In a recent edition of The Boston Globe, Hilary Price’s strip, “Rhymes with Orange, ”featured a worried looking driver reading a road sign on the “Inner State Highway” bearing this message: “Is it missing your exit that’s bothering you, or something deeper?”
The idea of the inner state highway appeals to me as a psychologist. For many of us, it was the first road we learned to travel in graduate school when our professors, supervisors, and patients taught us how to do psychotherapy.
Elvin Semrad, the dean of Boston psychoanalysis from the 1950s to the time of his death in 1976, was often asked how to answer a patient’s question about how long he would need to be in therapy.
His response, like the man himself, was honest and straightforward, “As long as it takes.”
That’s how the inner state highway works. We come to psychotherapy when we encounter life challenges that feel overwhelming and insurmountable – a significant loss, failure, a chronic annoyance that wears us down when we are most vulnerable, a fear that we finally recognize as an obstacle to living the life we want for ourselves, a vague feeling of discontent, or any number of behaviors that cause pain to us or our loved ones.
We tell our story to a therapist who listens with curiosity, empathy, and respect. And then we tell it again, and again, and again, each time adding something different.
We update with descriptions of new developments or backtrack to fill in details that we forgot or were too timid to disclose. We move forward, backward, and sideways, meandering down interesting byways, guided by spontaneous combinations of our goals and free association. It’s funny, Doc, but I can’t say why I just thought of Uncle Leo’s encounter with the polar bear in Greenland. Don’t worry about that now, just let your thoughts go and tell me more. All will become clear in time.
Time, as much time as it takes – that’s what you need when you travel the inner state highway. Yet someone has to pay for that time, and the insurance companies set a limit, at first, just enough to pay for 12 sessions of psychotherapy at the going rate of the day. And so, necessity begat time-limited psychodynamic psychotherapy with 12, 50-minute hours to help a person make the changes he or she wants to make, achieve some measure of relief, and gain some insight into his or her particular version of the human condition.
The journey was both expanded and shortened with the interstate highway’s focused attention to the presenting problem now joining a more limited exploration of the byways of the inner state highway. That was our first session, there are 11 more to go. We learned to respect the calendar as we had first learned to respect the clock. Fifty-minute hours had long been the accepted standard, and now we were learning that they could not go on forever. See you next week, that was our fourth session, you have eight more left.
Folk wisdom taught us that work expands to fill time, and now we realized that psychotherapy does the same thing. Yes, we are terminating today. I’m glad you are feeling better. You made a great deal of progress, but there are some areas that still need your attention. Now you know what they are and have the tools to address them.
There are always some areas that need our attention, and sometimes they multiply despite our best efforts to keep them under control. Fortunately, therapies multiply as well, and both research and the wisdom of clinical practice have given us cognitive behavioral models with a sharp focus on eradicating the most debilitating symptoms.
Who would forgo a chance to eliminate panic attacks, phobias, addictions, depression, or crippling anxiety when specific psychological and pharmacological treatments are readily available?
These are the interstate highways of healing and personal growth, and psychologists know how to guide our patients along their well-traveled lanes. Yet, no matter which road we choose to begin our journey, as reflective travelers we will recognize the benefits of both the inner state and interstate highways as we move freely between both as the situation requires.
The inner state highway calls to mind William Least-Heat Moon’s best-selling memoir of 1982, “Blue Highways,” chronicling his 38-state journey along the secondary roads marked in blue on the old-style Rand McNally road atlas.
He took the interstate only when he had no other choice. “Life doesn’t happen along interstates,” he wrote, “It’s against the law.” At a time of loss, the writer was looking for life or, as he put it, for “places where change did not mean ruin and where time and men and deeds connected.”
He traveled in the tradition of all great wanderers, knowing that “a true journey, no matter how long the travel takes, has no end.” At the conclusion of his travels, Least-Heat Moon doubted that he had even found insight, perhaps just the strength to keep on going, asking questions, living with uncertainty, and appreciating “an inheritance of wonder.”
This is not covered by insurance companies, but good psychotherapy, on and off the interstate, can help us in our travels. The real work of the journey is up to us.