August Quandary: How Do I Get Clients to Engage in Work Between Sessions?

Five Clinicians Weigh In

Chris Lyford

Thank you to everyone who responded to our August Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.

August Quandary: I have some great exercises, like journaling prompts and guided mediations, that I know would benefit my clients between sessions. Although they seem interested when I introduce the idea, they always “forget” or can’t find the time to follow through. Do others who give “homework” between sessions have this problem? What should I do?


1) Ask Yourself: Is This for You, or Them?

If I was in this therapist’s shoes, I’d check in with myself. Whose idea is it to do these exercises between sessions? Am I initiating the suggestion that they do them, or are my clients asking for them? Let’s say the exercises are my idea. When I propose them, am I taking in my clients’ feedback, both verbal and nonverbal?

Clients might initially agree to do exercises to please their therapist or avoid a larger discussion about their reluctance to do them. In my own practice, I try to ensure that my clients feel comfortable being honest with me about how interested or uninterested they are in doing work between sessions. If it turns out a client is genuinely interested in it but has trouble following through, there are a couple strategies that can help keep them on track.

First, I’d recommend the client pick a time and a location that seem conducive to doing the exercise. Might something get in the way? How will they approach any obstacles that arise? These are questions I’d make sure to ask. I’d also ask the client to notice any thoughts, feelings, or sensations that arise when they think about doing the exercise. They might notice resistance and develop awareness of where it’s coming from.

Next, I’d advise that the client not wait until they feel like doing an exercise to begin. It’s a little like going to the gym: if you’re not in the habit of doing it already, it’s going to be hard to start. Last, I’d ask that once the client does the exercise that they notice how they feel during and after. Did they notice any immediate benefits? What worked well? What was challenging?

Exercises need to align with what’s important to our clients, so they need to get clear about why they’re doing them. When sticking to them becomes challenging, remembering this can help them follow through.

Morgan Jai-Morincome, MA
Canberra, Australia


2) Don’t Be Afraid to Get Playful

Homework is a big part of my therapy approach, and I make a big deal out of it!

When our son was young, he was dealing with some behavior problems, so we took him to see a family therapist. First, this therapist had our son choose something he wanted to work on. Then, she presented him with a big sheet of paper with dots, that when connected, spelled out the word YES in big block letters. Every day our son performed a task he and the therapist agreed upon, he got to connect a dot. The therapist and I agreed that after each letter was completed, he’d get a little prize, with the biggest reward given after the S was complete.

Since then, I’ve used the same strategy in my own practice with clients who are trying to set goals or learn new behaviors. First, I ask what their favorite color is, and then I use that color of paper and marker. I tell my clients that it takes 21 days to form a new habit and that connecting the dots will give them a tangible measure of their progress from session to session. I also help them come up with ideas for how they can reward themselves as they finish up a letter. I also help them commit to their plan by giving them sticky notes, so they can write themselves reminders.

Of course, I do all of this with a big, cheesy grin on my face, while also letting my clients know I'm serious, and that I will ask about their at-home work during the next session.

Kathryn Lichty, MSW, LICSW
Alexandria, MN


3) You Don’t Always Have to Offer Homework!

I love this quandary; it speaks to how much we want to help our clients. But therein also lies the problem! I no longer offer homework. If a client asks for some, I invite them to be curious about why they want it. Often, valuable information is revealed. Perhaps the client is frustrated with the pace of therapy, or feels a desperate need to make progress, whatever that may mean to them. Or maybe they’re trying to be a “good client” in the eyes of their therapist.

I try to get curious when I, too, feel a desire to incorporate homework. Is it for any of the above reasons? Do I feel like I need the client to make faster progress?

Here’s the thing about homework: while one part of the therapist or client may want homework, there’s likely another part that doesn’t. Our internal systems contain many polarities—parts that want to change, and parts that are terrified of change. Change rarely occurs without consequences, and not all are welcome.

So if a client asks, I may offer homework, but I’ll do so lightly, making it clear that the homework is optional, not an expectation. As part of the homework, I’ll usually ask the client to notice how they feel if a particular inner part is triggered, and what his or her impulse may be. If a client asks for homework and then doesn’t do it, we can be curious together about what might’ve happened.

I see my job as helping clients become acquainted with, appreciative of, and compassionate toward all their parts—the eager beaver parts as well as the slow, cautious parts. As they say in Internal Family Systems, “All parts are welcome.”

Tish Miller, LCSW
Washington, DC


4) Give Some Reassurance In Between Sessions

When working with new clients, I tell them from the beginning that I might ask them to do some reading and letter writing, help facilitate family meetings, or do other things outside of therapy over the course of our work. I ask for their buy-in and tell them, “The best part of therapy is from the time you walk out this door until you come back in.”

I explain that our goal in treatment is to help them tap into the wisdom they already possess and combine it with new information and approaches to help them get to the next best place in their lives. We then talk about ways in which doing work outside of therapy might be helpful and what the expected outcomes might be.

After giving clients their assignment, I like to send a short letter in between sessions that says something like:

I want you to know that our time together last week and your courage and willingness to learn is appreciated.  I hope you’re finding the assignment to be helpful. I know that some of this work can be hard, even painful. Please be assured that if you’re not ready at this time, or if “life got in the way,” we can slow down this process. We will take our time to discover at a different pace. I look forward to our session next week.

Writing a letter like this gives the client an out and helps me learn more about what may or may not be effective in working with this person.
 
Shirley Faulkner, LCMFT-LCAC
Hutchinson, KS


5) Do Some Therapeutic Detective Work

It’s only natural for us to feel discouraged when a client repeatedly says they’ve forgotten to complete “homework” or couldn’t find time to do it. Sometimes, it even results in us working harder than our clients! Resist this urge. Working harder than our clients is a disservice to their therapeutic experience. To avoid this, I’m transparent in my observations of clients’, behavior and try to collaboratively explore the significance around their forgetfulness or lack of time.

As part of this exploration, I ask questions such as “Why do you think you’re forgetting to complete the homework?” or “Are you forgetting to complete tasks in other areas of your life?” These can jumpstart an important discussion. Other questions such as “Are the tasks overwhelming or triggering for you?” allow me to offer modifications.

When working with a client who struggles to do homework, I also explore whether I’m meeting their needs as a therapist. Am I helping them achieve their therapeutic goals? Am I somehow enabling their lack of follow-through? Am I expressing enough empathy and compassion toward them?

In The Gift of Therapy, Irvin Yalom describes therapy as the client’s dress rehearsal for life. The therapeutic relationship and the nature of sessions are the therapist’s only clue as to what transpires for clients outside sessions. Sharing this insight with clients serves as a gentle reminder that desired behavioral change results when learned therapeutic tools are applied in day-to-day life.

Kristin Greco, MSW, RSW
Newmarket, Ontario

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We'll post a new response to each Clinician's Quandary on the first Tuesday of every month! See how to submit to next month's Quandary here.

September Quandary: I’m a new clinician working with a client who’s expressed some suicidality at times. I don’t think he needs to be hospitalized, but I’m worried about him. I think it might be a good idea to have him sign a no-suicide contract, but I’ve heard mixed things about them. What should I do?
 
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Topic: Challenging Clients & Treatment Populations

Tags: Challenging Cases & Treatment Populations | challenging clients | chris lyford | Clinician's Quandary | Exercise | journaling | Journals | practices | therapeutic homework

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1 Comment

Wednesday, September 4, 2019 6:51:38 AM | posted by Josephine Ferraro
I work suggest to stop calling it “homework,” which probably reminds clients of school. If I think the client could benefit from continuing to process what came up in sessions, I usually give a subtle suggestion to their UNCONSCIOUS MIND, which might be something like, “You might find that during the week you’ll continue to think about and process what we’ve talked about, especially _____________ (fill in the blank with whatever was significant in the session). This might come in the form of random thoughts throughout the day or it might come to you in dreams or daydreams. I don’t know how it will come up and how ever it does, it will come up in just the right way for you bc your unconscious mind continues to process these issues even when your conscious mind is unaware of it. How ever it comes up, you might want to write down your experiences so you can bring them in with you next time.” Although this is indirect (Ericksonian hypnosis), it is more effective than telling them to do homework.