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.
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.