I’ve been thinking about therapeutic technique, the pace of therapy, and how unpredictable therapy and healing can be.
My reflections were stimulated by a recent article in The Guardian (http://www.theguardian.com/lifeandstyle/2015/jul/03/why-cbt-is-falling-out-of-favour-oliver-burkeman) which focused on how Cognitive Behavioral Therapy (CBT) techniques may not be as effective as once thought. (The article postulates a possible “placebo effect” with patients entering CBT-based therapy.) Although I’ve not seen the study cited by the article and therefore can’t speak to its accuracy or reliability (or the journalist’s interpretation of its findings), I was reminded that meaningful change and healing takes time—often longer than patients believe—and is not solely contingent upon the technology the therapist uses. Healing has its own pace and milieu.
(Insurance companies don’t want to acknowledge the reality of how long therapeutic processes can take, and they certainly don’t want to pay for long-term treatment. Many of the “evidence-based practices” insurance companies are willing to reimburse are touted for their ability to produce rapid change—beneficial change but that is also, in my clinical experience, superficial and too often short-lived. I’ve long suspected that this is one of the reasons why medications are so heavily promoted in mental health treatment. I’m certainly not anti-medication: I know that medications take the edges of one’s distress, thereby allowing clearer perspectives. But medications themselves do not address the underlying psychological dynamics that sustain the emotional cores of patients’ problems.)
Years ago when I was in training, a supervisor talked about how meaningful change takes years to achieve. He noted that although therapists can provide tools that facilitate reduction in symptoms and distress, meaningful healing unfolds within the client who co-creates a safe, well-bounded relationship with the therapist. The therapeutic relationship allows the origins of the distress to be explored and, over time, reconfigures the psychic structures that are the source of pain and suffering. Healing is always organic and integral to the context of one’s life.
No one really wants to hear that healing takes time. Patients come to therapy in pain and want to feel better—now. Many patients come to therapy because there is a crisis in their lives, and the very act of reaching out and meeting a therapist often helps. The simple act of talking in that first session can help. Indeed, some patients leave the first few sessions feeling better, and they ARE better, having talked to someone who listened deeply and tried to understand. These patients not only talk but listen to themselves as they speak, and in listening tap into a deeper wisdom that helps them find a way through the distress. And because they feel better, some patients choose to end their work after a few sessions—often without having found or addressed the root causes of their suffering. But if their distress returns, these patients feel disheartened—or worse—and begin thinking that their brief therapy was a failure.
The work of changing one’s mind and heart is hard. Feeling better does not always mean the problem is resolved. That said, feeling better might signal an internal openness that allows the deeper work to be done. And having good tools and techniques can certainly support and facilitate the deeper work.
I happen to believe that many of the techniques espoused by CBT are effective—if and when they are practiced again and again and again over time. (I’ve done enough CBT training and therapy to know that CBT is not the rapid cure some purport it to be. It helps, to be sure, but is not, in my experience, a cure.) So, too, with newer mindfulness strategies which have been touted as helpful remedies for distress. For both CBT and mindfulness, integration is key: CBT and mindfulness techniques must be practiced sufficiently to be integrated into one's repertoire of thinking and behavior. And CBT and mindfulness techniques are insufficient if they are used to feel better at the expense of actively exploring, understanding, and deconstructing the core structures that create and sustain a patient’s distress. In my experience, a therapeutic relationship that constantly reaches for understanding and creates well-being is more important than any technique. (A wise therapist once observed, "the relationship IS the technique.")
We heal in relationship.
Just as there can be no specific time by which one will feel better, there can be no prescription for the length of therapy and no guarantee that any specific technique(s) will always work. Everyone is different, every situation is different. CBT and mindfulness are only tools for healing. They should not be mistaken for healing itself.
In any event, it is important to talk with any your therapist about what goes on in therapy, about what to expect from therapy. Every therapist has a conceptual framework that guides how therapy is conducted. Every therapist also has clinical experiences that give them insight into how change occurs. These frames are general and should be lightly held. Similarly, every therapist can offer tools that facilitate a change and healing process. Talk with your therapist about what tools he or she might offer.
Therapy is always collaborative. It’s important to tell your therapist what you hope to achieve in therapy, what you expect from therapy, and how you are experiencing therapy as each session passes. Such feedback gives the therapist a better sense of who you are, what is needed, and how to relate to you so that healing can occur. It’s likely that you will both be surprised by what you discover throughout the process. It’s like that you will both be surprised by how healing occurs.