What should happen in a session?

This is tricky. Relationships, even psychotherapeutic ones, do not follow rigid guidelines. Of course, if you are miserable in the first session, find someone else. Barring that, you and your therapist should agree on some time frame at which point you will discuss whether or not there has been any progress and in general how things are going. If a patient is comfortable with me in the first session and wants to return, I tell him to come 4 times. By then, I tell him, we should have a good idea what we will be discussing and how these discussions will proceed. He should have a sense of what a session feels like and what will happen, and that the conversations are different from what he experiences elsewhere. It is important during this trial period not to obsess over whether it’s working, do you really like the therapist, can the therapist help, etc. It’s too early to know. It’s like going to the gym twice and then checking to see if your muscles are getting bigger.  

Sessions should feel intriguing. They may also be erratic, inconsistent, and fraught with resistance that makes you want to quit, but there should be some sense of the new and interesting happening. You want to find yourself getting curious about what is making you think, feel, and act they way you do and how various aspects and events of your life are related in ways you hadn’t considered. 

You also want to feel that you are getting to the truth of what you feel, how you act, and what you believe. (As one patient put it, "I want you to cut through my bullshit".) If you walk out of all of those first five sessions with no sense of this, you need to bring it up with the therapist. It may be that your resistance is too great for psychotherapy at this point; it may be that this particular therapist in some way puts you on edge, on guard, and you can’t open up; it may be that you feel no connection to the therapist and can’t get interested in the process. In any event, bring it up. If you feel no glimmer of resolution of this issue and things don’t soon change, quit or find another therapist. 

What you want most from a session is the experience of insight. (see Why psychotherapy?, What’s the cure?, and the case examples in those sections.) Insight is psychotherapy. You will know when it happens. It is not like intellectual learning. You will find yourself suddenly feeling clearer, saner, more hopeful, more decisive, more energetic, and your symptoms will clear up. This is the one magic psychotherapy offers. When you feel the things you’ve been trying not to feel, when you become aware of things you’ve avoided, you feel better and you function better. If this isn’t happening, ask yourself what you are getting from the sessions.

Please note: You do not have to talk about your past, nor do you have to blame your mother for everything. In fact one patient was with me for over 3 years, made great progress, became quite a different woman in many ways, yet rarely discussed her past. Despite my personal belief in the importance of childhood experiences, we were never able to explore the subject. When I tried, she would promptly tell me to keep my snoot out of it. And she was right that it was not necessary. She made a great many important and desirable changes in her life without delving into her childhood; by any measure, hers was a very successful treatment.

When we do talk about your mother, the goal is not at all to cast blame. The goal is to understand what happened to you, what effect it had, and how it is still affecting you, so that you can be freed to choose other behaviors and to feel better. If I point out to the bully that in his experiences with his mother it sounds like he felt intimidated, humiliated, powerless, and very anxious, my interest is not in who’s fault that is. It does not really matter if his mother was doing the best she could and was simply sloppy, or was a vicious sadist. What matters is that the bully begin to understand what he lived through, how he understood and tried to cope with it, and how it continues to intrude in his current life. 

Once your sessions are under way, it becomes too personal for me to tell you what will happen. One person’s symptom that abates in 15 sessions is another’s resistance that hides the real issues until session 20. By about the 10th session Ron was admitting to me, as he did to no one else, the depths of his feelings of fragility, fear, and loneliness. After about a year of this, however, it became clear to both of us that he was now using these admissions as resistance; he had to struggle much harder to acknowledge and express the angry, bitter, vengeful, and even sadistic aspects of his personality. Until he did so, he was stuck in the perception of himself as a hurt, lost soul, while his subtle acts of hostility were endangering his career and his relationship with his girlfriend.

By contrast, Nancy spent the first six months of treatment relating to me as if I was a rival for a man’s affection. She was sure I was trying to cheat her out of session time and she told me only the stories in which she felt either anger or the satisfaction of having gotten her way. It was only after half a year with me that she began to drop this resistance and acknowledge how uncertain and lost she really felt. Her deepest feelings were Ron’s means of resistance, and vice versa. Your own road from lost and stuck to awareness and freedom may be just as unpredictable.

How long does it take?