Category Archives: Therapeutic Relationship

Client Attendance

young woman in therapyI’ve been seeing a client for three months, but she has only come to 7 sessions.  Sometimes she calls to cancel, but often she just doesn’t show up. I don’t know whether I should stop seeing her or if there is another way to help her understand the importance of coming in regularly.

This is a common dilemma, especially for clinicians in training or agency settings. It is difficult to make therapeutic progress when clients miss one or more sessions each month, and it is often challenging to engage the client in examining the reasons for irregular attendance. I will describe two approaches to this issue, and you may find either or both of these approaches helpful with this client and similar situations.

The first approach involves having a standard policy regarding attendance, setting a limit on the number of missed appointments or late cancellations. Your agency may have such a policy or you may develop one if you are working in a private practice setting. This policy should be part of your informed consent process, and I recommend that you remind the client about this each time she misses an appointment without notice or with late notice. A common standard is to allow three missed appointments or late cancellations (usually less than 24 hours’ notice) in a four month period before ending treatment. You may decide to make exceptions for illness or unavoidable emergencies, but be sure to discuss this with the client and let her know the reason for making an exception. The purpose of this type of policy is to insure that there is discussion about the issue of attendance and that the client is able to make progress on the issues she wants to address.

The second approach, which can be used instead of or in addition to an attendance policy, is to handle the client’s sporadic attendance as a clinical issue. The basis for this approach is an assumption that the client is repeating a traumatic or maladaptive interpersonal relationship and that you can provide the client with a different experience that will have a therapeutic outcome. I will outline a three step process for making such a clinical decision.

The first step in understanding the meaning of the client’s missed sessions is to reflect on her developmental history, especially regarding attachment and loss, and her descriptions of current relationships with intimate partners. Identify one or two themes that are present in these early and recent relationships. One common theme is an unpredictable attachment figure which leaves the client with feelings of longing and inadequacy. Another is an intrusive or abusive attachment figure leading the client to sacrifice safety to meet her need for connection. Think about the implications of these interpersonal experiences for the client’s view of herself and expectations of others.

The second step is to examine your countertransference and identify the interpersonal experience that the client is repeating with you. Be honest and thorough in reflecting on all of the thoughts, emotions, and images that are present when you wait for your client or when you pick up a message cancelling a few hours before the appointment. Notice any attributions you make about the reasons for the client missing the appointment and about the value of the therapy or your value as the therapist. Think about parallels between your thoughts and emotions and the client’s interpersonal themes. The client may be placing you in the position of the attachment figure or in the more vulnerable position she was in as a child.

Once you have identified the relevant experience and the roles being enacted by you and the client, you are ready to decide on a response that will allow the client to experience this interaction differently. This third and final step usually begins with shifting your countertransference state so that you are in touch with your therapeutic intentions and skills. You can then talk with the client in a different way than is possible when you are in the grip of the client’s enactment. In the best of circumstances, your response allows the client to become more engaged in the therapy whether or not she gains insight into the nature of the repetition. At other times, the client continues her side of the repetition, and you will need to decide whether to introduce limits as discussed above. Even in these situations, however, there is an opportunity for your learning and you can end the therapy, if necessary, knowing that you provided every opportunity for a therapeutic outcome.

I hope you are able to use these suggestions when working with clients whose attendance is irregular. Please email me with comments, questions, or suggestions for future blog topics.

Clinical Issues at Holiday Times

psychiatrist-mental-health-doctorThe holidays are coming up soon, and I am thinking about how to prepare my clients for the issues that are likely to come up.  This is my first year in a practicum placement, so I also wonder how much to be available to see my clients during the holiday season.  

The time between mid-November and early January is a difficult time for many of our clients.  Family gatherings can trigger painful memories and can give rise to conflict over past or present disagreements.  Those who choose not to spend time with family or who are estranged from family may feel a heightened sense of isolation during this season if they don’t have relationships with a partner and friends.

In approaching the topic of the holiday season with your clients, I recommend that you adopt an attitude of curiosity and interest, free of assumption and agenda.  You have probably worked with some clients for a few months and with others for only a few weeks.  They will vary in their sense of trust and engagement with you and in their readiness to plan for upcoming events and gatherings.  You can bring up the topic with a general statement like “the holiday season is challenging for many people and I wonder if you’d like to talk here about some ways to take care of yourself during this time.”  This leaves an opening for the client to focus on the aspect of the season that is most challenging or to let you know that it isn’t a priority.

Some of the issues your clients may want to discuss are family gatherings, other social events, financial pressure, and managing stress.  Remember that your role is to support and collaborate with your client rather than to attempt to fix the dilemma.  Find out what specific difficulties have arisen in the past and ask how she would like to handle a similar situation in this holiday season.  It is usually better to apply skills the client uses in other situations or to make small adjustments in the familiar pattern rather than taking on a major change.  For example, if she has used a mindfulness exercise in other stressful situations, suggest trying that before or after a tense shopping trip.  If the client reports that the family gathering becomes heated and conflictual after a couple hours, ask if he could plan to leave after two hours before things escalate.

Regarding the question of being available to see your clients, reflect first on your needs for self care during the holiday season.  Our personal lives contain the potential for family conflict, painful memories, and feelings of loneliness as do our clients’ lives.  Be sure to make your decisions about taking time off from client work in a way that includes meeting your needs.  Consider the possibility that some of your clients will miss their scheduled appointments and that you will feel particularly frustrated or resentful if you defer your needs for time off and the clients don’t come in.

Once you have decided on your schedule for the holiday season, let your clients know when you will be out of the office and confirm the dates you are available for scheduled appointments.  Some clients don’t think in advance about the impact of changes in work schedules and children’s school schedules on their ability to keep an appointment, so it may help to reduce the number of late cancellations you have if you go through the calendar with them.  Provide your clients with information about emergency coverage during your absence, and develop a safety plan with those who are at risk or who anticipate particular difficulty at this time of year.

I hope you are able to use these recommendations for your clients and yourself in the holiday season.  Please email me with comments, questions or suggestions for future blog topics.

Client Disengagement

Client DisengagementI’ve been working with a client for about six months, and we’ve agreed on a treatment plan. However, he doesn’t seem very engaged in working toward his goals. My supervisor suggested I bring this up with him, so I asked if he has changed his priorities and he said no. How can I help him make progress when he isn’t motivated?

This is a difficult situation, and it sounds like you haven’t yet identified the reason for your client’s lack of engagement with the treatment plan. In addition to a change in priorities, this type of withdrawal could be due to his reluctance or inability to verbalize his preferences or due to pressure from someone in his life about the purpose and outcome of the therapy. Your client told you his priorities haven’t changed, but you still don’t know whether that or another factor may be explain your sense that he isn’t working collaboratively with you. I’ll make a few suggestions of ways you might work with yourself and your client to change the pattern or your interpretation and response to it.

The first step I would recommend is to identify and explore your countertransference response. You say he seems disengaged, which suggests that there is a disruption in your experience of the therapeutic relationship. Give thought to his behavior and your emotional response without making an interpretation of what it means. Also, reflect on whether your client’s behavior has changed over the six months you have worked together. It is possible that there is a mismatch between you and your client in interpersonal pace, rhythm, and emotional expression. If that is the case, the meaning you are assigning to his behavior, i.e., that he isn’t engaged in working on goals, may not be accurate. In addition, if you notice a similarity in your emotional response to this client and to other situations in your personal life, you may need to become more flexible in attuning to your client’s preferred style and not assigning the same interpretation to his behavior as you have made in other relationships. Talk with your supervisor about your countertransference and your observations of your client’s behavior to help you get clearer about why you have come to the conclusion that he isn’t motivated.

After you have checked your countertransference responses, consider bringing up the issue of your client’s engagement as a process comment. Be sure you are feeling open and nonjudgmental when you initiate this discussion. Examples of ways to bring up the issue would be “I’ve noticed that our discussions of your treatment goals haven’t been very fruitful and wonder if you have any thoughts about that” or “I’m wondering how the therapy is feeling for you and whether we’re addressing the things that are most important to you” or “I’d like to check in with you about how we’re working together to make sure I’m helping you in the ways you want and need.”

Last, after you have initiated this process level discussion, respond with curiosity and interest to the client’s comments. It is especially helpful to use reflective listening, empathy, and clarification. Even if your client responds by saying “everything is fine,” you can respond with “so you feel we’re working on the things that are important to you?” to affirm the client’s statement and encourage him to elaborate. If he gives any indication of ambivalence or dissatisfaction, you can follow up on that using reflective exploration which may lead to greater understanding and collaboration between you. If he doesn’t directly express any discontent, you can still express your openness to hearing his negative feelings by making a normalizing statement. An example is “people often find that they have a mixture of feelings about therapy, so if that does happen for you I hope we can talk about it.”

I hope this discussion has been useful to you in understanding client disengagement. Please email me with questions, comments, and suggestions for future blog topics.

Updating Client Documentation

imgresI have seen a client for three months and have learned new information that changes my diagnosis from major depressive disorder to post traumatic stress disorder. In light of this new information, we’re also working on different treatment goals than we talked about at the beginning. What is the best way to document these changes in our work together?

You are describing a situation that is common in clinical work. The information that clients give us at the beginning of treatment reflects what is uppermost in their minds as well as what they feel safe to disclose. Often they remember and reveal more after they feel understood and become less worried about being judged or criticized. When you work with children or adolescents, you may also get additional information from parents or teachers that affects your diagnosis and treatment plan.

Before discussing how to document these types of changes, I’ll share some thoughts about the content of your documentation. Since your new diagnosis is post traumatic stress disorder, your client has evidently told you about past traumatic events as well as revealing more about the different symptoms she is experiencing. The details of these traumatic events may be sensitive, and you should think about the possibility of your client or a third party viewing your record as you record this information. Your documentation should include enough detail to support and explain your clinical decisions while also preserving your client’s privacy. For example, you could say that the client was exposed to domestic violence but put the details of the incident and the family situation in your psychotherapy notes rather than the clinical record. (Click here for an explanation of the difference between progress notes and psychotherapy notes.)

Your documentation of these changes in your clinical work can take two forms: progress notes and separate assessment and treatment planning documents. Ideally, the changes would be reflected in both of these documents. If your agency receives a request for the client’s record, they may only send the assessment documents and not include progress notes. However, your progress notes should describe the treatment progress, and this requires including the information you describe above.

Regarding the progress notes, they should incorporate your client’s report of symptoms and traumatic incidents and your revision of the diagnosis. If you only included the client’s report in your previous notes, you can add a paragraph to your next note identifying the new diagnosis and your assessment that led to this revision. Similarly, you should describe your conversation with the client about new treatment goals and your plan for working on them. It is best for this to be included in the note for the session in which you had that conversation, but if you have already written that note you can create a supplemental note or include the information in a note for a later session, identifying the date of the original conversation.

If your agency has one or more documents for assessment and treatment planning, you may have a form for revisions or updates that you are required to complete every three, six or twelve months. If you don’t have a version of those forms to use for revisions, check with your agency supervisor. You may be able to write an addendum to the original form or simply complete a new assessment and treatment plan with a new date.

I hope you found this helpful in updating client documentation. Please email me with comments, questions or suggestions for future blog topics.

Silence as Avoidance

1-1I have a client who uses silence as a defense or avoidance. What can I do to make therapy effective when he isn’t engaging with me to work on his goals?

I previously discussed general guidelines about managing silence in session, which will be helpful to read if you didn’t do so before. In this situation, you are experiencing the client’s silence as an obstacle to therapeutic progress and it sounds like he hasn’t responded to your encouragement to work more actively in therapy. I’ll outline a couple suggestions that may help you reframe the meaning of the silence and respond therapeutically.

My first comment is that this client actually is engaging with you through his silence. My guess is that you have spent a lot of mental energy and emotion in attempting to solve what you experience as a problem between you, so he has been successful in creating a relationship with you. The obstacle or problem lies in the fact that he is engaging with you in his preferred way rather than in your preferred way.

A question I would pose is “why does this client prefer to engage with me through silence rather than through talking?” There are a number of possibilities. He may feel vulnerable to being controlled and/or judged by you if he speaks about what he thinks, feels and wants in therapy. He may be sensitive to the implicit power dynamics between the two of you, and using silence to recalibrate the balance of power. He may be highly anxious and/or obsessive, such that his cognitive process becomes paralyzed or blocked when he thinks about painful or unsatisfying aspects of his life. Other explanations may come to mind based what you know of his history and presenting symptoms, if you frame the question in this way.

Once you have developed a hypothesis about the reason he prefers to be silent, you can make a tentative comment like “I wonder if it feels safer to stay silent than to risk hearing what I might say if you were to talk about what is on your mind.” He may or may not respond to this directly or verbally, but communicating your desire and effort to understand him will have a positive effect on the therapeutic alliance.

I would also recommend thinking about your therapeutic role with this client as containing elements of both joining his interpersonal world and providing a different interpersonal experience than is familiar to him. This is always part of the therapeutic process, but the two worlds or experiences are usually closer together than they are in this case.

You may have an assumption that his goals for therapy will be met only if he talks with you as most of your other clients do. Joining his world means letting go of that assumption and meeting him on his terms. This may mean that you remain silent for some of the session or that you comment on his silence without a requirement that he begin talking, as in the example above. In this context, providing a different interpersonal experience may mean that you accept his need for silence without insisting on an explanation. Maybe he has felt forced into interacting with others when he needed distance, and therapy feels like a repetition of that coercion. He will let you know if and when he is ready to engage in a more traditional form of talk therapy. In the meantime, remember that you are demonstrating your capacity to relate to him differently than he may expect and fear.

I hope you this has been helpful in thinking about silence as a defense or avoidance. Please email me with comments, questions or suggestions for future blog topics.

The Value of Listening

Grieving womanI’ve seen a client for three months and am at a loss for what to do. Her husband of 35 years died suddenly last year, and our work has focused on her grief and loss. Her feelings are still very intense, and I’m beginning to wonder if I can help her. I’m in my early thirties with both of my parents still living, so I don’t know what she’s going through.

It’s good that your client is getting your help and support at this difficult time. It isn’t necessary to have personal experience with issues like those of your clients in order to be helpful to them. Instead, your grieving client will benefit from your attention and skillful listening as she struggles to live with her intense grief. Listening to your client is a vital part of the therapeutic process and will facilitate her healing.

You may be more accustomed to thinking about and planning for active interventions in your clinical work. Clinical training often emphasizes the use and mastery of techniques, and this may have given you the impression that being a therapist centers on finding something to do that will lead to change in your clients’ lives. You may undervalue the impact of your presence in listening to your clients and sharing their pain without pressure to make it go away. This is especially true for feelings of grief and loss, which many people in our society avoid. Clients who have experienced a recent loss often have been encouraged to “get over it” or advised to “move on” by well-meaning but ill-informed friends and family members.

In this case, your primary task is to give your client as much room and time as she needs to talk about her 35-year marriage, the circumstances of her husband’s death, the feelings she has had during the last year, and how she feels on a day-to-day basis as she copes with this loss. Although you haven’t experienced such a loss, you can and should be open to hearing from her what this loss has been like for her. Your empathy, warmth and acceptance will be the primary therapeutic tools you need. You may find yourself feeling overwhelmed with the intensity of her emotions, since it sounds like she feels overwhelmed with them. It’s not your job to change her feelings, but they will become more manageable over time as she feels your presence and support in sharing them with her. This process will unfold gradually as she recognizes your ability to work on her internal timetable rather than imposing one of your own.

If you work in a setting that places a time limit on treatment, you may need to let go of your wish for a specific outcome and instead focus on her need for you to share this part of her journey, which began before she came to see you and will continue after she ends. She will be grateful for your capacity to sit with her rather than to rush toward an artificial end point.

I hope you found this helpful in understanding the value of listening. Please email me with comments, questions or suggestions for future blog topics.

Making Referrals to Additional Services

hispanic young woman in therapyI have been seeing a client for a couple months and I think she needs more help than I can provide with individual psychotherapy. I have recommended that she get a psychiatric evaluation, join a DBT group, and sign up for a subsidized housing program. All of these services are available at the agency where I am doing my practicum training, but so far she hasn’t followed up on any of my referrals. How can I encourage her to get the additional help she needs?

Many clients in individual psychotherapy also need and benefit from additional services. Therefore, our work as therapists often involves some case management such as making referrals and collaborating with other professionals. We sometimes think of these case management tasks as outside of our therapeutic role and handle them pragmatically. This blog posting will help you think about making referrals as an integral part of the psychotherapy, which may lead to a better outcome.

I’ll start with some discussion of the reasons for recommending additional services. The combination of services you mention suggests you have multiple purposes for your referrals: clarifying the client’s diagnosis, managing crises or instability, improving living circumstances that contribute to symptoms, and following the recommended practice for specific clinical presentations. It also seems like your client presents with a complex set of emotional and psychosocial issues and you may be feeling overwhelmed. I would suggest first that you take some time to reflect on your countertransference responses to this client, preferably with some consultation from your supervisor and colleagues. This may clarify the support you need in managing this case and help you identify the reasons for your referrals. With a clearer perspective you can develop the most effective method for helping your client.

Once you have become clearer about the purpose of your referrals, approach them in order of priority. You can prioritize the referrals based on the client’s preferences and goals as well as safety concerns. It may be useful to use a harm reduction approach, which is often used with substance use disorders and has application for other situations involving safety. Identify the areas of greatest potential harm to your client and work first to reduce that harm, through your work in therapy as well as through referral to additional services. For example, if your client’s suicidal ideation puts her at serious risk, you would begin by looking for ways to reduce that risk. She might benefit from any of the referrals listed above or from accessing a 24-hour suicide prevention hotline, and the best recommendation would be the one that she is most willing to pursue. The remaining referrals would be deferred until her suicidal risk is reduced.

You express a view that your client needs more help that you can provide. There are some instances in which individual therapy can only be effective in conjunction with other resources. Talk with your supervisor about the client’s risk so s/he can help you decide whether to require the client to use one or more other services as a condition of individual therapy. That is sometimes the best decision to make in a complex, volatile clinical situation.

A final issue to consider is the therapeutic tone and manner of your referral recommendations. Pay particular attention to your countertransference and the possibility that you want to hand off this client to someone else because she feels like too much for you to handle. It is easy for a client to experience a referral as a sign of rejection rather than support. The client is bringing her concerns and difficulties to you and may feel your ambivalence about helping her. She is more likely to experience your support if you discuss your countertransference with your supervisor, then make it clear to the client that you plan to continue working with her. It will also help to describe how you believe the other services will contribute to the therapy rather than being a substitute.

I hope you found this blog helpful in making referrals in a therapeutic manner. Please email me with comments, questions or suggestions for future blog topics.

Managing Silence

LGBT therapyI have a client who has a hard time talking in our therapy sessions. I want him to benefit from therapy so I prepare for the session by having topics for us to talk about. This has been going on for several months now, and I’m beginning to wonder if there’s a different way to handle this situation.

This is a common question for therapists in training. Since the nature of our work is listening and talking, we tend to feel uncomfortable when the back-and-forth flow of our interactions with clients is interrupted by silence. One aspect of professional growth as a therapist, though, is becoming comfortable with therapeutic interactions that are different from social interactions we have with friends, family and co-workers.

When I am working with a client who doesn’t initiate conversation or falls into silence, I usually respond first by simply sitting quietly myself. Often the client will then continue with the previous line of thought or bring up a new issue that we can explore together. In the beginning of therapy, I don’t let the silence continue for more than 20 or 30 seconds especially if the client seems uncomfortable, but that is often enough time for the client to guide the direction of our conversation.

If I do choose to break the silence, I ask an open-ended question rather than bringing up a specific topic. Examples are “is there more you’d like to say about that?” or “what’s on your mind?”. If I notice something in the client’s body language, I might say “it looks like you’re feeling sad about that” or “maybe it’s hard to realize how much pain you’re in.” If you use this type of question or statement, your client will know you’re interested in his inner experience and that he sets the direction of the therapy. Usually he will feel encouraged to continue exploring the thoughts and feelings related to the current issue or to shift to an issue that feels more relevant.

When silence is a recurring part of the therapy and the client doesn’t respond to your open-ended questions or reflective statements, your task becomes one of assessment or conceptualization of the reasons for his behavior. Some possibilities are a lack of familiarity with therapy and self-reflection, social anxiety or skill deficits, and cognitive limitations. Talk with your supervisor about your client’s history, diagnosis and relationship experiences as well as the therapy process and your countertransference responses. This discussion will help you develop an understanding of your client’s experience of the therapy and choose the most therapeutic way to engage him. You may also need support from your supervisor in managing your countertransference with a client who seems passive and disengaged.

When silence is recurring, it is sometimes helpful to provide some education about the therapy process. Clients who are new to therapy may be unsure of what is expected, and clients who have a history of contact with social service systems may have been socialized to take a passive role with professionals. Giving a short description of therapy and your approach and expectations provides guidance in these situations.

Another helpful intervention is to make a process comment or question related to the silence itself. Examples are “what’s it like for you to sit quietly here?” or “it looks like you’re not sure what to say next” or “how would you like me to respond when you’re quiet?”. You may learn that the client has assumptions about your role or your reactions to him that lead to a fruitful discussion between you. For example, the client may express a desire for you to provide an answer to a complicated emotional dilemma or may be worried that you are bored by the circumstances he is describing. In general, process comments and questions serve the purpose of communicating your presence and interest in the client and provide an opportunity to talk directly about obstacles to the client’s engagement.

I hope you found this helpful in managing silence in your therapy sessions. Please email me with comments, questions or suggestions for future blog topics.

 

Generational Differences in Therapy

stock-photo-27330798-senior-woman-and-psychiatristI have been working for the past year with a 78-year-old woman who has a moderate level of depression. She has a limited income, lives alone and has very little contact with other people. I have suggested several resources, including some that are online, that she could use to reduce her isolation. She agrees with me in session but doesn’t follow through. I’m starting to feel both frustrated and discouraged about being able to help her. I talked with my supervisor about ending the therapy but she told me to keep trying.

This question highlights the way in which generational differences can enter into therapy. When we work with individuals who are separated by one or two generations from us, we need to be aware of the age-related psychological issues facing our clients as well as the cultural differences that exist between us.

Starting with the psychological issues facing your client, she may be facing a high degree of loss and grief related to each of the risk factors you mention: limited income, living alone and lacking contact with others. Find out whether there were significant changes in your client’s life in the two to five years before she became depressed. If so, she may still be grieving the loss of income and financial status, the death of a spouse or close friends, and/or facing health problems that reduce her mobility. Even if these risk factors were present before she became depressed, she may have become less able to stretch her budget, participate in social activities or function independently as she ages. If you haven’t given her an opportunity to talk about feelings of loss or offered your empathy for her grief, I would suggest doing so. She will need to feel understood emotionally before she is ready to follow your suggestions about other resources that might help to improve her depression.

Another set of psychological issues arises in the fact that your relationship with your client mirrors a parent/child or grandparent/grandchild relationship for both of you. On your side, your frustration and discouragement probably include feelings you have about your parents or grandparents who faced or are facing some of the same issues as your client. Talk with your supervisor and therapist about these personal relationships to gain a better understanding of your countertransference. On your client’s side, working with a therapist who is young enough to be her child or grandchild exacerbates the sense of invisibility and devaluation she may feel as an older person in a culture that equates youth with worth. Your suggestions may feel condescending or invalidating if you are assuming you know more than she does about her experience and needs.

Moving to a cultural perspective, your client’s values and world view are different from yours due to the generational differences between you. Your client was a child during the Great Depression and World War II, came of age during a time of nationwide financial expansion, and experienced the civil rights, anti-Vietnam War and feminist movements as a young adult. Her experience of technology has spanned the period from radio and black-and-white television to internet and smart phones. It is a mistake to assume that she is comfortable, either emotionally or technologically, using online resources to reduce her social isolation. Her agreement with your suggestions may reflect a deferential attitude toward professionals who hold positions of authority, based in the values of her generation. Viewing your relationship as a cross-cultural one may help you to bridge your differences and approach your client with curiosity and interest.

I hope you find these suggestions helpful in working across generational differences in therapy. Please email me with comments, questions or suggestions for future blog topics.

What to do with Things that Can’t be Changed

therapyI’m working with a 20-year-old woman who has a bad relationship with her parents. I’ve been encouraging her to use better communication techniques with them but their conversations always end with the parents yelling and my client feeling blamed. She’s asked them to go to family therapy with her but they refuse. How can I help her when her parents won’t change?

As therapists, we focus on the potential for growth and change, and we maintain hope for our clients when they are discouraged. This is an important and effective trait in many clinical situations; however, it is equally important to recognize and help clients deal with circumstances that can’t be changed.

The first step I would recommend for you is to examine your countertransference. Sometimes we develop unrealistic goals with and for our clients because of personal issues and feelings. In this case, I would ask yourself if your relationship with your own parents is related in some way to your feelings about your client’s situation. You may be trying to achieve something that wasn’t possible in your own life or to replicate an aspect of your life that worked well for you. Either way, work to separate your parental relationship from your client’s relationship with her parents.

Another countertransference issue that may be present is related to feeling competent and effective. Therapists in training are often more comfortable when giving advice, teaching a skill, or proving an active intervention. Reflect on how you feel when your client follows your suggestions and reports they don’t work. If it is hard for you to sit with your client’s painful feelings, your definition of therapeutic success may be too restrictive. Talk with your supervisor about what it’s like for you to be less active in session and explore the usefulness of being emotionally attuned and present.

If you are able to sit with your own feelings of discomfort you will be better able to help your client with one of her therapeutic tasks: accepting what cannot be changed. It sounds like you and she have become invested in her parents changing their behavior toward her and that change isn’t possible right now. It will feel painful to both of you to face this, but it seems to be the current reality of her life. Acknowledging this and allowing her to express her anger, fear, helplessness, and loss will be an important therapeutic intervention. It may take time and will be painful but it is in the service of her developmental growth. Accepting the state of her parental relationship will facilitate her ability to focus on other aspects of her life. She is entering adulthood and facing decisions about work, friendships and intimate relationships. If she has put these on hold to resolve things with her parents, it may be time for her to shift her attention and energy.

Paradoxically, you may find that your client reports some improvement in her relationship with her parents as she moves toward acceptance. Sometimes relational conflict is exacerbated by an implicit desire for change that is experienced as an unwanted demand. Your client may have been communicating a more complex message than what you and she worked on with better communication skills. Her acceptance conveys a different message and may lead to a decrease in conflict.

Your question also raises an important issue related to treatment goals. Clients often enter treatment with a goal for change in something that is outside their control. You may have inadvertently agreed to a goal for individual therapy that can’t be achieved in that modality, so consider reviewing your treatment goals with your client. It sounds like a goal related to understanding her feelings about her parents and a goal related to de-escalation and detachment would be more appropriate than a goal about better communication between your client and her parents.

I hope you find this helpful in facing aspects of your clients’ lives that cannot be changed. Please email me with comments, questions or suggestions for future blog topics.