How does therapy work?

I often hear this question from people I meet. It’s also the first question asked by prospective patients inquiring about the therapy services I offer. To begin answering this question, here are eight simple steps for starting therapy.

1) Gentle Introductions

When prospective patients call and leave me a confidential message, I call them back and ask to set at a time when they have 15 to 20 minutes to speak freely with privacy. I then talk with the patient to get a sense of what might have inspired him or her to reach out to me. Human beings are complex, and so are their life histories; therefore, I find it best not to rush my gathering of information, nor to hastily make a recommendation for treatment without fully thinking things through and getting to know the patient.

2) Initial Assessments

The initial evaluation/assessment is completed over at least three sessions (45 minutes each). A comprehensive life history isn’t learned within these three sessions, but it is usually enough for me to start thinking about what may have happened in a patient’s life to lead to the struggles he or she is now experiencing. Generally, by the middle of the third session, I curtail history gathering, and instead summarize for my patient what I have heard thus far, and what I am learning from this about their strengths and challenges.

3) Mental Mechanisms

I discuss with my patients how their earlier lives leading up to this point may have shaped them, as happens for each of us. In order to survive in the families in which we are raised, each one of us develops (without knowing it) a set of mental mechanisms allowing us to cope with what life brings to us. These mechanisms, helpful as they have been in helping us survive as children, often persist into adult life, which then cause difficulties for us. Even when we have other choices and resources available to us as adults, we may not utilize those. We may stay locked in ancient patterns of functioning that may no longer be necessary for us as grownups. This is how working with an experienced therapist can help you. With good therapy, you can learn to differentiate between what was in the past and what is in the present, so that you can live, love, work, and play more freely and more creatively.

4) Professional Recommendations

Based on what I have heard from the patient, I make a recommendation for treatment. Initially, the recommendation is completely separated from what the patient can afford and what the patient’s schedule permits. Otherwise, it is not an ethical recommendation. Just as when a patient with pneumonia or cancer sees a doctor, the doctor does not make a recommendation for treatment based on what the patient can afford or how much time the patient is willing to give the treatment. If the doctor did that, it would be highly unethical, harmful, and ridiculous. Similarly, as a serious clinician, a good therapist must make a recommendation for treatment that is in line with the patient’s real emotional struggles and the patient’s real therapeutic needs. Based precisely on these needs, I recommend therapy for the patient, the frequency depends on what I believe would allow the patient to make needed changes to function better and more happily.

5) Informed Decisions

I discuss with the patient my rationale and reasoning for the recommended treatment. In addition, I explain the differences between various forms of therapy and the varying frequency of sessions per week. We discuss what can be achieved with each kind of therapy and what the difference would be if we were to meet once a week, twice a week, or more often. I then do my best to answer the patient’s questions about my recommendations. I encourage them to research the kind of therapy and the frequency of sessions I have recommended. The patient is free to discuss this recommendation with other people, including family members or other professionals in the mental health field. I believe patients must be informed consumers and have a right to fully understand their treatment options. I offer to meet after the research phase is complete. This often leads to the patient coming back for a fourth and at times a fifth session to discuss concerns or other practical matters about starting therapy.

6) Arrangements

If the patient feels that he or she would like to work with me, the next step is to begin wherever the patient is ready to start. The treatment, ultimately, belongs to the patient. My most honest recommendation for treatment and frequency is clearly stated; however, if time and money do not permit the patient and I to work together, I would work very hard to connect him or her to another good therapist with whom they can work. And if, for any reason, the patient feels he or she cannot work with me or if it isn’t a good fit, I respect the patient’s decision; in turn, I would help connect them with another therapist.

7) Therapy Framework

The next step is to set a frame for the therapy. This involves clearly discussing the frequency of treatment, the length of each session, the times of the appointments, fees, the cancellation policy, therapist availability, and (last but not least) the important idea of the patient saying whatever comes to mind in every session. This last one is easier said than done. Patients should feel free to say whatever they find themselves thinking or feeling. It could be something the patient sees outside the office, while at other times it could be thoughts about a movie or a dream. This is a free form of thinking and talking, which we generally don’t do with most people. As a therapist, I can gradually start to see patterns. And as I do, I share the patterns with the patient. Together, we would then try to look at how these patterns might explain any difficulties in their lives. What is most fascinating about therapy is patients eventually start doing with me what they do with most people in their lives. This is a highly positive development in each treatment, because it makes the therapy a kind of “living lab” in which we can understand what goes on between a person and the other people in his or her past or present. As their therapist, I make myself available for such interactions, not in a forced or artificial form, but in ways that are spontaneous and inevitable.

8) Comfortable Progress

At any moment patients are uncomfortable talking about something, I let the patients know NOT to force themselves to speak about what is on their mind. Rather, patients should simply let me know they are thinking or feeling something, but cannot talk about it. In that case, the important issue is not how to get a patient to talk about something, but rather to understand the anxieties and struggles that might be causing embarrassment or worry about sharing the thought. The understanding of these anxieties and worries is in itself a most important part of therapy.

This then is the work involved in the beginning of therapy. If done well, it gradually opens up the road leading to a stable initial phase of therapy, in which the patient and the therapist start to work well together, both with the common goal of helping the patient.