Thank you to everyone who responded to our March Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
March Quandary: I have a client I’ve been seeing for eight years now. Although we made a great deal of progress early in our work, I fear we’ve stalled out. I find myself getting bored in sessions with her, and dreading the hour we’re scheduled to see each other. I’ve brought up the possibility that perhaps it’s time for us to end therapy, but she’s insisted it’s still helping her, despite the fact she doesn’t say much has changed from week to week. What should I do?
1) Make Becoming Obsolete Your Goal
There are several reasons why it’s hard to be honest and direct when we suspect a client may no longer be a good fit for therapy, especially when they insist that it’s still helping them. We might fear abandoning our client, potentially causing them harm or damaging trust. Me might fear being wrong—progress can be subjective. We might fear complacency. Or, we might want to avoid the discomfort of challenging the status quo.
I recommend clinicians pay attention to their own feelings and examine their possible meanings. We need to listen to ourselves when something doesn’t feel right, when it feels like there may be something more to be explored. Boredom and dread are often signs that we don’t feel useful. They may also mean it’s time to terminate therapy.
To decide how to proceed, I’d want to discuss with the client how therapy has benefitted them since they began it. This honors the work that’s been done and can be eye-opening for both the client and clinician. I’d ask the client whether they have any fears about maintaining their progress. Then, we’d write a new treatment plan together and look to see whether there are any new goals, or whether the goal is to maintain the hard-earned progress they’ve achieved so far.
In either case, I might consider reducing the frequency of sessions and assigning the client more self-study and follow-through exercises between sessions. Independent work helps clients become confident in maintaining their progress without the clinician’s direct monitoring. I’d also want to explore whether the client might be a candidate for peer support or could better utilize their natural supports.
Last, I’d recommend this therapist ask herself how she can prepare clients earlier for transitioning out of therapy. For example, I tell my clients at the beginning of our work that my goal is to become obsolete. During our work, I may reference them being happier or healthier in the future and emailing me a fun story telling me about it. I enlist natural and peer supports throughout our work, when appropriate, and encourage as much outside-of-session work as possible, using apps, social media, self-help books, and courses.
Ultimately, therapists want to be useful. Feeling less than useful is important information for us to determine the next phase of growth for our clients, with or without us.
Jennifer K Pietrzak, LCSW
2) You Don’t Need a Crisis to Do Good Work
Getting bored during a session or dreading a client on my schedule is a sign that I need to take a deeper look at what I’m doing as a clinician. I ask myself: Where am I stuck? How invested am I in this client? Have I gotten lazy? Am I triggered? The revelations that come usually open a door to the next phase of our work. It makes it easier for me to admit to the client that the work has stalled, to acknowledge that maybe we’re at the edge of our old work and need to try something new—something that hasn’t been defined yet—and look at setting new, specific goals.
Maybe this client’s insistence about staying in therapy is the only way she can say “I have more to explore.” It’s our job as clinicians to lead this exploration of what’s next, and to celebrate and name the results of the work so far. This helps us open the new doors in therapy, and better assess whether it might be time for the client to take a short break so we can just enjoy the progress they’ve made so far. It’s important to keep in mind that we don’t need a crisis to continue doing good work in therapy. This client might simply not have anyone else in her life with whom she can just be herself. Maybe focusing on that is a good place to start.
Rosa Glenn Reilly, therapeutic arts center director
3) Ease into an Ending
I’d suggest that this therapist help her client by having her clearly define what changes she wants to make in her life this year, this month, this week, and maybe even today. My guess is that she may be anxious that without your support, things will revert to how they were before she started getting help. Assuming that’s accurate, I wonder what her initial complaint was eight years ago. Was it anxiety, depression, or something else? Perhaps what she needs now is help with relapse prevention. David Burns writes about this in his new book, Feeling Great. In a nutshell, help your client understand what helped her improve and how she can recreate the therapy in her head. I’d tell her that if this doesn’t work for her, she can turn to you or another therapist in the future.
Just as we raise our kids and gradually give them more responsibilities, letting them know they’ve learned enough and are ready to take matters into their own hands now that we’ve spent time teaching them, perhaps it’s time to tell this client that you believe she’ll be fine without therapy. You could also wean her off gradually, perhaps by meeting every other week for a while and seeing how that works for her. Of course, it’s possible that when you bring this up with her, she’ll suddenly come up with other problems she wants to work on. That’s fine, too. It should get you more engaged and feeling less bored.
Deborah Bach, family therapist
4) Sometimes the Feeling is Mutual
Once a week, for eight years, this client has found safety and comfort in therapy. Even without much changing from week to week, I wonder if deep down she also feels like the work has stalled out. Is she fearful of losing the familiar safety and comfort of your sessions? I’ve noticed that when I start feeling boredom or redundancy in my sessions, the feeling is usually mutual. Following my instincts, I usually then explore cutting back on sessions with the client. We do this by first reviewing the client’s goals with them. Have we met these goals? And if so, where do we want to go from there?
After that discussion, and setting new goals, I usually suggest that we try meeting every other week and see how it goes. Often, we’ll meet for a few months on the new schedule and do a quick review of these goals at the end of each month. After a few months, my clients have usually found other activities to replace their sessions and are open to meeting once a month.
I always let these clients know that they can return to a more frequent schedule at any time if the need arises, but my experience is that once-a-month check-in sessions seem to satisfy their need to stay in touch and work on goals until the client feels ready to terminate for good.
Jan Canniff, LMHC
Friday Harbor, WA
5) Put the Client First
The first thing I would do is reduce the number of times I’m seeing this client. Seeing them once a week when they’re experiencing no progress and you’re dreading the session isn’t workable or healthy, for you or the client. Since the client says therapy is helping, I’d ask them to list the ways it’s continuing to be beneficial for them. I’d also want to assess whether the client’s diagnosis changed at all over the last eight years, and look at what measures I’ve been using to evaluate the client’s progress, or lack thereof. If it turns out the client needs a treatment that I don’t specialize in, I’d consider referring them to someone with that specialty.
If the client is dependent on the therapist for social interaction, it’s certainly time to encourage them to connect with their external community, family, or friends. COVID-19 has made this difficult, but things seem to be improving so it’ll become easier for friends and family to reconnect.
Last, if this clinician is feeling bored and exhausted by the prospect of seeing this client, and none of the above suggestions work, it’s time for her to either significantly reduce their appointments and ask herself why she’s remained in this situation for as long as she has, and perhaps seek out her consultation group. Continual self-reflection is vital for all of us in order to best serve those who seek our help.
Shirley Faulkner, LCMFT
Next Month’s Quandary: I’m a couples therapist, and I’m currently going through an emotionally wrenching separation from my partner. I’m finding it’s a strange experience to try to help my clients repair their torn relationships while I can’t seem to mend mine. Of course, I’m discussing this with my supervisor, but I wonder if anyone else has some words of wisdom.
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