How to start a session

Even patients who have been in therapy for a long time may experience that anxiety at start of the session when they are not sure what to talk about.  To them, as well as to the newbies, I say the same thing: start anywhere.  Talk about whatever interests you, even if it’s last night’s ballgame.  If you do that and you’re talking about what really is close to your heart – however trivial – the session will always be fruitful.  In fact, and I’ve watched this carefully in my records, often the most productive sessions start in this way.  (By contrast, it is almost always a mistake to come in and start “This was a good/bad week” or “last time we were talking about something important” if you’re heart’s not in it.)  Two recent sessions on the same day (different patients) demonstrated this beautifully.  I’ll talk about the first one here, the other in a second posting next week.

Ted began therapy about six months ago.  He described being “in a rut” for many years, particularly the past two.  He said he could recall no happiness during this time, worried a great deal about his job, often to the point of being unable to sleep, questioned all of his life decisions and “failed relationships”, drank more than he wanted to, and procrastinated often.  In my office over the past half year he’s been pleasant and what we call in court testimony “appropriate”, but with a stiff and constricted affect, a limited range of emotional expression, and a tense joylessness.  His body is often tight, sometimes even seems to be scarcely breathing.  Asked about this, he would acknowledge feeling “a little uptight” but not to the degree that I could see, not to the degree that was apparent in his inability to make even simple decisions, and not to the degree that he realized this was interfering with his social and professional life – such tension tends to be offputting to others.

He came in last week and largely in passing, “by the way” as he put it, shared joke that had recently heard.  As he got into the story, there was a relaxation and expressiveness in him that I had never seen, although he’d described sometimes being that way in the bar with friends.  But as soon as he was finished he returned to his usual inhibited, stiff demeanor and vocal tone.  I rather casually observed this change, and probably because it had just happened in session, right in front of our eyes, he was able to notice for the first time just how tense he usually is; he described it in some detail and surprise, “how I walk around so tight!”  I “wondered” if in fact his work would suffer, remain unchanged, or improve if he managed to approach it with a similar lightness and sense of fun.  Ted was very clear that in fact it would only help.  He added with a sense of surprise that usually at work “my body is curled up in a ball, hardly breathing”, again something “I usually don’t notice”.  He then spoke with a passion I had never seen about how tense he always is, not just at work, and how he approaches all aspects of his life, perhaps each moment, “with such heaviness and severity”.

He then described leaving our sessions energized and asked me if I thought it would help him to take notes.  This question led to our discussing quite productively how in the asking he again slipped into his helpless, avoidant, burdened, “weight of the world” (his term) mode of being, similar to how he feels when he thinks about his career, job hunting, networking, and thus why he so procrastinates in all of these.  The fact is, he realized, he knows the answer to the question and has known it for a long time.  From my inquiring about the details, he explained – and realized as he did so – that he leaves sessions with ideas and direction, does not forget them immediately but rather they fade over the next few hours.  Thus he need not take notes during our sessions but could certainly make a few immediately afterwards.  It would only help, at worst it would do nothing, but he’d always “just sort of forgot”; again, upon inquiry he realized that “just sort of forgot” is always preceded by a lot of anxiety about what he should do, who he should be, how to be a “good patient”, and other such “weighty, dreary stuff”.

From here he remembered a pattern of passivity and helplessness in his approach to life, both in the present and the past.  He recalled his family and friends commenting in past decades (Ted is in his 40s) that he walks around “like Atlas” weighed down by the world.  He left the session last week with an even stronger sense of energy, direction, and excitement than he had in previous weeks, including a resolve to immediately write down a few reminders before leaving the waiting room.

The lesson here is that by starting the session as genuinely as possible, even though the topic seems so trivial, Ted was opened up to very productive learning about how he lives, behaves, sabotages himself, and feels. More, he left the session feeling excited, energized, and with concrete direction for how to address the problems that brought him into treatment; he suddenly had plenty of ideas and a developing and well-reasoned plan for handling his problems at work and for beginning a job search.  That’s a good session.

(You can read more about what should happen during a session in the main website, particularly this page.)

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