcher and clinician, recently tweeted, “Psychotherapy is about slowing things down—so we can begin to see and understand the patterns that otherwise happen quickly, automatically, without reflection or awareness.“ Had I chosen to see my patient’s nickname for me as simply endearing or respectful, we may have missed the opportunity to discover the anxiety he experienced around connection and the futile and harmful ways he coped with those feelings.
Through our many conversations, we were able to trace his ways of moving through the world to old feelings of loneliness in the face of his parents’ frequent absences when he was young and the loss of his grandmother at age 7, the only “parent” to whom he’d ever felt close. Instead of acting out feelings he didn’t understand, we slowed things down, making space for thinking and allowing lesser-known feelings to emerge.
In our modern world, we want convenience—fast food, fast deliveries, fast therapy—and we’re certain there's an accelerated, cheaper way to cure human suffering, a McTherapy or Therapy Prime if you will. To be sure, there are shorter-term therapies aimed at alleviating symptoms, but my patients and I are interested in transformation—therapy that changes not just our symptoms but changes us, makes us healthier, wiser, kinder versions of ourselves. Psychotherapy that goes deep can accomplish this but not on an assembly line. Effective therapy takes, well, as long as it takes.
It Pays to Go Deep
Yes, deeply-transformative psychotherapy is expensive and, in some cases, can take years. Dysfunctional patterns that take a lifetime to develop are unlikely to change in six sessions. The emotional safety and trust that make such therapy possible can’t be rushed.
Facing our demons and the defenses that conceal them takes mounting courage. Emotional suffering is not comparable to a broken leg or diabetes, because we can’t separate our psyches from our injuries. No doctor wants to prolong the suffering of her patient, but in therapy, the truth often lays in the despair and rushing to alleviate it could mean rushing away from the answers to that despair.
People who do seek therapy are often directed to didactic therapies of a predetermined length. “Mental health care" has been redefined to mean prescribing medications or providing brief versions of psychotherapy. For those consumers who’ve realized effective therapy isn’t akin to a quick Botox injection relaxing our emotional wrinkles and desire a better, longer treatment, insurance often won’t cover it. Psychotherapy is the least invasive treatment of our ills, and it accounts for a tiny fraction of health care costs, yet there is more regulation and oversight than any other area of health care.
If we must look through the lens of an accounting ledger, research shows that in-depth, long-term psychotherapy actually saves money, decreasing health care costs by reducing hospital admissions, inpatient care, general medical visits, and missed workdays. And people continue to feel and function better after therapy ends, presumably because they have changed something fundamental about themselves, and not merely put salve on the symptom. Unfortunately, long-term savings may not matter much to health insurance companies whose customers company-hop, and whose administrators change jobs long before the benefits of in-depth psychotherapy show up on a balance sheet.
Long-term psychotherapy has the potential to not only alleviate emotional suffering but to help us be more present, engaged, and fully alive. Perhaps because the process asks so much of us, its worth is derided and dismissed. Psychoanalytic therapy asks not just for patience and money, but above all, courage. It asks us to face sorrow we have spent our lives avoiding, to forgo immediate gratification, and to set our sights on something more distant and more precious.
The long-term reward is a more conscious, less painful existence. Our lives make more sense, our struggles gain meaning, and we reduce the sense of helplessness so many of us feel. And when we are not imposing our fears and the painful parts of our past on other people, our relationships improve.
The effects of an analytically-informed therapy go beyond the individual on the couch and, I dare claim, can make a prodigious difference to civilization as a whole. Psychoanalytic therapy takes time and money, but not because it wastes it.