Although you can’t tell it from the cases that appear in publications and training videos, psychotherapy mostly involves talking to clients who like working with us, but find it hard to change. Eventually, rather than helping these clients navigate dramatic whitewater rapids, our main challenge becomes steering the clinical relationship out of the swamps and marshes where it can get stuck, sometimes for years.
Often when we begin with these clients, our early work generates some movement and change, but then a kind of stagnation sets in. This is the case with my couple who’s fully engaged in therapy sessions but “too busy” to try anything different at home, and the woman who uses sessions to recap the ins and outs of her week but never addresses any serious issues. Without much happening—with no real intensity or vitality—ease eventually turns to boredom, at least for the therapist. After months or years circling the same issues, we end up with what I call “Groundhog Day therapy,” named after the early 1990s film in which a burned-out TV weatherman played by Bill Murray is doomed to live through the same day, with the same events, over and over again.
So why do therapists tend to get stuck in clinical relationships where we spend session after session spinning our wheels? One reason is that these sessions ensure a predictable, paying slot in our schedule. Another reason, however, is that we usually don’t tell anyone about these cases. We reserve supervision or consultation for more compelling crises or direct conflicts in the clinical relationship. Groundhog Day cases, where no one is threatening divorce or suicide, lack the drama of standard consultation cases.
Another reason we remain stuck with clients going nowhere in therapy is that most of us keep “progress notes” instead of tracking outcomes. I confess to this habit, especially when it came to a couple I’d been seeing for several years. When I looked through a year’s worth of their session notes, more than half of them recorded some improvement from session to session. But when I stepped back and asked the couple to evaluate the progress of their overall relationship, they concurred with me that nothing much had shifted. As therapists, we like to think we’re making headway, and our clients want therapy to be worthwhile, but treatment sometimes shifts without our noticing it from change-oriented work that has an ending to long-term, maintenance-oriented work that doesn’t have an end point.
The key to dealing constructively with stuck cases is to treat the clinical relationship pattern first, and only then to consider alternative treatment strategies. The following three steps detail a process I’ve developed, including the words I tend to use, for gently dislodging stuck clinical relationships.
Set time to evaluate progress together. After asking the client for his or her priorities for a particular session, I say something like, “I’d also like to spend some time in this session looking at where you are currently in terms of the problems you came to therapy with, how far you feel you’ve come, and where our work is now.” We decide together whether to start with the client’s priorities for the session or with mine. I do this in a matter-of-fact way, not assuming a challenging mode, but letting the client know this will be an important conversation.
Assess where you are in the course of therapy. After listening to the client’s sense of progress and affirming whatever I can agree with, I ask follow-up questions that direct attention to the work we’re doing together. An example might be something like this: “Where do you think we are in terms of our work in therapy? Are we in the winding-down phase, the middle phase, past the middle phase?” This question implies that we aren’t going to be doing this work forever—that there’s a beginning, middle, and end, and that the client has a big say in determining the timing of our work. Generally, I accept whatever the client offers as an appraisal of our current stage of work.
Share your perspective on the “plateau.” In the third phase, I share my perspective on the plateau I see in our work. I’ll say something like, “As I’ve been thinking about our work, it seems to me that significant changes were coming in the earlier phases, which is common, and that we reached a plateau a while back. I don’t know if you see it that way.” Plateau is a more positive description than saying therapy is “stalled” or “unmoving,” and invites the client to join me in evaluating the recent results of therapy. I focus on “we” and “our work,” not just on the client’s individual movement. In this way, I acknowledge that I’m part of this system and have a role in everything that goes on; I share space on the plateau. With this framework set up, most clients agree that we’ve been circling around issues without much forward progress. I sometimes even say that I prefer to work intensively with people and take breaks from therapy, rather than stay on plateaus for too long.
These are the questions I put to all clients who say they want to continue: “What are your priorities for the next phase of our work? What do you feel a sense of urgency about?” With these questions, I signal that I want a new contract if I’m going to sign on for another phase of therapy.
Of course, these conversations don’t always go this smoothly. Sometimes clients’ fears of abandonment and worries about making it on their own will surface. Fortunately, the emergence of these emotions can allow real therapy work to begin again, providing a new focus on issues of loss and autonomy.
How to Get Therapy Moving Again
So how do we effectively shift gears with stuck clients who repeatedly make unfortunate choices? Here are some approaches I’ve learned from respected colleagues and developed to use in my own clinical work.
Bookend major challenges with autonomy-granting comments. When challenging a client, it’s critical not to come across as a parent. If I feel I must confront clients about choices they’re making, I usually begin with words that acknowledge their autonomy. To a married man having a career- and marriage-threatening affair with a drug-using coworker, I said, “Doug, I’m going to say something challenging here. I’m going to offer it with an understanding that this is your life and that I don’t get a vote in your decisions. Here’s what I’m concerned about. . . .” Another way to set up these challenges is to start with something like, “I’m sure you’ve thought about what I am going to say.” The idea is to signal respect before getting pushy. After the challenge comes another autonomy statement such as “That’s just how it looks from where I’m sitting. You’re the one who gets to decide.” This bookend approach to challenges makes it less likely that the client will have a you’re-not-the-boss-of-me response.
When challenging stuck clients, use subjective, personal, and “ordinary” language. Saying things like “I see you enacting the same self-destructive pattern you learned in your family of origin” is therapy-speak and won’t resonate with the client. It’s better to use subjective phrases like “I’m worried for you” and “This is what I’m concerned about.” In an impasse, I say things like “I’m worried for you right now. I’m worried that a very positive part of you—your openness to each person who comes into your life—is getting you into one bad relationship after another. Each time this happens, you seem to go deeper into a pit of despair. That’s what I’m worried about for you.” This comes across as a personal, caring challenge delivered in human terms. It’s not a clinical insight subject to agreement or disagreement, and most clients can take it in. This kind of challenge is also not parental if it’s sandwiched between autonomy-granting statements. Step 1: I respect you as an adult. Step 2: I care about you and am worried for you. Step 3: It’s your choice, and I don’t get a vote.
Becoming a Therapeutic Craftsperson
If the risk for new therapists is falling on their faces because they’re still learning their craft, the risk for experienced therapists is being captured by our competence. We become habituated to the role of “pretty good therapist,” and we stop getting better.
How do we avoid being captured by our competence? I’ve learned that the key is never to stop being a student. It’s hard to habituate while being a graduate student because there’s always something new coming at you; there’s always someone who knows more than you and is paid to teach it to you. The challenge after leaving school is to learn how to keep learning.
The therapists I’ve admired most in my career have been those who continually change and develop while holding onto the core of who they are as therapists. They’re interested in new models and new evidence, but not in serially reinventing themselves with each new fad.
I find this kind of self-correction great fun, and I revel in sharing my experiences with colleagues so they can experiment with the change in protocol if it makes sense to them. Experienced therapists have had enough training to avoid serious undertows or completely capsizing the therapeutic conversation, but the more we strive to learn how other therapists practice the nuances of their craft, the more skillful we ourselves will be at navigating out of the bogs and marshes where our clinical relationships get stuck.
William Doherty, PhD, is a professor and director of the Minnesota Couples on the Brink Project and the Citizen Professional Center at the University of Minnesota. He is founder of Citizen Therapists for Democracy. His books include Helping Couples on the Brink of Divorce (with Steven Harris) and Medical Family Therapy (with Susan McDaniel and Jeri Hepworth).
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