Behold the man, Jacques Lacan himself, certainly not Freud and possibly a fraud. And yet even charlatans have insights. What were his?
The patient does not want to change. From the time he enters therapy, he's invested in return to his status quo.
Before he'd come, his symptoms had been a substitute satisfaction for what might really one day benefit him. At least initially, symptoms provide satisfaction of one kind or another, even though they fact may not be obvious at first blush to outsiders or even to the patient himself.
Therefore, the therapist can never rely on the patient's own desire to change. Such a desire doesn't exist. As such, much of his therapy is, for the patient, to get back to the symptom.
The patient is only there because his substitute satisfaction has failed him and he would like to return to it. Without outwardly disabusing the patient of his delusions, the therapist must represent a pure desire for the patient's presence and return, a desire for the patient to keep talking, without obviously prejudicing the patient toward one life decision or another. This is the beginning.
The beginning of therapy is with the jouissance crisis, the patient's failure to get a kick out of his own dissatisfying satisfaction, his own suffering, the cage he had come to love, and loves no more.