The first few sessions with Cain are evaluative and consist of multiple rounds of therapeutic dialogue aimed at establishing rapport. The therapist’s style is premised on an authentic interest in Cain. Wanting to learn more about him, how he feels, and what circumstances have contributed to his suffering is the fuel that sustains dialogue. Without a genuine interest and desire to know Cain the therapeutic dialogue will fall flat.

Showing genuine interest in another human being can be transformative for the person on the receiving end. For example, Margarethe Walter was taken to see Sigmund Freud, a notable psychotherapist, when she was 18yo. Recounting the therapeutic dialogue many decades later she said, “He was the first person who showed a genuine interest in me and who really listened to me…it completely changed my life” (Roos, 2016).

Once the therapeutic alliance is established, the therapist orients Cain’s expectations. The patient needs to understand what it is they’re committing to and what outcome to expect from sustained therapeutic dialogue. The endeavor of orienting Cain goes above and beyond the initial informed consent. Some patients will come right out and ask, “So, what am I supposed to do, just start talking?” Others ask, “How does this work?” Most often, new patients don’t know what to ask or how. Whether or not they ask, the therapist is responsible for answering these questions, spoken or unspoken.

In short, Cain is informed that successful psychotherapy often takes more than 30 hours of dialogue. Sessions are front-loaded, meaning we meet more frequently in the beginning. Most people engage in therapeutic dialogue weekly for the first few months, then taper to bi-weekly and finally monthly. The average term of care is approximately 14 months.

Cain is told that the first few hours of therapeutic dialogue are evaluative. It takes more than a single hour to properly assess and determine the proper treatment target. Patients present with symptoms such as panic attacks, depressive episodes, or ruptured relationships. However, uncovering the root or underlying issue is imperative and takes time. Second, patients are asked to evaluate themselves between sessions. For example, with Cain, who presents with knots in his stomach, the therapist will ask him to note all he can about his symptoms between sessions, such as the frequency, intensity, and duration of the episodes. All the details pertaining to the contextual factors, such as who, what, when, and where these “knots” present, will be made conscious and thoroughly processed to determine the treatment target.

The patients’ own observations are valuable from an evaluative standpoint because they contain perspectives, behavioral patterns, and emergent interpersonal dynamics that will serve as the basis for a cohesive material to be transformed. 

Emotions are bits of data stored in the body that remain unconscious (Damasio, 1999; LeDoux, 1996; van der Kolk, 2014; Barrett, 2017). This biochemical information, when activated, is experienced cognitively, either aligned with vulnerability or in defense against it, and often acted out behaviorally without choice or conscious awareness (Panksepp, 1998). For example, the knots in Cain’s stomach are unconscious material manifesting as learned behavior when he’s faced with situations, such as therapy, that his body senses are unsafe. When dialogue becomes deeply emotional, and he’s on the verge of feeling vulnerable, then the anxious knots surface in his abdomen, his body tightens, and he turns away from the therapist. He’s acting as if this setting is unsafe, but has no idea why, because the story he’s come to confess in therapy remains unconscious.

Usually, the patient’s first attempt at data collection during the evaluation phase of psychotherapy is limited. They often miss the unconscious behavioral and relational aspects of their presenting issue. At best, they can identify bodily sensations, such as heaviness or tightness, and occasionally mentation, such as thoughts associated with their mood states. This is only the beginning of the birth of productive self-awareness, and like a baby, the process of observing self and collecting data must be nurtured week after week (Lane et al., 2015; Dimaggio et al., 2015; Hayes et al., 2012).