One of the most rewarding aspects of my job is the opportunity to engage with patients in long-term therapy. In my practice today, I have a number of patients who began treatment with me years ago, in adolescence, and are now in their 20’s. These patients first presented in my office with their parents during middle school or high school, suffering from severe eating disorders or depression or debilitating anxiety or, in some cases, all of the above. Some entered treatment kicking and screaming; others reluctant but resigned; still others wanting help and suffering desperately but requiring immense parental support to stay afloat.
In many cases, these adolescent patients received intensive Family-Based Treatment for six months or a year or more. In other cases, the teenage patients received individual Cognitive-Behavioral Therapy with active parental involvement. All of them made substantial progress in treatment. The majority recovered fully from their initial presenting diagnosis. Those who have not recovered fully are doing significantly better, living independent, fulfilling lives, but still experiencing symptoms and receiving ongoing care to keep their illness at bay. Now, years later, some of them continue with weekly therapy sessions. Others come in once or twice a month, or perhaps biannually like dental cleanings (we call this “mental hygiene”). Still others elect come in on an “as needed” basis, scheduling a few sessions here and there to help them cope with life events, navigate relationships, manage stress, or deal skillfully with bouts of depression or anxiety.
What unites these incredible young men and women is the fact
that they have taken full responsibility for their well-being. They have chosen to engage in long-term
individual therapy as an act of self-care.
Through their adolescent suffering, they have become acutely aware of
their susceptibility to mental illness.
They are choosing to receive therapy not only to prevent relapse of
illness but also to pursue optimal health.
Many of these young adults have
chosen to abstain from drugs and alcohol, even as their peers regularly smoke
pot and drink to excess. Many of them
have adopted consistent home practices of meditation or yoga. They make conscious, health-promoting choices
when it comes to sleep, nutrition, stress management, and physical activity. When faced with an important decision about
which graduate program to pursue, which job offer to take, which city to live
in, or even which person to date, they carefully consider the impact of these
choices on their quality of life.
Engaging in long-term therapy with patients like these
involves a number of gradual but significant transitions for all members of the
therapeutic relationship: the patient, the parents, and me. For
the parents and for me, there is the progression from the crisis management of
an acutely ill adolescent to the joy of stepping back into a supportive role
for young adult in his own quest for greater levels of well-being. The parents and I often begin our
relationship communicating multiple times per week to put out fires and to
ensure that we are in lock-step as we form a circle of safety around a suicidal
or eating disordered patient. As the
patient gradually assumes responsibility for her own well-being (which often
takes several years for those with adolescent-onset mental illness),
communication between parents and me subsides into an occasional email or phone
call. The patient is now a much
healthier, more mature young adult, and is trusted to schedule, attend, participate
meaningfully in her own therapy sessions.
In many cases, she pays for her own treatment as well.
The therapy itself goes through a significant evolution as I
shift from being directive and prescriptive, setting firm limits around
dangerous or debilitating symptoms, to engaging with the patient in deep
psychological work and collaborative goal setting. For the patient, there is the very welcome
shift from being told what she must do, in therapy and at home, to deciding
what issues are important to her and taking the initiative to seek support,
both therapeutic and familial, in achieving personally relevant goals. For the patient, this shift brings with it
a transformation from a defensive posture (as evidenced by panicking, shutting
down, or lashing out in therapy and at home) to a stance of openness and
receptivity (as evidenced by increased self-disclosure and self-awareness along
with the display of more vulnerable emotions).
I cannot begin to describe how rewarding it feels to support
a frightened, malnourished, deeply depressed teenager as she blossoms into a
healthy, confident, independent young woman who is attending college or
graduate school in another state, working at an exciting full-time job, getting
married, or giving birth to her first child.
It is fulfilling beyond words to join with young adult patients in the
journey of long-term wellness as they clarify their personal values, decide who
they want to be in this world, and take concrete steps towards achieving their
dreams.
Those of you who have engaged in long-term therapy, either as a therapist, as a patient, know well how deeply personal and meaningful these relationships can be. There is a level of emotional intimacy that surpasses even that between spouses, between parent and child, or between the best of friends. In many ways, engaging in long-term therapy with self-motivated young adults is the polar opposite of Family-Based Treatment (FBT) for Adolescent Anorexia Nervosa. For most patients in my practice, the former would not have been possible without the latter.
