In lieu of my usual Friday post, I’m taking this opportunity to announce a new series of YouTube videos that I’ve initiated. Over on my After Psychotherapy website, I asked my site visitors for input/suggestions about what I should do next with my videos; one regular reader suggested something about “what to expect in psychotherapy” and I realized that a series on that topic would allow me to address just about all the suggestions I received, and all the clinical issues that are near and dear to my heart.

This first video concerns the intake, the natural anxiety that arises and how both client and therapist cope with it.

Adrienne said she’s having difficulty holding to our agreement that she reach out to me before cutting herself. The drive to self-injury feels “insatiable,” as she put it. She then told me the following dream: She was outside with her son, and they were having a great time together. She suddenly realized there were snakes everywhere, on all sides.

Most of them were small and harmless but as the dream went on, there were more and more of them. She tried very hard to remain calm, in order to get her son to safety, and finally succeeded. But Adrienne couldn’t go inside along with him.

She felt sad but oddly at peace, resigned to that fact. As she left her son behind, Adrienne knew there were too many snakes now for her to escape with her life. She walked directly toward the biggest, “most aggressive” one. As it struck her, she woke up.

After the spirited discussion about my two posts on ADHD symptoms, I felt eager for more experience working with someone who considered himself “ADD”; my intake on Friday with a new Skype therapy client did just that and, even in the first session, provided many details that pointed toward a psychological explanation for his ADHD symptoms.

Adam told me he had been diagnosed as an adult for having a history of difficulties in the areas of concentration, classroom behavior, and for performing below his ability level. He has taken medications for two years.

Over the course of the session, Adam described his struggles in several different areas. His main concern — the reason for beginning treatment — is his recent infidelity, uncovered by his wife, which is jeopardizing his marriage. He also talked about problems at the law firm where he is a first-year associate.

In preparing for a recent trial, he “went AWOL” in order to be with his wife on a day when she was awaiting some important test results. He told no one at the firm he’d be away, he just simply disappeared. The partner on the case kept calling and texting him throughout the day but Adam ignored him. He felt the other associate on the case could handle the trial prep that day and they didn’t need him.

When he returned to the office, the partner was furious. As a summer associate at a different firm two years ago, Adam had run into similar difficulties with the higher-ups and didn’t follow through on assignments; at the end of the summer, he did not receive an offer to return once he finished law school.

In thinking about the new videos on psychodynamic psychotherapy I plan to do, it came clear to me this week that an early focus of treatment with many clients is helping them to recognize the internal saboteur at work. Some people begin therapy highly aware of their “internal critic”; others suffer under its harsh regime but aren’t conscious of the saboteur operating behind the scenes.

As I said to one of my clients this week, “The cruelty is so pervasive and unnoticed that it’s like the air you breathe.” One of the videos should be about this issue — helping clients “tune in” to their superego as a first step in challenging its dominance.

Sarah, in particular, struggled with this idea and said she was having a hard time grasping it — that there could be a force inside of her that keeps her down, chokes off her voice, stops her from doing the things that matter most to her. I tried to link for her (1) the narcissistic mother who envied and sabotaged her as a teenager, (2) her subtle forms of self-sabotage; (3) the way she hears my interpretations as if I’m dismissing or discounting what she consciously says as being unimportant, and (4) her night terrors, where she’s afraid there’s something in her apartment that wants to kill her.

It feels as if she’s completely under its thumb; I used the analogy of someone living under a cruel and repressive regime who has never experienced freedom. It will take more time before this idea comes fully alive for her. It must be so frightening and painful to recognize that the killer is inside and not out.

In our last session, I felt a moment of clarity when some of David’s central issues came into focus and the bipolar dynamic became clear. Since we began working together a couple of months ago, I’ve caught glimpses — the way he’s so enthusiastic about our work in one session, and then hopeless about the possibility of change in the next; now, I feel as if I have a better handle on it.

He began the session with a lot of discouragement. No point in moving back to the town where he used to live, as he had intended, and no reason to stay where he currently lives either. Why should he even try to do anything? At his age (mid-50s), wasn’t it unrealistic to believe he could change?

He went on to talk about how he had no food in the house and hated cooking and cleaning. He’d make resolutions to do better but could never stick to them; he couldn’t even make himself take vitamins on a consistent basis. Regarding his father’s offer to help him buy a house, he felt that having a home would just mean more responsibility for him — more upkeep, more cleaning, etc.

The very idea seemed to make him angry. I remembered that during the session before this one, David had said he wished his father would simply give him the house money instead so he could “go play with it.”

Two emails over the weekend with references to murder. One from Sarah, telling me what she keeps forgetting to mention during session — that she has lately become unable to sleep with the lights off; the other from Dylan, about a recent dream.

Sarah tells me she feels as if her apartment is haunted by something that wants to kill her. She doesn’t believe in ghosts, but the feeling is very convincing to her, so much so that she’s been getting little sleep of late. It feels too charged to address via email, but this experience fits with the rage that has featured so strongly in our exchanges between sessions, as well as the history of self-injury.

The rage feels split off: for the most part, she only feels angry with me after sessions … and then there’s the killer who haunts her apartment, most likely a personification of that split off rage. She’s afraid of the power of those murderous feelings — afraid of what she’ll do if they “take over,” and afraid they will annihilate her.

After mentioning the sadness she felt over the break, about the damage she might have done to her therapy with those angry, accusatory emails she sent me, Sarah asked me point-blank if I disliked her. At first, I talked about her understandable fears — how in most relationships, other people might want to turn away from such rage — but then, I shifted gears and just told I didn’t dislike her, not at all.

I said that I personally understood how painful such rage can feel, how hard it is to bear, and I felt a lot of sympathy for her, going through it. I was moved as I said it; Sarah told me it was a relief to hear, and I could see that she felt moved, as well.

The experience took me back to that day in my own therapy, more than 30 years ago now, when Dr. P told me we’d have to stop in mid-session because we “no longer had the conditions to do the work.” I understood what he meant: he was telling me that my hostile, abusive manner toward him had made him so angry he didn’t feel he could continue the session. I remember standing at the exit door, feeling incredibly upset because I’d been so destructive that my therapist wanted me out of his office.

Regarding my upcoming intake with David — as always before agreeing to take on someone new for Skype therapy, I asked him to read my policies and Disclosure Statement carefully, to be sure I’m the right therapist for him and that he understands the way I work. He asked the amount of my fee and agreed to it.

This morning when I woke up, I found an email from David requesting that I reduce my fee 30%. He had learned from reading different posts on my website that I’d seen people for as little as $5 per session (many years ago during my training) but he hadn’t read the one on sliding scale payment and why I no longer reduce my fee for new clients. In our prior exchanges, David had mentioned that he thought he might be a “borderline” because of unstable relationships and a lot of “emotional drama.”

As Melissa continues to separate from me, her anger at having to think for and look after herself has begun to surface. She related a short dream – that the company where she works was being summarily evicted from their building; the landlord told them to “get out.” A large sum of money was owed, but she wasn’t sure if the landlord owed it to her company or vice versa. When I asked for her associations to the money, she linked it to my fee, how much she has paid me over the years.

Melissa then went on to describe an experience with the amateur orchestra she recently joined. At their last rehearsal, during a break when some of the other players in her section heard her practicing a difficult passage, they suggested to her that she lead an independent section rehearsal for them. “You really know what you’re doing,” one of them told her. She felt angry about this and didn’t want to take on the added responsibility.

There is Melissa’s dilemma in a nutshell: she experiences her growing ability to think for/take care of herself as if she’s being “thrown out” of her therapy, forced out into the world where she must assume all the responsibility and look after others. This makes her angry because she wants to stay “inside” forever, where I’ll take care of her and she won’t have to think for herself. She doesn’t feel that there’s a middle ground where she can be separate but I would still there to help, nor does she fully appreciate the benefits of all her growth.

Scissors and ribbon photo available from Shutterstock.

Psychotherapy remains a mysterious process to many. In society’s collective unconscious psyche, we often slip into believing modern psychotherapy resembles something from early Freudian days — the patient lays on a couch and the therapist sits out of sight of the patient while they recount their day or week, and earliest childhood memories. Therapy is never-ending.

But modern psychotherapy doesn’t much resemble that stereotype any longer. Today, therapy is often time-limited and more goal-focused, helping teach the client new skills or ways of looking at a situation or issue in their life, and gaining new insights into their motivations.

Therapy Case Notes is a blog that is intended to highlight interesting interactions in psychotherapy sessions — things that shed light on a particular issue or dynamic within the therapy session. The purpose is to try and demystify psychotherapy, and demonstrate the powerful healing abilities of the process.

All identifying patient information has been stripped and/or anonymized to protect the confidentiality and privacy of the patients.

We welcome Joseph Burgo, Ph.D. as the host of this blog — and the person who came up with the idea for it. You may recognize his name, as he previously blogged on movies and mental health for Psych Central. You can learn more about Dr. Burgo here.

Please give Dr. Burgo another warm Psych Central welcome, as we’re happy to have him blogging about psychotherapy topics with us.