Starting The Session
Posted by Dr. Vollmer on May 30, 2012
Lee, a fifty-six year old female patient, comes twice a week for psychotherapy, walks in with “nothing to say.” We wait. She stares at me with frustration and anger. “Why are you so irritated with me?” I ask, feeling the nonverbal communication. “I just had a large argument with my twenty-four year old daughter and I guess you are feeling the downstream effects from that,” Lee says bringing together her emotional trouble from the morning into our session. Previously, Lee might not have been aware of how her interaction with her daughter spilled over into subsequent interpersonal interactions. “She just keeps telling me that I am incompetent, that I am stupid and that I am wasting my time in psychotherapy,” Lee continues to detail the argument. “She really gets to you,” I say, opening the question as to why she takes her daughter’s ideas so seriously. “Of course, she gets to me. I wonder if she has a point.” Lee says with directness and acceptance that she may indeed be stupid and exercising poor judgment, particularly with regards to coming to psychotherapy. “She may also be trying to tug at you so that you become more insecure because, maybe, she is feeling insecure and so she wants you to feel that way in solidarity,” I say, trying to point out that her daughter may have another agenda. “That is a good point,” Lee says, “but I just don’t know.” The window into Lee’s emotional state all started in the first few moments of our session. No words had to be exchanged-just a feeling of anger and frustration.
Shirah Vollmer MD 
Jon said
The mathematician Kurt Gödel was able to show mathematically that there are statements that cannot be proven true or false in any mathematical system complicated enough to include arithmetic. He did this (way oversimplifying the argument) by using mathematics to examine itself – assigning a number to each operation and creating a number stating that this operation could not be shown true or false.
In a semi-analogous way you, Lee, and her daughter are playing a similar game. However, here the game is psychotherapy not mathematics undergoing self scrutiny. Fortunately, since psychotherapy is a much more complicated game than arithmetic, much more can be learned about the game and its players before the indeterminacy of the validity of statements can be reached. This is also not necessarily a self consistent situation; insights can be gained at many levels.
Dr. Vollmer said
Thanks, Jon, for your interesting enhancement to this discussion.
Eleanor Brown said
Hi Shirah, this post gives me a chance to integrate a response which will also include issues from your last post “I really look forward to therapy”. “Starting the Session” lets your readers know that for psychotherapy to be effective there must be “presence” with both the therapist and patient…emotional, intellectual and physical presence among others…ie: “being there”. Sometimes the mere act of silently being in the same room can initiate discussion, insight and understanding and ultimately aid in healing. If the patient, by choice, refuses to “be present” healing cannot take place. In addition, for healing to take place the patient must be committed to treatment…period. As far as lateness is concerned (previous post), there is a difference in a couple of minutes of lateness and 20 or 30 minutes of lateness. If it closer to the latter and after two years the patient still is acting out in this manner on a consistent basis, I would think this would be cause for at least a discussion for termination of treatment or if not termination, some “ground rules” should be agreed on in reference to “being there” for treatment to take place. As always ….just my two cents 🙂
Dr. Vollmer said
Hi Eleanor,
Thanks for your comments. I am not sure that I agree with you that if the patient refuses to “be present” then no healing can take place. Physical presence is consent for treatment and then the work begins. I agree that there are different levels of being present in therapy, such that there are different levels of therapeutic maneuvering. This is what makes the work of psychotherapy endlessly fascinating. As far as the lateness issue is concerned, this too is also subject to investigation and not to hard and fast rules. The individuality of this process is what makes psychotherapy distinct from what I call “cookbook” treatments. Thanks again.
Shelly said
When you start off treating a patient, do you talk about the goals of the therapy, i.e. learning more self-confidence, identifying defeatist behaviors, etc…Or is it more of a “We’ll see what comes up along the way?” I ask because as a therapist, I wonder how you know where to direct your energies in each session when there can be so many avenues of discussion available each time?
Shirah said
Hi Shelly,
Yes, you are right that there are so many choices about how to proceed that therapy is such an ambiguous process on the one hand, and yet so meaningful on the other. There is no road map, per se, although the newer psychotherapeutic models do come with manuals (or cookbooks, as I said in response to Eleanor). The direction of psychotherapy is co-constructed between me as the therapist and the material presented by the patient. Usually, by a process of both conscious thought along with intuitive understanding there are roads to pursue which yield a deeper understanding of one’s emotional interior. This understanding, in turn, often leads to the goals you were referring to of more self-confidence and less self-defeating behaviors. Thanks, as always.