How long does a course of psychotherapy usually last?

One of my clients with narcissistic personality traits and impulse control problem initiated psychotherapy by himself when he knew his personality issues and frequent temper outbursts affected the well-being of himself and his family members. After a few sessions, he started to have some insights into his automatic distorted cognitions contributing to his uncontrollable temper outburst. Since he is a person with fast temper, he kept asking how long he has to undergo therapy in order to “totally cure” his psychological problems. It is quite common for my clients to ask such a question and to hope the answer is pointing to a quick fix.

To answer this question, let me introduce a concept of automatisation. Automatisation is a mental process that operates unconsciously without conscious awareness and intentionality. Some automatic processes are developed by repeated conscious rehearsals initiated by conscious intention at the beginning. For example, learning to drive is a process of repeated conscious rehearsals. After many repetitions, a person can drive in automatic pilot in most of the circumstances.

There is another type of automatic process that does not require conscious repetitive rehearsals or initial conscious intention. For instance, our judgment on something tends to change with the alteration of our sensory experiences. Couples who were given hot drinks judge their relationship as more satisfactory compared with couples who were given cold drinks, given that these couples have similar relationship satisfaction level in reality. Some of our higher-level cognitive processes, such as moral judgments and cognitive biases, can be activated out of our conscious effort and awareness.

In fact, attachment patterns, depressive distorted cognitions, or anxiety-related attentional biases are some of the automatisation that are out of our conscious awareness. To reverse these automatic mental processes, psychotherapy initiating a conscious process to override the automatisation may be effective only with long-term repetitive practice. For instance, unconscious negative cognitions related to one’s negative self-image may be developed through repeated childhood traumatic experiences. Since these distorted cognitions are automatised, any conscious effort to monitor these distorted thought patterns may have a priming effect on the automatisation. The process of monitoring unwanted distorted cognitions may increase the risk of engaging in ruminating these thoughts. Therefore, changing automatic distorted thought patterns requires long-term and concentrated efforts. It is because conscious effort in overriding unconscious distorted cognitions or biases is difficult and time-consuming.

It is quite common for us to listen to someone saying that one realises his or her prejudices against someone, but cannot control oneself from automatically make negative judgments on that person in many occasions. This means that even we know about our distortions does not mean we can override them easily. My answer to the question asked by my client is that long-term psychotherapy may achieve better results for lasting change in one’s automatised behaviours and distorted thought patterns for some psychological issues or problems. In fact, conscious processes to override automatism need to be practiced over and over again until they become automatic, or at least at the same level as the unconscious distorted or maladaptive thought or behavioural patterns.

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