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Getting the Most Out of Psychotherapy

Session Frequency

The frequency of sessions helps balance cost, intensity, and emotional containment. Clients most often attend sessions weekly to balance cost and effectiveness and settle into an emotional rhythm provided by attending at the same time each week. If you see your therapist weekly, you’ve had some time to integrate the effects of the previous session, which is recent enough that it will have continuity with your next session.

Seeing a therapist less often costs less but may be less effective if you aren’t meeting often enough to accomplish changes at a steady pace. Clients immersed in intense emotional or life changes may see their therapist twice a week or more to help keep them be emotionally centered and assist them in activating coping skills.

Clients also meet more often in psychoanalysis, which is a specialized type of long-term therapy designed to restructure the personality through a thorough exploration of life history and issues. [5]

Client and Therapist Roles

In the therapy room, there’s a power differential between client and therapist, because this is the arena of the therapist’s specialized knowledge. Clients are seeking the therapist’s advice or expertise to solve difficult problems, discover new things about themselves or make important decisions. Because of this power differential, it’s the therapist’s responsibility to explain the psychotherapy framework and ground rules, and to act in the best interests of the client.

The psychotherapy relationship may feel imbalanced because clients talk about themselves, and their issues come first. The goal of therapy is to meet the client’s needs, and other than the payment required to make a living, the therapist is responsible to keep the work focused on those client needs.

Therapists often differ in how much they reveal their own emotions or thoughts, which anyone new to therapy may find unsettling. There are reasons for what is called therapeutic neutrality and ways that I believe it can be a barrier to natural relating.

The therapist neutrality concept began with the psychoanalytic idea that if the analyst remains unknown, the analysand uses the analyst as a blank screen for projecting attachment responses to early caregivers. These responses are often the basis for relationship difficulties today, so it can be very helpful to have them revealed for client and therapist to see.

The attempt to offer oneself as a blank screen can be a barrier to successful therapy if it is rigidly practiced without awareness of the client’s individual needs. It can also be an obstacle if the therapist remains emotionally cold and distant as a defense against revealing unwanted thoughts or feelings. Said another way, the blank screen becomes a barrier if it prevents the client from experiencing support from the therapist for healing. My own approach is to find a balance where clients have the opportunity to discover their own thoughts as the therapist does more listening than talking.

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Not all schools of therapy use the blank screen. Some, for instance, encourage the therapist to reveal personal responses to model emotional openness. Psychoanalysis may explicitly use neutrality in a disciplined way for clients who are sufficiently secure that they are ready to discover the depths of early childhood emotions and thoughts without distraction. I find that such depths can be revealed in therapy anyway by exploring our interactions here and now, when it’s appropriate in terms of timing, trust, and client capacity.

My own therapeutic style is to attune my senses to a client’s uniqueness by sometimes emotionally detaching from my own memory, desire and understanding. [6] This helps me tune into your thought processes in the moment, including your model of healing. If I’m not open to your ideas about healing and our work doesn’t cooperate with them, we’re not likely to succeed. [1] I balance neutrality with the discussion of therapeutic goals and such safety issues as substance abuse that may be endangering wellbeing or preventing change.

Disruptions Can Lead to Breakthroughs

Opening up in psychotherapy often stirs up primitive portions of the mind that are usually functioning outside awareness. When the therapist addresses these aspects of thinking and behavior, clients may experience deep personal transformation. What are these “primitive” sectors of mind?

We have all passed through infancy and early childhood. As young children, we experienced very intense emotions and lived in an inner world where cause and effect were more loosely understood. Many situations can stir up primitive thinking and feeling in adults including those that induce fear and insecurity, the passion of romance, excitement about achievements and good fortune, losses of loved ones through death or estrangement, and so on. When such early modes of thinking and feeling are stirred up, it’s as if things have always felt and been that way and always will. (This eternal, absolute quality of childlike thinking is why therapists sometimes remind clients that feelings are not facts.)

When child-like reactivity is stirred up, people may act on impulse and temporarily lose their ability to analyze situations or make wise choices. They may seem self-centered, without a sense of others as separate people. When we were little children, we didn’t represent such experiences in words. When early thinking modes are activated, there may be no running narrative to help provide a continuous self-representation (identity) beyond very recent moments.

Activation of Childlike Responses in the Therapy Relationship

Primitive sectors of mind can become reactivated even in well-functioning adults in therapy. This can happen when they share very personal experiences, such as troubling love relationships or habits they can barely admit to themselves. Anything that creates an intensive level of intimacy with the therapist will surface threads of attachment that are similar to the attachments needed with a soothing mother or protective father — even if such early relationships were deficient. When the pull for such attachment begins to occur, primitive responses often come into play, especially when there’s a disruption, such as the therapist going on vacation or revealing a failure to understand something the client is saying.

Primitive responses to the intensity of connection or empathic disruption are recognized in several ways, often after the fact, because they’re below the adult structures of consciousness, including acting out and the feeling and expression of intense emotions, desires and aversions. Addressed skillfully by the therapist and responded to with strength and courage by the client, these reactions can be grist for the mill of substantial personal growth.

Primitive attachment responses can include responding to anxiety or frustration by acting out with a lack of awareness. Typical examples of such “acting out” are missed appointments, last-minute cancellations, forgetting to bring payment, asking for reduced fees despite no change in financial circumstances, resuming a destructive habit, and so on. People acting out usually have an adult explanation, such as being so busy they were distracted and forgot the appointment, or that life pressures were so intense they had no choice but to relapse. When explored, such explanations often turn out to be habitual ways to deflect the client’s consciousness from the anxiety or frustration that was activated in therapy. For instance, clients may feel overwhelming neediness or dependence and be afraid that therapists and others would reject them if they expressed such feelings or used them as the basis for making “unreasonable” demands.

Other similarly intense feelings that can emerge from activation of the primitive mind include intense anger and hatred, anxious thoughts and habits, self-destructive thoughts, sexual attraction, and so on. Keep in mind that even sexual attraction can spring from activation of early attachment experience. In other words, the sexual attraction may be a reactivated feeling of an infant’s sensual need to be held and loved that precedes sexual differentiation. Such feelings can be especially confusing to adults when they run counter to their sexual orientation or their sense of relationship appropriateness.

When primitive feelings and impulsive or defensive actions emerge in therapy, they can lead to a breakthrough in the client’s ability to experience relationships or deepen access to the client’s feelings and understanding of their personal needs — or they lead to therapeutic failure. The latter occurs if clients blame the therapist or some external situation for their discomfort and are unwilling to return for one more session to try to understand what happened. This is why I tell my clients at the start of therapy that there may come a time when they feel worse before they feel better. I also encourage them to attend at least one more session before deciding to end therapy.

This last suggestion doesn’t emerge from my need to support my business. Any therapist driven by that motive would be too emotionally insecure to effectively help clients through such impasses. When the client suddenly wants to quit, the therapist also needs to be willing to explore the client’s nonpsychological explanations, such as schedule changes, significant changes in financial condition, or other issues. For example, a sudden illness in the family can be sufficient to disrupt anyone’s thinking regardless of anything that has happened in therapy. As Freud is reputed to have said, “sometimes a cigar is just a cigar.” Freud’s comment was a corrective for overly zealous adherents to psychoanalytic theory.

To summarize the above, no matter how intelligent or competent you are in your adult life, therapy is a unique situation that may bring into play unconscious parts of the mind. When this occurs, it is at first truly “unconscious,” and as such is not recognized. A good therapist will use the opportunity of the emergence of primitive processes to help you create a more cooperative relationship with your early childhood self. This is where personal transformation unfolds through the integration of today’s adult realities and innocent feelings.

No matter how destructive they seem, the actions of the childhood self, like the actions of a young child, have innocent motives, such as the need for love and protection and the avoidance of danger. The therapy framework described earlier in this article, including the agreements about time, money, appointments, and so on, is an effective barometer for revealing unconscious activation that may show up in something as subtle as consistently arriving five minutes late. My own attitudes toward addressing such issues include remaining aware of the here-and-now goals that bring clients to therapy, plus an attitude of helping clients pace the intense experiencing of early emotions through therapy.

Getting the Most Out of Psychotherapy


Gary Seeman, Ph.D

Gary Seeman, Ph.D. is a psychologist in private practice in Corte Madera and San Francisco, CA. He works with adult individuals and couples, specializing in addictions, bereavement, creativity, life transitions, personal fulfillment, relationships and spirituality. He maintains a website at www.drgaryseeman.com.

APA Reference
Seeman, G. (2020). Getting the Most Out of Psychotherapy. Psych Central. Retrieved on May 24, 2020, from https://psychcentral.com/lib/getting-the-most-out-of-psychotherapy/
Scientifically Reviewed
Last updated: 17 May 2020 (Originally: 17 May 2016)
Last reviewed: By a member of our scientific advisory board on 17 May 2020
Published on Psych Central.com. All rights reserved.