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When Therapy Is Going Nowhere

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PNMJ13-2Escaping the “Groundhog Day” Cycle

By William Doherty

Why do we get stuck in “Groundhog Day therapy”—cases in which we spin our wheels from session to session? Before lurching on to alternative treatment strategies, the key to progress is recognizing the need to shift the therapist–client relationship.

Although you can’t tell it from the cases that appear in publications and training videos, psychotherapy mostly involves talking to clients who like working with us, but find it hard to change. Eventually, rather than helping these clients navigate dramatic whitewater rapids, our main challenge becomes steering the clinical relationship out of the swamps and marshes where it can get stuck, sometimes for years.

Our long-term clients might have us banging our heads against the wall at times, screaming, “I can’t believe you’re making that self-destructive choice again! After all this time, haven’t you heard a word I’ve said?” But mostly, they elicit far less dramatic reactions. They’re cooperative, agreeable, and attached to us as therapists. They’re open to our insights and suggestions, fill a regular time slot in our schedule, and pay their bills. So what’s the problem? Nothing—except that not much goes on in sessions: no implosions or explosions, no breakthroughs or backslides, no itching to finish therapy and get on with life. It starts to feel like “till death (or retirement) us do part.”

Often when we begin with these clients, our early work generates some movement and change, but then a kind of stagnation sets in. This is the case with my couple who’s fully engaged in therapy sessions but “too busy” to try anything different at home, and the woman who uses sessions to recap the ins and outs of her week but never addresses any serious issues. Without much happening—with no real intensity or vitality—ease eventually turns to boredom, at least for the therapist. After months or years circling the same issues, we end up with what I call “Groundhog Day therapy,” named after the early 1990s film in which a burned-out TV weatherman played by Bill Murray is doomed to live through the same day, with the same events, over and over again.

So why do therapists tend to get stuck in clinical relationships where we spend session after session spinning our wheels? One reason is that these sessions ensure a predictable, paying slot in our schedule. Another reason, however, is that we usually don’t tell anyone about these cases. We reserve supervision or consultation for more compelling crises or direct conflicts in the clinical relationship. Groundhog Day cases, where no one is threatening divorce or suicide, lack the drama of standard consultation cases. We might worry that even our consultation groups will get bored of hearing about the same client who isn’t particularly miserable, but isn’t leading the life he or she wants, either.

Another reason we remain stuck with clients going nowhere in therapy is that most of us keep “progress notes” instead of tracking outcomes. I confess to this habit, especially when it came to a couple I’d been seeing for several years. When I looked through a year’s worth of their session notes, more than half of them recorded some improvement from session to session. But when I stepped back and asked the couple to evaluate the progress of their overall relationship, they concurred with me that nothing much had shifted. In fact, a mentor once told me that two-thirds of the records he reviewed for mental health hospitals reported progress, even for patients who never got better overall. As therapists, we like to think we’re making headway, and our clients want therapy to be worthwhile, but treatment sometimes shifts without our noticing it from change-oriented work that has an ending to long-term, maintenance-oriented work that doesn’t have an end point.

So what do you do when you find yourself with a Groundhog Day case? The commonest mistake—one I’ve committed myself—is what I call “lurching,” or making a sudden, unannounced shift in how you’re approaching the client. One form of lurching is shifting abruptly from a therapeutic posture of empathic support to one of hard-nosed challenge. I’ve seen frustrated therapists who’d been oozing nurturance for months suddenly blurt out, “You have a choice: you can stay miserable, or you can get a divorce.” These moves might temporarily shake the client up and reinvigorate the therapy relationship, but they usually end badly. Either the client forgives the unexpected rudeness and therapeutic homeostasis is restored, or the therapeutic relationship spirals downhill until the client fires us.

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