What is the system or flowchart that therapists use during psychotherapy conversations?

Psychotherapy Conversation Framework

Therapists use a structured three-phase framework (opening, middle, and closing phases) combined with a hierarchical spectrum of verbal interventions that progress from conscious to unconscious content, rather than following a rigid flowchart. 1

Three-Phase Treatment Structure

The therapeutic process follows distinct phases with specific tasks at each stage 1:

Opening Phase

• Initial evaluation and case formulation using psychodynamic theory to develop hypotheses about developmental and conflictual sources of difficulties 1
• Establishment of treatment framework: regular time/place, confidentiality arrangements, behavioral limits, and therapist role clarification 1
• Engagement of patient and caregivers to build a trusting, confidential relationship 1
• Transitions to middle phase once visit patterns and working alliance are established 1

Middle Phase (Longest Component)

• Identification of patterns in play, conversations, and transference relationships that reveal internal conflicts and maladaptive relational patterns 1
• Facilitation of change through repetition and elaboration ("working through") of themes 1
• Continual updating of case formulation as new psychological resources develop and deeper conflicts emerge 1
• Therapist follows the child's lead in a non-directive approach to maximize self-expression 1

Closing/Termination Phase

• Consolidation of therapeutic gains and preparation for separation 2
• In brief therapies (6-20 sessions), termination tasks are addressed throughout treatment rather than only at the end 1

Hierarchical Intervention Spectrum

Therapists select interventions based on the patient's ego strength (psychological capacities including intelligence, reality testing, impulse control, frustration tolerance, and affect management) 1. Children with good ego strength benefit from expressive therapy targeting unconscious content, while those with low ego strength require supportive interventions 1.

The intervention hierarchy progresses from conscious to unconscious levels 1:

Level 1: Conscious Content

• Ordinary social behavior: conventional greetings and leave-taking 1
• Treatment-related statements: information about session structure, behavioral limits, therapist role 1
• Life-related questions: biographical data collection while respecting resistance 1

Level 2: Supportive Interventions

• Educational statements, suggestions, encouragement, reassurance, and empathy 1

Level 3: Facilitative Statements (Preconscious)

• Invitations to continue: convey emotional availability and encourage verbalization of experiences 1
• Review statements: paraphrase, summarize, or integrate what the child said/did to validate subjective experience and model self-observation 1

Level 4: Clarifications (Preconscious Realm)

• Preparatory statements: focus attention on possibility of new meanings in comments, affects, play, and behaviors 1
• "Look at" statements: specifically identify and direct attention to affects, thoughts, behaviors, or play occurring in-session to engage the observing ego 1

Level 5: Interpretations (Unconscious Content)

• Clarification and interpretation of feelings and internal conflicts in developmentally appropriate terms 1
• Can be delivered directly or within the play metaphor ("the daddy doll" not "your daddy") 1

Key Decision Points

The therapist's assessment of ego strength determines intervention selection 1:

• High ego strength → expressive interventions targeting unconscious material
• Low ego strength → supportive, developmentally-assistive interventions

Therapist neutrality (non-judgmental, respectful, empathic attitude) establishes the secure relational setting and fosters free expression 1

Countertransference awareness allows the therapist to gain insight into the child's internalized conflicts from feelings the child induces, while preventing the therapist's own conflicts from undermining neutrality 1

Common Pitfalls

• Becoming an interrogator when collecting biographical information—respect the child's reticence and resistance 1
• Failing to work within the play metaphor when making interpretations, which can make interventions intolerable to the child 1
• Selecting expressive interventions for children with low ego strength, who may become overwhelmed by painful feelings and thoughts 1
• Ignoring countertransference reactions that provide valuable diagnostic information about the child's internal world 1