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The psychotherapy setting

Here I am in my consulting room, the place where I see patients for psychoanalytic psychotherapy in London. The light is dim, windows are closed, venetian blinds semi-shut. On my right a lamp sits on top of a leather bench that serves as a side table. In front of me there is an armchair and to my left lies the psychoanalytic couch. There’s a mirror on one of the walls and a modern picture of a tree on another. There are tissues, a cup holster and a clock on a side table next the armchair.

Why am I describing this psychotherapy room? Is it important? Well, it is, it’s very important indeed. In describing my surroundings I remind myself that every single detail in this room has been set up in a way that takes into account how the patient will experience this environment. From where the couch is positioned to whether tissues are available, everything has been placed with the psychotherapy experience in mind.

The consulting room is however only one of the many elements that compose what is called the psychotherapy setting: a combination of concrete and subjective elements in the psychotherapy framework that are set up to provide continuity, consistency and containment, in order to help the patient feel that they are free to explore and express their mind. Beside the consulting room, other elements of the psychotherapy setting include the session time and duration, the frequency, fees, absences and cancellations, breaks, communications, confidentiality and numerous others.

Although a patient will only come in contact with the element ‘consulting room’ once they come to their initial consultation, the reality is that one experiences the psychotherapy setting even before the contact with the psychotherapist is made. For instance, how did the patient find the therapist? Was it a referral, through a website, directory, indication from friend? Then how was the first contact – e-mail, telephone, mobile phone, text message? All this is already part of the setting and is experienced by both patient and therapist in a way that can provide a lot of material for thinking. In this sense, the psychotherapy experience begins long before the first face-to-face meeting.

psychotherapy setting

Sigmund Freud’s consulting room, at the Freud Museum in London.

So in this post I’d like to address some elements of the psychotherapy setting, in hope of elucidating how meaningful each aspect is in providing an environment where the person will feel encouraged to explore their internal world.

The consulting room: I’ve already mentioned the consulting room, and it is in fact a major element in the psychotherapy setting. It is undeniable that the physical space has a noticeable effect on one’s mind, whether consciously or unconsciously. In this sense, the consulting room is not arbitrarily set-up. As I mentioned before, where furniture is placed, the levels of luminosity, the decoration and everything else should be considered with the psychotherapy experience in mind, in a way to promote a reflective, comfortable and containing atmosphere. It is also important to keep the set up of the room as constant as possible, for instance, not changing furniture around too often, as the constancy of the setting promotes a sense of continuity, which in itself reflects on the psychotherapy work. So the space in where the sessions happen ought to echo the psychotherapy experience and promote its values, not in a superficial, magical or ritualistic way, but in a sensible way, taking into account how a patient will experience this major element of the psychotherapy setting.

Times of sessions: the session time is also an element that contributes to the sense of continuity in the psychotherapeutic framework. Normally at the end of the consultation process therapist and patient discuss and set up a mutually convenient time for the weekly sessions, and this should be kept as constant as possible. Again, it serves to promote a continuous experience. Of course, unforeseen things do come up, so therapist and patient can discuss whether a session can be re-arranged to another time. But no doubt, this will have some effect and meaning, consciously or unconsciously, in the therapy work. Life is not always constant, so sometimes having to move sessions around will mirror the dynamism of reality, and a sense of adaptation and flexibility can be learned from that. But changing session times around should really be an exception, as continuity provides containment and a sense of progression in the psychotherapeutic work

Duration of sessions: with the exception of the initial consultation, when a bit more time may be needed for the first meeting, the duration of a psychoanalytic psychotherapy session is usually 50 minutes. Why not the full hour you may ask? Well, this has been discussed over the years, but in my mind it comes down to practicality. When the psychotherapist sees patients one after the other, it would not be feasible to do so if a full hour is used. 10 minutes between sessions should be enough for the therapist to prepare his mind for the next patient, write some quick notes, drink some water, etc. As with everything else in the setting, it is the therapists responsibility to ensure that sessions start and end on time.

Frequency: this is also something agreed on when the initial consultation is concluded, where the psychotherapist will recommend and discuss the number of sessions per week. Once-a-week is really the minimum to make the psychotherapy process possible, but it all depends on the treatment needs and the patient’s personal circumstances. However, in terms of frequency, the more the better. This is because a major aspect of how psychotherapy work lies on forming a strong and intense relationship with the therapist. The dynamics, feelings and other things the patient need help with will be lived out and worked through in the context of the therapeutic relationship. So more sessions per week can promote a closer encounter between patient and therapist, thus opening up the possibility of a more intense experience of therapy.

Fees: we all have a particular relationship with money, and this can show a lot about our internal dynamics. The fees are not only pragmatic, but deeply symbolic, and so the question of money in psychotherapy is one that can bring about particular feelings and ways of relating that provide great material for thinking. For instance, by paying for therapy do patients sometimes feel: “I am the customer, and the customer is always right”? Most certainly! But when the psychotherapy process brings down the reality that the patient has to submit to a relationship instead of trying to own it or control it, it can challenge some particular narcissistic ways that the patient has of relating to others. So the question of money can be linked to controlling others, thus providing great therapeutic value. There are also feelings of anger and resentment that may rise up when the therapist raise his fees. Again, this aspect of the setting can link to issues in the way a person deals with dependence and need. So, as with everything in the psychotherapy setting, fees can provide a good opportunity for thinking and learning about oneself.

Absences and cancellations: another aspect of the setting that is discussed in the beginning of the treatment is how the patient’s absences and cancellations will be treated. Some therapist’s are happy to rearrange sessions, and not charge for when the patient can’t come, if notice is given of course. Other psychotherapists, myself included, charge for missing sessions, even when patients give enough notice. Patients often resent it, feeling it to be very unfair, as they expect to pay only for the sessions they attend to. There are two models to understand this. If one regards psychotherapy as a service, and the service is not used, then one may think that payment is not required. But if one sees the therapy sessions as a space and time allocated for a particular person, which will not be used for anyone or anything else but the sessions with the designated person, then it’s reasonable to conclude that the patient is required to pay for the absences. In this sense, the space/time is being offered, albeit not used by the patient, and the therapist is there should the patient decide and manage to come. This may sound controversial or perhaps unfair, but if we think about things like rent, gym membership, or courses and lectures paid for, payment is still due even when the person can’t attend or occupy the space they paid for, and so they experience a loss. However, if we look further to the surface, the question of charging for missing sessions again can provide great therapeutic opportunities in understanding how the patient deals with irreplaceable losses, unequal relationships (like parent/child), anger, greed and envy.

Breaks: holidays, pauses and breaks are also part of the psychotherapy process. Therapists do take breaks several times a year, which in the therapeutic relationship will bring out important dynamics to be experienced and thought about. I wrote on another post about the impact of breaks in psychotherapy, discussing that when the therapist goes away, it may stir up feelings of abandonment, separation, anxiety, anger and sadness. So breaks are also very symbolic, as it can mirror the patients early infantile experiences of being left or unmet by those they depend on, giving rise to difficult feelings (which many patients won’t be so aware until the therapist brings them to light). Within the psychotherapy setting, therapists try to let patients know as early as possible about upcoming breaks, so the feelings and dynamics can be digested and worked through in the sessions. Again, unforeseen circumstances may come up, where the therapist will have to cancel a session at a short notice. But as it is, everything that is brought and experienced in psychotherapy can be understood, thought about and worked through, in the hope that it will help the patient handle things that will inevitably happen in life.

Communications: another important aspect in the psychotherapy setting involves the communications between therapist and patient. Whilst some therapists overlook this and communicate rather informally with their patients as and when they get in touch, I believe that we need to think carefully about every contact made outside the sessions. The timing of every message, the way of responding, the medium through which the message was sent, along with every word expressed, they all carry meanings waiting to be uncovered and thought about in the therapy. It’s also interesting to notice how times have change, and how the contact we have with one another seems much more instant and close than it used to be. In the past, the norm was that communications between patients and therapists (and maybe everyone else) happened through letters and landline calls. None of these methods of contact are immediate. A letter might take days to arrive, and a call requires the person to be available at the premises in order to answer. We now live in a world of immediacy and rush, and there is an expectation that the other is ever readily available to be contacted. So there can be great anxiety when there isn’t an immediate response, as people may feel rejected, or that they did something to upset the other, etc. Whilst I’m not at all suggesting that e-mails, mobile phones and text messages are to be avoided, therapists do need to consider carefully the meaning underneath every contact before responding. But again, it’s also an opportunity to understand how we all deal with questions of separateness, when the other is not always within reach, or that we can’t have instant gratification when it comes to real relationships. As for the communication aspect of the setting, I encourage patients to, as much as possible, keep contact to within the context of the sessions.

I hope it’s clear from this article that every aspect of the psychotherapy setting has a meaning and a reason to be. The psychotherapy setting is very much linked to boundaries, and it is the therapist’s responsibility to establish and maintain it, so that the patient can be free to explore their internal world and learn more about themselves, thus developing the areas they need help with in life.

 

Allan Gois – Psychotherapist in Central LondonPsicoterapia em Português – Psicoterapia Espanol Londres

 

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“You’re going away again?!” – The impact of breaks in psychotherapy

This week I want to discuss something that happens in the course of every psychotherapy work, (possibly more often than patients would like), something that has a major impact on the therapy and the therapeutic relationship.

Everyone who has been in psychotherapy or counselling will know that therapists tend to take breaks (holidays, pauses, vacations, etc) several times a year. Every interruption, be it previously announced or unforeseen, bears a major effect on the psychotherapy work.

The therapist may try to plan the breaks as carefully and thoughtfully as he can, but there is no running away from some powerful dynamics that will take place in and around the inevitable pauses in psychotherapy. However, far from undesirable, the experience of a break will provide an important opportunity for the patient to understand and work through the ways he/she handles some of the facts of life, things like disappointments, dependence, frustration, neediness, separation, abandonment, etc. Therapy breaks will also mirror dynamics and stir up feelings linked to the patient’s early relationships, more specifically with those they had to depend on in their life.

So I will now highlight and explore some of the aspects that a break in the psychotherapy treatment will most likely bring about.

Abandonment and separation: perhaps the most obvious experience that a pause in therapy will bring about is the experience of abandonment and separation. Throughout the psychotherapy work, patient and therapist will form a strong bond, an intimate relationship that is to be the springboard for the therapy to take place. In order for psychotherapy to work, the patient will learn to trust and rely on the therapist. So when a break happens, the bond is disturbed. The way patients acknowledge and react to the experience of abandonment and separation in a break varies greatly. It depends on how defended the patient is against the powerful feelings that will arise. You may say that a break in psychotherapy is not really an abandonment, as the patient normally knows that the therapist will be back. But in the closeness of the therapeutic relationship, a break will very likely bring up early experiences of separation and abandonment, whether the patient remembers them or not, and so feelings like anger, anxiety, envy and sadness will take place. Whilst some patients may be quite detached and dismissive about it, others will perhaps worry about having such negative feelings towards the therapist. As much as possible, it is helpful for therapist and patient to stay with the feelings, that is, to acknowledge them and try to contain them in the context of the relationship.

The feelings: as I mentioned above, the experience of abandonment stirs up very intense feelings in the one who’s being left. Well, I agree that being left by a therapist who goes on holiday is not the same as being abandoned by a parent, or left by a partner. But as it is, psychotherapy is about understanding and living through experiences, feelings and dynamics that belong elsewhere, but are made present in the context of the therapeutic relationship. In this way, it’s important to notice the feelings that are around when the therapist interrupts the work by deciding to go away. Some feelings are more obvious, such as anger, sadness or anxiety. Others are not so much, such as hatred, envy, jealousy, inferiority. A break then can provide an excellent opportunity for patient and therapist to understand and work through powerful but important feelings.

Acting-outs: feelings and experiences that can’t be thought about and put into words, perhaps because they are too unbearable, are often discharged in the way of acting-outs. This is not different around breaks. For instance, it’s not uncommon for patients to suddenly make life-changing decisions (e.g a break-up, a break-through, a career change, etc) around the pauses in the therapy. These decisions may be well meaning and genuine, but they can also take place as a defense against the patient’s dependence and neediness as the therapist is experienced as cruel, insensitive or reckless for going away at such crucial moments. It may mean that the patient is ditching the therapy, downplaying the therapist’s helpfulness with contempt and with that saying that he/she can take care of themselves, never to feel abandoned again. This is the same for another kind of acting-out that I often observe around interruptions in the treatment, when patients decide to end the therapy. Whilst some care to discuss this in the sessions, others just never come back from the holidays. Again, how much of it is the patient showing contempt towards this selfish therapist, stating that he/she does the abandoning, not the therapist. When the psychotherapist goes away on a break, it highlights the patient’s dependance and need for help. In this sense, the patient trying to show who needs who can be an important message on how he/she handles experiences like being left. Other acting-outs include cancelling sessions just before or after the break, or not turning up, or messing up their session times. Some patients will dismiss it all as meaningless, but as psychoanalysis believes that everything has a meaning and that in life there is no act without intention, consciously or unconsciously, such acting-outs can provide a great source for thinking and understanding. Whatever it is, acting-outs are important expressions of feelings that the patient can’t put into words, so it’s down to the psychotherapist to interpret, to name and contain such experiences, providing meaning and promoting a truly therapeutic experience.

Guilt: some patients will experience what I described above, the abandonment, the intense feelings and reactions, the anxiety and so on, and become overwhelmed with a sort of unconscious guilt for having had destructive feelings towards a process that has meant a lot to them, a therapist that has helped them during perhaps some very difficult times. This is important, as it mirrors the development that happens when we are babies, in the experience of depending on a mother who can look after us and feed us, but then having to deal with destructive feelings towards her when she is absent (even if for a few seconds when baby is distressed). In this way, therapy breaks give rise to very primitive anxieties, but the guilt can hopefully prompt reparation and development, as it does in early life.

I believe that it’s clear now that breaks, holidays, pauses and interruptions in the treatment will very likely stir up feelings, experiences and dynamics, some more unconscious than others, providing a great opportunity for therapy to happen. As patient and therapist become aware and work through the equation of abandonment, intense feelings, defenses and guilt, the patient has the chance to come to terms with the ambivalences and complications of real relationships. We will have to lay down our defences and, to a degree, become dependant and vulnerable if we want to establish meaningful relationships in life. And for that we will be disappointed, heart-broken and frustrated, but we will also open up to the beautiful exchanges that real relationships can bring over. And so therapy breaks can provide the chance to work through this.

 

Allan Gois – Psychotherapist in LondonPsicologo em Londres

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Have you failed your New Year’s resolutions yet?

New Year's ResolutionsNew year. Again. Resolutions. Again. Failed… again!

It fascinates me the power attributed to the passing of one year to the next. The New Year clearly brings about a sense of new chance, a start over, a clean sheet, pointing perhaps to the cyclical nature of endings and beginnings in life. And with the New Year comes the ritual of trying to let go of the failures and shortcomings of the past, and the desire to focus on the promise of an ideal future as if we’re given another chance. Then comes another set of New Year’s resolutions (how much do they resemble the ones from the year before?)…

But who are we kidding? Isn’t a new year’s resolution an enlarged version of the ‘I’ll start my diet on Monday’? And when Monday comes and you can’t help but eat that piece chocolate that tastes like heaven but makes you feel like hell, the rest of the week is written off and you promise to start again next Monday, or the next, or the next… So really a new year’s resolution is but a statement of the procrastination we exercise yearlong.

We all know what we are lacking, what we need improve and look after in our lives. We know we need to lose weight, and for that we must eat more healthily and exercise more. We know the people in our lives we must pay more attention to, and the relationships we must work harder to improve. We are fully aware of the books we wish to read, the courses we want to take, or the bad habits we have to change in order to become a better person. But why don’t we then? Why wait until the New Year to make a promise that will be broken with the same easiness and speed as they are spoken. If we know what we need to work on, why not do it now?

Easier said than done, isn’t it? The reality is that we carry in our minds an ideal version of ourselves, crafted throughout the years, created in the image and likeness of those we admire, love, envy and fear. This Ego Ideal, as Freud called, is an image of our perfect self towards which we aspire, but it can acquire both an inspiring and tyrannising purpose. Our inner ideals can lead us to a healthy pursuit for the better, but it can also crush us under the cruel reality of our failures and shortcomings, be them real or imaginary.

So really, why punish ourselves every year with ideals we know we won’t achieve? Because we can’t help it. It’s within our nature to have things to aspire, and to have things to feel guilty about. We have in us instincts that lead to improvement and development, and instincts that lead to self-defeat and destruction. The challenge then is to stop attributing responsibility to a calendar, and take ownership of the fact that in life there will always be things to improve, to work on, as much as there will always be things to feel bad about within ourselves. But there will also be numerous chances to learn from our failures, shortcomings and to work towards developing the bits of ourselves that need improvement. And this is a minute after minute chance, not just every New Year. So, what stops you from starting now?

If you’re tired of starting over, stop giving up.

Happy New Year!

Allan Gois – Psychotherapist LondonPsicologo Brasileiro em Londres

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A psychotherapist’s guide to surviving Christmas

For most people, Christmas is an amazing time. It takes us to a state of childlike excitement, reminding us of the cyclical nature of life as we have a chance to reminisce and relive some of our childhood dreams and experiences. The fantasy and expectation of Christmas may point to a sense of joyous family time, but to some of us the reality beyond the hollywoodish dream can sometimes be quite cruel. Far from a big happy family having a great time, Christmas can be a painful reminder of the sort of things we try to avoid along the year, like feelings of abandonment, loneliness and resentment. The seasons can also make us face unresolved interpersonal conflicts, which are often re-enacted in the centre stage of a family reunion.

It’s not a coincidence that suicide rates spike after Christmas, and that a lot of people seek the help of a psychotherapist after the festivities. It’s for this reason that I thought about compiling a simple and brief guide on how to survive 3 of the most difficult experiences I could identify that happen around Christmas. My hope is that it will help those who struggle even more around this time to think and change some of the patterns that may be happening year in, year out.

1- Loneliness: it’s very common for people to feel quite lonely around Christmas. But this loneliness is not exclusive to those who have no friends or are more recluse anyway. I believe Christmas actually accentuates the bit of loneliness we all carry within ourselves. As we see friends going home to their families, or for those who are from another country and won’t be able join their loved ones for Christmas, this can be a very lonely time indeed. But what can be done then? Well, have you considered asking some of your friends if you can join them in whatever they’re doing? A lot of people assume that everyone is busy at Christmas and that no family will want to have a stranger around, but you’ll never find out unless you ask. I have a feeling that some of us actually feel a sort of satisfaction in dwelling on how lonely we may be at this time of the year, feeling sorry for ourselves and becoming even more recluse and resentful. And in doing so we may lose the opportunity to come out and find somewhere we would be welcomed this Christmas. So it may help to acknowledge this kind of resentment, and perhaps this will bring the willingness to go out there and be bit more forward about our wish to be with someone this Christmas.

2- Abandonment: alongside feelings of loneliness, the experience of abandonment around Christmas can be quite difficult to acknowledge and deal with. Everything stops around this time, and it can feel like everyone is going somewhere else to spend time with someone else. So for those who are actually spending Christmas on their own, loneliness and abandonment go hand in hand. But it may be a good opportunity to think about how you actually feel, and if you do feel abandoned, to try and see if it reminds you of other experiences of abandonment and rejection you may have had in your life. This may help putting the abandonment aspect of Christmas into perspective, and it may help you understand how you react when you feel abandoned in other contexts of life.

3- Family conflicts: if some people dread being alone at this time of the year, others actually long for it. In the tradition of gathering the family around for Christmas, some of us are thrown into a hurricane of deeply unresolved family conflicts. The elephant in the room, things like old grudges, resentment, betrayals, hatred, etc. may be ignored for a few days, but soon enough things are likely to kick off. And much like weddings, funerals and other family reunions, Christmas can become the centre stage for the re-enactment of past battles, a failing attempt to work through issues in the wrong context. But we have to remember that families are systems, and each member plays a function in this system, like clogs in a machine. This mentality takes away the simplistic victimised way each family member may feel at times, as everyone in a family is contributing to the dynamic, be it a funcional or dysfunctional one. It amazes me to see how easily we can all slip back into old roles in a family situation. Our parents may make us feel like we are 10 years old again, or our siblings may put us down, or we may be made to feel insignificant in the family context. But how much do you feel you contribute or collude to being placed in the position and function you have in your family dynamic? And if you feel pushed or provoked, do you really have to take it all out and try to resolve it during Christmas. So perhaps it would be helpful to try and step back and think a bit before reacting in the usual way you would do. Being together with the family may also be a good opportunity to think about how you relate to others out there. Because as much as we may try to be and do the opposite of what bothers us in our family dynamics, we carry within ourselves a way of relating to others that will most likely repeat these unresolved conflicts. Whilst this may be more easily disguised in other relationships, when back with the family everything may be a bit more raw and saturated, thus harder to overlook. But try and remember that it’s highly unlikely that any family conflict will find resolution during the festivities, and that you don’t have to counter everything when you feel attacked or provoked. Like a machine, if a clog suddenly stops and reverses it will cause friction and break down. So perhaps a more easygoing approach may slow down the system and even change its direction in due time. But this requires a throughout the year kind of attention, and not just at Christmas.

So for those who are unfortunate to have a bad time during Christmas, it may also present itself as an opportunity to reassess what’s not working and to change things around, in the hope that next year things will be better. Psychotherapy can support people in this process.

 

Allan Gois – Psychotherapist EC1 – Psicologo Brasileiro em Londres – Psicoterapia en Espanol Londres