Getting the Most Out of Psychotherapy
Stages of Psychotherapy
Like any relationship, psychotherapy can pass through stages of getting acquainted, becoming more deeply involved, and eventually, ending. I am not the only one to envision the stages of psychotherapy as 1) initial contact, 2) evaluation, 3) early treatment, 4) deepening, 5) working through, and 6) termination. There may be occasional breaks from therapy when either party goes on vacation or some life circumstance necessitates a pause. I describe these stages to help new clients recognize where they may be in the process as it unfolds.
Initial contact is what it sounds like, a phone call, an e-mail or other communication in which the therapist responds, so therapist and potential client start becoming acquainted and can decide whether a first meeting is a good idea.
The evaluation may last a few sessions and includes the first meeting. Here, client and therapist see if they can agree on therapy goals. More importantly, clients determine whether they feel a personal chemistry with the therapist that encourages him or her to speak openly and work collaboratively. During this stage, the therapist conducts an initial assessment of the client’s needs and psychological condition to determine whether the therapist is sufficiently trained in meeting those needs, including any apparent psychopathology. It is the therapist’s ethical responsibility to acknowledge if at least some of the client’s needs lie outside the therapist’s scope of practice. In this case, the therapist provides referrals and may or may not continue treating the client for those aspects that lie within the therapist’s areas of expertise. As evaluation proceeds, the therapist recommends a treatment plan.
During the early treatment stage, client and therapist get to work on the issues at hand and apply the initial treatment plan. Goals and treatment are further specified as both participants experience the results. Re-evaluation and adjustments to treatment can occur throughout the course of therapy.
The deepening phase may not occur in brief therapy. However, in medium- and long-term therapy, the client’s attachment issues come into play as primitive aspects of the mind respond, as described above. If deepening does occur, therapy has the potential to gain power, stall or fail. This is the stage where a person usually feels worse before they feel better. It is here where one realizes that achieving personal change in psychotherapy involves facing more intense emotions than one usually does. The avoidance of such emotions or failure to limit them to appropriate situations is what causes the symptoms that motivate people to seek therapy.
Termination follows a successful course of therapy, with the agreement of client and therapist, and is not the same thing as quitting therapy against the therapist’s recommendation. To be successful, therapy does not need to reach overly ambitious goals, especially in brief therapies where the goal is to alleviate specific symptoms. Therapy that aims at more fundamental change usually takes longer than 5, 10 or even 20 sessions. Even here, the person may be ready at this life stage to achieve a significant change and leave therapy temporarily, resuming later when time, budget, life circumstances and emotional resilience allow.
Sometimes clients will transfer to another therapist with a different type of expertise for the next stage of growth. For example, someone who has undergone successful cognitive therapy for depression may want to do in-depth dreamwork for personal growth that extends beyond controlling depression symptoms. It’s best if such a transfer occurs after successful termination of an earlier course of therapy, and not as an escape from therapy if a client is challenged to undertake significant changes.
“Why Do Therapists Ask Those Types of Questions?”
The types of questions therapists ask have become a cliche in movies and television shows. The most typical one is “tell me about your mother.” Okay, okay. Sometimes we’re guilty of asking such stereotypical questions. But why is this so? And is this our total repertoire?
Why do we ask about earliest experiences or relationships with parents? Because behaviors in relationships are largely formed as conditioned responses. In other words, they become habitual because at one time they were rewarded or reinforced by other people’s actions or by situations. The earliest experiences are the most influential, because children learn with more openness and less discernment than adults do. And what can be more influential than a child’s dependent relationship on its earliest caregivers?
Clients sometimes complain when a therapist asks about these early relationships with the stereotypical fear that the therapist hopes to relieve the client’s pain by allowing her or him to use a dysfunctional early relationship as an excuse for current problems — or blame the parent for the poor decisions of the client. Recognizing cause and effect does not assign blame. It does provide insights about how seemingly dysfunctional behaviors were learned, so the client can make new and better choices today, with less self-reproach for behaviors adopted when less discernment was available.
Another typical line of therapist questioning is about earlier relationships or experiences that were painful or traumatic. The intent here is not to have the client wallow in the pain. Rather, it’s a way to discover why the client may avoid situations that seem similar and help the client differentiate the present from the past. Also, many clients appropriately find comfort in learning that today’s problems have understandable origins and do not fit such simplistic explanations as a defect in character.
Therapists may also ask about ways that a client avoids experience or defends against awareness of it. A stereotypical but sometimes helpful question is, “how do you feel about that?” This question helps some clients overcome a tendency to explain through intellect the origins of experience that may be directly accessed through warded-off emotion. Of course, asking this question of someone who is very unaware of his or her emotions may be inappropriate and nonproductive — which brings me to the final point in this section.
A skillful therapist may ask questions that surprise you, ones where after they’re asked, you say to yourself, “why didn’t I think of that myself?” Skillful questioning will often lead you to insights that were just below conscious awareness. Skillful questioning may also help you find motivation that was already available below the surface to overcome current problems. Skillful, open-ended questioning can help you search the contents of your mind for your own thoughts rather than overly shape your responses through implications you do not quite agree with. So, if your therapist asks questions that seem to squeeze you into a stereotyped corner rather than help you explore the contents of your mind, voice this concern to the therapist who can then adjust his or her technique to facilitate your self-discovery.
Standards of Ethical Practice
Licensed psychologists and other licensed therapists work under legal and ethical standards that have been carefully thought out to promote clinical safety and safeguard consumer interests. (Please note that I am not an attorney, and that the information given here does not constitute legal advice but is for educational purposes only.) These standards include the conditions under which confidentiality applies and where that confidentiality may or must yield to protect people when clients are a danger to themselves or others. The ethical and legal standards also cover therapist reporting of suspected abuse of children, elderly or disabled adults.
There are also federal laws that govern the administration of medical records. These can be exceedingly complex. For example, any psychologist who exchanges information electronically (not including facsimile) with clients is probably bound by the Health Insurance Portability and Accountability Act.
Therapists Should Not Take Advantage of Clients
A key element of the ethics code and legal regulations is the principle that therapists not take advantage of their clients. For example, the material above about sexual feelings emerging in therapy introduces one of the ways that therapy can go very wrong.
One of the principal ways that psychotherapy heals is by teaching the client that any emotion can be experienced without being acted upon. When one learns this through experience, one builds what is called “affect tolerance” and can have a cooperative relationship with one’s emotions that then become another way of sensing the world. It follows that when a therapist acts on sexual feelings that emerge in therapy, this is a betrayal of the client’s healing process where vulnerable thoughts and feelings are explored, not acted out. There is no professional psychotherapy situation in which sexual contact is appropriate between therapist and client  unless the client is specifically working with a surrogate partner supervised by a sex therapist. Otherwise, the therapist has stopped providing a safe container in which vulnerable feelings can be experienced and understood.
Avoiding Dual Roles
Similarly, therapists usually seek to avoid dual relationships with the client, such as having the client provide a business service for the therapist. This is because dual relationships have the potential for the therapist’s personal needs to compete with those of the client. The only reason that such relationships are “usually” avoided is that sometimes exceptions are made when therapist and client live in a small community where both, for instance, may be members of the same church or neighborhood association. Even in such cases, therapists take care to avoid having their personal needs impinge on those of the client. The client’s paying the therapist a fee does not constitute a dual relationship but is a paradox of therapy that arises out of the therapist’s need to make a living. This is not unlike other business relationships where a proprietor may have a collaborative and caring relationship with a client.
Therapists also take care to avoid providing duplicate services to clients. For instance, if a client is seeing another therapist for individual cognitive therapy, a therapist may not simultaneously provide the same kind of service. Avoiding duplicate services helps motivate the client to work out any differences or perceived deficiencies with the one therapist she or he is working with rather than avoid that necessary confrontation by seeing two therapists for similar work.
Seeman, G. (2020). Getting the Most Out of Psychotherapy. Psych Central. Retrieved on September 25, 2020, from https://psychcentral.com/lib/getting-the-most-out-of-psychotherapy/