“Hey Jeff, I just realized that by the end of this month I’ll have known you for 14 years.  I didn’t realize we’d been seeing each other that long.  Did you?”  I thought for a few seconds about Adam’s statement and question before responding.  “What makes you think of that now,” I asked.  I prepared myself for a response about him feeling like he’d made no progress, or him telling me something about how this must mean there is really something terribly or deeply wrong with him.  I was just sitting in this office thinking about who I was when I walked in all those years ago, and who I am now.  I feel kind of proud of myself,” he responded.  “Thank you.” 

I glanced at my appointments for the rest of the week.  I wondered about the length of time I have been seeing other clients.  I wasn’t surprised when I counted seven clients this week who I have been seeing for over 10 years.  I haven’t been seeing any of them weekly all these years, but there have been periods of regular sessions, periods of meetings twice per month, and then months and sometimes years between any sessions at all.  When I looked more closely at my overall caseload, I found that I had another 6 clients I have been seeing for over 15 years.  In today’s world of immediate gratification, immediate results, and evidence based practices, I asked myself how I can explain these long term therapy relationships.

Differences Between Short Term and Long Term Work

It’s not that I believe any of these people don’t need therapy or aren’t benefitting from the work we are doing.  I just started consciously thinking about some of the differences between the people who I see for much shorter term work (under two years), and those with whom I have established an almost life-long relationship, much like someone would see the same internist for years and years, until the internist retires or until the patient or internist relocates.  I also thought about some of the external and cultural pressures that make this kind of therapy less and less possible.

There are the obvious constraints around finances and, for those who want to use insurance, the rising cost of deductibles that make even short term therapy challenging and long term therapy a luxury.  There are pressures from the evidence based practice world where symptoms are clearly identified and addressed through any one of a number of research proven techniques.  With many of my longtime clients, I have engaged in periods of very specific evidence based and even manualized treatment.  Sometimes however, these interventions don’t alleviate the deeper, more diffuse concerns that are so present with those I’ve been seeing for years. 

Feeling Unloveable

Adam is the man who invited me to remember our 14 year anniversary.  I started seeing him all those years ago because he had ended an 18 year relationship in which he realized he was being emotionally abused and manipulated.  Several months after leaving the relationship, almost surprised, he realized how he was treated by his partner paralleled the verbal and emotional abuse he experienced throughout his childhood by his parents, and more specifically, his father.  He also realized that some of the physical violence he endured in his 18 year relationship, was almost identical to the physical violence he experienced at the hands of his oldest brother. 

We spent a fair amount of time looking at the repeating patterns in his life; how he often found himself in relationships with men who were older, more powerful in many ways, and who perpetuated Adam’s image of himself as weak, passive, and ineffectual.  Despite going to a prestigious college and even more prestigious graduate school, Adam’s default was to experience himself as “broken” and “unloveable”.

We looked at Adam’s beliefs about himself, how his beliefs reinforced his feelings, and what he might be able to tell himself to challenge some of his long held beliefs and this helped.  He saw a psychiatrist and was prescribed antidepressant medication and this helped.  He exercised and in the last few years also went to yoga classes.  These helped.  And while Adam could now better self-regulate during particularly rough periods, his sense of himself as weak and “broken” remain themes in his life.

Managing Repressed Anger

Will began therapy with me after his previous therapist had died.  He had been seeing his former therapist for 7 years before he began with me.  A veteran of the Vietnam, Will also grew up in a home where his father alternated between being physically and emotionally abusive---whipping Will with a belt on his back and buttocks---and neglecting him entirely.  He remembered times as a child in grade school, having to walk miles to a relative’s house in the midst of winter to get food for dinner.

Soon after Will began with me, his father became seriously ill and despite having cut off from him in adulthood, he assumed responsibility for his care.  Eventually, he entered a skilled nursing facility and Will visited each day.  During this period of time, he would come to therapy and share with me the most recent way his father had demonstrated disappointment and/or given messages that what Will was doing wasn’t enough.  “I feel seven years old again,” he said one day after visiting.  “But I’m starting to feel angrier and angrier.”  I took this as an invitation to explore not only his sadness about how he had been parented, but also his anger about not receiving the love he deserved.

Will continued to see me throughout his father’s illness and his eventual death.  With a new awareness about the anger he had repressed for so long, he began to talk about past romantic relationships where he had accepted love “like a pigeon tries to quickly eat as many bread crumbs as possible.”  As his anger surfaced more regularly, he struggled with finding ways to express it without tapping into rage.  This is something he continues to struggle with and continues to work on in therapy.

Developing Trusting Relationships

Alayna was another young woman who was in therapy for many years.  She started therapy with my business partner, Bruce Koff, due to a history of severe sexual assaults as a child, perpetrated by her maternal uncle.  When she tried to disclose to her mother what was happening, she was beaten and told never to speak of it again.  When she began therapy with Bruce, she was barely able to speak above a whisper.

After several years of therapy with Bruce, he was eventually able to support her in accessing a closed group for female survivors of childhood sexual abuse, which I was co-facilitating with a female therapist.  Alayna remained quietly participative in the group and while there were definitely bumps in the road, she developed a trusting relationship with the other women in the group and with me and my co-facilitator.  While in the group, Bruce left town on several occasions and Alayna asked if she might see me individually during his absence.  Bruce was relieved that Alayna identified another man she could trust.

After the group ended and over the course of the next four years, Alayna continued to see Bruce individually, but would see me when Bruce was on vacation or away for other reasons.  There were even times when she was seeing Bruce, that an issue arose that triggered something related to her group experience, and she would see me once or twice to complement her work with Bruce.  We also brought in another friend and colleague who was a massage therapist.  Soon, there was a team of people supporting Alayna as she created new patterns around developing trusting relationships.

Needing Time to Practice

Neither Adam, nor Will, nor Alayna could have made the gains they did in short-term therapy.  I don’t mean to imply that certain evidence based practices did not help them---they all benefited from CBT, meditation/mindfulness, some DBT skill building, and Adam also experimented with yoga.  All three of these people, however, had experienced prolonged trauma that significantly altered their beliefs about themselves, their relationships, and the world.

These belief patterns had been strengthened through years of repetitive experiences and relational patterns.  From what we know about neurobiology, we can assume that these patterns had been neurologically reinforced so many times that what once may have been states of mistrust, fear, sadness, or even rage, had now become traits of mistrust, fear, sadness, and rage. For all three of them, neural patterns had been created and strengthened;  their psychological, emotional, and somatasensory  conduit had widened and was covered by layers of protective rubber sheathing.  Just as these circuits and been created and reinforced over time, they can only be changed and/or new patterns developed through time and repetition.

I recently received a call from a former student who had just started employment at a residential treatment agency in Minnesota. These young people with whom she was working had experienced trauma during formative attachment years.  The agency’s treatment philosophy included the belief that any neural circuitry or brain cells that had been damaged and/or any new circuitry created as a result of that damage was permanent.  She was told that what she had learned in graduate school wouldn't help her with this population.  “Do you believe this is true, Jeff,” she asked, hoping I could help her understand this philosophy through the lens of everything she had learned in the trauma class I teach. 

I know through my studies, my teaching, and my clinical experience that early and prolonged exposure to trauma changes us.  What we once understood were only psychological changes, we now know are neurobiological changes.  We also know that our brains have much more plasticity than we thought they had---even in adulthood.  Adults who have experienced strokes where lack of oxygen or blood flow has destroyed brain cells, find “workarounds” so that through new, or newly strengthened neural patterns, skills can be relearned.  This takes time, practice, and patience.

Adam, Will, and Alayna had opportunities to develop “workarounds.”  Through on-going relationships with trusted others, new circuitry was developed that changed the way they see themselves, their relationships, and the world.  This did not occur through a 10 week program of cognitive processing therapy; a course of trauma-focused cognitive behavior therapy, or 10 sessions of EMDR.  I have great respect for all of these interventions.  I am inviting us, however, to use the same knowledge we have that supports these evidence based practices and consider what we know through practice based evidence.

Even in a world where we can’t wait for anything, where we seek immediate gratification, where we keep everyone informed of what we are doing at every moment, some things take time.  Adam, Will, and Alayna---and probably many people with similar histories with whom my colleagues are now working, will need time and patience to make lasting changes.  It may be a luxury or not possible for some people to access therapy for years.  I am not implying that long term therapy is necessary for everyone.  I do hope, however, that for those of us who have some clients who have long histories of abuse, neglect and other traumas, we’ll come to understand the necessity of this, rather than quickly jump to the conclusion that we are enabling or creating dependence.

Almost two years ago I adopted an 85 pound three year old golden retriever/poodle mix from a county animal shelter in Indiana.  We had no specifics about his history, except that he had been found wandering the farmland of Indiana and brought to the shelter.  When we got him home, his history became clear.  He ducked his head whenever we approached him, and when we patted his back, he growled at us.  I was beside myself with anxiety.  How could we keep a dog who wouldn’t let us touch him or, worse yet, would growl each time we touched him.  I quickly called a dog behavior specialist and described what we were experiencing.  “I think you’re going to have to give him at least two years,” she said with confidence.  It’s been 18 months, and as I type this final sentence, his head is in my lap.

Well it’s time to change when it’s time to change.  Move by the time.  Come along for the ride.  Don’t you see?  When it’s time to change, you’ve got to rearrange.  Move your heart to what you’re gonna be.

—Raymond Bloodworth, Billy Meshel, and Chris Welch (performed by The Brady Bunch---click here)