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Thursday, December 28, 2017

Starting Where the Client Is In Psychotherapy

One of the first clinical lessons that beginning psychotherapists learn from their clinical supervisors when they work with psychotherapy clients is "Start where the client is."  This is a reminder that a psychotherapist might have good ideas about where the therapy needs to go, but if the therapist is getting ahead of the client, it's going to be detrimental to the client and to the therapeutic work.  The therapist needs to listen to the client to discover where the client is and be empathically attuned to the client (see my articles: The Therapist's Empathic Attunement Can Be Emotionally Reparative For the ClientPsychotherapy: The Importance of Therapists Listening and Learning From the Client and Why is Empathy Important in Psychotherapy?).

Starting Where the Client is in Psychotherapy

Even experienced psychotherapists can sometimes forget, in their sincere concern to help clients in therapy, that getting ahead of the client isn't useful to the client or the work in therapy.

For example, clients often come in with a particular presenting problem, but the therapist might sense that the presenting problem is really something else.

In this example, the therapist is often right, but if she gets ahead of the client and tries to steer the client in another direction before the client is ready, the client will either get confused or feel unheard and leave.

As a result, even when an experienced psychotherapist senses that there is another issue that is a bigger problem than the one the client presents, the therapist needs to proceed in a tactful and gentle way.

Rather than rushing in with astute psychological insights, the psychotherapist first needs to assess the client for what s/he might be ready for, especially at the beginning stage of psychotherapy, and then decide how to proceed.

The following fictional clinical vignette will demonstrate these issues:

Fictional Clinical Vignette: Starting Where the Client Is in Psychotherapy

Ned
When Ned began attending psychotherapy, he told his new psychotherapist that he wanted to improve how he communicated in his relationship so he and his girlfriend could get along better.

Ned described a relationship dynamic where his girlfriend, Jane, liked to talk about their relationship from time to time, especially when she thought they had problems, but Ned hated these talks.

He felt that his girlfriend usually made "a big deal out of nothing" and he told her this.  At first, when she told him that this hurt her feelings, Ned didn't understand.  But after they argued about this a few times and Jane threatened to leave him, he decided he had better improve his communication skills.

As his psychotherapist listened to Ned describe how he often dismissed other loved ones' concerns, she suspected that there were deeper issues involved, but she also knew that if she brought this up with Ned too soon, she would alienate him, so she waited for the right moment when she thought he would be more receptive.

At the point when Ned and his psychotherapist formed a good working relationship in therapy, his psychotherapist explored with Ned what he thought was going on for him in this relationship.  She recognized that Ned seemed more open to this type of exploration at that point.

Ned responded by telling his therapist that, even though he no longer dismissed Jane's concerns, he still couldn't understand why she wanted to talk about the relationship.  He thought he was being much more considerate with Jane by not dismissing her concerns.

His therapist helped Ned to put himself in Jane's shoes to try to understand what was bothering her.  He thought about it and said that Jane said she would like to get closer to him, but she felt that he pushed her away emotionally.

As he thought about it more from Jane's point of view, he acknowledged that too much closeness frightened him and maybe this was why he dismissed Jane's concerns.

Over time, as Ned and his therapist continued to explore these issues, Ned realized that he could only take so much closeness with Jane and after that, he was uncomfortable.  That's when he dismissed her concerns and, in effect, created distance between himself and Jane.

He was now realizing that whenever he did this, this made Jane anxious and the more anxious she became, the more she wanted to talk about the relationship so they could get closer.  But the more she  wanted closeness, the more distant he felt.  So, this became the cycle that they were caught in.

Starting Where the Client is In Psychotherapy

Earlier in the therapy, his psychotherapist suspected that Ned and Jane had two very different attachment styles.  It appeared to her that Jane had an anxious attachment style and Ned had a dismissive attachment style (see my article: How Your Attachment Style Affects Your Relationship).

As his therapist talked to Ned about this and provided him with psychoeducation about attachment styles, it was as if a light went off in his head.  Suddenly, this made sense to him and he was motivated to work on the problems in his relationship (see my article: Why It's Important For Psychotherapists to Provide Clients With Psychoeducation).

Even though Ned was now ready to work on this problem, his therapist knew that if she had brought up this issue at the start of therapy, Ned wouldn't have been ready to hear it, and he acknowledged as much to her when they discussed it later on in therapy.

Gradually, Ed worked on the underlying issues that caused him to feel frightened of closeness with Jane.  He was also able to tell Jane that, ultimately, he wanted to be closer to her, but he needed to take it slowly.  Jane understood, and she said that she wanted Ned to tell her when he was getting frightened, so she wouldn't keep pushing him and alienating him.

Conclusion
Starting where the client is in therapy is important for the client and the success of the therapy.

A psychotherapist needs to use her clinical skills to assess where the client is, especially at the start of therapy, so she doesn't jump ahead of the client.  She also needs to use her clinical skills to assess when the client is ready to go deeper.  The timing will be different for each client.

It's important for the client and the psychotherapist to have a good therapeutic relationship first before going any deeper in therapy.  A good therapeutic relationship means that the client trusts the therapist and would most likely be willing to look at underlying issues.

If you're in therapy and you feel your therapist is jumping ahead of you or something else in the therapy is bothering you, it's important for you to communicate this to the therapist (see my article: How to Talk to Your Psychotherapist About Something That's Bothering You in Therapy).

Getting Help in Therapy
Asking for help can be challenging.  

If you're considering getting help in therapy, the first step is making an appointment for a consultation (see my article:  Tips on Overcoming Your Fear of Asking For Help).

When you choose a psychotherapist, it's important that you feel heard by the therapist (see my articles: The Benefits of Psychotherapy and How to Choose a Psychotherapist).

I usually advise clients to trust their instincts when they're trying to decide if a particular therapist is right for them.

Psychotherapy can free you from your problematic history so that you can maximize your potential, and a skilled psychotherapist can help you to overcome your problems at a pace that feels right for you.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who uses Integrative Psychotherapy to tailor the therapy to each client's needs (see my article: The Benefits of Integrative Psychotherapy).

I work with individuals adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (212) 726-1006 or email me.
























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