Mention long-term psychotherapy (think years, not months) and you will most likely hear skepticisms expressed such as too expensive, too time-consuming, or they don’t really do that anymore, do they? For individuals with complex or comorbid conditions, and/or those who continue to struggle with deep-rooted problems that impair functioning, long-term psychotherapy can be effective when other shorter-term therapies fall short.
In my late twenties, over the span of several years I was diagnosed with anorexia, major depressive disorder with psychotic features, and borderline personality disorder (BPD). After the BPD diagnosis, the psychiatrists told my parents (but not me) that my prognosis was poor and not to hope for much.
I was locked away in an acute psychiatric unit in Manhattan following my second suicide attempt when we received the diagnosis of BPD. The plan was to transfer me to a private psychiatric hospital in Westchester County, New York that housed a long-term unit dedicated to treating BPD with dialectical behavior therapy (DBT), which is considered the gold-standard treatment for the condition.
Regardless of how many times I cycled through the four DBT modules of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance, though, this therapy was not effective for me. Sometimes, knowledge of the skills is not enough. Knowing the skills didn’t abate my deep-seated self-loathing or my wish to be dead.
The next two decades were filled with multiple inpatient psychiatric admissions for depression, for suicidal ideation accompanied by detailed plans, and for starving myself. I endured trials of every type of psychotropic medication. I frequently ended up with a medication cocktail consisting of two or three antidepressants, an antipsychotic, a mood stabilizer, and a benzodiazepine.
Twenty-five years after being diagnosed, I abruptly quit therapy and stopped all my medications. I surprised myself. I’d always been a good girl, one inclined to follow the rules, even those that were unwritten: Eat your vegetables. Go to therapy. Take your medication.
Predictably, I spiraled quickly into a suicidal depression. A social worker I knew referred me to a psychiatrist for what was supposed to be a one-time medication consultation. This psychiatrist, Dr. Lev, also specialized in treating people diagnosed with borderline personality disorder with a psychodynamic treatment known as transference-focused psychotherapy (TFP).
A 2008 study reported, “LTPP (Long Term Psychodynamic Psychotherapy) showed significantly higher outcomes in overall effectiveness, target problems, and personality functioning than shorter forms of psychotherapy. Dr. Lev asked me if I wanted to begin twice-a-week TFP treatment with her. I was tired of therapy and tired of living. The past 25 years had left me entrenched in my eating disorder, arms marked with scars, and three failed suicide attempts. What was another year or two? I could always kill myself. Once you’ve crossed that line from thought to action, navigating that unthinkable barrier again doesn’t seem so daunting.
I had to sign a treatment contract. This was standard for TFP. My contract included not dropping below a certain weight; otherwise I’d be hospitalized on an eating disorder unit. If I cut myself, even a scratch, I had to seek medical attention before I could resume therapy. If I attempted suicide, Dr. Lev would do everything she could do to save me, then she would end our treatment. Dr. Lev did not accept insurance. She graciously lowered her considerable fee so I could engage in this intensive treatment with her. There were times I could not afford to pay her, and she allowed me to carry a balance. If it were not for her generosity, I would most likely would have died by suicide.
I worked with her for 11 years. I immediately put her on a pedestal just like I had elevated my mother (who had passed away three years earlier), while villainizing my father. He was an alcoholic and had been verbally and emotionally abusive.
Dr. Lev would ask, “What comes to mind?” At times, the pace of the therapy slowed to a crawl as I found it torturous to speak extemporaneously. My perception of myself included being unfixable and I was terrified that if I disclosed this to Dr. Lev, she would agree and reject me.
It took years for me to trust that Dr. Lev would not abandon me. With each new revelation came a wave of fear: Would this be the divulgence that finally proved to her that pure chaos reigned within my psyche? That I was beyond her expertise and the limits of TFP?
Once trust was established, I revealed truths I’d been reluctant to admit even to myself. How deep the river of self-hate coursed through my veins. A heavy veil of shame ascribable to ambivalence around my sexuality felt like a weight I couldn’t escape. I lived with a feeling tossing about in the caverns of my gut. A feeling that whispered I never should have been born; hence, I didn’t deserve to live.
Nine years into the therapy with Dr. Lev, my father passed away. All my life I’d chased a shell of a man, just to hear him tell me I was good enough. When he died, I expected to feel relief but instead I was filled with rage and resentment. I realized I’d never hear those words, and I plummeted into a deep depression. Eleven months later I made my fourth suicide attempt that resulted first in a medical hospitalization, followed by a psychiatric one. I’d broken my contract. I assumed treatment with Dr. Lev was over, and I was devastated.
A 2014 study on long-term psychodynamic psychotherapy found that a “considerable proportion of patients with chronic mental disorders or personality disorders do not benefit sufficiently from short-term psychotherapy…LTPP was superior to less intensive methods of psychotherapy in complex mental disorders.”
Dr. Lev compassionately decided to resume working with me while presenting my case to a group of senior TFP clinicians. The next two years were the most intense, and the most productive.
After this fourth suicide attempt, I was finally able to express to Dr. Lev the anger I felt toward her. Anger was an emotion that was not openly permitted in our household when I was growing up. With Dr. Lev’s help, I took her off the pedestal on which I’d placed her years before. More importantly, I was able to see my mother as a human being who, while having numerous amazing qualities, was also a flawed person who struggled with her own demons. Memories resurfaced of times my father simply showed up, no questions asked. His presence conveyed how deeply he cared. He was not the monster I’d made him out to be.
Dr. Lev and I allowed a year for termination, which I initiated. I never thought I could survive without paying someone to talk to each week. Ten years later, I work on giving back as a licensed clinical social worker and an adjunct instructor teaching counseling at a local college. I write about my experience as a psychiatric patient, fighting the stigma of mental illness with the power of my words. I’ve learned to trust and have a small but close circle of friends.
Dr. Lev continues to manage my medication. I see her several times a year to check in. I credit the work we did together in TFP with saving my life and giving me a life worth living.
If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the 988 Suicide & Crisis Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.