Therapy’s agenda is based solely on the patient’s needs

When someone is in therapy, should the therapist have an agenda or a curriculum after determining what the patient’s issue is/issues are? It seems that talking about what’s on the patient’s mind each week will only lead to a bunch of disjointed sessions and won’t lead to resolution of the underlying issue. Who should be in the driver’s seat during therapy? Who should determine the direction of the discussion? The patient or the therapist?

— G.R., Las Vegas

Yes. No. Maybe. It depends.

Seriously, there are as many answers to this question as there are patient circumstances, patient diagnoses, therapists and therapeutic models. But let me try to sort out the broad strokes, at least.

Classical psychoanalytic theory would describe the therapeutic agenda only in macro terms. That is, psychoanalysis identifies and works through (makes conscious) unconscious feelings, thoughts and behaviors. That’s the agenda. And the way a strict psychoanalyst goes about realizing that agenda is … by not having an agenda!

The psychoanalyst offers little or no self-disclosure. He/she nurtures and guards a comprehensive neutrality — what Sigmund Freud called “the blank slate.” This “therapeutic opacity” is provocative to the patient. Or, I should say, the hope is to provoke in the patient dialogue, body language and assortments of feeling states through which the therapist will sort, analyze and then interpret back to the patient.

Now, having said that, let me hasten to say that there are very few strict psychoanalysts left in the world this many years since Freud’s pioneering work. Most therapists are “theoretical mutts,” as it were, each perhaps with specialties and preferred clinical bias but having been trained in and amalgamated a breadth of modalities.

Most people need more of an agenda, regardless, and for two reasons. First, very few Americans have $200 once or twice a week (for upward of two years!) of discretionary income to afford classic psychoanalysis. And modern insurance panels won’t touch these kinds of expenses. Plus, insurance panels sometimes won’t pay you unless you can articulate goals and objectives (an agenda) for therapy.

But, even more important, many of the patients who present themselves for therapy don’t have two years of discretionary time! I’m saying many patients need things to change right now, before someone gets fired, goes to jail, gets a divorce or dies.

Cognitive Behavioral Therapy and Dialectical Behavior Therapy are two modern modalities that have clear agendas. The former is about problem-solving and behavioral changes. The latter includes the former but is especially aimed at teaching people how to tolerate the discomfort of intense emotional experience and how to be more discerning about the necessity of intense emotional experience.

My own “therapeutic mutt” includes narrative therapy, family systems (Bowen), but leans most especially on constructivism. The latter means asking questions in a way that invites patients to deconstruct vestigial, unhappy or even destructive world views and to reconstruct happier, more constructive world views. I’ve always got a “Freudian camera” running, as it were, alert to splitting, transference, dreams, slips of the tongue, body language and/or other signs of the unconscious life crying out for attention. But, like most modern clinicians, strict psychoanalytic theory is not in the forefront of my work.

In the first session, my first question is always, “Why are you here?” So, right out of the gate, I suppose I’m asking a patient to propose an agenda. And sometimes what they propose turns out to be the agenda. Other times the presenting issue pales, fades or is entirely discarded and forgotten. I’m saying you’d be amazed how often the conscious, presenting issue is more the occasion to make the appointment. The real reason/issue emerges later. From the unconscious.

In later sessions, I might ask that same question in the converse: “How would you recognize when counseling is over/completed?” With questions like these, I keep floating and circling back to a review of what the patient is getting out of the sessions. What he/she still wants to get out of this work.

I also, frankly, do a lot of psychoeducation. I’m always suggesting books. I suppose you could say I have “a curriculum” for healing infidelity. For divorce, remarriage and blended family. Certainly for suicide intervention. I teach type/temperament theory. Parent education makes up a ton of my work. I say, “Have you tried …” and “I wonder what would happen if …” a lot. Brainstorming. Just pulling on experience.

Bottom line? Skilled therapists will know when it’s time to push you a bit on clarifying goals and objectives. But they will also know when to wait. Specifically, when to give you a neutral time and space within which you might hear the voice of your unconscious.

When the unconscious is ready to deliver its great treasures forged timeless in the depths of the human soul … well, who would want to interrupt that with a mere mortal agenda?

Steven Kalas is a behavioral health consultant and counselor at Las Vegas Psychiatry and the author of “Human Matters: Wise and Witty Counsel on Relationships, Parenting, Grief and Doing the Right Thing” (Stephens Press). His columns also appear on Sundays in the Las Vegas Review-Journal. Contact him at 702-227-4165 or