Tag Archives: Psychotherapy

Holding Different Perspectives on a Clinical Situation

I’m working with a couple who report very different versions of their interactions with each other. I trust the wife’s report more than the husband’s, but I don’t know how to figure out what really goes on between them. How can I determine who is more accurate?

The dilemma you describe comes up frequently in working with couples, and it illustrates an important capacity that we need to develop as clinicians. It is natural to begin with a view that there is a right, true, or accurate version of a particular situation or interaction. However, you will learn with clinical experience that each person in an interaction experiences it in slightly different ways, and sometimes in dramatically different ways. This requires us to develop a capacity to hold different perspectives on the same interaction. I will begin my discussion with some suggestions about this issue in working with couples, then address how it also applies when working with clients who feel hurt, angry, or misunderstood by us and when working with colleagues or supervisors.

Couples who enter therapy often present with each member of the couple invested in his or her position, trying to enlist the support of the therapist to convince their partner that their position is correct or superior. The therapist’s countertransference response is often to feel compelled to take the role of a judge and developing a verdict on the conflict. However, with rare exceptions for situations related to physical safety, the couple’s conflict is due to differences between the individuals and their ability to communicate and listen to each other.

The first step in helping a couple in this situation is for you to understand the perspective of each individual in the couple and to hold their perspectives, even if widely divergent, as valid and important. Your capacity to hold multiple perspectives can help shift the focus of the couple from a quest to identify who is right to an appreciation for each individual’s unique emotions, needs, and motivations. For example, a couple may begin a session with the wife reporting an argument in which the husband yelled at her, and the husband reporting that he didn’t raise his voice but only asked his wife to move her car into the garage. You can help both clients feel heard and understood by pointing out that the wife felt criticized and bullied, even though her husband may not have intended to criticize her, and the husband felt ignored when his wife objected to his request.

The ability to be interested in different perspectives is more difficult to attain and express when you are one of the parties in the situation or interaction. When a client reports something you said that she felt was unempathetic or when a client reports feeling hurt or angry with you, it is natural to identify distortions in the client’s perspective and attempt to correct her point of view. You will learn that this is rarely if ever successful. You need to hold your point of view without defensiveness while encouraging the client to tell you more about her experience of the recent interaction between you. Similarly, when you talk about a mutual client with a colleague who views the client very differently than you or when you experience a conflict with your supervisor about the direction of treatment with your client, you need to be able to express your point of view while being open to and respectful of that of your colleague or supervisor.

You may wonder how to develop the capacity to hold multiple perspectives and how long it will take. Anything that helps you identify and reflect on your emotions and thoughts will facilitate this capacity, which is sometimes referred to as an observing ego or mindful self-awareness. Some helpful ways to work on this are to seek psychotherapy from a psychodynamic or other depth psychology orientation and to engage in meditation or other mindfulness practices. It is a capacity that is an area of continual personal growth, since different clinical situations will pose different challenges to our tendency to look for the one right or accurate view. You will find it easier over time, though, as you make it a priority in your professional growth.

I hope you find this discussion helpful in working with clients, colleagues, and supervisors. Please email me with comments, questions, or suggestions for future blog topics.

Resolving Problems in Supervision

I am having problems with my supervisor and am thinking about requesting a new supervisor. She seems impatient and critical of me, so I feel intimidated and that makes it hard for me to take in her feedback. When I tell her how I feel, she says she’s trying her best to help me learn. I don’t know how to make this better so maybe I should change to someone else.

This is a painful situation, since supervision is a crucial part of growing into the therapist role. It’s easy to feel hopeless and think that a change of supervisor is the only alternative. My experience has been that this kind of impasse can often be improved with thoughtful self-reflection and conversation, so I’ll first suggest some ways to examine the possible dynamics of this situation. Then, I’ll outline some recommended steps to approach the conversation that are likely to make it more clear whether your supervisory relationship can improve and contribute to your learning and growth.

My first comment is that engaging in self-reflection and finding ways to shift your feeling of intimidation to one of empowerment will contribute to your ability to handle other difficult clinical situations. You are likely to face interactions with clients, family members, or other professionals that contain some of the same features of this supervisory relationship. Since your supervisor’s job is to support your clinical growth, she is likely to be most responsive to your efforts so it is a good place for you to test out some new relational skills.

To begin your process of self-reflection, I encourage you to shift your attention from your supervisor’s comments to your own response. You mention feeling intimidated, so explore the thoughts, feelings, and images that are present in that sense of being intimidated. You may identify thoughts undermining your self-worth and competence, feelings of shame and inadequacy, and/or images of yourself as a child being chastised by a parent or other authority figure. As you identify your response on a deeper level, remember that these thoughts, feelings, and images are yours and are stimulated by your supervisor but are not the only response you might have. Although your supervisor is an authority figure, you are not a child dependent on a parent’s care and approval but an adult growing into a professional role. When your supervisor gives your feedback on your clinical work, it is not confirmation of incompetence but confirmation that you are in the early phase of learning a set of new skills.

It may be helpful to talk with other supportive people while you engage in this process of self-reflection, especially if your supervisory interactions stimulate unresolved issues from your early life. Talking with your therapist, academic mentors, or past clinical supervisors may be useful. It can be hard to recognize and challenge old patterns when your feelings are strong and painful. It may also be helpful to talk with peers and friends to gain support and encouragement; however, be careful to avoid presenting the situation in a way that will lead them to see the situation as hopeless and affirm your fear that it can’t get better.

After you made progress in understanding your response, challenging some of your underlying beliefs, and grounding yourself in your clinical role, it is time to return your attention to your interaction with your supervisor. Consider the possibility that simply shifting your response from one of intimidation to collaboration will change the dynamic in a positive way. I would suggest initiating a conversation about your supervisory relationship, acknowledging it has been difficult and sharing that you have examined your response and are attempting to shift some of the things that have interfered with your openness to her feedback. State in a positive way what you feel you have received from supervision and what you wish to gain from her expertise.

If supervision continues to be difficult after having a conversation like I describe above, the next step that may be helpful is to talk with the director of training or another clinical supervisor in the agency. Your agency may have a procedure in place for resolving supervision difficulties, which you should follow, but if not seek out someone who has some supervisory and/or administrative responsibility for the training program. A conversation with a third party may give you further insight into the difficulty you are facing and lead to a more fruitful conversation with your supervisor, or it may lead to a decision to schedule a meeting between you, your supervisor, and the third party to discuss the problems and attempt to reach resolution. A decision to change to a different supervisor is rarely necessary if you follow all of these recommended steps.

I hope you are able to use these suggestions in understanding difficulties you face in supervision. Please email me with comments, questions, or suggestions for future blog topics.

Applying for Internship Training

I plan to apply for internship training in a few months, and I want to work with children and families. How can I make myself a competitive candidate when my clinical experience so far has been with adults?

Your question highlights a common dilemma that isn’t limited to clinical work; i.e., how does one gain experience when the positions require prior experience? You are wise to plan for this ahead of time, and there are several strategies that will increase the likelihood of you being accepted into a training position that will give you the experience you want. Typically, there are two steps in being accepted for a training position. The first is to be invited for an interview, and the second is to be offered a position. Therefore, it makes sense to think of your strategies in two steps as well.

Your written application will determine the decision of the training agency to invite you for an interview, so let’s look at that step first. You are more likely to be invited for an interview if you submit written materials that follow the format and structure requested by the agency and are professional in appearance and language. Prepare your materials in advance of the deadline so you have time to proofread them. It is preferable to have someone else also look over them for obvious errors. If you submit materials electronically, by email attachment, be sure they are in a commonly used document type (PDF or Word document) without complicated formatting.

Familiarize yourself with the agency, and mention in your cover letter the aspects of the agency that are particularly attractive to you. You can research an agency by looking at their website, talking with other students in your program who have done training there, attending an open house if possible, and asking supervisors and professors what they know. Be careful to not make assumptions, though. I have received applications that incorrectly assumed the agency used a specific modality of treatment or served a particular client population, based only on its name.

Regarding the content of your written application, I would recommend that you both acknowledge your lack of clinical experience with children and families and highlight other relevant experience. For example, you might have done child care, teaching, camp counseling, or volunteer work. In your cover letter, explain how the work you did gave you valuable knowledge about the challenges faced by children and families and how you want to expand that knowledge by working clinically. You would be wise to take on a volunteer commitment now, even if only 5-10 hours per week, that would demonstrate your commitment to improving your skills. Also consider applying to agencies that see individual adult clients as well as children and families, so that your prior experience will be more relevant to the agency population.

If you are successful in step one, you will be invited to interview with one or more staff members. Think about the interview process at your prior placements, and be prepared to answer typical questions about your interest in the agency, your preferred theoretical orientation, your self-assessment of strengths and challenges, and your future career goals. It is also wise to prepare a short case vignette that illustrates a challenging situation that you managed successfully.

Plan your answers to interview questions about your lack of child and family experience carefully. In addition to the suggestions above which apply to an interview as well as a cover letter, consider ways in which your clinical experience with adults will transfer to child and family work. For example, you may have worked with parents and developed empathy for the difficulty of raising children when living with a history of trauma and psychosocial stress, you may have had worked with young adults facing many of the developmental issues of adolescence, or you may become aware of the impact of family relationships in your contact with the family members of adult clients living with serious mental illness. Also highlight the skills you have acquired that will transfer to child and family work such as diagnosis and assessment, case formulation, treatment planning, or the use of trauma or substance abuse treatment models. Be realistic in acknowledging how much you have to learn while describing the knowledge and skill you have attained thus far.

After your interview, solicit feedback from the interviewers if you aren’t accepted into the agency training program. Ask if they have suggestions on how you could improve your presentation or performance in the interview. This might give you valuable information about how to be a more competitive candidate for future positions.

I hope you find these suggestions helpful in applying for internship training. Please email me with comments, questions or suggestions for future blog topics.

Clinical Issues at Holiday Times

The 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.

Updating Client Documentation

I 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

I 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

I’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

I 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.

Client Responses to Therapist Leaving

I am leaving my practicum placement at the end of the training year in six weeks and have just told all of my clients. Most of them didn’t seem to have much of a reaction to this news. What can I expect between now and when I leave?

This is a typical situation during training, when most of your placements will last a year. If you haven’t read my previous blog posts about termination, you can do so to get more information about planning for ending treatment with your clients and about structuring the ending process. In this blog, I’ll focus on the range of client responses you may experience during the next six weeks.

One common response, which sounds like how most of your clients responded when you told them you are leaving, is to avoid discussing the end of treatment and your relationship. This may be accompanied by a statement like, “I know interns always leave after a year, so I’m used to it” or may simply be apparent in shifting the topic away from your leaving. Clients may also deny having any feelings about ending treatment with you, in response to your questions or comments about the impact on them and you.

Another response you may see is that clients miss sessions more frequently or make a decision to end before you leave rather than waiting the full six weeks. This often functions partially as an avoidance but also serves to express anger and to exert control over the timing and process of ending. A related response, especially in clients who have seen other interns before you, is to focus on the pragmatic questions about being assigned to another therapist at the beginning of the new training year.

Last, some clients may bring in descriptions of past or present interactions with others in which they felt rejected or abandoned or other situations involving loss. These clients usually do not make any conscious connection with the upcoming end of treatment and may deny the impact of your leaving if you make the connection. This may be due to avoidance of the painful feelings associated with your leaving and may also be influenced by the client’s lack of familiarity and experience with intentional endings.

Depending on your own feelings about leaving this placement, you may find yourself feeling frustrated or relieved by your clients who avoid talking directly about ending treatment. It is generally helpful to provide some education to clients about how treatment can end in an intentional way, using some of the suggestions in my previous blogs. It is also important to have some discussion of your leaving before the final session, since you can anticipate that some of your clients will not attend the final session as scheduled.

The best contribution you can make to a therapeutic ending with your clients is to talk about your feelings in your own therapy and supervision. This makes it more likely that you will be emotionally available during your remaining time with clients and that you will provide the opportunity for them to end with you in a therapeutic way.

I hope you found these examples of client responses helpful in managing your transition from this placement. Please email me with comments, questions or suggestions for future blog topics.

Managing Silence

I 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.

Diane A Suffridge, Ph.D

Consultant, training and author in behavioral health.