Who’s Steering the Boat?

Navigating Therapy with Today's Clients

Magazine Issue
January/February 2018
An illustration of two people on a boat

Jess Throndson, an addiction specialist at an Iowa mental health agency, wasn’t feeling optimistic. A past client, John, was back in her office seeking therapy—for the fourth time. Some months back, his wife had begun calling Throndson, telling her John was hitting the bottle again, hard, and wouldn’t stop yelling at her and their five kids. Her husband’s longstanding emotional demons, she confided, had bubbled back up.

Working with John had always been deflating for Throndson. A former Army sergeant, John had a PTSD diagnosis, along with signs of depression and long-term addiction. But he’d been relentlessly buttoned up in therapy. “Everything’s fine,” he’d repeated like a mantra whenever they’d met. “I’ve got it all under control.”

This time, John would be coming into her office sober. He’d just completed a month in residential treatment for alcoholism. But now that he was out, Throndson wasn’t sure the sobriety would stick. She’d learned that he’d gone kicking and screaming into the program after his probation officer had drawn a line in the sand: get therapy, plead your case before a judge, or serve your original three-year prison sentence for bringing a loaded weapon to a county fair.

Throndson wasn’t without hope for him. But she’d been working with addicts long enough to know that those mandated to meet with her were tougher to help than those who came in under their own steam. Plus, John’s PTSD and depression were longstanding. Now in his late 50’s, he was still reckoning with the trauma of his many combat tours. The last three times he’d worked with Throndson, he’d blown off a bunch of their appointments and then bailed out of treatment early.

By now, she’d tried nearly everything in her therapeutic toolbox. She’d utilized the how-to-stay sober protocols she’d been trained in, encouraged him to write down a personal recovery plan he could follow outside their sessions, and advised him to get support from others who’d gotten sober. They’d talked about medication for PTSD and depression. That he was back for the fourth time was all the evidence Throndson needed that a replay of those conventional approaches would be fruitless. She wasn’t sure what, if anything, would help.

Does the Therapist Really Know Best?

What Throndson hadn’t tried yet was a new approach to therapy that’s slowly gaining ground in agencies and private practices around the country, and may shortly become a precondition for behavioral health accreditation and for therapists who work with insurance companies, Medicare, and other powerful institutional players. It’s not about a different protocol, but something larger and more encompassing: a fundamental shift in a therapist’s identity.

Since the earliest days of mental health treatment, when holes were drilled in people’s skulls to cast out evil spirits, the person treating the sufferer has held the upper hand. Just as these protoscientist-healers believed they had enough knowledge to cure the problem, the modern-day therapist remains the assumed expert in the craft of therapy, however gentler the method may be.

Today’s clients, of course, have input, especially in the realm of broad goal-setting: I want to get over my depression, or I want to have a better marriage. But in the unspoken hierarchy of most therapeutic encounters, the therapist is a kind of benevolent guru who directs the process of healing. If a clinician favors a cognitive-behavioral approach, that’s what the client will get. If a therapist believes in the primacy of the body–mind connection, then she might prescribe, among other things, a meditation and yoga practice. And so on.

Of course, these approaches aren’t inherently problematic, and they’re often immensely helpful. What’s different about the emerging meta-approach to therapy is that the client, not the clinician, leads the way in treatment to an unprecedented degree. Clients drop their customary position of mannerly deference and are encouraged to assert specifically what they want—and don’t want—from therapy. Perhaps more harrowing for the therapist, clients are prompted at the start and sometimes at the end of sessions to say, “Here’s how what you’re suggesting is working or not working for me. Here are my ideas about what could help me more.”

In this new therapeutic universe—formally known as feedback-informed therapy (FIT)—clinicians are willing to tumble off of their proverbial pedestal and enter into a more egalitarian relationship with their clients. For some, it engenders a sea change in the therapist’s professional identity, from the acknowledged expert in the room to something approaching an informed colleague. But a growing body of evidence suggests it may pay off handsomely for both clients and clinicians—and for the critical relationship between the two.

Charting a Course Together

As it happened, Jess Throndson had the opportunity to try out this new approach when she resumed work with John. Since she’d last seen him, her agency, Prairie Ridge Integrated Behavioral Healthcare, had been experimenting with FIT, training its therapists to rely less on protocols for directing treatment and more on clients’ specific suggestions for charting an independent course for their own recovery.

It turned out that John had already been exposed to the FIT approach during his recent stint in residential treatment. So this time, when Throndson asked him what he wanted to get out of therapy, he didn’t respond with his customary, “I want to be sober.” Instead, he looked directly at her and said, “I’m not sure I’m ready to do this, but at some point, I think I want to thank my probation officer.”

Throndson was stunned. John wanted to thank the person who kept pushing him to deal with his most painful issues? That was huge. And it could be a sign that he’d contemplated taking other specific actions in therapy. She took a moment—and a breath—to reset her expectations.

“Where’s the gratitude coming from?” she asked gently. John confessed that without his PO’s ultimatum, he wouldn’t have found himself back in treatment. And this time, treatment felt “different.” Getting the space to take the lead in his own therapy gave him new confidence, and he found himself advising other clients in the treatment program about how they might want to pull their own lives together.

Throndson took another breath, and then dove in. “It sounds like you really took on some leadership roles over there.”

A switch flipped. She could see it in his face. Later, she noted, “I think that statement alone completely shifted the way he saw me see him. He knew I was looking at him through a different lens. He’d been so avoidant and had kept things so to himself that I’d never have seen him as a leader, someone who longed to be respected and listened to. But of course he was,” she said. “It was his entire background as a sergeant.”

In subsequent sessions, they started with a detailed check-in. John would sit in front of Throndson’s computer and score how things were going that week: how well he was getting along with others, how satisfied he was with life at home, at work, at social gatherings.

After a few meetings, a graph emerged that they could look at and discuss, further delving into his thoughts on how therapy was working for him. At first, John gave the treatment and his recovery perfect scores, even when Throndson pushed him to be unabashedly honest. After all, he was still facing a probation violation, and the PTSD hadn’t just evaporated. “C’mon, John. From what we talk about in session, it’s pretty clear not everything is this good!” John would grin, “What can I say? I’m just an optimist!”

But Throndson’s FIT training had emphasized the importance of encouraging clients with high scores to feel they could be straight with their therapists. Was everything really so good outside of sessions or was he just trying not to hurt her feelings about therapy? John admitted that things weren’t perfect, and they dug into his wants. They continued to start new sessions this way and spend even more time brainstorming about what could help him. “What’s really on your mind?” she’d prod. “What’s not working right now? How would you like things to change? What would be better?”

During one such talk, John confessed that it was high time he improved things with his wife. She’d put up with so much for so many years, and he was ready to transform his guilt into positivity and appreciation. He and Throndson discussed repairing the relationship with talk, but they also brainstormed actions he could take. In their next session, he told her how he’d scrawled love notes on the kitchen chalkboard every day and snuck little gifts into her drawers. “She went bananas!” he reported.

Throndson and John have cocreated therapy around his new leadership focus, and his fourth time in therapy is leading to big changes. He’s stayed sober and worked hard to better his relationships with everyone in his family. He’s about to be nominated to be a peer facilitator in his treatment group and is looking into a new career in addiction treatment. He’s still in therapy, but the old “everything’s fine” guy from years ago is gone, says Throndson.

“He’s all in. He’ll talk about triggers and craving—whereas before, he supposedly didn’t have any. He’ll talk about his emotional experience and do it in a way that’s clear he trusts his relationship with me. Now I hear about those terrifying raids in the Middle East. He’s seen and done things that many people can’t fathom. But he finally thinks he can share them with me. And he’s accessing the 12 Steps, something he’s never done in the past.”

Those keeping an eye on the outcomes of FIT suggest that Throndson is likely right about John’s trust. Clients who know they can critique therapy and the therapist and that, rather than derail treatment, their feedback shifts the work in new directions, can shed the common concern that therapy is too fragile to be malleable and responsive to their real needs. It’s part of what accounts for practitioner reports that FIT outcomes are often better than other evidence-based practices.

Throndson says that John has been sober long enough to taper off therapy. If he decided to terminate right now, she said, he could walk into his PO’s office with a certificate of completion that would likely help resolve his case. But he’s choosing to continue therapy. “What really matters to me,” he told her, “is getting better for good. Then I can really pass it forward.”

A Challenging Transition

Throndson and six of her coworkers that we spoke with at Prairie Ridge report that their new way of working with client feedback and guidance, and with a focused eye on each client’s outcomes, has had a remarkable effect on client retention and thus success. In some cases, the number of direct service hours Prairie Ridge provides has nearly doubled. Groups are consistently larger. Financially, FIT has been a windfall.

But a few of the therapists say that when they started doing FIT and gathering regular data on outcomes, it was a bewildering shift. They knew how to be client-centered, but this was client-centric on steroids! What if the client asked them to go in a direction they knew nothing about? What if their trusted ways of working got dismantled by devoting so much time to the client’s critique of the therapy? What if their scores on that intimidating graph were consistently low? It was enough to make some Prairie Ridge therapists flee.

Lorrie Young, associate director at Prairie Ridge, is sympathetic toward the clinicians who were so unnerved by having their work determined and evaluated by client feedback that they packed up their offices and left. They were worried that their professional identities as knowledgeable healers would disintegrate. They believed they knew best how to work with their clients. They needed to be able to apply their method in a way they believed was most effective. Having to subject themselves to regular evaluation and client input seemed unnecessary and unpleasant.

Moore remembers a few of these fleeing clinicians in particular. “In Iowa, an independent clinical social worker is an ISW, and we had a therapist, more than one, who said to us, point-blank, ‘I’m an ISW, and I stands for independence.’ Unfortunately, I do think there is a lot of that still in the field: the sense that I’ve arrived, and there’s nothing left for me to learn.”

On top of this, some therapists weren’t convinced their clients would want to lead at all. In their experience, most clients wanted to know that the expert was at the helm, and they could sit back and simply trust in the healing journey they were being taken on. Of course, feeling lost is often part of what brought these clients to therapy in the first place.

But Young believes that most therapists would be surprised by how much they can dial back their own leading of clients without losing them. And she feels if the therapists who left had weathered the initial discomfort of FIT, the end result would’ve been worth it—in client progress, client retention, and therapist satisfaction. She says the emphasis on possibly discomfiting feedback isn’t a blame game. In fact, in most cases, it’s a force for good, which takes the form of the change the client is looking for.

“What I would say to clinicians who are leery is that it’s the feedback that helps us determine—are we making a difference?” she says. “The therapist and client are working in partnership to figure it out.”

So far, Throndson and her Prairie Ridge coworkers may still be specks in the giant landscape of today’s therapy world, but more people are training in this kind of work, both in the United States and Europe, and tens of thousands of clients have experienced it. According to Counseling Today, Scott Miller, cofounder of the International Center for Clinical Excellence and one of the biggest advocates of FIT, has reviewed outcome research that finds incorporating the treatment in counseling programs improves outcomes by as much as 65 percent, and slices drop-out rates in half.

Early results have been powerful enough to get the attention of those who fund and accredit therapy across the country. Insurers like Cigna, and influential policy bodies like the Kennedy Forum, have embraced feedback-and-outcome measures for therapists and are pushing for their adoption. Large behavioral health-accrediting agencies, such as the Joint Commission, are now requiring them, and The Substance Abuse and Mental Health Services Administration has added FIT to its recommended evidence-based practices. By 2019, therapists who work with Medicare or Medicaid will be required to present therapy-measurement data.

Doubt and Disquiet

As many of the therapists at Prairie Ridge can attest, initial attempts to implement performance feedback can provoke anxiety, even when the therapist continues to use her preferred orientation. Skepticism and resistance are common. Who is the therapist, really, if her client charts the course for therapy? What happens to her status as a trained healer? Is she now just a flexible friend? A first mate who pops into action only when the captain needs help reading the chart?

And what about therapists whose professional identities have been formed by the practice of protocols or orientations that they truly believe are effective? Are they to just drop their methodologies in favor of client feedback? If you’re a therapist trained to tap into the deep healing power of Internal Family Systems, for example, how do you respond to a client who prefers to test out a cognitive-behavioral approach that they heard on NPR had worked with a struggling population in the Ozarks? Must we become a jack-of-all-approaches to retain our clients, or do we hunker down like niche specialists, crafting the verbiage on our websites and waiting for the next person to walk in the door who’s willing to relinquish the reigns of therapy and be guided by us?

The norm, according to the proponents of FIT that we spoke with, is that therapists continue using their orientations, as clients don’t often request changes that would force them to challenge overarching concepts anyway. That doesn’t, however, mean that particular protocols or ways of working won’t face the clients’ chopping block. However one characterizes this shift in the field, it’s a significant one. Are therapists willing to give it a try?

Some aren’t sure, and are pushing back. They wonder if the new egalitarianism in therapy, the loosening up of their say over what heals and what doesn’t, will undermine the therapist–client relationship. How will more emphasis on client input and feedback, with the concomitant weakening of the therapist’s role as expert, affect what happens to established rules around the therapeutic relationship? What are the risks that a client will push to cross ethical or personal boundaries?

These are big and valid issues that need wrestling with. At the same time, it may be wise to remain open to a new, more collaborative identity, because that’s where the culture is going. Bit by bit, perhaps without fully realizing it, therapists have already lost some of their status as peerless psychological experts. For the sake of self-preservation, they need to become conversant with this new reality.

Firefighter, Teacher, Therapist

Fifty years ago, if we were to have asked the average person to envision a therapist, an image of Freud would likely have come to mind—perhaps the famous portrait of him staring stonily sideways, cigar in hand, the chain of his pocket watch looping from a vest button on his double-breasted suit. Fast-forward a couple of decades, and the image has morphed into a nattily dressed shrink in a Woody Allen movie, sitting silently in a mahogany-paneled Manhattan office while a wealthy nebbish talks nonstop from a prone position on a chaise longue.

It’s been nearly 20 years since the Mental Health Parity Act made therapy available through insurance to middle- and working-class Americans (though how affordable mental healthcare actually is to at-risk populations who really need it remains a valid concern). For many young people, therapists have become commonplace figures on the cultural landscape. The generation that grew up in the US in the ’90s tends to view psychotherapists less like rare sphinxes and more like the cutouts of doctors and firefighters and teachers that populate children’s books—a thoroughly accessible type of “professional helper.”

As therapists have become less illusive, the mysterious powers they once seemed to wield have become more explicable. Increasingly, people who might once have been clients are turning to various versions of self-therapy. Heavily marketed videos show how to combat anxiety on your own using common clinical techniques like thought-stopping or sustained deep breathing.

Mindfulness-based stress reduction has made its way out of the consulting room and into meditation apps, activity trackers, and watches. The nervous and the worried can take anti-anxiety vitamins and wrap themselves in special, soothing blankets. Adult coloring books for trauma are widely available. Via thousands of blogs, webcasts, and books (many of them written by therapists), people are learning to develop compassion for themselves, counter negative thoughts, dip into their bodies for important emotional information, and express anger while maintaining connection—without ever consulting a therapist. To keep our practices and our profession viable, we need to match prospective clients where they are in this cultural moment.

Generation Equal

Young clients, in particular, are more emboldened to engage with the course of their therapy, partly because they consider themselves better informed about the process. Ron Taffel, chair of the Institute for Contemporary Psychotherapy in New York City and a specialist in working with teens and young adults, thinks there’s a lot to like in this new climate. He appreciates Millennials’ knowledge of various orientations and their fearlessness about the therapeutic process. Nonetheless, he wrestles with the new relationship expectations, because they pose an ethical challenge for him: these “young adults are pulling for more transparency from the therapist, and that means personal transparency as well,” he says.

At times, he’s felt compelled to answer pointed questions from his young clients about his own marriage, his religion, and his cultural background. In the consulting room, they push him to weigh in on every conceivable public debate. They feel entitled to such information, he says, and to a relationship that they consider real. Real and equal. Anything short of that would drive them away.

This means that the therapist needs to be comfortable with identity flexibility. “Sometimes you’re going to be the one who’s being taught by your clients; sometimes you’re the one who’s doing the teaching, and offering guidance because you may know best what needs to happen for the client to get better,” he says. “And sometimes it’s going to be completely horizontal, peer-to-peer, just chatting and being curious about each other and brainstorming about life and what therapy can offer. Being able to be fluid in that is critical.”

But Taffel notes that even as therapists stretch to encompass the role of student as well as teacher, they do retain some hierarchical advantage if they limit personal transparency. Still, deciding to loosen those limits to be the kind of therapist young people seem to want is a tricky ethical business. He feels like he’s killing a sacred practice cow every time he’s pushed to answer a personal question from a client or offer direct advice when they prod him for it.

To get past his resistance, Taffel says he’s “focusing on the collaborative spirit.” But he also says his appreciation for what these young people collectively represent helps him mollify his fears. He likes them and their new brand of egalitarianism. “They’re more open to talk about what’s going on with them and more tolerant of differences. I love their sense of having the right to express themselves in a deeply personal way. From the time they’re in middle school, they’re talking about relational ethics.” Naturally, that ethic of equality will show up in the therapy room.

Do No Harm

Mary Jo Barrett, who runs the Center for Contextual Change in Chicago and works with complex trauma, has a different reason for encouraging therapists to address the current therapist–client hierarchy. This hierarchy is largely unspoken, and she believes that traumatized clients can be harmed when the therapist doesn’t acknowledge it.

“Here’s the thing in terms of trauma and abuse,” she says. “The original abuse happens in a hierarchical relationship, and therapy is a hierarchical relationship without question. Hierarchy, in my experience, triggers and shuts down people in terms of their capacity for healing.” By contrast, she says, change happens in collaboration. “When I say collaboration, I’m saying that I acknowledge that there’s a hierarchy here. I acknowledge that there’s something I have expertise about, and I also acknowledge that you have expertise. You can use your expertise on your life and my expertise on healing, and together we’ll make it happen.”

Follow the (Shrinking) Money

There’s one more reason to consider a power shift in the therapy room: fewer people are coming into therapy in the first place. Among those who do try therapy, a widely cited 2012 meta-analysis from the Journal of Consulting and Clinical Psychology found at least 20 percent drop out prematurely. More than ever, people want a quick fix. According to a 2009 survey in the journal Psychiatric Services, four out of five potential therapy clients now bypass the mental health system entirely and get psychiatric drugs straight from their general practitioners.

As drugs shrink the market for therapists, and as insurance reimbursements remain low, many therapists know they need to try something new to sustain their practices. Lynn Grodzki, a longtime business coach for psychotherapists, has promoted a variety of strategies to make therapy practices more profitable, from more targeted advertising, to sharing anonymous treatment success stories online, to developing a clear specialty. Over the last several years, she’s also been encouraging therapists to involve clients in the design of their treatment and get feedback from them in real time on how helpful each session has been. Sound familiar? It’s a tack that Grodzki says is essential for keeping clients coming back.

“A lot of the public that’s coming in, they feel like we therapists are for hire,” she says. “They don’t feel like therapy is a mysterious and special thing; it’s just a service. So they want to know, ‘What’d we do here today? What am I going to get out of this? Where are we going?’ And we need to be able to answer these questions.”

Grodzki compares therapists who use this strategy to wise businesspeople who gather feedback from their customers regularly, making sure they’re either meeting needs or quickly adjusting what they’re doing when they aren’t. Think fan-generating tactics of big airlines like Southwest, a company that’s first in customer loyalty because of its intense listening to complaints and emphasis on prioritizing each customer’s needs. Grodzki insists that when clients have a voice, and can get their changing desires met, then, like frequent flyers with countless other options, their loyalty is less likely to waver.

Being There

Dan Merlis is a Washington, DC–based therapist who specializes in EMDR and trains lots of younger therapists. Merlis was conscripted into the army as a young man to fight in Vietnam and had a long career working with traumatized vets and prisoners of war before entering private practice. He considers himself an emotional healer (rather than a quick-fix problem solver), which takes time in therapy, and he was heartbroken by the numbers of vets he saw unceremoniously drop out of treatment because, he said, their therapists didn’t understand how to help without pushing them to do things they didn’t want to do.

Merlis feels that at its heart, good therapy has always required a certain amount of openness, transparency, and a tolerance for self-reflection on the part of therapist, particularly if they expect that from their clients. “I share personal stories, and my wife and I have a home office. Clients are regularly coming into our home and seeing how I live. I like that. I think hierarchy can get in the way of healing. Sure, we might be skillful at accessing a client’s strengths and capabilities, but to be safe people for our clients, we have to give them time and space to proceed as they like.”

Merlis hopes that more of the newly minted therapists he trains will make sure clients engage in therapy at their own pace, and be certain that clients know that their own ideas for healing are always clear to the therapist—and that these ideas come first. But he’s concerned that the younger generation of therapists might have a rocky start these days. “Young psychotherapists haven’t been exposed to experiential psychotherapy. What they’re practicing is psychoeducational psychotherapy. But I’m encouraged that a lot of experienced therapists who are now trying to train young people to work with folks in more complicated situations and use themselves in a fuller way.”

Ultimately, he says, both young and experienced therapists will benefit from a lively sense of curiosity. He encourages them to worry less about their training in specific methods, and instead to nurture a deepened interest in their clients, their particular wants and needs, and the exquisitely personal ways they might heal.


Lauren Dockett

Lauren Dockett, MS, is the senior writer at Psychotherapy Networker. A longtime journalist, journalism lecturer, and book and magazine editor, she’s also a former caseworker taken with the complexity of mental health, who finds the ongoing evolution of the therapy field and its broadening reach an engrossing story. Prior to the Networker, she contributed to many outlets, including The Washington Post, NPR, and Salon. Her books include Facing 30, Sex Talk, and The Deepest Blue. Visit her website at laurendockett.com.