In a revealing study by Philip Kendall, David Kipnis, and Laura Otto-Salaj, reported in Cognitive Therapy and Research in 1992, therapists were asked how they handle failing cases. Nearly 30 percent said they refer to someone else, 41 percent continue with the same treatment, and only 26 percent said they change their approach to treatment. This suggests, at the very least, a lack of flexibility in some therapists, who may not be willing or able to shift their approach to suit different clients.
Another interesting study by Clara Hill and her colleagues in 1993 found that therapists are often unaware of clients' unexpressed reactions to therapy. Furthermore, 65 percent of the clients in the study left something unsaid (most often negative), and only 27 percent of the therapists were accurate in their guesses about what their clients were withholding. Clients are often too polite to be strictly honest and would rather slink away unheard than say something that might "offend" the therapist.
Gauging Emotional Intensity
The second question that should be considered with each new client is how much emotional intensity the person is seeking. The common expectation is that clients will want to discuss their problems at a deep level. However, an emotionally intense dialogue may not be right for every client, and few are prepared to share their deepest feelings in the first session.
One of my clients, who was having a difficult time in therapy, confessed to me that she thought she might feel more comfortable with a female therapist. I congratulated her on her ability to voice her needs. A few weeks later, she called me and pled to return to therapy. She'd tried a female therapist and, to say the least, it hadn't worked out. "Oh my god! Dr. Short, it was awful! This woman made me sit in different chairs and pretend to be different parts of myself. There was just no way I could do this, but I felt that I had to because she was so insistent." The client didn't tell this other therapist that she found the treatment unbearable or that she was going to leave therapy—she just never returned.
This client was exceedingly uncomfortable with emotional processing, which made any therapy difficult for her. However, she returned for more sessions with me because I didn't ask her deep, probing questions or have her provide details when she was discussing difficult subjects. More than once, I offered to change the subject, which paradoxically made it easier for her to let me into her private world.
By contrast, if an emotionally needy individual enters therapy in tears and the therapist responds with a blank expression and little evidence of empathy, the interaction could feel cruel. Although such a response seems to defy common sense, I've witnessed expert therapists use the blank-screen technique with individuals who weren't emotionally prepared for this type of interaction.