Clinician's Quandary

How Do I Make Therapy Stick?

Creating a Vision, Building Momentum Between Sessions, and More

Ending a Session-Photo by Timur Weber/Pexels

Quandary: I’m looking for a way to make therapy more memorable for my clients. What’s something you say, an activity you do, or something you have in your office that makes therapy “stickier”?

Make the Moments Count

This is a rather common quandary for many therapists. From a psychodynamic perspective, one would argue that what makes therapy memorable is the therapeutic alliance, the relationship between a therapist and a client. Traditionally, psychoanalysis with children and adolescents only makes use of a therapy box containing string, glue, tape, play animals, dolls, pens, paper and other such resources. Therapy rooms were bare and neutral. Adult psychoanalysis made use of no resources at all. 

However, treatments of this modality are extremely effective, because what matters the most is the human connection being created, the trust developed in the therapist, the safety and containment of the space, of the listening ear and the attentive other. Therapists need to be able to offer their clients an opportunity to work through ways of interacting, of discovering their internal selves as well as reflecting on their social experiences. This is what enables deep, meaningful changes that have a long-lasting impact. While an activity or a physical object may be helpful as medium of communication, it doesn’t necessarily make therapy more memorable. 

That being said, psychoanalysis has also been criticized for being rather persecutory, where the therapist’s silences and body language can be difficult to gauge and relate to, with nothing to do but to stare at one another or into the bareness of a room. 

In my own psychotherapy practice, my office is far from bare and neutral. While I strongly believe in the roots of psychoanalysis, my psychodynamic training has allowed me to develop a more holistic approach. Some clients, particularly parents, caregivers, and older teenagers, often choose to come in the seating area. I often find that having water, tea, and coffee available allows them to settle in and feel more comfortable. The many plants scattered around my office add a sense of tranquility. My younger clients have an array of resources to use, including a dollhouse, a sand tray, an easel, and a comfy corner with pillows. 

A lot can be learned about a client’s internal state by watching them play, move around, and chose resources. It may make sessions “memorable” as they enjoy building with clay or work on a painting or a craft project over several sessions. But it’s how I use these moments—how I interpret a storyline or drawing, or respond to an invitation to play—that matters much more than the resources themselves. This and the way the client’s presence makes me feel are the core principles of meaningful therapy. 

I would encourage this clinician to explore this quandary in supervision—or, even better, in their own personal therapy. Perhaps they feel pressure to sell their services by making therapy attractive or there’s a lingering impostor syndrome that needs some unpacking. 

Florence Nadaud, MBACP Child, Adolescent and Family Psychodynamic Psychotherapist 
Swindon, England


Stoke the Fire of Determination

As a couples counselor, I’m always reminding folks that every interaction with their partner counts. Every interaction brings them closer, drives a wedge between them, or is neutral and simply reinforces the current emotional climate. 

I like to live by the same edict: every session counts. So what makes it count? I’ve noticed that I do two things that seem to be helpful. First, I’m very clear with the couple I see about the desired outcome. I like “to begin with the end in mind.” I ask each partner “If today’s session is to be really useful, what needs to be different for you by the end of this hour?” I find that usually, we then move faithfully toward these desired outcomes throughout the session. Along the way, some clients may—and can—adjust their priorities, but I do my best to focus on what the clients have asked me to focus on.

The second thing I’ve found helpful is writing to my clients between sessions. Sometimes if partners have identified a new behavioral or emotional pattern between them that they want to tease out further, I’ll summarize what they’ve identified, sometimes by sending a letter of appreciation for their hard work. Sometimes I’ll also send along resources, like specific couples therapy strategies or articles about romantic partnership. To be clear, I ask for partners’ permission in advance and include these details in my Informed Consent. Do they want to correspond with me between sessions? Is there a private email address they feel comfortable using with me? I like to think that by being genuinely curious and supportive outside of the therapy hour, I’m stoking the fire of a couple’s determination.

Gemma Utting, MA, LMFT, CLC
Boise, Idaho


Check in Often 

Not all clients are ready to do the work it takes to bring about change in their lives. Many have no idea what therapy is, how it works, or know how much time, energy, and investment is needed to accomplish their goals. In the very first session, I explain how I’ll be utilizing their time and energy in sessions, and the work they’ll need to do in and outside of therapy. Providing this clarity helps clients better understand what they’ll need to do to succeed. It’s the client’s work and desire for change that moves the therapeutic process forward too. 

There are, however, some clients who resist exploring their thoughts and feelings. They may find homework assignments burdensome, or even discover midway through therapy that they’re just not as interested in it as they thought they’d be. These clients may have done all the work they’re comfortable doing, or an internal fear of change may be impeding their progress. I find that engaging my empathic curiosity by using supportive, frequent, and ongoing review and modification of goals helps these clients feel validated. It helps them see how therapy and their own work provides incremental progress toward their goals. I also find that regularly following up on homework assignments and assessing how useful clients find these assignments keeps them—and me—accountable.

When a client regresses to old behaviors, or the progress is not obvious to the client, I usually engage the client in gentle self-reflection. How do they now regard the issue that originally brought them into therapy? Has their situation changed, and if so, how? Do we need to consider additional or different approaches? Many times I find the client is struggling with past issues that have resurfaced, or issues that they didn’t disclose initially. Whether they’re related to early life thinking and behavior patterns or present-day stressors, they need to be addressed in order for us to move forward. If the client is interested in exploring these issues, I’ll update our goals. I find that there’s no one-size-fits-all approach, and being flexible with clients based on their present-moment needs is key to working effectively with them.

Focusing on where the client is at all times during the therapeutic process is an important part of maintaining their engagement. Empathic curiosity on the therapist’s part, as well as honest reviews of the client’s progress is also necessary. Sometimes it may even be necessary to refer a client out. The bottom line is the client’s needs come first, and it’s the therapist’s responsibility to empower them to feel engaged in therapy and own their successes. 

Janice Sandefur, LCSW, ACSW
Ocala, Florida 


The Mood Meter

In my therapy practice, I’ll often introduce the visual of a “mood meter, with a scale of 0 to 10. Zero is “the cool zone,” the calmest mood, whereas 10 is “the hot zone”—the worst imaginable mood. When clients tell me where they fall on the scale, I move my left arm up or down. If a client is getting activated or hurriedly giving lots of details about a story, I may shift the language and use a high, medium, and low settings (as well as hand movements) to convey their emotional intensity. 

When used regularly, I’ve found that a mood meter is a helpful way of regulating our thoughts, feelings, physical sensations, and behaviors. You can check in with yourself and ask “What am I feeling right now, and where am I on my mood meter?” You can also pose this question to clients. They might respond with something like, “I’m so angry about what happened. I feel my shoulders getting tense, I’m starting to pace, and I’m clenching my hands. This feels like an 8. I’m definitely nearing my hot zone.”

By labeling our feelings and sensations in the moment, we’re slowing down our reactivity and, stopping impulsive behaviors, and preventing negative consequences while moving towards making more conscious choices. We’re allowing a pause to happen, which gives us time to think through next steps. With clients, I demonstrate this pause by breathing audibly—inhaling, and exhaling—while sitting back in my chair with my shoulders back and my chin up. I tell them that before we react, it’s helpful to think about how to approach the issue at hand, to first answer the questions, “What’s the best way for me to handle this? What are my choices here? How do I want this to go?”

This problem-solving approach can help decrease the amount of time clients spend in a higher mood rating, decrease how often they feel reactive, and reduce elevated reactions if they’re triggered in the future. With practice, clients can stop and think, “I’ve been through this before.”

We learn to regulate our mood by becoming familiar with our triggers, developing different coping strategies that help us at each stage of our mood meter, and better matching our reactions to specific situations. Just like that, a mood meter can connect us to our feelings, thoughts, physical sensations, and behaviors and help us feel better sooner.  

Lenora Ziegler, LCSW, C-DBT
Manalapan, New Jersey



Next Month’s Quandary: One of my clients takes prescription medication for anxiety and often complains about the negative side effects. I can’t help but feel it’s getting in the way of his treatment, but I hesitate to suggest he get off the medication since I’m not an expert in this area. What should I do?

Photo by Timur Weber/Pexels

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