Other therapists I talk to have shared that they’re seeing not only more anxiety in new clients, but more crises. Clients are waiting longer to come into therapy because of its cost, in time and money. When they arrive, they have a bundle of complicated issues and are looking for immediate relief, as well as a sense of security, support, and belonging. For these clients, I provide more structure in a session and make the process of therapy transparent. I explain what I’m doing out loud as I do it, set measurable goals, validate all advancement, debrief on any and all progress at the end of each session, and emphasize my flexibility in meeting their needs. I call this willingness to be flexible my revolving-door policy—which means telling clients up front that if they need to interrupt treatment because of finances, work, or family demands, they can focus on an issue for a while with me, leave when they want to without any shame or blame (I will never say the word resistance to them), and return and pick up the work when they’re ready, knowing that I’ll be glad to see them again. Using this approach, I’ve maintained consistent therapeutic relationships—although of an often on-again, off-again kind—with ECs for years. Paradoxically, it’s by bending that I make myself a constant, stable factor in the otherwise volatile, insecure world they inhabit.
Recently, I received an email from a potential client, Sherry, who’d found my website and liked the way I explained my services: individual therapy with a coaching approach. We spoke briefly on the phone. She was 26 years old and in graduate school, with few financial resources. She was depressed and anxious, and said she was “shopping for therapists,” so I immediately shifted into EC mode and proposed that she come in for a single session. I have a fee-for-service practice and knew that even a single session would be a considerable expense for her, so I felt some pressure at the start to make the session count. In this session, Sherry had trouble organizing herself. She said she had so much to say and didn’t know where to start. In the past, as a more traditional therapist, I’d have met this statement with silence and a receptive but neutral expression, letting her find her own way into the conversation. This time, however, I asked if she wanted help figuring out where to focus. She nodded eagerly, so I asked her to start by telling me what concerned her the most right now.
I knew that taking this approach meant that I was eliminating some of the unconscious resonance that a blank or neutral nonresponse would have evoked, but since I might have only one session with her, I opted in favor of helping her find something to take away, some small signs of progress I could summarize for her at the end. Although she’d have readily gone in many other directions, I kept her focused on the presenting issue, which was her severe doubt that she’d be able to finish her semester because of her depression and lassitude. At the end, I framed the 10-minute debrief by saying that I wanted to take a short time to hear how she felt about meeting me and our session, so we could discuss what to do next.
“You seem nice enough,” she said, “but I have so much on my mind. I still feel loaded with issues, and I’m not sure how this will help.”
In the past, I’d have heard this statement as part of an unconscious contract for future work to unpack her concerns further. Instead, I stayed with my plan with ECs. “May I share with you what I thought we did here today?” I asked. “We talked primarily about the problem you came in with, how to finish out your semester despite your feelings of sadness and fatigue. We talked about two steps you can take this week: calling your best friend for support and getting out of bed earlier to take a walk before classes. You only need to go step by step this week. We also began to look at some of the other reasons for your sadness. But it’ll take more time to know all the reasons. Based on what we did today, I think you now have some immediate steps you can take to help you feel more in control, if you want.”
Sherry thought about this summary and nodded. “I get it,” she said. “You’re right, that’s what we did. Good.” Then, realizing she was still in shopping mode, she asked to come back one more time. By the following session, she was fully on board for weekly therapy. She told me she’d heard my voice inside her head all week, calming her down, reminding her just to take the next step. She became a hard-working client, who, even after taking a break over the summer to travel, came back in the fall to resume our work.
Do the needs and expectations of ECs like Sherry signal a paradigm shift in how we need to do therapy? If so, what’s lost, and what’s gained? I know that as a therapist and change-agent, it’s important to be open to change myself, even if it means changing the way I understand what therapy means and what it can offer. In a field like ours, it’s hard to know for sure after only one session what each person will need from therapy. What I do know, however, is that today’s clients need to be their own advocates in all areas of healthcare, to find their own information, to choose from various options, and to assert a level of control that would have seemed foreign to clients during therapy’s golden age. Often the best I can offer is to give them choices about ways I can work with them and let them decide what they think might be best. This has the double benefit of allowing them a sense of agency and control, while giving them an opportunity to make mature decisions, at least about therapy.