Tag Archives: Therapeutic Relationship

Holding Different Perspectives on a Clinical Situation

Couples CounselingI’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.

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.

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.