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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.

Return regularly to the client’s need to stay on course and honor the client’s stance. Virginia Satir used to talk about the two universal drives operating simultaneously in people in distress: the desire for growth, which means change, and the desire for stability. As therapists, we have to address both drives. For my client Cindy, choosing yet another inappropriate boyfriend gave her more pain, but reassured her in a way: even at age 50, I can attract guys, and I’m never without one.

In the case of a woman who can’t stop bringing home new men from AA meetings despite a series of disastrous relationships, I’d prepare myself to see something positive and honorable or wise and smart in her choices. For example, I might say, “You’re somebody who doesn’t want to give up on men, even though you’ve had bad experiences in the past. An important value for you is to bring yourself fresh to each new relationship and not assume this guy must be a jerk because some other guys have been jerks.” If she seemed to feel understood by this reflection, I might add, “And you believe deeply in AA and its philosophy, so AA meetings seem like a good place to find a man who’s making a fresh start in his life.” (I should note that actually believing what you say is critical to pulling this off.) As psychiatrist David Burns’s work with therapeutic motivation and resistance-to-change has shown, this exchange would almost certainly lead her to express the other side of her ambivalence: the dashed hopes, the feeling of being used, the sense of futility in making the same poor choice over and over.

When a woman continues to stay with an abusive partner, therapists often make the mistake of focusing solely on her vulnerability or her “codependency.” A better approach is to start by honoring her commitment to keeping her family together: “Lynne, I see you as someone who cares deeply about keeping your commitments to your marriage and your family. You know your kids love their dad, and you want to keep your family together if it’s possible. You’re not someone who cuts and runs when times get tough in a relationship.” Notice that there’s no but at the end of this statement. It’s important to let her take it in and talk with her about that side of her experience for a while without pouncing on the risk or pathology associated with it. If you can honor her commitment in this way, you’re telling her that you see her as a strong person who cares about those around her—and not as a helpless victim. If you work this side of the coin in a heartfelt way, she’s likely to be open to exploring the other side, which involves her feelings of not deserving to be treated better or her worries that keeping the family together may actually be harming the children.

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.

Learn how to recover when you’ve come on too strong. Cindy, the woman who’d been with a series of mooching men, had started seeing yet another new guy who talked money early on. She knew well my concerns about her pattern and shared them. After a particularly challenging session in which my conversational craft had slipped into badgering, I knew I needed to do repair work.

So I began the next session by saying, “You know, I came on pretty strong last time with my concerns about this new relationship. How are you feeling now about the stance I took in our last session?” She acknowledged that my concern made her feel cared for, but she worried that she was disappointing me. We then processed the clear reality that I was skeptical about a choice she was making and talked about how we could live with that tension and still do good work together. In fact, she thought I was probably right, but then revealed for the first time that she saw herself as a “betting woman,” who was OK with long shots when it came to relationships. She thought she’d decline to lend money to this current guy, but would keep open the possibility that this could be a good relationship. This exchange helped repair a frayed clinical relationship, in which I’d almost become overresponsible and not therapeutic.

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