Reveal Yourself, and Voice Your Concerns
It takes courage to tell a relative stranger about your most sensitive issues. So, one of your first goals in therapy may be the discovery of whether you can trust your therapist enough to reveal yourself openly. If you can put your fears into words, a good therapist can help you understand their origin and whether or not they apply to the current situation. As therapy proceeds, if you still find it difficult to trust your therapist, this is a valid issue to bring up and discuss whenever it arises.
I encourage you to reveal thoughts and feelings that aren’t comfortable because these may have the greatest leverage for growth. I achieved much of my current inner peace through pursuing my own therapy. Once I’d established trust in my therapist, I began to trust my own process to the point that the first issue I would bring up in any session was the one with the greatest emotional charge. That practice accelerated my inner healing. If you feel yourself flooded with feelings or obsessing about thoughts so that they interfere with your inner peace, your therapist may help you to take a break from these thoughts and feelings and improve your dialogue with them.
Ask your therapist to explain anything you don’t understand, even if asking the question may reveal that you’re not as knowledgeable as you think you should be. Ask even the “dumb” questions. If you don’t understand the therapist’s answer, ask for clarification or a different explanation or example.
Polite people often find it difficult to say that they’re dissatisfied with how things are going. Because of this, the nicest people often store the most intense resentments because they’re afraid to bring them up. I encourage you to discuss your frustrations early. Therapy is a healing process, and you may get a different response than what you fear. What are some of the useful ways a therapist can respond?
- By taking your complaint seriously
- Being open to changing technique or approach to something that will work for you
- Showing willingness to admit the therapist’s contribution to any dissatisfaction
- Helping you understand your part in the dissatisfying exchange
I encourage you to meet such therapeutic responses with your own best efforts. For example, your chances of success are enhanced if you’re willing to explore your cherished beliefs and attitudes. Be open to discovering your own part in a dissatisfying therapy encounter. This openness can reveal relationship issues you need to address. By understanding the interaction from both sides, you’ve got the opportunity to heal, especially if the therapist responds more openly and fairly than did important figures in your past.
If you still disagree with your therapist’s technique or recommendations, voice your disagreement and invite a discussion about it. This allows the therapist to consider whether her or his technique is the most appropriate and to explore emotional issues that the disagreement may reveal. After such disagreements have been explored thoroughly without a satisfactory resolution, the best solution may be to ask your therapist for referrals to other therapists who may better meet your needs.
Clients soon discover that when therapy starts to get at their emotional issues, it’s no walk in the park. When it reaches this level of intensity, therapy becomes an even more powerful opportunity to make decisions and changes that can transform your life. I encourage you to make your best efforts to help your therapy succeed, including following through on your therapist’s recommendations even if this takes substantial effort.
One of the most difficult tasks for any client is facing the truth about addictions, self-destructive habits or impulsive actions that shut down uncomfortable feelings. Ask your therapist for help in overcoming such issues. The solution may include referrals to a medical doctor, specialist or clinic. If you don’t address these very difficult issues, they’ll continue to block your path to happiness and success — or worse.
Understanding the Psychotherapy Framework
“For psychotherapy to be effective, a close rapport is needed …. The rapport consists … in a constant comparison and mutual comprehension, in the dialectical confrontation of two opposing psychic realities. If for some reason these mutual impressions do not impinge on each other, the psychotherapeutic process remains ineffective, and no change is produced. Unless both doctor and patient become a problem to each other, no solution is found.” Carl Jung. 
The following discussion of the psychotherapy framework is intended to help you understand some of the “rules of the game,” why they’ve been established, and their role in making therapy effective. Although there are many approaches to psychotherapy, some elements are found in most approaches. These elements include:
- A standard session length
- Frequent sessions held at the same time(s) each week
- Typical roles and tasks of therapist and client(s)
- Disruptions of the framework that can lead to breakthroughs
- Activation of childlike responses
- Stages of therapy
- Types of questions and comments presented by the therapist
- Adherence to legal and ethical standards
People often wonder why the typical “therapy hour” is 45 to 50 minutes. Group therapy sessions usually last longer and brief therapy interventions may take much less time. One answer that’s funny and probably true is that psychotherapy pioneer Sigmund Freud couldn’t last more than 50 minutes before visiting the bathroom!  There are other useful reasons for this session length:
- Therapy can be emotionally intense and someone may learn many things in session. More time in session can be difficult to absorb mentally and emotionally.
- Psychotherapists spend time outside of session thinking about the client(s), completing required notes and doing treatment planning. The minimum needed is 5-10 minutes, so the standard session time allows for scheduling of sessions on the hour. In some situations a therapist may offer longer sessions. For instance, a couple in therapy may find themselves just getting into a long-needed conversation. Added time may help them maintain the momentum.
- A standard session time helps the therapist pace the session for the client, for instance, giving them time to pull themselves together before going back to work. This predictable session length helps establish an expected emotional rhythm to even intense sessions. It instills a sense of emotional safety and teaches the client that he or she can choose to open up difficult feelings and then contain them.
- Standard starting and stopping times and session length provide a way for client and therapist to notice if emotional reactions or issues are expressed in lateness or attempts to stay beyond the end of the session. Exploring such attempts to go “outside the therapy frame” often gives the client powerful and unexpected insights.
- Often clients bring up significant issues at the very end of the session. This can occur for many reasons. Sometimes it’s because the issue is uncomfortable to talk about, but as the end of the session approaches, the client realizes it’s something she or he really wants to bring up. This happens so often, there’s even a name for it — “doorknob therapy”! 
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. 
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.
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.  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.  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.
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.
Working Within One’s Scope of Practice
In most states, a person cannot be a psychologist without completing an accredited doctoral program, doing years of supervised internship and training, and sitting for licensing exams that require long and dedicated study. But not all psychologists are therapists. Some specialize in research, others teach or provide expert witness testimony and other legal services, such as divorce mediation, some do organizational consulting, and others specialize in psychological testing.
Within these general areas are specialties. Psychologists are ethically bound to practice only within their areas of sufficient training and education. This boundary is called working within one’s scope of practice.
 For more information about what makes therapy work, see Talking Cure.
 Jung, C. G. (1961). Memories, dreams, reflections. Jaffe, A. (ed.) R. and C. Winston (trans.). New York: Vintage Books Edition, 1989.
 Michael Hoyt, Ph.D., personal communication, 2001.
 Ann Bernhardt, Ph.D., personal communication, 2002.
 I provide long-term, depth psychotherapy for clients, as needed. I am also informed by psychoanalytic theory. However, I do not do psychoanalysis, which requires years of specialized training and certification.
 Bion, Wilfred (1967). “Notes on memory and desire.” Reprinted with permission in Classics in psychoanalytic technique. Revised edition, 1991. Robert Langs, Ed. Northvale, New Jersey: Jason Aronson Inc. Original work published in Psychoanalytic Forum 2:271-280. 1967, ed. J. Lindon. A similar attitude is suggested by Carl Jung. Jung, C.G. (1946/1966) “The Psychology of the Transference.” In Jung, C.G. (1966). The practice of psychotherapy: Essays on the psychology of the transference and other subjects. 2nd ed. (R. F. C. Hull, Trans.) Princeton, NJ: Princeton University Press, p. 329.
 On this website, you can access the publication, Professional Therapy Never Includes Sex to understand the therapist’s obligations and your rights in such matters. Therapists who are discovered to have been sexually involved with their clients usually lose their licenses to practice.
* All initial appointments are arranged through a brief phone call so I can get a general sense of the issues you’re addressing. I also ask questions to make sure that your needs are likely to fit within my scope of practice (areas of training and expertise). If those issues are outside my scope of practice, instead of meeting, I try to offer referrals to therapists or community resources with the appropriate specialization. 24-hour notice is required to reschedule the no-charge visit once only.