It is much easier to meander across a myriad of worthwhile topics and legitimate concerns and not connect the conversation to what the client can do between sessions to improve his or her quality of life.
The great Jeffrey Kottler and the late (and great) Jon Carlson (Kottler & Carlson, 2014) asked me to consider four questions about what made my work effective. This is the third of four blogs that addresses these questions.
What do most people, and even most professionals, not really understand about what it takes to be really accomplished in our field?
There are two things (in addition to ongoing attention to the alliance). First, while proponents of different models would like you to think otherwise, the truth of the matter is that we don’t know ahead of time what model or technique will be helpful with the client who is in our office now. In other words, there is a lot of uncertainty that accompanies the work of psychotherapy. To be accomplished, I believe, is to embrace uncertainty. It is the place of unlimited possibilities for change, the space for new directions and insights to occur to both the client and the therapist. I discussed uncertainty in a previous blog.
The second thing that I think is very understated regarding doing good work is perhaps the most difficult skill for therapists to master, namely the ability to keep sessions focused and not get lost in the sometimes confusing and nearly always complex ways that clients unfold their stories. When the conversation jumps from important topic to important topic without thematic connection or relevance to the way the client is experiencing life between sessions, it is almost a guaranteed recipe for failure. But it is not easy to change this dynamic. It can require therapists to step up their involvement and steer the conversation toward ensuring that some meaningful difference is accomplished in the client’s day to day life.
But it can be tricky to follow the client’s lead while simultaneously never losing sight of where the client wants to go—to balance being empathic to the sometimes overwhelming presentation of topics and concerns with ensuring that these topics and concerns are tied to making a meaningful difference in the client’s experience of life. It is much easier to meander across a myriad of worthwhile topics and legitimate concerns and not connect the conversation to what the client can do between sessions to improve his or her life. The unfortunate result is a therapy that devolves into an ongoing commentary of the client’s life that never leads to any real change. Sometimes such practices fall under the euphemistic categories of “process oriented” or “supportive therapy.” These therapeutic stances often have negative effects in clients’ lives.
But, it’s not easy. I have been there and done that. I used to write in my progress notes, “Get some focus, dummy!” What I ultimately concluded was that it was my job to ensure therapy had a focus, a purpose beyond processing the everyday occurrences of life and providing support. All therapy has those components, but it is not therapy without a commitment to change. While some clients and situations can be challenging, therapy must build the bridge between what is discussed and what will improve the client’s quality of life.
It doesn’t have to be heavy-handed and it is, of course, collaborative. For example, I ask clients whether they think it is better for us to continue talking about the topic at hand or whether we should return to what they are most concerned about. I also ask if it is okay with them if I return us to task from time to time. Other useful questions: You raised several important issues. Which one do you think we should focus on first? Which one, if improved a little, would provide the most relief?
The Partners for Change Outcome Management System (PCOMS) really helps here. Monitoring benefit on the Outcome Rating Scale (ORS), after ensuring that the client’s reasons for service are represented, enables the focus to start and remain on what the client would like to see happen. It helps the therapist stay on task and channel the complexities of clients’ lives toward something tangible that will make a difference.
Processing and supporting, without a dedication to change, are what friends are for. Therapy is those things plus a deliberate focus on change.