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.