How long does psychotherapy take? Why it is important for psychiatry residents to have long-term outpatients.

I was out for a hike in the hills surrounding Loch Raven Reservoir when the path forded a stream. Never one to hesitate plundering Mother Nature for her bounty of psychiatry-related metaphors, I noticed how beautifully the water had shaped the streambed. The recurved, organically shaped indentation in the rock and the seemingly gentle burble of the water belied the power of the water to shape this rock. But it hadn't happened overnight.

How long does outpatient treatment take? For students and residents used to working with psychiatric inpatients on units with lengths of stay measured in days, or, if you are lucky, weeks, it can be unsettling when the patients thoughts and feelings do not change right away. Behavior deeply ingrained, dysfunctional assumptions about the world, habits of mind so routine they are hidden from view - these take a long time to form, and a long time to re-form.

The fact is, there is a wide range of time courses of outpatient treatment. As the American Psychological Association says, psychotherapy can work very quickly - one session, or a few sessions. The length of treatment depends on lots of factors - the nature of the problem, the nature of the patient, the skill and patience of the therapist, and so forth. Looking at a geologic map of Loch Raven (circled in red below), the streambed could be marble, schist, or gneiss, each of which would be moulded at a different pace.

Sometimes appearances can be deceiving. When I was in college, the institution informed the students they were going to renovate one of the classroom halls. There was a sentimental outcry that the stone steps - beautifully worn by a hundred years of our predecessors trudging up and down, grappling with timeless Ideas and struggling to comprehend them as we did - would be replaced by the soulless, geometric regularity of new steps. The horror! It turned out that the steps, though appearing ancient, were not actually that old, and had worn down rather quickly, in a matter of a few years.

It hadn't taken that long. Sometimes outpatient treatment is the same way. Sometimes the patient has done a lot of work before they ever came to your office, getting ready to change, identifying what needs to be done, girding their loins for change, etc. Calling you up for an appointment was nearly the last thing on their list of Things to do to Make Life Better. In that case your job is less like Archimedes, who famously said, "Give me a place to stand and with a lever I will move the whole world"...

...but rather more like Virgil, who guides Dante through Hell, through Purgatory and finally to Paradise. It is Dante who suffers; Virgil is unscathed by the experience.

Interestingly, the metaphor of the stream at Loch Raven is perhaps the most apt of the three, because while Virgil is untouched, and Archimedes does all the heavy lifting, as the water erodes the rock it carries with it pieces of the marble, or gneiss, or schist with it. We are not untouched by our patients' lives and their suffering, but through training we learn not to be depleted by the experience of going through Hell with them.

Training - taking care of lots of patients with skilled supervisors at hand, then striking out on your own to manage your own patients with supervisors at a remove - this is key to knowing when to push treatment, and when to be patient. Patience, it turns out, can be taught...

A critical part of this process is learning that some treatments, some problems, and some patients take time to get well. Eight or twelve weeks of CBT might be effective for some, or even many, patients. But sometimes it takes two years, or three. If you don't take care of patients over the long term, you will never see this kind of change take place.

So, bottom line? You can't really know how long treatment is going to take ahead of time. That's part of what is scary, and exhilarating, about being someone's doctor.