The psychotherapy setting

Posted on January 23, 2014 by Allan Gois

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.

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 London – Bloomsbury – Psicoterapia em Português – Psicoterapia Espanol Londres

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

Posted on January 17, 2014 by Allan Gois

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 London – Psicologo em Londres

The problem of help (Part II) – ‘The experience of help’

Posted on November 29, 2013 by Allan Gois

Last week I wrote about the problem of help in psychoanalytic psychotherapy. I mentioned how the idea of help in this context differs from simply removing the symptoms and the problems, and how help in psychoanalytic psychotherapy involves the process of finding out the meaning underneath the suffering, which will promote understanding, development and transformation. All well and good.

But a question still remained for me, one that comes back every so often both in my work as a psychotherapist in London and in my experience of myself being on the couch as a patient. Yes, psychotherapists and analysts do go through the process of being a patient for many years, and this is an essential part of becoming a therapist. Maybe I’ll write about that on another occasion. This week the question I wanted to address relates to the how it really feels to be helped.

You see, it’s not easy being a patient in psychotherapy. Although one might expect that being helped and supported in therapy will only bring the relief and sense of wellbeing one wishes for, the emotional experience of help is an intense one, often giving rise to feelings that can be difficult to recognise and work through. I would say that this is not only true for what happens in psychotherapy, but to any experience of asking for and receiving help in any relationship.

And that is the key word for us to tackle the question of how it feels to be helped: relationship. Everything that takes place in psychotherapy happens in the context of a relationship, a therapeutic one, but intense nonetheless. It is in the relationship with the therapist that the patient will, often inadvertently, repeat and re-enact the way they relate to others in life. Feelings and unconscious dynamics will then take place, which the therapist will help the patient recognise and understand. So how the person experiences the psychotherapist attempting and managing to help them should not differ so much from how it feels to be helped in other relationships. And to understand the dynamics of help is to become more able to give and receive help when needed.

But what sort of emotional experience does help bring about? If it’s not straightforward soothing and relief, what else is there to be felt? I’ll list but a few:

1- Vulnerability: to experience help is to face vulnerability. When we are hurting, physically or mentally, we will do all we can to protect our vulnerable spots. In this sense, it can be very difficult to trust others and let them through the defence to look after our wounds. So the person who wants to be helped must face vulnerability, which can be very anxiety provoking.

2- Dependence: to be helped is to experience dependence. Some people avoid dependence like Dracula runs away from the cross. To depend on another person is to submit to their disposition and ability to help. This can be a difficult experience, as it makes us vulnerable to be disappointed and frustrated. We bring within ourselves an innate mistrust, maybe mirroring some of the times when we felt that those we depended on to look after us failed to do so. But to receive help from another person is to have to submit and face such dependence. There is no other way.

3- Envy: the experience of help can bring out feelings of envy. When people need help they may often feel depleted, on the opposite side of self-sufficiency. There is an assumption that the helping other then possesses what they need to be ok, whatever form it takes. This disparity between one who feels empty and the other who has what they need may give rise to unconscious feelings of envy. This is not uncommon in the experience of psychotherapy, as the patient comes with their difficulties and they expect the therapist to have what they need to get better. So often the patient will feel that the psychotherapist is withholding from them what they need to be well again, to feel immediate relief, and this stirs up feelings of anger and envy. So to be helped is to have to come to terms with our own greed and envy, as we submit and depend on the other for help.

4- Frustration: to be helped is to be susceptible to experience frustration and disappointment. When we ask for help we are to an extent surrendering our self-sufficiency and depending on another person’s capacity and willingness to help us. This makes us open to experience frustration and disappointment if the help doesn’t come when we want it, or in the way we want it. This also happens often in psychoanalytic psychotherapy, as I explained on last week’s post. If we want to be helped, be it in psychotherapy or in other contexts of life, we must face the possibility of frustration and disappointment.

You may have noticed that the aspects mentioned above relate to a narcissistic blow that takes place when a person asks and receives help. To be helped is accept and, to a degree, surrender our narcissistic defences, becoming vulnerable, dependent and sometimes envious, willing to face possible frustration and disappointment.

However, the process of help in psychotherapy doesn’t leave the person in such a state. This narcissistic blow is part of the process, and slowly the patient starts realising that help is an interaction, an exchange between two fallible and incomplete human beings. This will then translate to other realms of relationships, where the person will be able to find equilibrium between narcissism and depletion, between self-sufficiency and unhealthy dependence.

Allan Gois – Bloomsbury Psychotherapist – Psicologo Londres – Psicologo Espanol Londres

The problem of help in psychoanalytic psychotherapy

Posted on November 22, 2013 by Allan Gois

As a psychotherapist I am part of what is called a helping profession. This includes doctors, nurses, physiotherapists, social workers, therapists and all those who are committed to help people develop and work through physical, psychological, intellectual and emotional problems, aiming for their wellbeing.

Psychoanalytic psychotherapy however is a peculiar helping profession, as the help someone will receive may be very different from what they wished for in the first place. I’ll explain.

I see a wide range of people in my psychotherapy practice in London, coming from all sorts of cultural, social and ethnical backgrounds. Many seek help in the middle of a crisis, some reaping the consequences of the aftermath. I see people suffering from depression, obsessive-compulsive symptoms, stress, acute anxiety, panic attacks, you name it. So it’s fair enough to assume that what every person wishes for is to get rid of what has been making them suffer. In this sense, help would consist in removing whatever symptom, issue or problem that brought the person to seek my help as a psychotherapist. Fair enough, it’s a reasonable thing to wish for.

However, a psychological or emotional problem, be it a symptom or patterns of behaving and relating to others, is not a foreign entity like a virus or bacteria, nor something that can be surgically removed like a growth or an abscess. Psychoanalytically speaking, everything that happens in the the mind and translates into everyday life is part of a complex construction of ways in which we organise our internal world, as we attempt to deal with some difficult aspects of ourselves and of life. This includes the way we handle our destructive impulses, our innate capacity for hurting ourselves and those we love and how we deal with painful experiences in life, things like frustration, disappointment, guilt and loss.

People often decide to seek the help of a psychotherapist when the way they lived their lives so far becomes unbearable, or when they realise they can no longer sustain a healthy balanced life in regards to how they feel, behave and relate to others. A lot of it has do to with the collapse of this complex mental structure that was put in place to deal with the undesirable and unbearable experiences we all face in life, be them internal or external. Nonetheless, the help that people often wish for when they first come is to actually be taken back to the place they were before the crisis, before they were debilitated by their struggle. As a psychotherapist I then meet (break) this expectation by helping the person realise that the way they were before is actually what led them to collapse in the first place.

Every symptom, conflict and difficulty that people seek help in psychoanalytic psychotherapy is there for a reason, and they all have a function and a meaning. They offer an important opportunity for the person to find out more about themselves, in how they behave, feel and relate to others. In this way the suffering that someone needs help with is not there to be simply gotten rid of or removed through a magical psychological surgery, but to be understood and worked through in the context of the therapeutic relationship. In doing so, the symptom or destructive pattern loses its functions and gives ways for the person to organise their internal world in a less defended and more conscious way.

So the help offered in psychoanalytic psychotherapy really comes through the painful process of discovering the meaning underneath the suffering, which will promote understanding, development and transformation. When what is unconscious surfaces to the conscious mind and is contained in the process of psychotherapy, the person can then become free to live a more integrated life. This unexpected help is long-lasting, as opposed to the short-lived illusion that one can simply get rid of symptoms and bypass the struggles in life without having to deal with them.

Allan Gois – Psychotherapist London Bloomsbury – Psicólogo Brasileiro em Londres