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Why Does Therapy Take So Long?

Encorporating the rules of neuroplasticity is essential for effective therapy!


As I learn more about how the human brain works and changes, I find myself wondering how in the world is talk therapy effective. The numbers just don’t add up. As I figure it, there are 168 hours in a week. Most people in individual psychotherapy meet once a week for an hour (which, of course is actually 45 - 50 minutes). That means a patient or client spends roughly one hour a week actively trying to change his/her brain and behavior with the remaining 167 hours spent in the real world struggling to escape from the deep grooves of complicated relational dynamics. That is .5% of engaged, neuroplastic change time with a therapist and 99.5% of time spent with the same life stressors that led them to therapy in the first place. These numbers just don’t speak to rapid change. When you look at therapy this way, it is easy to see why American’s embrace the use of psychotropic medications – at it’s best, taking an antidepressant like fluoxetine can produce results in three to six weeks while popping an antianxiety medication can reduce stress in less than an hour.

This is not a complete knock on psychotherapy, but I just think it needs a neuroplastic facelift.

Lisa Langhammer used with permission
Source: Lisa Langhammer used with permission

Original psychodynamic theories, formulated a century ago, encouraged a therapist to be objective and unemotional with clients, the proverbial “blank screen” on which patients could project their deepest, most conflicted thoughts and feelings. The therapist's role was to interpret these conflicts with the expectation that behavior change would follow. My clinical experience is that even the most brilliant interpretation rarely leads to lasting change and in fact, the structure of traditional psychoanalytic therapy was the perfect disconnected relational style to starve a client’s neural pathways of connection. Thirty years of attachment studies highlights the importance of mutually responsive engagement. Research tells us that children who try to attach to parents or other caregivers who are not emotionally and facially responsive first become distraught and then hopeless. A client struggling with relationship issues working with a therapist invested in a strictly analytic and objective style is a set up for a chronic, unproductive psychotherapy. While even traditional psychoanalytic therapists are now understanding the importance of the relational context in their work, the bias against authentic responsiveness remains in the mental health field. If therapy is going to survive as a viable option for brain and behavior change, it must encorporate the rules of neuroplasticity (use it or lose it and neurons that fire together, wire together) and the knowledge that we are hard-wired to connect in order to create strategies that deal head on with the dilemma of .5% time in therapy and 99.5% time out of therapy.

As I write this, I can hear the cognitive-behavioral therapists (CBT) applauding as another psychodynamic talk therapist has come around to their time-tested modality of treatment. CBT helps a person identify a problem behavior or thought, track it, speak back to it or distract from it. Over time the neural pathways for this behavior diminish and change happens. Sound research has proven that CBT is effective in treating many mental health conditions. CBT treatment, with its emphasis on cause and effect, is easier to study. Many cognitive behavioral therapists have developed easy to use manuals to implement treatment protocols as if all therapists are interchangeable automatrons. The relational context, which should be the biggest ally in healing, is usually left out of the CBT equation for success.

Almost twenty years ago, I attended the first neurobiology of PTSD conference in New York City with my bestfriend and colleague, Frank. We were both on a steep learning curve around issues of trauma and abuse and were thrilled to hear many of the leading researchers in the field present their piece of the neurobiological puzzle. The results were fascinating. People suffering from post-traumatic stress disorder were found to have a dysregulated hypothalamic-pituitary-adrenal axis, too much amygdala activation, too much norepinephrine stimulation and not enough cortisol production. The sum total of these alterations in brain chemistry is a very reactive, irritable person who struggles mightily in relationships. At the time PTSD treatments were poorly understood and difficult to implement. However, one research group stuck out as having more effective treatment. Edna Foa, a clinician and researcher from the University of Pennsylvania, was getting better then usual results in a group treatment designed for woman who had a history of abuse. Conference attendees were puzzled by the results. At one point, someone mentioned that Edna was an unusual woman, but no one went as far as to say that the relationships she was forming with clients or with students may be a factor both in the research and in the success of her standardized treatment. Relationships simply were not a part of the equation. The overwhelming bias was that consistent cognitive treatment could rise about the impact of a marginal treatment relationship.


These days, as I supervise students in early therapy training, I am more aware then ever before how important it is for the world of cognitive behavioral therapy, with its strength in identifying and stopping problem behaviors, and the world of psychodynamic therapy, with it emphasis on building a strong therapeutic relationship to come together. Healthy relationships cause the release of both dopamine and oxytocin. These two chemicals help to melt away old unwanted neuronal pathways and to solidify new ones. Because the human brain works more efficiently and smoothly in healthy human connection, a healthy relationship can be the biggest asset you have when you are trying to change. At the same time, a healthy relationship without repetitive stimulation of a new pathway may not be able to effectively compete for brain space with existing unwanted neural pathways and their troublesome behaviors. The equation for brain and behavior change, whether you are in therapy or trying to change without professional support, is clear – repetition, repetition, repetition, dopamine. And when dopamine is stimulated within the context of a healthy, mutual relationship the results are far more likely to stick!