This is a common dilemma, and clients’ requests often seem straightforward and compelling. Depending on your own personality and style, you may be inclined to be consistent with everyone or you may be inclined to be flexible and responsive to each client’s requests. Rather than relying on your personal preference, the best clinical practice is to respond to the client’s request based on an understanding of her underlying motivations and the meaning it will have for you to be consistent or to be flexible. This means reflecting not only on what she says about this issue but also on everything else you have learned about her so far.
Generally, the more serious the client’s diagnosis and symptoms, the more important it is to meet every week. Weekly contact fosters the therapeutic alliance and improvement in symptoms, especially in the beginning of treatment. If your client has a diagnosis of bipolar disorder, had a manic episode three weeks ago and has been in treatment for a month, cutting back to every other week is not advisable. However, if her diagnosis is an adjustment disorder and she has experienced steady improvement during four months of treatment, it may be fine.
The client’s past and recent history helps you understand her reasons for cutting back. If she grew up in a chaotic, abusive home and has been involved with abusive partners, she may need to assert control in her relationship with you in order to feel safe. You would agree to her request in order to assure her that her needs are your concern. On the other hand, if her early life was emotionally barren and she has suffered a recent loss, she may think of herself as not deserving care and attention from others. You might talk about the benefit you believe she would receive from meeting weekly and state clearly that you want to work with her.
Next, reflect on how the client relates to you and whether anything might have gone awry in a recent session. If your relationship has been generally smooth and positive without any interpersonal turmoil, think about whether anything different or unusual happened in a recent session. You may have been more confrontive, may have mentioned an upcoming vacation, or may have misunderstood something the client said. Sometimes, even a small misattunement can lead a client to withdraw out of disappointment or anger. You can bring the conversation back to that incident and ask about the client’s feelings before making a decision about how often to meet. If the treatment relationship has been volatile or stormy, this recent request may be a continuation of the client’s way of bringing her interpersonal challenges into treatment. Agreeing to meet every other week is unlikely to improve this situation and may exacerbate the relational conflict.
Once you have reflected on her diagnosis, history and the treatment relationship, you can respond to her request, informed by your understanding of the meaning and motivation. I recommend talking about the reasons for your decision as well as telling her whether or not you think it is a good idea to meet less frequently. Whatever you decide, be sure to notice what happens in the therapy in that session as well as the next 2-4 sessions. If your understanding and decision are consistent with the client’s underlying motivation, the treatment should progress in a positive way. If not, you need to reconsider your decision, possibly with the help of a supervisor or consultant.
I hope you found this helpful in facing this common clinical dilemma. Please email me with comments, questions or suggestions for future blog topics.