Investing in You
Therapy is an investment in you. Its healing and nurturing process serves to heal old wounds or trauma, promotes involvement and presence in daily life and in relationships, and establishes personal calm, enjoyment and balance. The lessons learned in therapy provide enduring change and knowledge that will last a lifetime. This article provides an overview of what happens in the therapeutic process.
The Initial Session
The first session is a time for the therapist to get to know you and to understand what is bringing you into therapy. Of all the scheduled therapy appointments this is the longest session. It typically lasts for an hour-and-a-half to two hours. During this time, many questions will be asked about the difficulty which brings you to therapy; this is known as the presenting problem. Having the opportunity to express and unload your problem and meet your therapist might initially make you feel better. You might feel relieved that you have gotten started, but the presenting problem has not yet been addressed.
The majority of the initial session or assessment is focused on your history. Questions are asked about your family, the current family if you are married, divorced or have children; and the family you grew up in. What are the relationships like in the family? You will be asked about friends and support, community involvement, and employment or school. These questions are asked so that the therapist has an overall picture of who you are. They provide context or background to the presenting problem.
During this initial session, questions will be asked about symptoms you might be experiencing such as your mood on most days. For example, are you feeling sad or blue, anxious or worried, disorganized and scattered, stressed or irritable; or are you feeling relatively calm and content except for occasionally when you are bothered by the difficulty which brought you to treatment. Other questions are related to sleep or eating habits, physical symptoms such as upset stomach or headaches, bothersome or ruminating thoughts, and finally questions related to general behavior: are you easy to cry, keyed up, argumentative, have difficulty getting along with family members, friends or co-workers.
At the end of this first session, the therapist will have an idea of how to guide you through therapy. The state of Wisconsin requires a mental health diagnosis and a treatment plan. After this first session, the therapist will have an idea of what diagnosis is appropriate to describe your presenting problem as it is put into context with your personal history and your symptoms. The term diagnosis can be off-putting to some, but it is actually just a way of describing symptoms which are universally accepted by other professionals. So for example, if you have an upper respiratory infection, commonly known as a cold, we are able to understand that the symptoms are likely, congestion or runny nose, maybe a headache, and fatigue. In the same way, a mental health diagnosis is simply a description of symptoms. The difference is that most people do not know the symptoms of mental health diagnoses. So for example, if you were to receive a diagnosis of adjustment disorder with depressed mood, other mental health professionals know that in basic terms this is a disorder related to a specific event which occurred in someone’s life, such as divorce, which has resulted in that person feeling depressed; and as a result they were not able to go to work on some days, they were easy to cry, and they were uptight and irritable around their children. Their symptoms were bothersome enough to bring them to treatment. Just as with the common cold, the person with the adjustment disorder is not defined by their diagnosis. Consider diagnosis to be a form of communication and not a label.
The Treatment Plan
The treatment plan is a one page document that will be presented to you at the first therapy session after the assessment. It outlines the goals and objectives for therapy. It is an overview of what the therapist thinks will be beneficial to you during the therapeutic process. Goals are general statements which indicate the focus of treatment and objectives describe how the goals will be met. So for example, a general goal might be: “Conflict between parent and child will decrease.” Objective: 1) “Both parent and child will identify their role in conflict. “2)”Both parent and child will learn communication skills to decrease conflict.”
Goals and objective are part of your right to knowledge about therapy and its process. It is not meant to worry or to stress you. It is not a homework assignment, nor is it intended as pressure for you to produce during the therapy session. It is the therapist’s job to help you meet your goals. Your job is to show up for therapy and to participate in the process. Finally, the treatment plan offers a sketch of how many sessions are needed to complete the goals and objectives. This is NOT a contract. Treatment may complete before the number of sessions indicated and it might extend beyond those indicated.
Therapy sessions last for 45- 50 minutes. Sessions typically begin with the client talking about whatever is on their mind. This might be something they have thought about for the last few weeks, what happened that morning, or be as simple as what happened on the drive into the therapy appointment. It is your therapist’s responsibility to listen, to attend to you and to assist you in seeing or experiencing what is not in your awareness. This is the basis of insight oriented therapy, moving the client’s subconscious experience into their awareness or conscious mind. Sometimes, it is possible in session to assist clients to experience themselves in a different way which increases a client’s awareness, but sometimes it is not. There are some sessions that are quite light hearted, simple and straight forward, where the therapist simply listens and supports. However, lasting change occurs with the optimization of insight and awareness.
All therapists should subscribe to a change theory. How do they believe people change? Three common therapeutic styles are Behavioral Therapy, Cognitive Behavioral Therapy and Insight Oriented Therapies. Behaviorist therapists believe that if you change behavior then emotions and thoughts will follow. A Behaviorist’s intervention, not surprisingly, typically focuses on behavior. Many child and adolescent therapists are behaviorists. For example, a behaviorist interested in changing the child’s behavior will intervene by suggesting a chore chart and reward system. If the child does the chore they earn a reward. Others will promote natural consequences for behavior.
Cognitive Behavioral Therapists (CBT) endorse a change theory based on changing cognition. If an individual changes the way they think about or perceive a situation then their emotions and behavior change as well. CBT therapists will, most of the time, intervene on the client’s perceptions or thought processes. For example, if a person is depressed the CBT therapist might challenge or questions their perceptions about depression. If the depressed college student believes that no one likes her and this is why she feels depressed and believes she has no friends, the CBT therapist will challenge that notion. A common intervention for this situation would be: “What evidence do you have that people don’t like you?” “There are many people in the world; it doesn’t make sense that no one likes you.” Note, that CBT therapists are empathetic, these interventions are not meant to dismiss the client’s experience, but rather to challenge the overwhelming nature of their assumption.
At Riverview Therapy, the insight oriented Gestalt Therapy approach is the primary therapeutic model. The change theory of the Gestalt Therapist is unique. It is the paradox theory of change—the more the individual knows or experiences that which is difficult the less powerful it is. The paradox lies in the counter intuitive experience of attending to or addressing difficulties rather than avoiding or blocking them. For example, if a client presents with anxiety, the Gestalt Therapist will work with the client to attend to their anxiety in session, in a safe environment with the guidance of the therapist, thus by increasing the client’s awareness to their anxiety the less powerful it becomes. When difficult emotions are not in our awareness, we spend much time and energy avoiding, blocking or damping down those difficult emotions. Sometimes individuals act and behave in ways which are driven by their emotion. They are not aware that their strong emotional process is the driving force behind negative behaviors. The paradox theory of change places a heavy emphasis on the emotional process. This change theory believes that as the emotional process is attended, the less powerful the emotions become—thoughts and behavior then begin to integrate and the individual experiences themselves as a balanced whole person. Gestalt is a German word meaning whole. The beauty of Gestalt Therapy is in the movement between and the integration of our thoughts (head) and our emotions (heart). Individuals experience emotion, even strong or difficult emotions, with the knowledge that our experiences are not solely emotional, our thoughts will contain our emotion and provide logic to our experiences, and both of these processes influence our behavior. To explain it simply, life is experienced, cognitive responses provide reasoning and logic to those experiences and emotional responses provide meaning, depth and significance.
During the therapy session, it is the responsibility of the therapist to attend to and to move the client into awareness. It is also the responsibility of the therapist to connect with the client in their experience on that given day. It might be that a client is in need of supportive contact on a specific day; during that session there will be less movement towards awareness. In other sessions, a client might be in need of problem solving strategies, need to clarify boundaries, or need assistance with how to communicate with others. The duty of the client is to attend sessions, just show up, and be willing to participate. The therapist will work with the client to move them forward in attaining goals.
The Termination Process
Therapy ends when goals are attained, or when the client is feeling better. The ending process in therapy is called the termination process. During this process, the client’s progress in therapy is reviewed and the client and therapist address the issue of closure. They look back to where the process began, celebrate achievement and say good-bye.
The termination process although typically brief is a significant part of therapy. Therapy should not last for many months or years. It has a beginning, a middle, and an end. Individuals need to move out of therapy to practice their skills, connect with others, and to enjoy life. If due to life circumstances there is a need for therapy in the future, they may always return.
The intention of this article was to provide an overview of the therapeutic process with the aim of providing enough information to relieve worry about the unknown. Most people begin therapy with a mix of emotion—apprehension yet interest. They often are hopeful for relief, but are apprehensive about the process. Therapy is a two person process; your therapist walks with you through this journey. You are never alone.