I saw my first therapist in my senior year of high school when I was dealing with my first bout of depression and anticipating major transitions. Since then, I’ve had another handful of therapists over the years in the different communities and life stages that I’ve lived. So when I approach therapy, I do it as a pro–not just as a provider, but also as a client.
When I get therapy veterans on my couch, there’s both a sigh of relief (“Oh good, I don’t have to explain this to you”), as well as a nagging anxiety (“Am I going to measure up to their last therapist?”). Therapy newcomers give me less anxiety, but require a different kind of work. One of the trends I’m noticing as I talk to clients and friends about their previous therapy experiences is that many people do not really know what to expect from their therapy journey. Many people worry about offending their therapists, looking overly needy, or not “trusting the process.” Since most clients are going to follow the therapist’s lead, it is important for therapists to lay out an adequate road map for struggling clients. If you are a therapist, how do you set this up for your clients? If you are a therapy client, how has this been done for you in the past?
In grad school, budding therapists learn that there are stages of therapy, which flow in progression, but perhaps not always in a perfect linear way. Although different theorists will use different vocabulary to describe the stages of therapy, it can basically be broken down into early, middle, and termination stages.
Early Stage
In the early stage of therapy, there are some primary goals that the therapist and the client collaborate to meet. Both individuals have work to do to get the therapy engine running.
Rapport
The first job is to build rapport. You need to “gel” with your therapist, to feel like he or she gets you and can help you. Therapists may tell you they will be looking for the right fit. It doesn’t help anybody if I discover that I can’t help you, there are conflicts of interest, or that our personalities don’t work well together. In this stage, you should feel like your therapist is really listening and genuinely interested in finding out about you and what brings you to therapy.
Presenting Issues
While building rapport, your therapist will be watching and listening for the issues that are bringing you into therapy. I like to ask my clients, “Why is now a good time for therapy?” The problems may have been building for most of your life, but there was something that pushed you to call the therapist at this precise moment. This phase is also known as assessment. Particularly if you’re going to be using insurance to pay for your therapy, your therapist will be asking questions about your symptoms and their frequency, duration, and intensity. Insurance-based practices are required to come up with a quick diagnosis within the first or second session, so your therapist will want to figure this part out quickly, even if it needs to be changed later. Look for another post about diagnosis pros and cons coming soon on the blog.
Treatment Planning
Once your therapist has begun to build rapport and has the “lay of land” regarding the issues that are bringing you to therapy, he or she will want to collaborate with you on treatment planning. A simple breakdown of a treatment plan includes these basic parts: your current symptoms and functioning, how you would like to see them improve, what goals and objectives you would like to meet, and how you will measure them. You will talk about some ways to get you to the other side of the problem, and your therapist may describe some of his or her methods and philosophy. If you’ve been with a therapist for a while and don’t have a good idea of your treatment plan, it’s totally OK to ask about it. This will be a sign to your therapist that you are really invested, and you will be able to help keep therapy on track when you know what the plan is.
Middle Stage
The middle stage of therapy is really the meat. Unfortunately, a lot of people drop out during this stage. Why? Because it can take a long time and it’s often painful. Did your therapist tell you about that? Yeah, it’s going to hurt.
I like to use this analogy with new clients: when I was 21, I used to ride a 54” longboard skateboard. Riding down a paved trail one day, I got the wobbles and couldn’t control my speed as I careened downhill. Faced with impending doom, I had the choice to hit the blacktop or smack into a tree. Blacktop won, and a piece of my knee was forever lost in the forest. When I was taken to the ER, nurses spent over an hour picking gravel out of my wound with forceps. Now, if they hadn’t taken that time, what would have happened? Yes, my knee could have healed, but I would never have been able to kneel again, because there would have been rocks and dirt buried in my skin. I most likely would have developed a nasty infection. The mental and emotional wounds that bring us to therapy are like knees that have healed over with gravel in them. You can pretty much function in your day to day life, but it’s always painful. Going to therapy can be like laying in the ER getting rocks picked out of your knee. It’s painful, but if it doesn’t happen, the healing can’t progress. So I tell my new clients, if it feels like it’s getting worse before it gets better, that’s normal, and you need to hang in there.
Now, despite giving you this warning about the looming pain, I also want you to know that therapy should not be all pain. A physical therapist recently reminded me that there is a difference between working your muscles to feel a sense of tiredness, but we don’t “push through” the pain and cause further injury. Your therapist should be starting by giving you some strategies to manage anxiety and depression symptoms early on, so that you have the coping skills to navigate the harder topics.
The middle stage of therapy is where you’ll see the most “interventions,” or techniques that therapists like to use to get you thinking, feeling, and acting in new ways. As I’ve mentioned before, therapy is actually work, and the more you put into it, the more you’ll get out of it. Don’t just sit on the couch and complain. Try your therapist’s suggestions, do your homework, and even put in a little research about methods that might help you. As the work progresses, you’ll start to see some resolution to those problems and symptoms that brought you to therapy.
Termination Stage
Termination sounds like an ominous word, right? (Who picked that?) But just like the Terminator, you can always tell your therapist, “I’ll be back.” Honestly, we work in a profession that is trying to work ourselves out of a job, so if you don’t need to come back, great! If you do, we’ll be here. So don’t let the termination conversation scare you.
How will you know you are ready for termination? How will your therapist know? More often than not, as I said above, clients drop out before they reach a complete termination. But when one happens, it’s magical. It’s the ability to say, “We’ve done good work!” For some, it may mean symptom reduction: you’re back to work and social engagements, you’ve stopped crying every day, you no longer think about ending your life, you haven’t had a panic attack in a while. For others, it may be new relationship and communication skills, the ability to set better boundaries, or more self-awareness. Getting to the point where you have a conversation about ending regular therapy is really a collaborative effort between you and your therapist. If you’ve decided that the end is coming soon, your therapist will want to review the progress you’ve made and make sure you have a plan in place for handling challenges that will continue to arise. The therapist may suggest tapering down from every week sessions to twice a month, to once a month, and then just “as needed” or “check in” sessions.
Maintenance
There’s another part of therapy that is basically post-termination, and it can be referred to as “maintenance.” I especially love this for relationships that sometimes need a couple of therapy sessions here and there in the same way a car needs tune-ups. I typically tell my clients that once we have done the main work of therapy, I am essentially “on retainer” for them, although no money is exchanged for this status. I know their issues and I’ll be here to help them out if something new arises. It’s a major bummer to have to find a new therapist if you’ve already had a good experience working through something with a therapist you like, so I always try to make room in my schedule if someone needs to return.
Along with offering “touch up” sessions, I also like to send my clients on their way with some ideas of how they could continue their growth without regular therapy, such as support groups, workbooks, podcasts, and other resources that help keep them on the upward track.
The words “beautiful mess” come to mind when I think about the therapy process. A person pours out his soul to a stranger who is tasked with making sense out of the wounds of a lifetime. I can’t really think of a more rewarding calling than getting to see clients move through these stages I’ve outlined above.
How about you? Has your therapy experience progressed in the way I’ve described?
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