Many people find that after talking to a counselor or therapist for many weeks, nothing much has changed. This is especially true if they are trying to change a behavior—if, for example, they are trying to procrastinate less and study more, or drink or eat less, or get angry at someone less often.
In traditional therapy, you talk in a session and the therapist or counselor listens. Depending upon how they were trained, your therapist or counselor may ask questions but say very little else. Others may have been trained to engage in “active listening.” They will empathize with you and often say back to you what they are hearing to ensure that they understand what you’re saying. But they may not do much more than that.
In contrast, many modern therapists and counselors now take a different, more structured and integrated approach. They aren’t wedded to one school of psychotherapy or one technique. They also encourage you to change your brain’s neurochemical/neurological system through exercise and meditation in addition to the therapy. To a modern therapist, what happens between sessions may be as important as, if not more important than, what happens in the session.
A modern counseling or therapy session is flexibly structured, depending on what the client wants to work on. Most sessions have six parts, even though the parts may not be clear-cut or evident. Of course, if something terrible has happened in a client’s life, the counselor may just listen and be empathic and supportive, as a traditional therapist often does in every session.
What are the six parts of a modern therapy session?
1. Building the therapeutic relationship, hope, and motivation. The conversation at the beginning of a session is designed to build the therapeutic relationship. It is also designed to give an incoming client hope and to enhance whatever motivation to change may already exist. Almost all the research shows that the better the therapeutic relationship is, the better the outcome. Consequently, it is very important that the practitioner work carefully to build a good working relationship. That is the first order of business and an important ongoing one.
2. Assessment. The second part of all modern sessions focuses on assessment. Assessment continues in every session as clients change—or have great difficulty changing. In the past, the clinician first spent a good deal of time assessing the client and coming up with a diagnosis or multiple diagnoses. Figuring out how to help the client came only after that, leaving them for at least several sessions without any actual therapy. Most modern therapists try to suggest something to do in the very first session.
Ideally, you should leave that session feeling heard and with some steps—developed collaboratively with your therapist—that you may try to take during the week. Those exercises will be designed to increase the probability that you will begin to change right away, not after months or years of therapy. In the next session, assessing what happened when you tried something new or different will be especially important and valuable for your understanding of yourself and the therapist’s understanding of you.
3. Goal- and agenda-setting. What traditional therapists and counselors do in a session is usually guided by what the client starts talking about at the beginning. This very pervasive approach becomes evident when I work with new clients who have experienced traditional therapy before. They have been trained to just talk about what happened in the past week, how they feel, and how that might tie in with what happened in the distant past. Similarly, many practitioners have been trained to be non-directive—and they are. Consequently, a session may be quite unstructured and lack any obvious agenda, and the goals of the sessions may be quite vague or unstated altogether. This all makes sense given the old theories of the causes for psychological problems. But this approach doesn’t make sense today, when we have a deeper understanding of how people change.
THE BASICS
- What Is Therapy?
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Modern therapists explicitly ask a client what they want to work on. What are the goals of their therapy? The goals are entered into the therapist’s notes. In subsequent sessions, your therapist may review your goals, and, as the therapy evolves, you may add new goals to your list.
Some clients don’t know exactly what they want to work on. All they know is that they absolutely don’t want to be so miserable. That’s a good beginning goal. Often, however, clients do have specific goals in mind. They don’t just want to feel better, they want to do better. They want to change specific behaviors, which they see as getting in the way of a richer, more fulfilling life.
At the beginning of each session, the client and clinician work to make sure that they both know what the client wants to work on. The word “agenda” may or may not be used, but it is a vitally important part of most sessions. If your therapist doesn’t know what you want to work on, how can they keep the session on track?
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4. Doing therapy and counseling. The middle part of the session usually is a combination of typical supportive work and discussing new ways to manage problematic emotions, thinking/beliefs, and behaviors. Insight was the primary goal of traditional therapy. In modern therapy, a client no doubt seeks insight into a problem, but wants to work more on developing new skills and strategies to manage it. For example, they may practice in session and between sessions ways to strengthen their resilience and distress tolerance. They may start to meditate using a new app. They may begin to exercise again or to learn something new. During the session, they may also role-play better ways of responding in difficult situations—when a family member or co-worker says something hurtful or untrue, for example.
5. Between-session work. In the mid-section of the session, ideas may come up for worthwhile ways of working on various problems between sessions. Some people refer to this as “homework.” No matter what you call it, it’s clear that what people do between sessions is critical to changing behaviors, ways of thinking and feeling, and ways of relating to other people in the world.
The most important part of traditional therapy occurred in session. As a result, people often went to psychoanalysis several times a week. Today, the most important part of a session may be a discussion about what went well and didn’t go well between sessions. What strategies worked? What didn’t? How should those strategies or combinations of strategies be changed?
6. Wrap-up. Do you and your counselor or therapist know what you are hoping to try in the time before the next session? That interval might be in a few days or a few weeks. And did something happen during the session that should be addressed before ending the session?
Some Additional Thoughts
If you are going to a therapist and you have nothing explicit to do between sessions, you are probably not doing modern therapy. That doesn’t mean that your therapist can’t be tremendously helpful. Just having someone outside your family and circle of friends to talk to can be immensely useful. However, supportive therapy can turn into ineffective therapy. In fact, you may become dependent on the therapist or counselor in a way that doesn’t help you change and grow and thrive.
If the person you are working with forgets to ask you about your “homework,” maybe you aren’t working with the right person. This can be a very tricky part of modern therapy. Can a therapist ask about “homework” without sounding like a high school teacher or a nagging parent? Yes. It can be done. The way it’s done will either strengthen or weaken the relationship and will make working on change easier and more effective or the opposite. Consequently, some therapists will avoid asking. Work with someone who knows how to do this without making you feel guilty or ashamed if you didn’t do anything or if you tried to do something and it didn’t go well. This can be a wonderful opportunity to learn more about what’s causing you to remain stuck. Each of you can learn a great deal from successes and partial successes, failures and partial failures.
Your counselor may help you focus on your FDI. Is the frequency (F) of the behavior or the feelings or thoughts that you want to change changing in the direction you want? If you have a problem with a behavior, such as staying angry for too long or spending too much time binge-watching TV, is the duration (D) of the behavior decreasing? Finally, is the intensity (I) decreasing? Perhaps you still stay angry longer than you think you should, but when you do get angry, do you feel less angry and out of control?
The way we respond emotionally and behaviorally often changes slowly, but, with patience, persistence, the right strategies, and the right help, the FDI does change.
To find a therapist, please visit the Psychology Today Therapy Directory.
References
Further reading:
Bishop, F. M. (2018). Self-guided Change: The most common form of long-term, maintained health behavior change. Health psychology open, 5(1), 2055102917751576.
Knekt, P., Lindfors, O., Laaksonen, M. A., Raitasalo, R., Haaramo, P., Järvikoski, A., & Helsinki Psychotherapy Study Group. (2008). Effectiveness of short-term and long-term psychotherapy on work ability and functional capacity—a randomized clinical trial on depressive and anxiety disorders. Journal of affective disorders, 107(1-3), 95-106.
Maljanen, T., Knekt, P., Lindfors, O., Virtala, E., Tillman, P., Härkänen, T., & Helsinki Psychotherapy Study Group. (2016). The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up. Journal of affective disorders, 190, 254-263.
Norcross, J. C., Beutler, L. E., & Goldfried, M. R. (2019). Cognitive-behavioral therapy and psychotherapy integration. Handbook of cognitive-behavioral therapies, 318-345.
Thoma, N. C., & Cecero, J. J. (2009). Is integrative use of techniques in psychotherapy the exception or the rule? Results of a national survey of doctoral-level practitioners. Psychotherapy: Theory, Research, Practice, Training, 46(4), 405.
