I’ve been in practice since 1981. During that time, I’ve seen around 1000 clients and in the last decade consulted to other therapists about at least a thousand more. DSM diagnoses are one way to describe clients. Another way is by the length of time they stay in therapy. (Not counting analysands) Here is a list of clients, by length of time spent in therapy.
- Fly-over: never a "customer", leaves after a few sessions because it wasn’t his idea to come, or the therapist isn’t a fit (lost one because I wore Birkenstocks in the 80’s), or she’s too scared to stay.
- Questioner: Needs something normalized. "Am I crazy because. . . I’m grieving/I like to have sex the way I like it/I just moved and I don’t immediately have new friends, etc." This client needs information about normal human behavior and reassurance that a trained professional finds her/him sane. (Not to be mistaken for a client with underlying issues who tests you with this kind of question.) One session.
- Three-session wonder: The famous (and extremely rare) well-attached car accident victim who clears the trauma in two sessions and comes back to praise you wildly on the third. I’ve treated about 20 of these in the 14 years that I’ve been doing EMDR. For them, therapy is penicillin: Take a good dose, and the symptoms go away.
- The Next Developmental Step Client: She’s at the cusp of differentiating from her family of origin/partner/workplace and finding out how to be herself. If she’s reasonably well attached and reasonably untraumatized, she’ll be around from three to eight months. If more traumatized or with an abusive or alcoholic or otherly dysfunctional family and/or attachment issues, you might be seeing her from months to a few years.
- Big "T" Trauma client. She takes some time. If she was raped more than once or injured badly in the accident, or spent too many months in that war zone or horrible work environment, you have months to a few years of work. Best case, you nail the root trauma early (that molestation by the neighbor) then the rape, then work on integrating it all and dealing with her current, hopefully safe, life. Worst case: despite your thorough intake, you keep finding more and more suprise antecedents and the current life stays unsafe and in flux, and you spend three or four years getting her life in order and trauma moved through.
- Horrible attachment, relatively light trauma: Years of finding the baby parts that go into shut down or cling or fight or flight. Years of helping him own the baby and hold the baby and soothe the baby, instead of reflexively disappearing or pushing you away. He de-hunkers. He connects. He finds someone else with whom to connect. He learns self-regulation. He leaves therapy, after checking 6 times that he can return, if necessary.
- Bad chemistry clients. It depends. If she gets on the meds and "feels like myself again" and the good feeling stays, say goodbye and thank your favorite diety. If he only gets depressed in the summer. You may see him for a year or so, the first go round, and then every time he goes down. You’ll remind him to call his medicator person for a medication adjustment, and help him cope with the affects and effects of the bipolar/major-depressive dx/schizo-affective dx. In every round of therapy, you’ll help him clear some more trauma and help him reset his thoughts (there’s nothing wrong with Cognitive Behavior Therapy, when you need it.). When he’s back on the horse, you review what you both learned, and cut him loose until the next round. If he’s more chronic, fighting debilitating chemistry with little respite, or rapid cycling, you become insulin. The attachment relationship is paramount. Attachment to you may be thing that keeps this client around. Each interaction raises hope, reregulates your client, gives them an experience of being witnessed and loved. You won’t fix him. You will help him cope. If attachment disruption and trauma created the depression, therapy can, finally, nail it. And it will often take years. If it’s 95% "bad brain", you need to hold to your presence as the most healing tool you have. Use all your tools: CBT, EMDR, adoring your client, cheerleading ability, and connectivity. Work with them to try yet another med, keep exercising, keep eating well, get to work. Find them the best psychiatrist in town. And settle in for a long-term relationship.
- Severe dissociation with awful attachment and horrible trauma: Settle in for the long haul. You and the therapy are both penicillin and insulin. It may take months or years to make a good, trusted attachment relationship. It may take just about the same years to stabilize your client. Then you can tackle the trauma with some good penicillin (EMDR, Life Span Integration, Brainspotting, etc.) And tackle more trauma, and more trauma, and more. Then you can help her integrate all the changes. It’s 10 years later. She’s in a good relationship; has a better job; can have sex; and finally can say, "How do I know if I’m done?" She’s making her own insulin. She may come back for another dose of penicillin. Maybe more than once. But you did your job.
As a trauma therapist,I get to see my merely traumatized clients move through material quickly. They may go from debilitated to functioning to joy in a few weeks or a few months. These people connect quickly, don’t "slap" me, have appreciation, and leave grateful. If I’m working with someone with poor attachment, thus poor affect tolerance, and, often, poor relationship skills, I have to keep my whole job description in mind: The relationship is paramount, the trauma healing can go forward only when the client is ready. It will happen as it can.
I have a huge box of therapeutic tools. I can and will try every one of them. I can seek more tools. And the relationship is paramount. If I’m attached to the client (which I must be), I’ll feel his hopelessness and despair. I must metabolize it, and when it’s digested, find a way to hold it, without buying into it. As a consultant, I’m constantly helping consultees metabolize their clients’ despair. "Yes, it’s a long therapy. And you want to take the pain away. And the client is really hard on you. And that’s what this kind of client is like." I normalize. I empathize. I give examples. We work with the countertranference. And we find where the client and therapy are, developmentally, name it, and surmise what the next steps are. As the therapist holds her client, the consultation holds the therapist, offering insulin so that the therapist can metabolize another month of a long therapy. Then we talk about the client again.