Client-therapist relationship

[Mary S]

This seems like a pretty good article on client-therapist relationships. Some encouraging excerpts:

"one key to effectively addressing a client’s issues is to first understand those issues within the context of the client.

“It’s critical for the counselor to learn the client’s worldview in order to enhance cooperation in the counseling process,” ... When counselors diagnose the problem and launch into a prescribed method of treatment without first discussing the client’s concerns and goals, they are likely to be met with resistance,"

 “Meet the client where they are. ... This is true even if this means spending five minutes on topics that are important to the client that may not be directly related to the reasons they are coming into counseling.”

"Hitting roadblocks

But sometimes, despite attempts to offer respect, validation and space, client and counselor still don’t click. Is it time to throw in the towel when both the client and counselor are frustrated?

Not necessarily, says Guterman, who reiterates the importance of first learning the client’s point of view. In such situations, he recommends that counselors again ask themselves if they have made their best effort at thoroughly understanding the client’s worldview.

If that’s not the problem, Guterman suggests evaluating the pace of the counseling sessions’ progress. “Are you pacing with the client? All clients are different, and some clients prefer to go slow,” he says. “You [the counselor] may be solution focused, but if you go too fast, the client who is very problem focused may think that the problem is being stolen away from them.”

Even counselors who have absorbed a client’s worldview may forget that it is the client who ultimately is in charge. The client will define the goals that he or she would like to achieve.

“Let the client determine what is most important,” Ostrowski advises. “Sometimes what seems small to a counselor may be the most crucial element of what is happening in a client’s life right now.”

"In cases in which a lack of therapeutic alliance exists, it is always tempting to look at the client as the source of the problem, but counselors should also look in the mirror, Guterman says. “We always tell our clients the only one you can change is yourself. This applies to us counselors too,” he asserts. “If we’re not connecting with our clients, what can we do differently?”

[Eve B]

From Mary's link: 

“With everyone I counsel, no matter how much they despise me or how much they resist, I try to bring a spirit of excitement to the relationship,” he says. “[A spirit] that I can’t wait to come and have another session with them because there’s something about them that I find intriguing, something I want to learn and there’s something that I’m really excited to continue discussing with them.”

“I just try to convey that element of acceptance, of excitement,” Martin says. “So no matter what behavior they are manifesting, there is something really worthwhile [about them]. … 

I doubt that the majority of therapists would be capable of consistently showing that much patience and tolerance. Easy to write how they should ideally (or rationally) respond to conflicts within the therapy relationship, but how often do therapists actually practice what they preach when a client's reaction offends them? I've been accused of taunting and inciting by my therapist when he takes the criticism personally, like voicing my anger and honesty should be condemned because he can't or won't see his own role in escalating the argument. I quickly lose respect for therapists who emotionally freak out on me in the heat of that moment.

 

[Mary S]

12 hours ago, Eve B said:

From Mary's link: 

“With everyone I counsel, no matter how much they despise me or how much they resist, I try to bring a spirit of excitement to the relationship,” he says. “[A spirit] that I can’t wait to come and have another session with them because there’s something about them that I find intriguing, something I want to learn and there’s something that I’m really excited to continue discussing with them.”

“I just try to convey that element of acceptance, of excitement,” Martin says. “So no matter what behavior they are manifesting, there is something really worthwhile [about them]. …

A therapist who tried "to bring a spirit of excitement to the relationship, ... [A spirit] that I can’t wait to come and have another session with them because there’s something about them that I find intriguing, something I want to learn and there’s something that I’m really excited to continue discussing with them,”" would really turn me off. If a therapist shows excitement or finds me intriguing, that to me is a boundary violation -- a form of  treating me as an object; of putting their interest or excitement above respecting my boundaries, of using me to gratify their greedy desires.

I find it disconcerting that the author seems to put acceptance and excitement together. Acceptance (as long as it is acceptance as other, rather than

acceptance into their world) is OK, whereas excitement is not -- it is using me.

[Eve B]

9 hours ago, Mary S said:

I find it disconcerting that the author seems to put acceptance and excitement together. Acceptance (as long as it is acceptance as other, rather than acceptance into their world) is OK, whereas excitement is not -- it is using me.

Most therapists wouldn't see the harm in showing excitement and enthusiasm towards their clients because to them, it means they genuinely want to be of help. In a real world social setting, a person's excitement and curiosity in conversation wouldn't usually be received as offensive, but therapists shouldn't be assuming their clients' feelings regardless. Encouraging client feedback still seems to be the best solution to minimize these kinds of misunderstandings.

Below are excerpts from  When Therapy Causes Harm:

" ‘There are things that therapists just don’t do…,’ Fonagy continues. ‘You’re looking at two different animals when you look at an RCT [randomized controlled trials] and when you look at practice as it really is. I think there is a disconnect between the two.’ "

"For the last 16 years Michael Lambert, professor of psychology at Brigham Young University in America, has been studying the use of client feedback to improve outcomes in psychotherapy. The principle is simple – before each session, ask clients a few brief questions about how they are feeling and how they feel the course of therapy is going. 

Part of the reason client feedback has such a dramatic effect is that, as we saw earlier, without this information, therapists seldom expect their clients to get worse. In one striking study conducted by Michael Lambert and colleagues, 40 clinicians were asked to predict which of over 500 of their patients would be worse off at the end of treatment. ‘Even though we told them the deterioration base rate for all patients is about 8 per cent, they predicted that virtually no patients would be any worse off. Our algorithms and stats methods picked up 85 to 90 per cent of the 40 cases who deteriorated, the therapists picked up like 3 per cent.’

Clinicians generally react with resistance to client feedback systems. Lambert quips: ‘If you think you’re a superior clinician, as all clinicians do, then why would you feel you need it? Why collect data that can only bring you down?’ "

"Lilienfeld believes the answer lies with spending as much time teaching students critical thinking skills as teaching them the facts about conditions like schizophrenia and depression. Students need to be taught how to think about the evidence, he says, ‘to understand the basic biases and heuristics that can impact our judgment and lead us to believe that certain techniques or treatments work even when they don’t.’ "

[Mary S]

12 hours ago, Eve B said:

Most therapists wouldn't see the harm in showing excitement and enthusiasm towards their clients because to them, it means they genuinely want to be of help. In a real world social setting, a person's excitement and curiosity in conversation wouldn't usually be received as offensive, but therapists shouldn't be assuming their clients' feelings regardless.

When you go to therapy in large part to learn to cope better with personal attention, having unnecessary personal attention tossed at you at the therapist's whim doesn't seem like an appropriate form of treatment .

When I told my worst therapist I was somewhat shy, she said, "You gave up your power." Not appropriate, in my opinion.

12 hours ago, Eve B said:

Encouraging client feedback still seems to be the best solution to minimize these kinds of misunderstandings.

My experience was that therapists didn't ask for feedback, and slapped me down when I tried to give it on my own initiative.

12 hours ago, Eve B said:

"For the last 16 years Michael Lambert, professor of psychology at Brigham Young University in America, has been studying the use of client feedback to improve outcomes in psychotherapy. The principle is simple – before each session, ask clients a few brief questions about how they are feeling and how they feel the course of therapy is going.

The idea of asking for feedback is fine with me, but I don't see why it has to be in the form of asking the client about how they are feeling. To me, that approach is very (and unnecessarily)  intrusive; the opposite of user friendly for me. I would be glad to give feedback if it were framed as giving my perspective, or my evaluation, or my assessment, or my opinion.

12 hours ago, Eve B said:

Clinicians generally react with resistance to client feedback systems. Lambert quips: ‘If you think you’re a superior clinician, as all clinicians do, then why would you feel you need it? Why collect data that can only bring you down?’ "

They also react with resistance (Defensively? Perhaps with the attitude "The best defense is a good offense)  when the client takes the initiative to offer feedback or (especially) ask why they are doing what they are doing. Examples of such resistance:

"Are you sure you're not trying to second guessing me?"

"Do you realize you're asking me to give up my control?"

"I resent that"

"You'll never get better if you keep seeking the perfect therapist." 

13 hours ago, Eve B said:

"Lilienfeld believes the answer lies with spending as much time teaching students critical thinking skills as teaching them the facts about conditions like schizophrenia and depression. Students need to be taught how to think about the evidence, he says, ‘to understand the basic biases and heuristics that can impact our judgment and lead us to believe that certain techniques or treatments work even when they don’t.’ "

Yes, students preparing to be therapists need to be taught these things. But it needs to be emphasized that these are things to apply to themselves.  I have had  some instances of a therapist telling me I have used faulty logic when in fact the therapist is saying I said something that I didn't say.  So careful listening and not jumping quickly to conclusions are also things therapists need to learn. 

[zygomaticus]

I like the aspects that are client-centred, but I always question the sincerity or plausibility of the kinds of sentiments stated in the article. For instance, the reaction of intrigue and excitement in the face of a client that he recognises as despising him. This is not a normal reaction, this is the response of the lab technician observing the lab rat. This is clearly turning the client into a subject. The kid despises you, yet you ignore that entirely and get excited by the challenge to 'get through'. What authenticity is there in such a response? What respect is there for the emotional output of the client? They've been objectified into a challenge, a puzzle, an opportunity for the therapist to show his quality and array of tools. When the therapist treats the client like a curiosity, this is not an equal, genuine, human-to-human dynamic. in actual fact, the client has been dehumanised. If this isn't stigma against those with mental health issues, I don't know what is. What's disturbing, too, is that people like this therapist in the article, is that he genuinely thinks he's connecting with people that he himself admits have rejected his help:

Quote

“In some way, shape or form, I feel like I’ve connected with everybody, even the folks who have terminated on me or have found therapy to be unsuccessful on the whole,” he says.

And when his methods don't work, he says the kid isn't 'ready for counselling'. That's right, the methods aren't to blame, it's always the client. I suppose it's better than some of the explanations that are typical, that the client is difficult, rebellious, hostile, lazy or even, too unwell. It's never the model, never the training, never the toolbox. If it doesn't work, it's always the client that's to blame. Bloody zealots!

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At the same time, Martin cautions that a counselor’s interest in and excitement about clients has to be sincere, particularly with those who don’t want to be in counseling in the first place. “If you fake it, they will smell it, and they will hate you more than ever,” Martin says.

The translation for this is that therapists need to be convincing in their simulations. It's the same for therapists as it is for those in sales and politics. Hide the agenda, polish the exterior.

Quote

When it comes to adolescents, Martin says, counselors cannot fake a sense of acceptance or a willingness to understand their stories. Adolescents know when they are being lied to, he says. “Insincerity is blood in the water to the youth client. They know when someone is being genuine, and they know when someone is not being genuine,” Martin notes.

And yet, he talks about out-manoeuvring clients, letting their hurricanes blow out, being unmoved so that when the baring of teeth is done, he will still be there to out-last the opposition. It is an attritional stance, one of adhering methods once the client is in a state that's more vulnerable, all built on some contradictory notion of planned, methodological, theory-based 'sincere' acceptance. I've said it elsewhere: it is a simulation, a very practised, rehearsed, well-drilled act, with a lot of attention to detail in how to present it. It's the very definition of fake and contrived and the aim is to manifest a very convincing appearance, but these people say to themselves, 'oh, it must BE authentic. Let's go again, let's do a little theatre so we can practice sincerity until we nail it and if feels real... but IS real... one more time... not quite, let's try again... ten more reps and you'll seem authentic!'

All the talk of rapport is typically artificial, using any interests or motivation that the client shows as a lever, a pretence of valuing it in-itself, when in truth it's only a stepping stone, a pace along a path the therapist has in mind. It gets them to trust, to open, to feel heard, when on the part of the therapist it is merely a strategy. It's false. Acquire trust, get the client believing you're in their corner, you WANT to listen, then you have the platform to do the real work and the client is more likely to want to please you, especially if they're vulnerable. Securing trust and rapport is only ever part of an overall agenda of control and influence. It's not a human connection, it's a con.

Yes, therapists are in love with their techniques, with their toolboxes. In some models, they're told that there can be no deviation from the manual, a methodological bible replete with gospel interventions one must show unwavering faith in. In these cases, the client is very much made to fit the model, and a fit for them as an individual isn't on the agenda.

I suspect most of the content of this article is coming from a more humanist perspective, insofar as there is talk of the client's values and meaning. That's something, at least. However, I think they are kidding themselves if they think they can have two dynamics at the same time that are incompatible. On one hand, they preach the value of a human connection, but on the other, it's all about finding ways of applying a raft of techniques that are concealed from the client under the veil of trust that something more meaningful and sincere is taking place. Essentially, the client is being fooled by appearances that are only ever functional in delivering the underlying methodological agenda. This ulterior agenda may not even match the client's expressed needs at all, it may end up being what the therapist or the philosophy the therapist's model(s) preach as manifesting 'health'.

[Eve B]

 Therapists know that outcome depends on client response, so it's not surprising to me if they resort to manipulative and controlling tactics. Maybe authenticity is more real when therapists and clients are more compatible with each other, therefore, the emphasis on a "good fit"? 

[Mary S]

7 hours ago, zygomaticus said:

I like the aspects that are client-centred, but I always question the sincerity or plausibility of the kinds of sentiments stated in the article. For instance, the reaction of intrigue and excitement in the face of a client that he recognises as despising him. This is not a normal reaction, this is the response of the lab technician observing the lab rat. This is clearly turning the client into a subject. The kid despises you, yet you ignore that entirely and get excited by the challenge to 'get through'. What authenticity is there in such a response?

I think excitement toward a client can indeed be authentic for some therapists -- I see it as a type of voyeurism.  I remember  one "phone interview" with a prospective therapist. I said that I didn't like being treated as an object of interest, and he replied (with a snarky tone of voice), "Why do you think I went into this pr0fession?" I didn't find it as shocking as I would have if he were the first therapist I tried, but it still seemed shocking to me.

[Eve B]

I don't like being an object of their curiosity either, but from the therapist's perspective, it's supposed to be a good thing. Showing interest usually means they're more motivated to be helpful, and I think their profession can't avoid being voyeuristic because of what they expect their clients to tell them-- personal information that nobody else but the therapist will know and keep confidential. 

[Mary S]

2 hours ago, Eve B said:

 Showing interest usually means they're more motivated to be helpful

I"m skeptical of this. It may be the case with some therapists, but I think a lot of therapists focus on what they are interested in, which sometimes coincides with what the client is hoping for help with, but which often does not. When the latter is the case, the therapist's pursuit of their interest is just using the client to pursue the therapist's agenda/whim/whatever, and perhaps failing to even try to help the client with what they came to therapy for -- and that is a boundary violation! The client has a right to informed consent/refusal -- in particular, the client has a right to refuse to answer questions that aren't relevant for helping them, and the therapist has the responsibility to respect the client's boundaries.

In my case, I went to therapy largely to learn to cope better with intrusive thoughts of people behaving intrusively toward me. Therapists' asking me questions because they were interested or curious (along with their tendency to tell me what I liked, wanted, felt, or thought) made the problem worse, not better. My problem (and  big part of me) just wasn't on their radar; I was de facto just an object for them to do whatever they chose with me.

[Eve B]

When therapists don't listen to their clients, then yeah, they're only interested in satisfying their own curiosities. Listening and good communication are two important skills that psych schools don't seem to teach and train adequately enough.