In Defense of (Very) Long-term Therapy

Renee B. Lonner, MSW

The truth may be that time, and lots of it, is a necessary condition for the healing of broad and very deep wounds from childhood. Time may be such an essential part of the therapeutic process for these particular clients that it needs to be understood in an entirely new way—particularly when much of what we value as a culture and society has to do with speeding things up.

“Hold on, I see what you are doing and I don’t like it!” my long-term client said when I attempted to set her next appointment for three weeks later; after all, she had been doing extremely well for some time, the biological component of the major depression which she had presented with years before was controlled well with medication, she had returned to university and obtained a graduate degree (in her 40s) and was about to establish a new career. She had stopped smoking, established decent eating habits after decades of anorexia and bulemia and made close friends—she was the poster child for the tremendous benefits of psychotherapy and psychiatric collaboration. And we had recently discussed many times, in therapeutic and practical terms, that decreasing the frequency of her therapy appointments would be appropriate. She had agreed with that plan. Or so I thought.

Stunned, I sat in my chair, ran through the above enormous progress over our years of working together, our numerous previous discussions on this topic and essentially told her, in a supportive way, that she did not need me anymore. I thought—in my ultimate wisdom—that we could begin to terminate our work together. Then I waited for her response, which was clear and swift: “So Renee, have you ever considered that I am able to maintain those positives and even add more exactly because I receive regular support and feedback from you? Why do you think the goal is termination? For my taste, I would like to remain in therapy for the rest of my life—or yours, whichever comes first!”

Almost never am I, or probably most therapists, speechless, but on that morning I had very few words. I think I mumbled something, and she added “And if you feel guilty or whatever, that is your issue. Now you know where I stand.” Though this may not be the impression from simply reading her words, she stated her views in a warm and affectionate manner—with more than a hint of challenge to what she suspected were my long-held, basic beliefs.

Over the next few weeks, we discussed the issue further and she remained in therapy, on a weekly or every other week basis, for many more years, until a couple of years ago, when she suffered a sudden and fatal heart attack. One of her invaluable legacies, for me, is that she taught this therapist probably more about the world of early emotional deprivation, resilience and the triumph of the human spirit than ever was learned in graduate school. On the day she confronted me with the gulf between my “plan” and hers, I started to think differently about termination as a goal for a small, specific population of people: those who have suffered significant emotional neglect or abuse as children, who experience a traumatic event or health crisis as adults that permanently reshapes how they see the world and their sense of safety in it, as well as others for whom having a long-term therapeutic figure provides the necessary and sufficient condition for them to navigate their lives well.

The therapist becomes the holder of their unique psychological culture—an anthropologist and historian of sorts, a curator of the artifacts of the past—and the holder of hope for the future.

There are numerous complex issues that come to mind, inherent in providing treatment to specific clients over what may well be decades, and these issues are valid and worthy of consideration; however, there is not space to address most of them here. Rather, I will focus on a more basic philosophical-professional view that we were not taught in graduate school and which is frowned upon by many in our profession: simply put, we may need to consider that certain very deep wounds from childhood or emotional assaults as adults emotionally entitle the individual, if they desire, to remain in treatment for as long as they wish without the therapist overtly or subtly pushing them toward termination. I use the word “entitle” deliberately—they should have the right and deserve the opportunity to remain in treatment, without judgment.

We were taught that a major therapeutic principle—and it is totally valid—is that therapeutic interventions are to serve the clients’ needs and not the therapists,’ and that extending the therapeutic relationship is almost always for the purpose of meeting the therapist’s needs. Of course, this may be the case in some situations; unethical professionals exist in every profession and ours is no exception. But the issue here is different—in some cases, setting termination as the goal, working tirelessly toward it and assuming the client has the same goal, may be meeting the therapist’s wish for closure and tidiness and not the client’s more significant, deeper psychological and emotional needs.

In general, the therapist is an active guide, providing the client with a compass for the reality of who they are and who they are becoming. This role for the therapist is exponentially more so in the case of a client who never got the ground set solidly under them because of a chaotic childhood or whose psychological home was permanently shaken by later trauma—and this role is to be valued and respected within our profession. Emotional well-being is much more than the absence of symptoms or frank pathology; it is the presence of the broad range of feelings and access to the best parts of the self. For that to be achieved, some clients need their therapist to walk the road with them for a very long time. The therapist needs to be most active and engaged on this long walk—this journey is not meandering through the tulips.

Enough about what this unique type of long-term therapy is—let’s be clear about what it is not:

Chit-chat that amounts to socializing in an office setting
A blurring of boundaries so that the therapist is more a “friend” than a therapist
A loss of focus on therapeutic goals
A therapeutically passive position—or the “how does that make you feel?” style

As I started to discuss this subject with my peers, in preparation for writing this article, I found that nearly all my seasoned colleagues had at least one client in their practice who met these criteria. I learned, by observing their responses to my questions on this topic, that this is a “shadow” topic: many of these therapists, seasoned and ethical in their practice, were ambivalent about the very long-term status of these clients and had never directly discussed this issue with another professional.

Reviewing the literature on this subject would give them good cause for their attitude. All one need do is google “long-term therapy” (never mind, very long-term therapy) and one finds a list of articles that assume that this type of treatment meets the needs of the therapist and not the client and is not more effective than brief, goal-oriented treatment. To be fair, there are a limited number of articles that pose the question seriously and attempt to employ standard research methods (Knekt, 2016; Bateman, Anthony, & Tyrer, 2018).

Most of these articles seem to focus on the lessening of symptoms as equal to “success” and as the marker for the end of treatment. Few of them acknowledge the nearly impossible task of applying generally accepted scientific techniques to an area that is uniquely qualitative, and therefore, inherently ill-suited to an “objective” study of what Dr. Jonathan Shedler (2010) refers to as “active ingredients.” One hardly needs to look beyond the titles to guess at the content of some of these e.g., “Is Long-Term Psychodynamic Psychotherapy Worthwhile? New Review Raises Doubts” (Coyne, 2012) and “In Therapy Forever? Enough Already” (Alpert, 2012). While the focus of Shedler’s article is not specifically length of treatment, the issues raised are the same and the discussion of the research shortcomings, as well as a description of actual mental health, is both comprehensive and elegant.

Some of the opponents of long-term and/or psychodynamic therapy cite rising healthcare and insurance costs as part of their reasoning (Associated Press, 2019; Psych-Appeal, 2020). But odd bedfellows exist here, in the defense of clients who want to have the opportunity for a full and satisfying life. The judicial system, as represented in a March 5, 2019, landmark ruling in the class action consolidated suit Wit et. al. v. UnitedHealthcare et. al., and Alexander et al. v. United Behavioral Health, emphasizes the need to deal with underlying issues and not simply decide that symptom abatement equals success and help the client out the door. Judge Spero ruled that “At every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.”

One occasionally hears this subject discussed in a public arena, sometimes in the most unlikely public space. While beginning the research for this article, I heard a brief and totally spontaneous debate on Bill Maher’s television show (Maher & Felber, 2019) between the host and Howard Stern. In referring to Mr. Stern’s recent book, Mr. Maher said that Mr. Stern “talked about therapy.” Mr. Stern replied in the affirmative, saying that it had changed his life and made a positive impact on him. Mr. Maher’s response captures what I suspect is the view of the majority of both the public and psychotherapists—“You said 25 years; to me that’s a scam.” Then Mr. Maher added “But when are you cured?” Mr. Stern chuckled and said that therapy had made him a much better father and a better person, to which Mr. Maher responded by shaking his head in (joking) disbelief. These couple of minutes of dialogue demonstrate the view and, in my opinion, misunderstanding by the “enough already” contingent. It is not just about “cure” of negative symptoms, rather it’s about living; living a full and even joyous life—it’s about having that instead of an existence.

The knowledge base in our field has grown over the last couple of decades in truly impressive ways; many of us have woven neuroscience findings seamlessly into our practice, no matter which theoretical orientation may have infused our education and training. Talking early in the treatment relationship about the value of mindfulness and meditation is common practice, as are teaching other techniques that help people self-soothe and calm themselves in a world that is routinely agitating and destabilizing. However, one fact remains unchanged even as our field evolves and grows: healing, deep healing, is done from the inside out—and often, that takes a long time.

Renee Burns Lonner, MSW, LCSW, is an AAMFT Professional Member and maintains a private practice in Sherman Oaks, California, providing individual, marital and family psychotherapy with children, adolescents and adults. She is a consultant for mental health clinicians and organizations in general practice areas, as well as the specific area of risk assessment.

REFERENCES

Alpert, J. (2012, April 21). In therapy forever? Enough already. The New York Times. Retrieved from https://www.nytimes.com/2012/04/22/opinion/sunday/in-therapy-forever-enough-already.html

Associated Press. (2019, March 5). U.S. Federal Court finds UnitedHealthcare affiliate illegally denied mental health and substance abuse coverage in nationwide class action. Retrieved from https://apnews.com/press-release/pr-globenewswire/7ac8e3da7f47c4064e7c49d28b82db4c

Bateman, A., & Tyrer, P. (2004). Psychological treatment for personality disorders. Advances in Psychiatric Treatment, 10(5), 378-388. doi:10.1192/apt.10.5.378

Coyne, J. C. (2012, January 12). Is long-term psychodynamic psychotherapy worthwhile?” Psychology Today [Blog].

Knekt, P., Virtala, E., Härkänen, T., Vaarama, M., Lehtonen, J., & Lindfors, O. (2016). The outcome of short- and long-term psychotherapy 10 years after start of treatment. Psychological Medicine, 46(6), 1175-88.

Maher, B., & Felber, A. (2019, October 11). Season 17, Episode 30. Bill Maher: Politically incorrect. HBO Downtown Productions.

Psych-Appeal. (2020, November 4). U.S. Federal Court orders special master and 10-year injunctions for UnitedHealthcare affiliate that breached fiduciary duties. Retrieved from https://www.globenewswire.com/news-release/2020/11/04/2120403/0/en/U-S-Federal-Court-Orders-Special-Master-and-10-Year-Injunctions-for-UnitedHealthcare-Affiliate-That-Breached-Fiduciary-Duties.html

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109.

In Defense of (Very) Long-term Therapy

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