ARE WE THERE YET? The time it takes to change.

Why does psychotherapy take time? Why is it difficult to predetermine how long a treatment will last? Are we there yet? My patients want to know. How long till we get there? How long do I have to come to therapy for? Good questions.

It reminds me of the questions we used to ask as children, when our experience of time was nebulous and one hour or sixty miles or kilometers had very little meaning. We just knew we were going somewhere, and minutes and hours stretched long ahead of us, without any sense of when we would get there. The time depended on who was doing the driving, and how they explained it. So we asked, often to no avail, and somewhere along our travels we began to have a sense of the time that it would it take. Psychotherapy is not quite like that, for one thing there are two people doing the driving, and yet, it takes time, sometimes long stretches of time that appear just as indeterminate. This post is about the time that psychotherapy and change require, and some possibilities about why.

First, there are many variables in a psychotherapeutic relationship. There is the patient, walking in with his/her own history, experiences, relationships, memories, desires, fears, heartbreaks…life in all of its personal details and complexities. It takes time to tell one’s story, to find the words to narrate it to another, a stranger who knows nothing about us and who over time will get to know us intimately. This stranger, the therapist/analyst, and his/her own history, education, training, and perspective will interact, inquire, confront and hold the patient and their history in a manner consistent with who they are and how they have internalized their understanding of human nature. Time, as it has been lived, has had an effect on both patient and analyst.

Then there is the fact that narration, and our personal story, is not just the accumulation of words which describe what we have lived and what has happened to us. There are also all of the emotions that surround the words, locked inside of us, which lend texture and meaning to what we have to say, to what and how we have lived. The intensity of our emotional life is not easily translated into words, and thus it has to be experienced by another in the context of a relationship. The therapeutic relationship takes time to build.

Human experience develops and grows over time, each new experience lending new potential meaning(s) to what has already been lived. New experiences are  re-interpreted through the lens of old experiences, and when all goes well, integrated anew. Developmentally we are always adding on to what we have already learned, automatically integrating and  re-working information. When we encounter conflicting situations we may create new categories, or when this is not possible, hold the conflict in various self-states which may interfere with our ability to experience ourselves as unitary beings. This is often the case with traumatic experience, which tends to isolate information, feelings, and thoughts from our immediate awareness, so that integration is not possible. Instead, traumatic experience remains isolated from consciousness and returns to awareness in unexpected ways. Accessing traumatic experience takes time. It takes time to find words to address it and speak of it, time to re-experience it and let another experience it with us, and time to integrate it anew into our lives.

Furthermore, human experience is not limited to what we can recall and speak of, but is also made up of sensations, affect and emotions – what we sense and respond to implicitly- and working this out requires time. Neuroscientists believe that implicit memory powers much of what we experience, unconsciously and at the neuronal level. Take mirror neurons for example. These neurons are responsible for our ability to read and respond to another with feeling, a neuronal system that operates inter-personally and gathers data about how the other is feeling and how they are likely to respond. A colleague of mine (who is a neuroscientist) believes that it is these very neurons that are responsible for the time that the therapeutic exchange requires. I think she is on to something.

Current brain and neurological research indicates that the basis for our relational self (our interactions, emotions, thoughts and actions) is laid out in early development and is directly related to the kind of caretaking relationship we have had. Further, that early brain development provides the neurological roadmap of our personality. To my mind such research offers a potential explanation about why therapy takes time. In effect, psychotherapy creates changes at the neuronal level, causing our brain to re-wire itself in order to integrate and understand old and new experiences and behaviors. This necessarily requires time. I sometimes ask patients to think of our brain and its complex network of neurons as a highway with many exits and roads, some of which are known to us and  well traveled- our usual way of being and responding in our life. When we  become aware of other routes and begin to use other exits and other roads, they are new and unused, so with each repeated use we build stronger pathways that become known and integrated over time.

Bottom line: psychotherapy requires time because neurological structure requires time to grow and develop. It requires new experiences. And it requires an ongoing relational exchange (just as it did in early development) which addresses both previously lived experience as well as a new understanding of that experience. Knowing and understanding alone does not produce lasting change. It is our relational exchange with others that creates meaning and context, and such exchanges alter and shape our neurological structure. They literally shape and change who we are.

If you are still with me, then consider this: In psychotherapy it is the doctor-patient relationship that is the crucible for change. This occurs through dialogue, as well as through felt experience- the stuff that mirror neurons are about, the stuff that makes up implicit knowing. The relationship between patient and doctor is a reflective relationship that is based not only on what is said but how what is said feels like and is experienced by both participants.  The attunement or dis-attunement between patient and doctor provides the basis for the discovery of conflictual states, the re-living of them, and their potential reparation through new experiences that are contextualized within a relationship that allows for new possibilities of being. The time that is involved in understanding something and integrating that knowledge, has to do with the kind of relationship that is established and its ability to hold, re-interpret and re-experience what has been lived – but this time in a different way.

How much time does it take to process and understand de-stabilizing experiences which re-occur without warning and interfere with our sense of personal integrity? The reparation of the self that occurs through psychotherapy is rarely a smooth and linear process. It requires an ongoing relational negotiation that addresses the old within the new. It brings about new behavioral possibilities which challenge our brain and stir it into action.  The bridge that is built between information (what we know) and experience (how we are) in psychotherapy  requires a relationship that addresses how we experience and re-experience ourselves with another, and the opportunity to negotiate the relational nuances that were non-negotiable in the past. It is this relational link that activates neuronal integration and growth. There is no mistaking this kind of change, as it is based on a new experience and sense of oneself. It is known from the inside and reflects on the outside.

It should come as no surprise that the answer to “Are we there yet?” is  relationship based. It occurs within the context that has been built between patient and doctor, and in my experience,  when we are there  we both know it.

*Image credit: Doug Smith