How do we decide what to work on?
People can seek therapy for a variety of reasons. Some may want to change something about their internal state – to feel less anxious or depressed or feel more satisfaction or pleasure. Others may seek therapy to change an aspect of functioning-more intimacy in relationships, or a greater capacity to organize themselves in some particular area of their life such as work or school.
There are also times when they may be considering or experiencing important life changes (e.g., career, marriage, divorce), or adapting to life events like trauma, or loss. While goals for treatment can vary widely, people generally seek therapy because they want to feel better in some way. Ultimately, it is not up to the therapist to make the final decision about the goals of therapy; however, it is our responsibility to propose a reasonable and appropriate focus for treatment.
What is a focus of treatment?
Choosing a focus means agreeing with a patient on how we will make sense of a problem, and how we will work to resolve it together. Each individuals’ problems can be explored and understood from a variety of levels or different perspectives.
Therapy can be confusing and difficult enough on its own without having to also experience it as too wide ranging or probing, meandering, inefficient, or even nonproductive. Thus, as I work collaboratively with patients on identifying and understanding their goals, I also try to discern where therapy would best be focused for each individual.
While each individuals’ difficulties and struggles can be understood from many levels, defining a focus of treatment means choosing one level to work on primarily. Common areas of focus include things such as internal/identity issues, relationships/systemic issues, life cycle/developmental issues, or other neurobiological matters (e.g., temperament, psychiatric symptoms, etc.).
Each level of explanation or focus has its strengths and weaknesses, and different focuses may be more in line with the patient’s own way of thinking about themselves and the problem.
Choosing what to focus on
During the initial therapy appointment, I typically begin by asking individuals what made them want to seek therapy. In addition to the what, I’m also interested in understanding why now?
While these questions may seem simple enough, they facilitate a way to jump start the therapeutic process and build a collaborative relationship and mutual understanding of the problem, or goals someone has in mind as well as determining a focus for treatment. The what often relates to the goals an individual has in mind for seeking therapy and the why now often reveals important information related to the focus for treatment.
While individuals can sometimes come to their first session with relatively clear goals for treatment, developing a focus for treatment can sometimes take several sessions. Usually, the patient expresses feelings and ideas about their goals and then the therapist works backward to define a focus.
Understanding the why now involves gathering important information about an individual’s life such as their current relationships, stage of life, and relevant adaptations and challenges they may be faced with. I’m also seeking to understand their internal experience and narrative about who they are and why they are the way they are.
One factor that plays a role in determining both the goals and the focus of therapy is an individual’s willingness to make changes in themselves and their lives. Therapy can be hard work fraught with painful experiences and memories, struggles, stagnation, and confusion.
Perseverance to endure these challenges can vary significantly and thus is essential to think about when considering how ambitious of goals to set and how wide of net of focus to cast. Motivation and symptoms can be intricately linked.
For example, when people are overwhelmed by feelings of depression or anxiety, small goals can seem daunting and large ones insurmountable. It is also important to consider motivation as there is something to be said for treating only what needs to be treated.
Wide or narrow focus
In an ideal world, problems would be easily seen, uniquely isolated, and neatly cleaved from the other areas of a person’s life. Occasionally, a problem someone presents with is very specific and narrow in focus; however, more often than not I find that problems tend to extend into multiple areas of peoples lives and to be more pervasive.
For example, an individual may seek treatment for difficulties in their professional relationships, but upon further exploration, find similar problems exist in their romantic relationships or friendships. Another example may be a patient who is focused almost exclusively on a particular symptom, such as panic attacks or obsessive thoughts, but may not realize their anxiety ultimately relates to fears of rejection or abandonment or difficulties with wanting to control unpleasant emotions such as anger.
Not only can symptoms negatively affect other areas of life but improvements to specific problems can also have wide reaching impacts on other areas without specific therapeutic attention. Ultimately, the success of having accurately decided upon the focus of treatment is whether the patient’s self-awareness and understanding of themselves and their problems is developing and getting clearer.
Discovering unstated goals along the way
Sometimes in the beginning of therapy individuals have formulated very specific goals they would like to pursue. However, as a psychodynamically oriented therapist, I also realize that people often act in ways, both knowingly and unknowingly, to avoid aspects of their experience that they find troubling.
I also appreciate that patterns and themes in relationships tend to repeat themselves, and that past experiences can have a way of living on in the present. Thus, while it’s important to discuss and explore goals early in therapy, it is also important to be aware of the ways in which private or unconscious goals or wishes may also present themselves throughout the course of therapy.
For example, many individuals may have unconscious wishes to be protected, admired, saved, or unconscious fears of being abandoned or rejected. Often these types of goals are not explored or discussed at the onset, if they are even things that have been thought about or taken seriously. However, as therapy unfolds, they often show up and provide further opportunities for new goals as well as increased self-awareness.