Why Does Consistency Matter?

For many people, therapy is sought out in response to a crisis, or as a last-ditch attempt to deal with some form of chronic mental or emotional dis-ease. The assumption is usually that the therapeutic encounter is something akin to a doctor/patient relationship – I feel broken so I need a doctor to fix me. As the mechanisms that make psychotherapy effective are much more complex than a doctor/patient dynamic, the layperson usually requires some form of psycho-education about what therapy is, how it works, and why.

The appropriate framing, determined by the therapist’s approach and the individual’s unique circumstances, in most cases, is essential to help clients feel safe and secure. This is an ongoing conversation that evolves from the beginning stages all the way to the conclusion of the work. A crucial aspect of this framing that is sometimes either challenged or resisted relates to consistency of attendance. Although there can be exceptions, in this essay I will outline some good reasons why therapy is most effective when it takes place on a weekly basis, and what unconscious motivations might be at play when there is a wish to break that structure.

The most obvious place to start is to point to the ways in which therapy can offer the experience of a reparative attachment. Arguably, this is the core mechanism of action for the majority of long-term therapeutic approaches. More goal-focused approaches such as EMDR and CBT are not concerned with encouraging an attachment, but with targeting very specific memories and symptoms with tried and tested technique. I have noticed that many clients who have had some degree of success with these approaches will, at a later point, seek out longer-term depth psychotherapy to meet a need for a particular type of holding that consistent therapy provides. In simple terms, it is the depth of relationship that is sought, rather than the accumulated knowledge or well-practiced technique of the therapist. This motivation is not usually explicitly stated, but rather implied when the presenting problem that brought the client to therapy, or the content, recedes into the background and is replaced by the being with of relationship, which now becomes the foreground.

This foreground/background reversal is highly significant as it marks a shift from a left-brain focus on analysis and solutions to a more right-brain, holistic way of perceiving oneself and the therapeutic process. Crucially, it also signals the beginning of an integration of polarity within the psyche of the client. The list is endless, but some examples of polarities relevant to this essay are - self/other, mind/body, conscious/unconscious, and left/right hemispheres of the brain.

British psychiatrist and author, Ian Mc Gilchrist, writes in The Master and His Emissary, about the different way in which each hemisphere of the brain perceives the world and processes information.

According to McGilchrist, the left-brain sees the world as made up of distinct parts, has a very narrow attentional field suited for grasping, uses analysis and rationality to navigate, and seeks to manipulate the world. It controls-by-doing.

In contrast, the right-brain perceives the world as made up of nested wholes, has a very broad attentional field suited to perceiving connections, uses intuition and pattern-recognition to navigate, and relates to the world. It allows-by- being.

Importantly, their 'proper' relationship to each other is made explicit in the title of the book; the left-brain's appropriate role is emissary, or servant to its master, the right-brain. This ideal might look like the ability to feel the fundamental wholeness of reality, while retaining a capacity to discern and manipulate parts; compassion, wisdom and utility are the result.

McGilchrist's convincing thesis states that most of the problems of contemporary Western societies emerge from our left-brain dominance. In effect, the servant has usurped its master and is doing a very bad job at ruling.

A short explication of why this is relevant to both the subject of this essay and successful therapeutic outcomes will follow.

Trauma of all kinds give rise to a fragmented experience of self and world. Specifically, early-life attachment trauma forces the developing psyche to split-off intolerable feelings and memories such that a functional false-self, or persona, is cobbled together from the chaos. This false-self is a collection of defences against registering the undigestible pain of either abandonment or annihilation - the twin fears that infants must negotiate at a critical stage of development called the rapprochement crisis*.

The nature of the infant’s primary attachment relationship will determine how successfully these fears become integrated with the conscious self. Inadequate or inconsistent care means the infant cannot use his attachment figure to hold and process powerful emotional states which, undigested, are forced into the unconscious where they exert a disruptive and destructive influence in adult life.

*Margert Mahler describes the rapprochement crisis as a phase within the larger and critical separation-individuation transition that infants must navigate. This phase, spanning approx. 15-24 months, is the point at which the infant vacillates between the safety of its fusion with mother, and the curiosity and excitement of its developing independence. Closeness with mother arouses fears of annihilation, or loss of self, while distance from mother arouses fears of abandonment.

The splitting-off of ‘bad parts’ happens simultaneously in the internal and external world - which is now perceived as a collection of separate good and bad objects. It’s important to note that some degree of this kind of splitting is both necessary and normal in the course of development. What I’m invoking here is a somewhat extreme example that gives rise to a sharply contrasted experience of the world where a capacity for nuance is replaced by black and white thinking and overwhelming emotional states. This results in a dissociative defence, and correlates with a left-brain bias towards reductive thinking, which is further reinforced by our current educational and scientific paradigms.

How, then, might weekly therapy affect a healing of the splits caused by trauma?

Returning to an earlier point, in the initial phases of psychotherapy, the content is the focus or foreground, and the container the background. Content can take the form of a recapitulation of one’s life story and its significant events in the effort to connect the disparate parts into a cohesive whole that makes sense on a cognitive level. It also frequently involves a frustrated dialogue about one’s limitations, and implicit or explicit demands for solutions. This is the fix me frame that people invariably bring to therapy, and it is characteristic of a wilful, left-brain, and goal-oriented state of consciousness. This left-brain bias is akin to using the wrong tool for the job, and unbeknownst to the client, happens to be contributing to many of the problems that have brought them to therapy in the first place.

Provided the therapist is successful at establishing trust and rapport, the client will feel safe enough to relax their defences and the work can move into a different phase where the cognitive content becomes less urgent, and the containing quality of the relationship begins to be registered consciously. This allows more space for the exploration and processing of emotional affect.

A foreground/background reversal replaces compulsive doing with a sense of shared being. 

A useful analogy here is that of tuning forks and the resonance that forms between them. Consistent therapy encourages the psyche to open at progressively deeper levels, as an attunement or resonance between therapist and client occurs. This correlates with the increasing activation of the right-brain and gives rise to an embodied felt-sense of the therapeutic space as a whole, rather than a collection of parts. The conscious experience of this attunement is the kind of relational intimacy that is resisted, precisely because it unearths primal unmet needs, and traumatic early-life associations and memories; exactly the undigested aspects of the psyche that require care and attention.

If relationships have been experienced as unsafe, the prospect of risking another rejection of one’s most vulnerable core-self seems entirely too devastating.

Perhaps a mytho-poetic framing is the best way to convey the anguish of early-life attachment trauma, and appropriately for this topic, it happens to be the language of the right-brain.

It’s as if the soul recoils from the pain of separation inherent in embodied existence, so retreats into the fantasy-life of the mind, resulting in a chronically avoidant disposition. Unwilling to endure the descent into matter, it exists in a kind of drowsy limbo where it can retain a connection to spirit, never feeling safe and supported enough to experience the limitations of embodiment. If we propose that the fundamental purpose of the soul is to fully incarnate for the short span of its journey through matter, this retreat becomes a retrograde move, albeit a necessary protective strategy. The soul, whose nature is eternal and unbounded, seeks a physical life precisely to have an experience of limitation that it cannot have in its natural domain. Without the tempering and creative friction of limits, it meets no resistance against which it can develop itself.

At its very best, the consistent holding of the therapeutic relationship can function as a container for the soul to complete it's descent into matter.

At this stage, you may be thinking - why do I need weekly therapy for this? Surely, other kinds of relationships can serve the same purpose?

In answer to the second part of the question - I agree, other kinds of relationships can serve the same purpose, but I would argue that this is an exception to the rule.

When you make the decision to start therapy, you are paying for a very specific kind of relationship; one that is focused on your needs, and with a relationship partner who has integrated enough aspects of their unconscious such that they can offer a compassionate and discerning perspective on your life - one that is largely free of distortion, personal agenda, and their own undigested shadow material. Provided your therapist has found their way to the profession with an innate capacity to think psychologically, and to understand the landscape of human transformation in their own experience, there is a good chance that you will have found a reliable and clean-enough mirror upon which to accurately see your life’s reflection, in both its light and dark hues.

Other kinds of relationships rarely offer such a mirror, at least without some skin in the game, so to speak. ‘Ordinary’ relationship partners come with their own attachment needs that demand some emotional and conversational reciprocity, and thus offer a somewhat distorted mirror. Although a kind of reciprocity can and does emerge over time with a therapist, clients are not required to reciprocate in order to avail themselves of the relational nourishment they might need. While the therapist’s fee is compensation for relevant experience, accumulated knowledge, and extensive training, it is also a proxy for this kind of reciprocity, and it allows the relationship to become a container for all kinds of useful projections and unresolved material.

Besides the person of the therapist, there is also the practical structure of the relationship that holds it together even when the waters inevitably become turbulent or placid. These are the times when seemingly reasonable justifications arise as to why consistent attendance is unnecessary. I would suggest that it is precisely during these periods when some of the most important work might take place. Negative feelings and moods such as anger, shame, dissatisfaction, performance anxiety and even boredom, while unpleasant, can often be surface manifestations of unconscious grief or fear related to attachment trauma. In this case, there may be a learned and habitual avoidance of relationship due to a fear that one’s needs or destructive feelings are too much for anyone to bear, including a therapist. Importantly, the roots of this avoidance are usually unconscious and will manifest as perceptual distortions that justify distancing impulses. Another name for this is projection.

While the boundaries of weekly therapy support the therapist, they are also there to contain these dark and destructive parts, and to hold the natural expansions and contractions of the psyche. As these are frequently the parts of ourselves that were most disparaged, criticized, humiliated, or neglected, they require the most holding. Holding does not simply equate to a passive tolerance, but is a willingness to engage with constructively and compassionately.

On the occasion that I do accommodate a client's wish to attend on a bi-weekly basis, I notice several issues that consistently appear. The therapy hour inevitably becomes a kind of check-in where the content is the focus, leaving little room for process, nor the deepening of the relational space. In this way, the potential depth of the therapy is limited, and so too its effectiveness.

'I wont have anything to talk about if I come every week' is a common refrain that expresses both a misconception about what makes therapy effective, and resistance to the kind of relational depth that heals - It is precisely within the conscious experience of not-knowing, and it's associated awkwardness, shame and uncertainty that insight, growth and healing can be found.

Learning to tolerate and to find balance in the felt-experience of one's vulnerability is a skill worth the discomfort it takes to master, and it will dramatically improve all areas of one's life.

Ultimately, it is the client's experience of therapy, and not any particular therapeutic framing, that must have the final word on it's value for them as an individual. If value is found in bi-weekly, or even monthly sessions, then it is entirely the client's prerogative to seek out a therapist who can support this. My intention here is to describe the potential landscape of the therapeutic process with the hope such a description might offer some cogent reasons as to why weekly attendance is prescribed - It can be a determining factor for psychological growth.