Q: Some clients connect with me more easily than others. How much can a professional do to foster a good therapeutic "fit" with every client?
A: There's a lot you can do—and the faster you do it, the better. In a matter of minutes, new clients will decide how good your relational fit is, and whether to return for more therapy. The first impression is created by the earliest interactions. Even unconscious signals from clients determine how much self-disclosure and emotional risk-taking they'll engage in during the first session, how much benefit they've experienced, and whether they'll return.
For example, a recent client walked into my office and stood distractedly, not knowing what to do. I invited her to sit across from me on the couch. When I asked her why she'd come to see me, she said she'd seen another therapist the previous day, but didn't think she'd return because she didn't feel "understood." I asked her what she'd discussed with the other therapist, and she replied that he'd asked her about her feelings. Following this exchange, she sat passively on the couch, gazing at me, politely waiting for her next set of instructions. So I asked her to tell me the worst thing that had happened to her in recent months. Cocking her head to one side, she said, "Now there's an interesting question. Let me see. I guess it would have to be last week, when my husband put a loaded gun to my head." Out of curiosity, I asked, "Did you happen to mention this to the therapist you saw yesterday?" Again, she gave a quizzical turn of the head. "He never asked, and so I guess I just didn't think to bring it up with him." The previous therapist didn't have much of a chance at success with this client because he failed to engage her properly during the first few moments of therapy.
Clients shouldn't have to adjust their style of relating to fit the therapist: a skillful professional should continually adapt to the interpersonal needs of each client. This ongoing process is informed by three basic questions: How much direction does this individual need? How much emotional intensity is this person prepared for? And what thoughts, feelings, or actions is this person showing me right now that I can use to form a connection?
To Direct, or Not to Direct?
In the example above, the first therapist might have been working from a client-centered model of empathic equality, in which the therapist strives to be as nondirective and noncontrolling as possible. This is fine, unless the therapist is seeking to help a client who needs direction, as this woman did. When she entered my office, she was confused and didn't have much self-direction. Therefore, she needed a therapist who'd tell her where to sit, ask specific questions, and help her figure out her problems.
On a different occasion with another client, I listened to bitter complaints about his first visit to a previous therapist, who, he said, "told me where to sit and how to think." Working from a cognitive approach, the therapist instructed the client to replace illogical and self-defeating thoughts with more realistic and helpful ones. The client felt that this therapist didn't let him talk about the things he wanted to talk about. During my first visit with this man, I mostly sat and listened—not offering any direction until close to the end, when he asked my opinion. He was an artist and extremely temperamental. Rather than asking him to tell me about his problem, I asked him to draw it. This was a request that he thoroughly enjoyed fulfilling.
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.
What produces progress for one client may rupture the relationship with another. If you don't have the habit of carefully studying your clients' facial expressions and physical posture so that you can adjust the depth and pace of therapeutic exploration, you run the risk of being in the position of the therapists described in the previous examples, who acted as if they were completely unaware of their clients' internal reactions to therapy.
Connecting by Staying in the Present
The question of what the client is showing at the moment and how to use it to form a connection covers a broad set of dynamics. When developing a new relationship, people naturally seek out those who seem capable of understanding and accepting them. This validation can occur at the level of thoughts, feelings, or actions. If this validation doesn't occur on at least one level, then seemingly "helpful" interventions can harm the therapeutic alliance.
For instance, at the level of thoughts, if a client believes he's unworthy of love and the new therapist argues that this belief is incorrect, the client isn't likely to feel greater self-acceptance, but rather, misunderstood, as if his thoughts don't matter. Instead, the therapist should be willing to listen quietly and convey openness to whatever the client is saying, without starting a discourse about "dysfunctional cognitions." At the affective level, if a client feels utterly depressed about a particular event and the new therapist responds with a positive emotional tone, the client may feel uncomfortable with his own emotion and more reluctant to express it. At the behavioral level, if the client shares a great deal of personal information and the new therapist responds to questions about him- or herself by refusing to disclose anything, the client may feel that he's in an unfair, hierarchical relationship with an aloof, unbending therapist. He may even feel subtly humiliated by the interaction.
Rather than assuming that there's one correct way to greet all new clients, I try to determine what I can do to make the first visit less stressful for each individual. I've responded to adolescents who said they didn't want to talk by doing all of the talking myself—at least during the first visit. I've responded to others who didn't want to talk and were tired of listening too, by suggesting that they close their eyes and silently collect their thoughts as we sat quietly. When clients experience the therapeutic relationship as a good fit, more energy is available for personal problem-solving and collaborative involvement. In addition to being the primary vehicle for the delivery of care, the strength of the therapeutic relationship—from the very first session—is the best predictor of outcome success. Or as experts in impression management have noted, "As it begins, so shall it end."
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