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When Therapy Is Going Nowhere - Page 2

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Another form of lurching is trying out a different, more dramatic type of therapy without preparing the client. It’s like when a physician moves from prescribing a simple acid reflux medication to scheduling major esophageal surgery without first stopping to reevaluate the diagnosis or overall treatment plan with the patient. For example, in one couples therapy case I consulted on, the husband wasn’t getting over his wife’s affair. The therapist, familiar with the current trendiness of traumatology in the field and having just taken an introductory course in Eye Movement Desensitization and Reprocessing therapy, jumped to initiate two trauma treatment sessions with the husband. Both of these sessions failed, and the therapist gave up on the couple.

In pulling a new technique out of her hat, this therapist failed to ask herself something basic: how could she uncover what might be causing the husband to cling to his grief and anger? She’d regarded the husband’s reaction as a symptom to be expunged, rather than part of a larger narrative. In a sense, she skirted the very heart of talk therapy. But she’s not the only one. These days, many of us are overly focused on the flashy public-workshop intervention in which the proponent of some new attachment-based, body-oriented, Buddhist-inspired, or neurophysiological-leaning approach enthralls us with a new method. When we throw all our energy into the latest fads in the field, we stop working at the essence of what we do: the routine conversational practices of psychotherapy—the skills that keep therapy moving from minute to minute and session to session.

The key to dealing constructively with stuck cases is to treat the clinical relationship pattern first, and only then to consider alternative treatment strategies. The following three steps detail a process I’ve developed, including the words I tend to use, for gently dislodging stuck clinical relationships, without lurching.

Set time to evaluate progress together. After asking the client for his or her priorities for a particular session, I say something like, “I’d also like to spend some time in this session looking at where you are currently in terms of the problems you came to therapy with, how far you feel you’ve come, and where our work is now.” We decide together whether to start with the client’s priorities for the session or with mine. I do this in a matter-of-fact way, not assuming a challenging mode, but letting the client know this will be an important conversation.

Assess where you are in the course of therapy. After listening to the client’s sense of progress and affirming whatever I can agree with, I ask follow-up questions that direct attention to the work we’re doing together. An example might be something like this: “Where do you think we are in terms of our work in therapy? Are we in the winding-down phase, the middle phase, past the middle phase?” This question implies that we aren’t going to be doing this work forever—that there’s a beginning, middle, and end, and that the client has a big say in determining the timing of our work. Generally, I accept whatever the client offers as an appraisal of our current stage of work.

Share your perspective on the “plateau.” In the third phase, I share my perspective on the plateau I see in our work. I’ll say something like, “As I’ve been thinking about our work, it seems to me that significant changes were coming in the earlier phases, which is common, and that we reached a plateau a while back. I don’t know if you see it that way.” Plateau is a more positive description than saying therapy is “stalled” or “unmoving,” and invites the client to join me in evaluating the recent results of therapy. I focus on “we” and “our work,” not just on the client’s individual movement. In this way, I acknowledge that I’m part of this system and have a role in everything that goes on; I share space on the plateau. With this framework set up, most clients agree that we’ve been circling around issues without much forward progress. I sometimes even say that I prefer to work intensively with people and take breaks from therapy, rather than stay on plateaus for too long.

For one couple I worked with, the pressure of coping with their son’s problems had brought them into couples therapy at the recommendation of an adolescent psychiatrist who was alarmed about how divided they were in dealing with their son. Of course, they had marital issues as well, including difficulty with emotional intimacy, which they were trying to tackle. But that phase of the therapy was slow going. They seemed to use the sessions well, but admitted to inertia at home, where they rarely followed through on what they’d learned in our sessions. Despite my best efforts to have them reflect on what might be blocking the energy for intimacy, therapy was bogging down.

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