The Element of Time in Psychotherapy

COMMENTARY

Time is an important part of the frame of psychotherapy that also includes the setting, fees, confidentiality, the role of the therapist, and limit-setting and other boundaries. Time, like gravity, is just there and we do not usually pay much attention to it in its own right. In this brief article, I will discuss various aspects of time itself and then address considerations applicable to the practice of psychotherapy.

Preliminary Considerations

Time, according to artificial intelligence, is the continuous, irreversible progression of existence and events from the past, through the present, and into the future. It is both a fundamental physical dimension and a subjective human experience.

1. Scientific perspective: Modern physics, particularly Einstein’s theory of general relativity, treats time as a 4th dimension integrated with the 3 spatial dimensions into a single entity called spacetime. Unlike absolute Newtonian time, relativistic time is flexible depending on the gravitational field or speed relative to an observer. The arrow of time only flows in one direction, in contrast to most other fundamental laws of physics. Time is related to the second law of thermodynamics, entropy (disorder) in the universe that generally increases over time.

2. Philosophical interpretations: Presentists believe that only the “now” is real. Eternalists argue that the past, present, and future all exist simultaneously in a “block universe” and our perception of “a flowing now” is an illusion. Some philosophers (like Leibniz) argue that time only exists as a relationship between events; others (like Newton) view time as an absolute container that exists whether anything happens. Solar and lunar cycles have been used to organize longer spans into days, months, and years (calendars). Kalendae (Latin) means the “first day of every month” in the Roman calendar.

3. Human perception: The brain constructs a sense of time based on memory and anticipation (psychological time). Time “flies” when we are busy and “drags” when we are bored. Biological, internal circadian clocks produce 24-hour cycles that regulate sleep, hunger, and other vital functions.

Conceptualizing Time Across the Life Cycle

For preschoolers, up to 5-7 years old, time often does not move quickly enough and death is thought of as reversible. For preteens, 9-12, finality is appreciated, but cognition precedes emotional acceptance. When talking about death, avoid euphemisms. For example, use the word “died” rather than “went to sleep, passed away.” At the same time, to decrease anxiety about mortality, remind children that they are loved and secure in their families. For middle-aged and older adults, time seems to speed up, because most of life’s experiences lie in the past and with fewer novel experiences to anticipate in the future. Sadness and anticipatory grief—not depression—about one’s eventual death are normal and expectable.

Clinical Considerations Involving Time

When a patient first contacts a clinician, their unconscious clock has started ticking and treatment has begun. Once the frame of the treatment has been established (ie, when, where, the cost, boundaries, etc), the patient’s characterological features are immediately awakened. We learn about their attachment style, desire to begin treatment immediately vs desire to delay and put it off, diagnostic features (neurotic, characterological, psychotic), etc. Find out when the patient would like to meet with you rather than immediately offering them a time to meet. We should not assume that they are ready to begin right away.

Let the patient know what is expected of them in treatment. My own instructions to patients who are new to psychotherapy are: “When we meet, I’d like you to speak, starting anywhere, say whatever you’re thinking, we’ll listen together, and I’ll share my thoughts.” Sometimes I add: “Whatever you say is the right thing.” This lets my patients know how I think they can best use their time. This is a variation on the fundamental rule in psychoanalysis to say whatever comes to mind, without censoring.

When ending the session, I usually say: “It’s time to stop here for today (or now).” This implies to the patient that I am referring to our original agreement (or verbal contract) that we meet for 45-minute appointments and that I am not stopping because I did not like what they said last.

When I asked my psychotherapy supervisor, Irwin Marrill, MD, 50 years ago how often I should meet with my patients, he told me: “As much as the traffic will bear.” This brief reply condensed an enormous amount of wisdom. The frequency of meetings depends on the patient’s diagnosis, symptom intensity, suicidality, strength of desire for change, and all too often, practical considerations such as finances and insurance. All things being equal, meeting at a greater frequency allows for deeper characterological and symptomatic change than meeting at a lesser frequency for a longer period of time. This is an important part of the rationale for the meeting intensity of psychoanalytic treatment. Paradoxically, patients (unconsciously) love their symptoms and tenaciously hold on to them. It is only when the emotional cost of holding on painful psychological symptoms becomes greater than the cost of letting them go, that patients seek treatment.

How long will the therapy last, your patient asks? Ideally, the duration and frequency of treatment should be tied to achievement of therapeutic goals. The beginning and end of treatment is easier to define and characterize than the more amorphous middle phase, similar to the game of chess. Therapy duration ranges from short term (eg, 10-12 session CBT), to variable duration supportive and expressive psychotherapies (sometimes indefinite), to psychoanalysis, usually from 3 to 7 years, but sometimes longer. Occasionally I tell my patients: “I plan to be here for you for as long as you need treatment, and not a moment longer.”

To paraphrase Anna Freud, who compared psychotherapy with weeding a garden: “The weeds will always come back, but there won’t be as many, and they won’t be as tenacious as before. Treatment involves nurturing new buds and eradicating the underground roots.”

Salman Akhtar gives us his parable of 2 vases: “Two identically carved Chinese flower vases are on a mantle. A strong wind comes and blows one of the them off the mantle, shattering it into many pieces. An expert arrives and painstakingly glues the pieces of the shattered vase together such that it again appears identical to the other vase. BUT the repaired vase has a certain wisdom that the other vase will never have.”This quote can help counteract some of the despondency of patients in intensive psychotherapy for severe personality disorders.

When patients become silent, a common psychodynamic is that of passive-aggressive anger toward the therapist, often a manifestation of transference (but not always—sometimes the therapist made an inconsiderate mistake). Other reasons for patient silences include attempts to “freeze the time” to avoid discussing painful past memories or facing future anxieties, regression to an archaic time re-experiencing the infant-mother dyad, and regenerative silence, in which the somatic expression of trauma is silently processed. Catatonia is another important and not infrequent cause of silence.

Finally, cancellations, arriving late, and leaving sessions early all affect time in the treatment. These various assaults on the frame of the treatment may be unconscious efforts to control the time, to deny the passage of time, and to act out developmental conflicts involving time (eg, doing to others what was done to them). Patients may want to avoid expressing anxiety-laden content “until later.” Patients with borderline personality disorder may test the therapist to see if they are still “loved” despite their silent provocations. Patients may engage in a “tit-for-tat” reaction to the therapist’s cancellation of sessions due to an announced vacation, or in retaliation to a fee increase.

These actions that affect the time frame of the treatment may also reflect character structure and other psychopathology. Patients with narcissisim may believe that their time is more important than the therapist’s, such that they arrive late and leave early. Patients who are avoidant may skip sessions because of difficulties facing their demons in the now. Patients who are hysterical may not keep track of time in many areas of their lives. And patients with psychosis, bipolar disorder, or schizophrenia may be unaware of the existence of time. On the other side of the ledger, arriving late, leaving early, not showing up at all, can also be an indication of emotional growth, ie, being able to say “no” to the transferential authority figure of the therapist.

A Time to Conclude

This communication examines our relationship to time throughout the life cycle and the role of time in psychodynamic psychotherapy. On the one hand, time motivates our patients to do the work of therapy, since life is finite. On the other hand, time sets a cruel limit on how much time they—and we—have to get this work done.

Dr Perman is clinical professor in the Department of Psychiatry and the Behavioral Sciences at the George Washington University Medical Center in Washington, DC, and a clinical professor in the Department of Psychiatry at Creighton University Medical School in Omaha, Nebraska.