Changing the Emotional Climate
In a first session, clients are expecting something for their time and money: when they walk out, they want to feel differently from how they felt when they walked in. This is what I call changing the emotional climate. Simply listening and being empathic, allowing clients to vent, goes a long way toward accomplishing this. So does education. Talking to clients about the brain physiology of anxiety, for example, or typical family patterns can help normalize their distress and place it in a larger, fixable context. This is what your family doc does when she tells you that you have an infection or that your rash is simple contact dermatitis caused by the new cream you put on your face. You feel better having a label, an explanation, and a palpable sense of your physician's educated concern.
In brief therapy, though, you need to ramp it up experientially. One of the most effective ways of changing the emotional climate is, again, zeroing in on the ongoing process with the client. You want to pay extremely close attention to the nonverbal communication, to tap the subtle feelings that are just below the surface. When Sara looks hurt, stop the story and focus: "Hold on, Sara, what just happened? You're looking sad." If you say this gently, with real sincerity, Sara may be able to drop her defenses and actually begin to tear up or cry. This open and shared vulnerability will help her emotionally bond with you. You can also do this by asking directly about these often softer and less obvious emotions: "What causes you to feel sad? What worries you the most?" Or ask about positive feelings to offset all the focus on negative ones: "When do you feel your best? What are you most proud of?" By asking, you move to a different level in your relationship with a client and change the climate in the room. Even if Sara seems to push your questions away, you're still letting her know that you're noticing how she feels and that this is a safe place to talk about difficult things when she's ready.
While these points may seem fundamental to being a therapist, I'm always surprised when I see clinicians failing to create this powerful shift. They get too caught up in gathering history for assessment to notice these emotional subtleties, or they rationalize that it's too soon to tap them. But that's a mistake.
Linking Problems to Personality
The first question I always ask myself is: What keeps this person from solving this problem on his own? Sometimes it's because clients have situational stress: they just got fired from their job, they have a medical crisis, their kid got busted for drugs. Normally, they can cope, but now there's just too much on their plate. They need support and help to be able to zero in on the problem. Other times, it's a matter of skill or lack of it: they have continual financial problems because they really don't know how to set up a budget, or can't talk with their partner without triggering conflict or disengagement. Once you help them understand and implement a budget or master the keys to good communication, the problem begins to fade.
Other problems persist, not because they're rooted in stress or lack of skill, but are intrinsically linked to their personality and coping style. I think of this from the Buddhist standpoint: How you do anything is how you do everything. In fact, this is where some clients are stuck. While they're worried about the what--the content of their problems--the real source and solution to their current problem, and many of the problems in their lives, lies in the how, their overall response to problems. This is what I call their core dynamic--an expression of their primary childhood ways of coping, such as accommodation, anger, or withdrawal. While these ways may have helped them survive the challenges of their early environment, now, like outdated software, they're no longer helping them negotiate the more-complex demands of an adult world.
To move out of the 10-year-old's perspective and better handle the problems in their lives, they need to update their inner software. More traditional approaches might track this down by a long march through the past, but in a brief approach, you can tackle it in the first session by asking how they concretely and specifically cope with current problems on the job or at home. Of course, you may even detect their coping style during the session itself, through their responses to you.
Once I've defined their coping style, I often try to link it to their current problem, helping them see the latest manifestation of the same outmoded response. By doing that, I set the stage for their attempt to challenge their early wiring: instead of being good and accommodating, as they've always done, the might push back and say what they need; or, instead of spraying anger around the room, they might self-regulate and use their anger as information. I let them know that they can update the software, which will not only fix their current problem, but prevent future ones.
This focus on defining, understanding, and challenging the core dynamic is empowering for clients. The message is that you can help them map out new ways of taking acceptable risks, breaking old patterns, and acting more like the adult they are than the 10-year-old they often feel like.
Offering a Clear Treatment Plan
Finally, like the physician, you need to leave clients with a clear set of next steps. If you decide the client is stuck because of situational stress, talk about ways of navigating this challenge in the scope of their broader lives. If it's about coping skills, map out what skills you feel would be important for them to learn. If it's about their core dynamic and ineffective approaches to problems, or a combination of all of the above, let them know what you're thinking and what they concretely need to do.
Then, as always, track the process and see what happens next. Does this make sense to them? Do they agree? Do they understand how this is all related to their presenting concern? If there's a sincere and congruent yes, you may give them concrete behavioral homework to help develop new skills or reduce their stress. If there's hesitation, ambivalence, or accommodation, stop, clarify, or ask questions until you're clear about what's going on. Just remember that their resistance isn't the problem, but a source of valuable, additional information about what the solution might be. As in any other phase of psychotherapy, it's hard to go wrong if you bear in mind the clinician's most useful mantra: track the process like a bloodhound!
Robert Taibbi, L.C.S.W., trains nationally and is the author of more than 200 articles and five books, including the forthcoming Therapy Boot Camp: Brief, Action-Oriented Approaches to Anxiety, Anger & Depression. Contact: firstname.lastname@example.org.
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