Seminar 2: Psychotherapy Process and Dynamics PDF

Seminar 2 Organizational process and therapy dynamics: contact, assessment & contracting PSYCHOTHERAPY as a process CONTACT INITIAL CONTRACT THERAPY ASSESSMENT DYNAMICS I. Contact in Psychotherapy: Is it happening in every session? At all times? Should...

Seminar 2 Organizational process and therapy dynamics: contact, assessment & contracting PSYCHOTHERAPY as a process CONTACT INITIAL CONTRACT THERAPY ASSESSMENT DYNAMICS I. Contact in Psychotherapy: Is it happening in every session? At all times? Should be but intensity may vary Is it needed to make process of therapy effective? Definitely Lack of contact is a risk of drop out How to recognize it? Markers of contact? Good contact Poor contact active listening judgement from the therapist leaning over lack of mirroring eye contact (and other non-verbal) crossing boundaries minimal verbal reactions leading the patient paraphrasing biased therapist adequate silence breaks interruptions smiling client going silent suddenly attending pushing too hard, interrogative normalizing style of questioning slow pace of therapist voice closed body language attention on the patient unnecessary psychoeducation non-defensive therapist loosing focus on the patient patient sharing sensitive topics therapist who is sleepy Contact in Psychotherapy Feeling that the patient and the therapist are a unity Therapist imagines as if he/she was the patient (cognitive empathy) – at least wants to understand the patient! Biggest challenge with psychotic patients Accepts all feelings, wishes and desires expressed by the patient But not all behaviors – e.g. accepting patient’s anger and murder phantasies but not accepting that patient beats his wife.  Therapist needs to be engaged, make emotional efforts Allows patient to trust and reveal sensitive personal issues Patient behaves congruently on emotional and verbal level (e.g. emotions match the content of what is being said) Patient feels that the therapist is Interested (attentive, curious, neutral) Accepting (non-judgmentally) Understanding (empathic). Contact in Psychotherapy Contact It’s always asymmetrical! Does the contact remain the same in process of treatment and each session? Contact dynamics Throughout sessions the contact intensity is circular In a single session the strongest connection is in the middle of session (corresponds with patient’s highest tension). At the end therapist should dissolve the connection gradually and safely for the client E.g. we try not to open any new sensitive topic at the end of session, we try to keep patient safe that way and work against a common case of bringing emotional issues just at the session ending (the open door material) Topic 8 Countertransference and other professional issues of being a counsellor: role of values and cultural humility IV. Countertransference T→P From psychoanalysis – 2 meanings Narrow (Freud) – response to the patient’s reactions. Broad (Mahler & other object relation theorists) – every emotional reaction triggered by the patient or internal therapist’s factors. Types of countertransference Positive Negative Symmetrical Complementary When countertransference is less risky? Short-term treatments More structured therapies (SFT, CBT) Having own therapy Using supervision Analyzing own attitude towards the patient also before and after each session Projective Identification (Klein, 1952) Interpersonal phenomenon Therapist subjectively feels what was projected by the patient. Though therapist recognizes that the emotion is extraneous Being “invaded”/”polluted” from the outside. Patient is not aware of this mechanism. The self is fragmented due to splitting: good (+) bad (-) (patient identification) (projected on the object) Exchange on unconsciousness level happening at the same time: - patient’s projected material (P.I.) - therapist’s feelings (from countertransference) P T Projective Identification Complementary Identification But it’s not an empathy! Projective identification or countertransference? (Knott, 2016) Projective identification - involuntary and often perceived as extraneous (ego-dystonic) actions and thinking related to early identificatory feelings projected by patient. It leads to countertransference feelings. While other instances of countertransference – often easier to perceive, projective identification is considerably more difficult to recognize and therefore more difficult to work through. Other approaches view on countertransference 4.3. Interpersonal Communication approach to countertransference (Eisenthal, 1992) 1. Receptive phase Aim: the therapist is accepting what was projected by the patient, while at the same time patient gets rid of what’s unwanted (p.I.). Therapist should be: - Open, “passive”, accepting what is arriving from the patient - At the same time must be self-aware to feel the pressure from the patient (to recognize later that it’s extraneous). 2. Phase of internal processing Aim: the therapist becomes conscious of this affective pressure from the patient; naming emotions; attributing meanings; gaining understanding; separating own personal feelings from countertransference reaction to patient’s projections. Looking for answers (H building) - What the patient is trying to communicate this way? 3. Communication phase Aim: make use of the new understanding; put it into questions, interpretations, but not disclosing directly therapist's feelings, searching for proofs of their reasons in patient’s stories. 4.4. CBT approach to countertransference In the past, not recognized (Beck), later seen as therapist’s problem (like counterresistance) Currently recognized as a possible source of cognitive knowledge about the client (Cartwright, 2004) A material to detect client’s cognitive distortions, errors in thinking etc. Gives a more complex picture in working using still CBT methods. As a therapist you’re expected to have the knowledge about you’re expected to learn you work with major counseling assessment techniques “yourself” as a person theories (your practice and interpersonal skills will be theory-based) you’re expected to be curious about human but... that’s not all... nature Own therapy (Orlinsky et al., 2005): a model of therapeutic practice in which the trainee experiences the work of a more experienced therapist and learns experientially what is helpful or not helpful; a way to enhance a therapist’s interpersonal skills that are essential to skillfully practicing therapy; a way to deal with the ongoing stresses associated with clinical work. + learning about own blind spots and possible areas of biases.  According to Yalom (2003, p. 41) own therapy is more powerful than any training in counseling: “Self-exploration is a lifelong process, and I recommend that therapy be as deep and prolonged as possible—and that the therapist enter therapy at many different stages of life”. Self-aware counselors use own therapy processes several times during their training and practice. Own therapy “Healing the healer”. The Role of Values in Counseling Is there a room in therapy for therapist’s values? The Role of Values in Counseling Counselors who hold definite and absolute beliefs and see it as their job to exert influence on clients to adopt their values. These counselors tend to direct their clients toward the attitudes and values they judge to be “right.” 2 extreme Counselors who maintain that they should keep their values positions: out of their work and that the ideal is to strive for value-free counseling. They are so intent on not influencing their clients, they run the risk of immobilizing themselves. Cultural competance The ability to interact effectively with people of various racial, ethnic, socioeconomic, religious and social groups.  The ongoing process of self-exploration and self-critique combined with a willingness to learn from others. Entering a relationship with another person with the intention of honouring their beliefs, customs, and values. Acknowledging differences and accepting that person for who they are. Cultural humility  How do I describe my own ethnicity? Race? Religion? Gender? Sexual Orientation? Self-reflection suggestion What are my most closely-held values? Transference & Countertransference Seminar 7 Transference Unconscious process of transferring emotions, attitudes, expectations and desires that were previously addressed to important figure (usually from childhood) to other objects (e.g. therapist, spouse, boss). Patient treats therapist as if he/she was an the important figure in patient’s life. O P T 2.1. Unconsciousness of the transference Patient doesn’t remember experiences from childhood. Patient’s is not aware that he/she recalls them in reactions towards the therapist. Patient is aware of own feelings and desires but not of their origin. 2.2. Characteristics of transference Object that is being transferred: Usually caregivers (parents, grandparents), siblings, other important figures from the past (not here and now) There are many objects of transference and it usually changes in therapy process (transference dynamics). Clinical symptoms: Strong ambivalence: from positive to negative feelings (from idealization to devaluation) Includes a cognitive error: because it links affect towards the object (past) with the therapist (present). 2.3. Transference outcomes Source of information about the patient Source of patient’s motivation It’s difficult to experience but once it’s understood, it relieves tension and creates room for bringing sensitive material. Source of resistance Until patient realizes that his/her feelings come out of transference phenomenon. Types of transference Positive Negative  Good indicators of transference feelings in therapy Patient’s emotional Patient’s emotional reaction too intense reaction lasts long in time (inadequate to what (inadequately long to what happened during session) happened during session). 2.3.3. Handling transference in transference-focused therapies (Greenson, 1967) Confrontation: paying attention to some patient’s e.g. the fact that patient is being recently late or seems irritated behaviors that might be of transference nature hearing our comments in sessions. Clarification: talking about specific feelings linked e.g. “how do you feel when you hear my interpretations with these behaviors recently?”. Interpretation: making connections between the e.g. “does this feeling remind you of any other situations even past and present from your past, when you felt something similar?”. Working through: series of ongoing usually first interpretation is not accepted; there is always time needed to work through as we need to work against the repetition interpretations compulsion! (Freud, 1920). 2.5. Transference in other approaches than psychoanalytic/psychodynamic Currently recognized and not ignored The use of transference in other psychotherapy approaches CBT (Beck): transference is explained as an error in thinking and cognition of reality Therapist is confused with someone else Therapist shows the mistake to the patient A part of working with cognitive distortions. Formative Psychotherapy (Kaleman): body work, transference expressed through somatic-emotional reactions Body = another level of transference expression Trauma repeated in the body tensions and muscle patterns Therapist through transference triggers these tensions and works with them.  Means sharing personal information with the patient Goal: to give understanding and validation to patient’s feeling. There are different types of self-disclosure and it depends on the approach what is allowed to disclose. Use of Self-Disclosure Use of Self-Disclosure E.g. in existential counseling even sharing (but briefly!) personal experience is allowed if the counselor is certain that it would be beneficial for the client: “I know what you mean by that. I’ve been on the cruise once”; “I understand what you are feeling, in fact I had similar experience once”. E.g. in psychodynamic approach we share non-personal issues only or countertransference emotions: e.g. patient talking about the idea of democratic education, therapist: “I know what you mean, I used to work in this kind of school”. Countertransference: "I felt sadness when you talked and you seem detached from your feelings when speaking about such difficult things. What I felt was probably your sadness that you are detached from” Self-disclosure traps and hazards Redirect attention to counselor Risk of malpractice (crossing boundaries) Fake empathy I’ve been there=I know what you feel Every person’s experience is unique, even in the same situations we experience things differently! When you want to disclose something better wait till next meeting, don’t follow the impulse! What if the client asks for self-disclosure? I don’t know if I can talk about this with someone who doesn’t experience similar thing, do you at least have children? What would you answer…? Focus on the motives What’s behind this question? Why is that important to you to know that? The cardiologist metaphor Respect if client prefers to work with someone else.  Sharing with patient information not concerning the counseling process E.g. about university, about general psychological knowledge Giving specific instructions and feedback (e.g. in behavioural sessions) Goal: not to advise something but to show options e.g. patient talking about idea of getting into university program and not knowing when the recruitment ends, “You know, there are universities where the recruitment is still open, I know that at the X university they keep it open till October”. to normalize patient’s feelings e.g. patient saying that after he got robbed he is afraid to walk after dark and feels like a crazy person, “I’m not surprised you feel this way, it’s a common reaction to such trauma, people after such events experience similar things”. Informing Summarizing Used in most approaches in counseling Goal: to synthetize what has been communicated Man include some clarifications, interpretations, summary of a general theme of the session, of patient’s concerns, wishes etc. Usually done at the end of meeting Could be used from time to time during the same session Especially when the client brings a lot of material In some approaches (e.g. systemic family counseling) is used also at the beginning of session Summary of the last meeting To anchor the clients Guidelines for using verbal responses 1. Use the same language as your client 2. Speak slowly 3. Avoid rambling statements – be concise 4. Focus on one issue before exploring another 5. Talk directly to the client not about him/her 6. Use the “I” statements when you communicate feelings 7. Encourage client to talk about own feelings 8. Time your responses: short is better and rare is better that too much of too long talking… 9. Be sensitive to cultural differences. Resistance in psychotherapy Seminar 6 Psychotherapy Dynamics Psychotherapy Dynamics Include changes in relationship between patient and therapist A part of every successful treatment Depend on phenomena occurring in the relationship patient-therapist or patient-group of patients In different models stages of therapy are defined with different level of specificity, however they share a common recognition of 3 stages.  From non-voluntary participation But there is always a choice, even like prison vs counseling Every patient is partially Resistant reluctant and partially motivated as it takes a clients lot from a person to look closely at oneself… Resistance analysis as an important part of psychodynamic counseling – it becomes a material for counseling not an obstacle! How to attend a resistant client With nurturance and empathy Try to rephrase the issue and search for client’s reasons for counseling attending Try to make person curious about oneself Phenomena in the relationship Pà T and Tà P The relationship is real (emotional bond, development of inner representation) but not from the “real life” – outside of the office Restricted by therapeutic setting Boundaries Asymmetrical. Phenomena develop from the way patient bonds with therapist: Pß> T Resistance (& counterresistance) Transference Collaboration Countertransference I. Resistance in Psychotherapy Progress of every treatment is a resultant of motivation and resistance 1.1. Resistance in neurotic patients therapy (analytic approach) Phenomenon unconscious for the patient Inner force against psychotherapy progress In psychoanalysis an act of contract violation – by not collaborating with analyst Every reaction that makes analysis difficult (or even blocked) Could be seen as a repeated pattern of defenses that were used in dealing childhood trauma (the closer to trauma we get the more likely the defenses will strike back). 1.1. Resistance in neurotic patients therapy (analytic approach) Aim of resistance - prevents too quick recollection of early childhood memories (contrary phenomenon to transference). 1.1. Clinical examples of resistance (neurotic/higher functioning patients) “I have nothing to talk about” + tension patient is restless, visibly agitated, sweating, blushing, hands are shaking, though quit Talking about emotion issues without emotional reaction Non-verbally agitated e.g. walking around but no taking Rambling about unimportant things, avoiding things that are important e.g. about the past instead of present 1.1. Clinical examples of resistance (neurotic patients) Talking in a very general manner E.g. “people are afraid when…”, “everyone...” Being late Persistent physiological reactions E.g. Yawning, coughing, sneezing Sudden unexpected improvement (to end therapy without confrontation) Lack of imrpovement despite working on the problem. 1.2. Resistance in borderline or psychotic patients (lower functioning) Expressed differently - Acting out Usually not followed by conscious reluctance towards therapy 1.2. Acting out in borderline or psychotic patients Resistance and tension is relieved by taking actions that represent unconscious phantasies, desires, wishes and inner conflicts. E.g. shouting at the therapist, breaking things in the office, hitting the therapist but also hugging, clinging, kissing, suicide attempt in session, occupying the office bathroom, sending emotional messages, …. 1.3. Resistance in other models than analytic 1.3.1. Milton Erikson’s understanding: Resistance is therapist’s problem, not patient’s. Responsibility for development of patient’s resistance is on therapist who is not good enough. Approaching resistance in Erikson’s approach: Without interpreting (as it’s not patient’s issue) Changing therapeutic technique Specific Eriksonian technique: Indirect communication (using hidden messages, metaphors etc.): T’s communication: Overt level à Patient’s Ego is misled T’s communication Cover level à Patient’s Sub-consciousness is expected to change. 1.3.2. Transpersonal approach – J. Enright’s (1988) 5 ways of working without resistance 1. Autonomous motivation: own choice to be in therapy 2. Therapist is accepted: T-P agreement Patient accepts therapist the way she/he is, with age, gender and psychotherapy approach. 3. Realistic goal: otherwise it should be reformulated. 4. Mutual agreement on the goal: realistic goal must be well understood by the therapist and well experienced by the patient Patient’s responsibility to state the goal 5. Secondary outcomes analysis Secondary gains from having the problem Unpleasant consequences of getting rid of the problem. 1.3.3. Resistance in Pearl’s Gestalt approach Expression of patient’s self It’s an integral part of a patient’s true self and should be integrated with other parts Polarity between the part of the self that wants to heal and the part that resists change Borderline and psychotic patients can even transform the resistance into action (similar to acting out concept) — Gestalt work with resistance — Therapist should give it a voice in treatment (don’t fight against it!) — Integration through empty-chair technique. Additional techniques in psychotherapy  Means sharing personal information with the patient Goal: to give understanding and validation to patient’s feeling. There are different types of self-disclosure and it depends on the approach what is allowed to disclose. Use of Self-Disclosure Use of Self-Disclosure E.g. in existential counseling even sharing (but briefly!) personal experience is allowed if the counselor is certain that it would be beneficial for the client: “I know what you mean by that. I’ve been on the cruise once”; “I understand what you are feeling, in fact I had similar experience once”. E.g. in psychodynamic approach we share non-personal issues only or countertransference emotions: e.g. patient talking about the idea of democratic education, therapist: “I know what you mean, I used to work in this kind of school”. Countertransference: "I felt sadness when you talked and you seem detached from your feelings when speaking about such difficult things. What I felt was probably your sadness that you are detached from” Self-disclosure traps and hazards Redirect attention to counselor Risk of malpractice (crossing boundaries) Fake empathy I’ve been there=I know what you feel Every person’s experience is unique, even in the same situations we experience things differently! When you want to disclose something better wait till next meeting, don’t follow the impulse! What if the client asks for self-disclosure? I don’t know if I can talk about this with someone who doesn’t experience similar thing, do you at least have children? What would you answer…? Focus on the motives What’s behind this question? Why is that important to you to know that? The cardiologist metaphor Respect if client prefers to work with someone else.  Sharing with patient information not concerning the counseling process E.g. about university, about general psychological knowledge Giving specific instructions and feedback (e.g. in behavioural sessions) Goal: not to advise something but to show options e.g. patient talking about idea of getting into university program and not knowing when the recruitment ends, “You know, there are universities where the recruitment is still open, I know that at the X university they keep it open till October”. to normalize patient’s feelings e.g. patient saying that after he got robbed he is afraid to walk after dark and feels like a crazy person, “I’m not surprised you feel this way, it’s a common reaction to such trauma, people after such events experience similar things”. Informing Summarizing Used in most approaches in counseling Goal: to synthetize what has been communicated Man include some clarifications, interpretations, summary of a general theme of the session, of patient’s concerns, wishes etc. Usually done at the end of meeting Could be used from time to time during the same session Especially when the client brings a lot of material In some approaches (e.g. systemic family counseling) is used also at the beginning of session Summary of the last meeting To anchor the clients Guidelines for using verbal responses 1. Use the same language as your client 2. Speak slowly 3. Avoid rambling statements – be concise 4. Focus on one issue before exploring another 5. Talk directly to the client not about him/her 6. Use the “I” statements when you communicate feelings 7. Encourage client to talk about own feelings 8. Time your responses: short is better and rare is better that too much of too long talking… 9. Be sensitive to cultural differences. Using advanced psychotherapeutic techniques in different approaches Seminar 5 Advanced responses Clarification Confrontation (challenging) Interpretation & working through Use of self-disclosure Informing Summarizing Processing the relationship Working with silence  Comes from psychoanalytic techniques Widely used in all kinds of counseling Used from the beginning of counseling process Helps to clarify also the counseling goals Goal: to focus on the core of client’s message Clarification Examples: “Are saying that you feel overwhelmed?” “I’m a bit confused, could you explain this again?” “It seems like you are talking about the experience of loneliness”.  Also from psychoanalysis Currently broadly used in counseling Confrontation Goal: provide a honest comment on what is going on Usually on a meta-communication level (challenging) Commenting the way client speaks about some issues Especially any contradictory messages from the client (verbal vs non-verbal level) Confrontation (challenging) Done with care and empathy Non-judgmental Examples: “ You’re saying that therapy sessions are very important to you, I believe they are, but on the other hand you keep being late every week, have you noticed that?” “I feel you are angry with me” “It seems difficult for you to talk about it”  Also from psychoanalysis (Freud, 1900) Present in other approaches in counseling (with some exceptions) Present usually later in the process, in the active treatment Interpretation phase not at the beginning Goal: to give a new understanding of the feelings/problem/symptom/mechanism of its formation/intentions Interpretation It’s a mastery of thinking (cognitive level; making connections) and feeling (if the timing is right to say it) of the counselor Even a true interpretation but delivered in the wrong time will not be useful Recognition of client’s readiness to comprehend the interpretation is an art of counseling Most common mistake: delivering interpretation too soon! Especially before building a strong therapeutic alliance! Interpretation examples P: I felt bad today when I came late for the session, I was looking at you and I was… checking, I guess, if you’re angry with me for being late... mom always did. T: Maybe sometimes you are not sure if I am a different person from your mother. And you seem to unconsciously expect from me to behave the way she did. Interpretation Importance of patient’s reaction Acceptance: “yes, you’re right, sometimes I even feel during our sessions as if I was talking to my mom, not the therapist!” Acknowledgement but not agreeing: “No, I think it’s something different. I know that you are not my mother, but I guess I’m angry with myself for being late, and maybe even more angry thinking that you’re waiting for me! Maybe that’s why I expected you to be angry!” Rejecting: “What on earth are you talking about? Is it with all of you, psychologists, that everything needs to go back to the mother-figure?!” Interpretation – every reaction brings new understanding of the patient Importance of patient’s reaction Acceptance: The interpretation is probably right and patient deepens own understanding including this new clue. Acknowledgement but not agreeing: Probably the explanation is different but the interpretation inspired patient for thinking for other reasons. Rejecting: Probably the interpretation is right but the patient is not ready to comprehend it and analyze further. The material is too oppressive at the moment. Wait for bringing this later!  = Series of interpretations Working through Leading to long-term changes in patient’s functioning. Interpretation of the same theme delivered on different occasions. Case formulation Seminar 4 IV. Psychotherapy dynamics 1. Preparation for the change 2. The phase of change 3. The ending phase Ongoing process of therapy-related phenomena developing (alliance, transference, resistance, collaboration, mourning)... Major evidence-based approaches: what are they? Theoretical approaches to counseling Why do we need them? personality theories explanation of disease mechanisms ideas of treatment and creating the change typical techniques areas of interest - e.g. unconsciousness, beliefs, narratives Contemporary Psychoanalytic therapy psychoanalytic and psychodynamic Adlerian therapy Counseling Existential therapy Models Person-centered therapy humanistic-existential Gestalt therapy Behavior therapy CBT Cognitive behavior therapy new ideas of truth Postmodern approaches Family systems therapy relational psychopathology  4 major approaches to mechanism of disorders: Stimulus…Unconsciousness... Thought...Emotion... Reaction Psychoanalitic CBT Humanistic- Systemic /psychodynamic existential SàR Rà S Ellis, Beck Freud, Kohut, Klein SàthoughtsàEàR Rogers, Perls Bowen, Satir Sàunconsc.àEàR Patients learn to Disorder is an Repeated patterns, assess and get rid of outcome of l outside trans-generational them. world interfering influence, Making the with individual's role of the family unconscious Developing new development. system. conscious. interpretations of reality. Creating room for factors supporting individual’s growth and actualization (non-judgmental positive regard, empathy, genuiness). Clinical Psychology 2 Seminar 3 II. Initial Assessment in Psychotherapy II. Initial Assessment in Psychotherapy Whole psychotherapy process in an ongoing assessment. We keep learning about the patient all the time… Initial assessment includes: 2.1. Assessment of sources of patient’s problems 1. Emotional à treated with psychotherapy 2. Side effects of taken medicine à for M.D.s 3. Changes in CNSà for M.D.s 4. Reaction to specific life conditions à changed by social workers 2.2. Assessment of motivation to enroll in therapy Best motivation:...... Worse motivation:............ 2.2. Assessment of motivation to enroll in therapy Best motivation: inner, someone wants to change the way he/she experience the world, oneself, change unwanted habits, understand own behavior and needs better. Worse motivation: lack of it, people don’t seek professional help even though they need it, usually brought by their family. Other motivation types (-) Expectation that the therapy will change not the patient but patient’s environment E.g. wife contacting therapist to make her husband enroll into the treatment (-) Expectation that in therapy (especially group therapy) patient will find a true love/ friends etc. (-) Expecting advices from therapist, what to do, what to choose etc. Other motivation types (-) Having secondary outcomes from being in therapy (e.g. military service immunity, retaking exams at the University) (-)/(+) Non-voluntary therapy attendance (e.g. court order, spouse threating with divorce, parents forcing a teenager) Here at least there is a chance to work on individual motivation and therapy could be effective. III. Contract in Psychotherapy III. Contract in Psychotherapy When we know that patient’s problems are of emotional/psychological nature Patients is willing to participate in therapy Therapy goal Contract=Agreement on: Therapy form. Contract Written and signed Verbally agreed In CBT could already be a way to trigger patient’s In psychoanalysis usually not written engagement (like making a written promise to (but Nancy McWillimas gives examples of signed change) contracts). 3.1. Goal setting in different approaches Psychoanalytic therapy: also important is not what the patient says but what is not said as expected to change. therapy is a very long-term (years) and its goal may change. Strategic therapy: the smallest change recognized by the patient. Goal is not specific, short-term oriented, open to future change. Behavioral therapy: getting rid of pathological reactions/symptoms. Very specific, e.g. to get rid of morning panic attacks. Humanistic therapy: growth and self-actualization, personality change. Very broad, not very specific. Solution Focused Therapy, M. Erikson approach and NLP: positive goal definition, what is expected to happen instead of what is expected to stop happening. E.g. to be braver in social situations (instead of getting rid of social anxiety). 3.2. Therapy form ① Length of therapy process ② Frequency of therapy sessions 1-3 sessions per week: psychodynamic 3-5 sessions per week: psychoanalysis 1 a week or less: other approaches ③ Informed consent How the therapy is going to proceed What to expect Possible periods of discouragement and thoughts about quitting Possible emotional reactions (positive and negative) towards therapist and group members Wish to suppress important information That all of these situations should be addressed and discussed in sessions when they occur!