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I’m not exactly sure why, but the majority of my patients seem to require long-term psychotherapy (1 year or more of psychotherapy). On rare occasion (probably 20% of the time), treatment can be completed in less than 12 sessions. Perhaps it is the nature of the referrals I receive. The problems tend to be more complex and at a personality level. But perhaps it is that the prevalent paradigms for psychotherapy are not interested in the best possible outcome. I don’t really know yet what the answer is.
But I do know, that recent research1, shows that long-term psychodynamic treatment is the best approach for complex problems. And it also seems to me that a vast majority of my patients have complex problems. What I am uncertain of, is “Do I see problems as being more complex than other psychotherapists?” or “Do I see patients with more complex problems than the average psychotherapist?”
Regardless, what I do know is that I have done absolutely no advertising in a town of less than 10,000 people. One of my biggest referral sources is a bar in a town 45 miles away (that I have never been to). All of my recent new referrals have come from this bar. The comment from my new patients is, “I know you treated ‘Jane,’ she had a lot of problems. I thought to myself, ‘If she can change, I can too. I saw all of the changes that she made, and I was amazed.’” The patients talked to each other and started car-pooling to get to sessions with me. Other than one individual, their problems were very complex, requiring long-term treatment (treatment duration greater than 1 year).
So, on average, I’ve seen longer-term psychotherapy have great outcomes. Along the way, there have been a few short-term treatments with great outcomes. But on average, “Longer treatment is better treatment.”
On occasion, probably 10% of the time, treatment is a failure. The patient drops out without completing treatment, and continues to have problems. This percentage is fairly subjective, but I think it’s a fairly accurate representation. I’d like to get this down to 1 to 5%, and feel that this is possible if I can get better at my job. I think the main point I’m trying to get across to you, is that long-term treatment may be one of the best solutions to many problems that folks have.
1 http://www.sciencedaily.com/releases/2008/09/080930164454.htm
I remember one fellow I saw. He was a bartender. Over the years, he joked to all of his friends, “I’ve been a bartender since I was six.” He started out by getting his father a new beer whenever requested (which was often). He didn’t know any different. This was normal family life to him. Then his father was killed in a truck driving accident when he was 8-years-old. His mother became extremely depressed and couldn’t function (couldn’t cook, couldn’t comfort, couldn’t provide parental correction, and so forth). So, he became the perfect boy (independent, high achieving, extremely helpful, protective of those with emotional needs, and so forth).
Unfortunately, he missed out on his childhood. When he became an adult, he dropped out of college, started using drugs, hooked up with women who were bad news, and generally disappointed his mother. She didn’t give him any attention or concern after the death of his father (she couldn’t). He missed his dad horribly. He became a bartender to repeat the early pattern (serving beer and liquor to folks). He also repeated a number of other patterns from his relationship with his father.
These things represent an unconscious wish “for a better outcome.” The person wishes greatly that things had not turned out the way that they had. They keep repeating, in ineffective ways, the early traumatic experience. Unconsciously, they are trying to resolve the early problem–to make things turn out differently. On another level, their symptoms are communicating the problem from their past. When they end up finding a shrink who can understand these things, they are finally able to communicate, verbally, what bothered them so horribly. Unfortunately, with today’s training, there are not many shrinks who can understand this unconscious communication. It’s rare that I don’t see this communication. I see it every single day in my practice. The symptom communicates the problem.
Just as when you have an intense pain in your shoulder communicates that there might be a physical problem with your shoulder. This prompts you to seek medical attention. Life patterns and problems also prompt people to seek psychological help. Too often, this is not recognized in my opinion.
You may be able to ‘be your own shrink to some extent.’ I’ll tell you why I call myself a shrink. It’s probably different than most. I look at my role as ’shrinking’ the significance of the negatives in a person’s life. In psychotherapy, this is done in two ways. The first is releasing the emotion attached to negative experiences (Freud called this catharsis), and the second way is by adding as many positive things as possible to a person’s life.
Almost anyone can do the second thing, and I’ll tell you why it is so important. When you add something positive to your life, you ’shrink’ the significance of the negatives. The reason is that your life is no longer made up of ‘all negatives,’ but also now includes positives. This may be something very enjoyable that you can do. This may be something that brings you satisfaction and fulfillment. It may be your religious beliefs. Regardless of what it is, you want to add positives to your life. It gives you something to look forward to when times are bad, and allows you to ’shrink’ the significance of the negatives.
Now, you can’t completely ‘be your own shrink,’ but you can do the ’shrinking’ that I talked about earlier. You can shrink the negatives by comparison, but for help with shrinking the negatives, you may need a professional to help you do that.
Everyone doubts themselves from time to time. And at major life transitions, doubt is an extremely common thing. When a child goes from junior high to high school, they doubt themselves. When a high school student transitions to college, they doubt themselves. When a child attends a new school, they doubt themselves. When you get a new job, you doubt yourself.
But for some people, they have deeply rooted feelings of defectiveness. And it’s not technically correct that they “feel” defective, but rather that they think they are defective and that results in a number of different emotions (sadness, shame, anxiety, anger). For some people, their whole way of seeing what happens in the world is organized around their beliefs that they are defective. Jung developed the notion of a ‘complex’ that was later also used by Freud. More recently, the notion of a ’schema’ has arisen from cognitive therapy (or Schema Focused Cognitive Therapy), which has many similar characteristics to a complex.
A complex is described as “In Jung’s use of the term, a complex is literally a grouping of parts around some central emotional theme. For example, if you had a leg amputated as a child, you might develop a complex about it. Your complex might involve all the thoughts and emotions built up over a lifetime about the absent leg and the impact it might have had on people’s reactions to you, your opportunities in life, or anything else relating to the amputated leg. Unlike Freud, Jung did not assume most of these complexes were sexual in nature. A complex was due to some twist or turn in life that had a big emotional impact on a person.” (1)
A schema is described as “a mental structure that represents some aspect of the world. This learning theory views organized knowledge as an elaborate network of abstract mental structures which represent one’s understanding of the world. Schema theory was developed by R. C. Anderson, a respected educational psychologist.” (2)
In the Bible, it explains that,
“9(H) That which has been is that which will be, And that which has been done is that which will be done. So there is nothing new under the sun. 10 Is there anything of which one might say, “See this, it is new”? Already it has existed for ages Which were before us.” (3)
Psychologists often lose this perspective on things. But the fact of the matter is, most often, they are just using different words to describe things that have been observed by others. They feel important for their ‘ground breaking’ discoveries, but all they have really done is re-label concepts that have been explored and understood by others. The Last Psychiatrist would call this narcissism.
There are a number of ways that a person may develop a defectiveness complex. Problems with motor skills, problems learning how to walk, problems with a sensory system (such as vision or hearing), learning disabilities, and other problems that may occur during childhood. Sometimes there is an early severe fever that results in motor or learning problems. Sometimes there is an acute physical problem. Regardless, it is something that must occur early in life. What tends to happen is that all subsequent things that happen are filtered through this ‘complex’ or ’schema’ and are seen by the person as supporting the fact that they are defective.
I remember one woman who developed Rocky Mountain Spotted Fever as a child. As a result, she was uncoordinated and clumsy. So, she was constantly reminded of the fact of her ‘defectiveness’ by bumbling clumsiness. Subsequently, all things that happened in her life were filtered through this belief and frame of reference. She never had the confidence to ask for a raise, or seek a job that was consisent with her true abilities. She never had any luck in relationships because she expected others to discover that she was defective, and drove men away because of this. All of these things were seen as just more evidence for her defectiveness. Now, the person doesn’t usually have a conscious awareness of how this developed. But unconsciously, it influences how they interpret things in their lives, what they remember from the past (their personal failures), and their expectations for the future (continued failure, rejection, etc…).
These difficulties often take several years of treatment in order to resolve. The ‘complex’ or the ’schema’ is well defended within the individual and extremely difficult to challenge. The individual often develops information supporting their notion that they are defective despite any evidence to the contrary. The explanation that this is a ‘complex’ or ’schema’ often helps the indvidual come to the realization that their view is distorted based on beliefs that were developed through early life experiences. Once they develop this insight, they can begin to understand and change the ‘complex’ or ’schema’ that has been so self-limiting in their lives.
Interestingly, the notion of a ‘complex’ was developed by Carl Jung (a psychoanalyst), and the notion of schema-focused cogntive therapy has been expounded by Jeffrey Young 
Although I’m not keen on some of Jung’s notions (such as the collective unconscious and archetypes), I’m not one to ‘throw the baby out with the bath water.’ I have to largely agree with the following statement from Jung, “The patient who comes to us has a story that is not told, and which as a rule no one knows of. To my mind, therapy only really begins after the investigation of that wholly personal story. It is the patient’s secret, the rock against which he is shattered. If I know his secret story, I have a key to treatment.” (4) I find this to be exactly the case in treatment with my patients. My mentor likes to quote the old proverb:
“For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.”
In treatment, I try to find the nail. Once the nail is found, the battle is won. It’s not necessarily won right at the point that the nail is found, because we have riding, battle, and defense of the kingdom left, but it is the pivotal point around which the treatment revolves. There are many reason’s which people come to feel defective, and the discovery of this reason is the nail which leads to the ultimate success of treatment. And, I think the notion of war is appropriate to psychotherapy. It’s a war against the emotional difficulties of the patient, and often entails numerous battles. Sometimes, the enemy is more easily vanquished, and other times, the battles are ongoing and intense. So, God be with you, in your own battles.
Remember the verse from the Bible, “I can do all things through Christ who strengthens me.” (5) You may well need this strength to win your battle. But, I believe in you and the power of God, as I believe in my patients. Fight the good fight, and keep working hard to get to a better place in your life.
(1). http://www.psywww.com/intropsych/ch13_therapies/jungian_therapy.html
(2). http://en.wikipedia.org/wiki/Schema_%28psychology%29
(3). Ecclesiates 1:9-10.
(4). Jaffe and Jung
(5). Philippians 4:13
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