2400 words
Approximate 10 minute read

Have you ever wondered what happens in a therapy session…?

I’m not the most avid TV watcher, but I’ve yet to see a portrayal of therapy in a movie or TV show which comes close to what one of my own sessions looks like. Or for that matter, any of my colleagues’ work that I’ve seen.

Hence I thought I’d take some time to write about what happens during one of my own therapy sessions. Obviously, no two therapists are the same, and so while there may be some similarities between psychologists in terms of what happens in a therapy session, there will be just as many differences.

The First Session

My first session is two hours long (double the length of a usual session). Typically, people comment that the time went by really quickly (there’s a clock in their line of sight but most are too focussed on their session to pay great attention to this).

The extra time helps me get a good understanding of my new client (after all, they were a stranger to me mere moments before) and the difficulties that led to them reaching out for help. It also allows for them to feel heard, understood and not rushed to “tell their story.”

When things go well, a client will finish their first session with a deeper understanding of themself, their problems and the (often hidden) barriers which until now, has impacted them in no small way (e.g., in terms of their health, self worth, relationships with others, productivity, success, etc). This then fosters hope that they can get through their difficulties with help. We know from research, that hope is an important factor influencing the outcome of therapy.

Paperwork

At the start of the first session, there is some brief paperwork to be completed (“Information and Consent forms”). I send these forms out to my clients via email ahead of time so they can read them before our session if they wish. The forms have information which I hope is helpful for new clients to read such as

• what to expect during therapy
• how to get the most out of it;
• my fees and cancellation policy;
• how to get a rebate from Medicare or a private health provider (if applicable).

Some people read the forms ahead of time. Others do not. The information is summarised in a consent form which people sign (on an iPad) before we start. I try to keep the admin time as brief as possible so we can maximise the therapy time. It usually takes 5 minutes or so.

Video Recording of Sessions

I video record my sessions (where clients have given the ok for this to happen). This is standard practice for many university teaching clinics which have postgraduate psychology students delivering therapy under supervision. It doesn’t happen all that much once people have finished their postgraduate training though.

It is the standard for anyone practicing the type of therapy I do:  Intensive Short-Term Dynamic Psychotherapy or ISTDP as it’s more commonly known (click to watch a short 2 minute youtube video clip that explains a little more about ISTDP).

Research shows that getting expert feedback on one’s clinical work (through watching what actually happened in a session rather than simply relying on memory recall and written notes) is one of the most effective ways to identify and address when therapy is getting off course and therefore, improve outcomes.

I review my own therapy tapes each week and show portions of my work to a senior colleague based in Queensland (again, only if I have the ok from my client to do this).

I haven’t kept stats on the amount of people who allow video recording of their sessions but I estimate it’s around 90%. I record sessions on my macbook with the screen resolution turned down so my clients can’t see themselves in the monitor (maybe Apple might sponsor me one of these days :P)

Assessment Questionnaires

I ask my clients to fill in a short questionnaire (21 questions) which looks at symptoms of depression, anxiety and stress. Funnily enough, it’s called the Depression, Anxiety and Stress scale or DASS for short. (Click here to complete an online version of the DASS). This is not designed to give a diagnosis, but gives an idea as to how severe symptoms have been in the week leading up to the first session of therapy. The DASS usually takes 2-5 minutes to complete. I give this questionnaire out several times throughout someone’s treatment journey as it’s one of the ways I monitor progress.

The Work Begins

After the paperwork, I tend to jump straight into things. People are paying me after all to deliver a service to them and I want to do that as effectively and efficiently as possible. I will usually start by asking something along the lines of

“what are the problems you’re having that bring you here?”

Specifically, I try to focus on the emotional aspects of the problems (I explain why later on in this post). For instance, if a client tells me they have OCD, I will want to know what sort of impact this has for them in their day to day life. I may already have an idea of the problems experienced by my client if we have spoken on the phone before (e.g., to book in the first appointment). Other times, I haven’t had any prior contact with the person before their first session (e.g., if they’ve made an online appointment booking) and so my first glimpse into their inner world is when they are in the therapy chair.  

Process vs Content

What I do next, after asking my first question, is based off of the response I get from my client. I’ve had clients who have been overwhelmed with anxiety as soon as I’ve asked them about their problems. Others have been able to answer it succinctly and directly and we’ve been able to make headway. Still others without meaning to, or even realizing, erect a barrier towards my attempts at helping them.

I practice from a more process-based approach as opposed to a content based one. In practice, most therapists will lean more towards one approach but utilise aspects of the other. Content based is more about skills training (for instance, strategies to manage stress, and anger).

Process is all about what is happening in the here and now, how that relates to someone’s life outside of therapy and also their difficulties. For instance, if a client is vague in their description of the problems they are having, I and any other therapist would have a hard time understanding what it is they’re seeking help for.

For example, “I’m having a mid-life crisis”

Initially, I may ask them to be more specific: “when you say mid-life crisis, what exactly do you mean?”

If the vagueness were to continue, I would point this out to them and ask if it is something they are aware of:

“Do you notice that when I ask you about the problems that bring you here, you give a vague response? This makes it difficult for me to understand what it is you’re facing, and how I might be able to help you with it.”

Similarly, if my client only talked about things at a surface level and each time I pressed for more information, they changed topic, I would also enquire if they were aware of that pattern occurring between us. I would try to understand if this is something that happens not just in the therapy room, but in their other relationships as well (that is, does it represent a more characteristic way of relating to people).

These defenses (or ways of avoiding uncomfortable topics or feelings) often form part of a bigger problem for the client and can cause the very problems that led to their seeking help.

For instance, take a client experienced significant hurt from a previous relationship. On an unconscious level, any time he gets emotionally close to someone, it brings up all of the unprocessed hurt and pain from his last relationship. Thus, he becomes anxious whenever he has a meaningful emotional connection with someone else. When I ask him about the problems that bring him to therapy, it touches on painful feelings. He avoids this by keeping me at a distance (through giving vague responses). He not only does this with me, but in fact many others in his life, thus making it difficult for anyone to get close to him. He enters therapy because he is feeling isolated, lonely and depressed.

Anxiety Monitoring and Regulating

For most of the people that I have treated, therapy was not the first and only thing they had tried to fix their difficulties. It’s often their last ditch effort of finding a solution. They’ve come to me after they’ve exhausted all other avenues of coping (e.g., seeking advice from their friends, medication, drowning out the problem through sex, drugs, social media, etc).

For this and other reasons, they’re often very anxious when they come in to see me.

For therapy to be effective, anxiety needs to be kept at optimum levels.

If it’s too high, it can affect the brain’s ability to take on new information and symptoms can increase. If it’s too low, progress is delayed and clients can lose hope which can lead to them leaving therapy without getting what they came for. That is, when it comes to therapy, some anxiety is helpful and a sign that the issues being discussed are of importance at both a conscious (what we are aware of) and unconscious (what we are not yet aware of) level.

Everyone has a threshold for how much anxiety they can tolerate. Part of my work early on is identifying where someone’s threshold is. I do this work together with my client, as it allows them to gain greater self awareness and helps them to manage their own anxiety outside of therapy.

It also helps me to tailor the pace and intensity of therapy for my client’s preference and ability to tolerate and handle difficult emotions. This individualized treatment approach takes into consideration the fact that no two people are the same (case in point: I’ve yet to see two identical cases of depression, trauma, grief etc).

Loosely, my goals for the first session are:

1. Make sure that my client and I both have a shared understanding of the difficulties they have been facing
2. Explore some of the (often hidden) barriers that have stopped them from getting the results they have been seeking
3. Help them find the pathway to reach the goals they are hoping to achieve.
4. To give them an experience of what my therapy style is like, so that they can see if it and I are a good fit for them
5. To give them some hope that with assistance, they are able to overcome their difficulties and live a meaningful and happy life.

I don’t tend to take a lot of past history in the early stages of therapy. I have found that the relevant aspects of a person’s narrative tend to come up organically over time; especially once we have made some headway in overcoming hidden barriers or defenses.

Logic vs Emotion

It is not enough simply for clients to have a cognitive (or intellectual) understanding of their problems or of finding a logical solution to them. People will often do damaging things, even when they are aware of the price of doing so. Case in point, significant numbers of the population fail to sufficiently take care of their physical health despite being aware of the massive health risks associated with being overweight and obese.

This trend (of people acting in damaging ways despite the potential risks) is seen even when there are potentially lethal consequences (e.g., someone with type I diabetes who fails to monitor their insulin levels adequately). Most of the time, people know of the potential consequences of their actions. Yet, this knowledge in and of itself, is often not enough to shift their behaviour.

I had a patient several years ago whose alcohol addiction had destroyed his marriage and alienated him from his family. His health was deteriorating after a lifetime of alcohol abuse. He was able to tell me of the destructive nature of alcohol in his life and what it had cost him (i.e., he had an intellectual understanding). Yet, night after night he would return home and drink. He communicated the role of alcohol in his life in an almost robotic like manner, devoid of any kind of emotion.

We worked together for some time on helping him to realize and then turn against this emotional distancing. Underneath these barriers were massive amounts of grief, rage and guilt over events that had occurred in the past that had never been dealt with. Incidentally, this client’s alcohol use started to reduce as he started to face his repressed feelings which had been buried for years. He had a deeper understanding (both on a logical and emotional level) of how early life experiences had affected him and rather than process the feelings around this, he covered them up. Over time, this became harder and harder to do, until he was no longer able to do so without alcohol. In a cruel irony, the alcohol which he on some level thought to be the solution to his problems (i.e., it took away the pain temporarily), created a path of destruction that invariably led to a drinking addiction in an attempt to manage the fallout from this.

Session 2 and Beyond.

My usual sessions are 50 minutes long. I tend to let my clients drive the agenda for follow-up sessions. To begin with, I may ask them to recount their experiences of their first session, especially the emotionally meaningful aspects. I then ask them what they would like to focus on in our session today in line with their goals for therapy.

This can be unusual for people that have had previous therapy where the therapist was more in the driver’s seat. Obviously, I’m not privvy to things that have happened in my client’s life since we’ve last met together (unless they tell me) and so I have no way of knowing what would be important for them to look at.

While my client is talking, I’m listening to what they are saying, but I’m also closely observing their body language, posture, eye gaze, tone of voice, speech rate and a host of other “clues” which help give me an idea as to the underlying difficulties and ways that my client might be unknowingly avoiding the root cause of the problem.

For instance, a client was telling me about a hurtful situation with a friend but talking quite rapidly and avoiding my eye gaze. I asked them if they noticed they were anxious, and their tendency to “talk over” their feelings instead of paying attention to them. We then explored what it was about looking into the conflict with their friend that made their anxiety increase, and how they might face (or avoid) these feelings in real life (for instance, did they subtly withdraw from their friend or “vent” their feelings to others, lash out at their friend or were they able to communicate their feelings to their friend in a healthy way).

Through exploring other examples and situations that occur in the therapy room (e.g., how the client relates to me) and in the client’s recent and more distant history, what begins to emerge is a repetitive pattern of relating to oneself and others which starts to explain how the client came to have the problems that led to them seeking help.

For instance, a client that has OCD may adjust her clothing or wash her hands any time that she experiences feelings of stress or anger. The act of adjusting her clothing or washing her hands may give some temporary relief in the moment, but in the long-term doesn’t help with the things that trigger her OCD symptoms (i.e., feeling of stress and anger). The OCD symptoms also rob her of understanding herself, as the anxiety leading to “compulsive behaviours” happens so quickly it’s often hard to identify what triggered the whole sequence in the first place.

My overall aim in my practice is to help clients identify and work through the core root of their problem so that they can live a healthy, happy and meaningful life.

How long this process takes is completely different for each individual. In another post (shorter than this one!) I share a little bit more about how long therapy should go for.

I hope this article has in some way helped to answer any questions around what happens in a therapy session. Deciding to seek help takes a tremendous amount of courage, as does the act of continually showing up, being open, honest and vulnerable about areas that have likely caused great pain.

Please feel free add your questions or comments below. If there’s someone you think that may benefit from reading this, please feel free to share it with them (they may appreciate some discretion around this so you could send it via messenger or text/email the url).