Client’s Point of View Series

Note: This is a compilation of Frontier Friday, a weekly Substack published, originally released on 9 Apr. 2022

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PART I

Client’s Point of View
What is it like from the other side? This next few weeks, we are going to explore some of the empirical – and not so empirical – research that I’ve come across.

In this missive, I’d shared a catalogue of questions I’ve stumbled upon a site called Quora. Not the most scientific website, but nonetheless, noteworthy. Here are some stuff that people shared about their experiences – the good the bad and the ugly – in therapy. As you read through the client’s perspective, let them remind you about things you already know.

Sidenote: It seems to me some of the questions might not be “real” questions from clients, but some therapists putting up questions for others to comment on. Nonetheless, the ones I’ve selected are worth us pondering on, especially some of the replies.

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1. 😒 Why doesn’t my therapist come to our session prepared? Our sessions seem to go nowhere unless I have had a terrible week and need to vent about something. If things have been going pretty smoothly, she has nothing to talk about. I am getting annoyed.
    
2. 😠 My therapist asks me before every session “what would you like to talk about today?” We’ve had 10+ sessions, shouldn’t she have a plan or understanding of my issues by now?
   I love these 2 questions!
   I’ve heard several people articulate this question to me before about their prior experience in therapy.
   The real question for therapist to consider is “How do I develop a sense of direction and effective focus for this client, while staying open and adaptive to the unfolding of life happenstance, and weaving this in to the bigger picture?”
   Besides, there is no such thing as passive listening (well, maybe on Spotify and radio). You are an active agent of the healing conversation 
   So yes, deliberation, reflection and making the connection to the bigger picture is needed.
    
3. 😢 How should I interpret this? My therapist of 2 years recently told me that she will be returning to face to face sessions but only with certain clients and I will not be one of them. I feel so hurt by this. As a client, what would you do in my shoes?
   I recently heard someone experienced this exact situation and was so confused and feeling rejected.
    
4. 😩 After 2 years of therapy, my therapist terminated me mid-session. She stated “because of my dependency on her as well as her countertransference, she could no longer ethically treat me.” She then referred me to someone else. I’m devastated. What now?
   Read Susan Parifuku’s response to this question:
   
   “I too, after 2.5 yrs, was “terminated” by my therapist. Reasons were that “I was constantly in crisis”, which was true. I saw her after she was my therapist in a residential setting. She was strictly DBT oriented.”
   
   
5. ⏸ Words Worth Contemplating:
   “Love begins with paying attention to others, with an act of gracious self-forgetting. This is the condition in which we grow.”
   ~ John O’Donohue, Anam Cara, p. 28.
   

Reflection:

The paradox of our personal and professional development is to take the journey from self-examination to worrying less about how smart I sound, how impressive I am, and even how impactful I am.

A sort of “graceful self-forgetting” – to leave oneself – is required in order for us to be to fully engaged in conversation nature of therapeutic emergent reality.

Turn off the self-view. Remove mirrors. Shine the light were it needs to be.

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PART II

You might need more than 4 hours to cover all of this week’s recommendations, but if you have yet to hear about Very Bad Therapy podcast, please do yourself a favor and listen to my colleagues Carrie Wiita and Ben Fineman and their guests on their show on VBT.

Ben and Carrie also guest-posted on Frontiers of Psychotherapist Development blog 2 years ago. They shared about “4 Lessons from 20 Weeks of Very Bad Therapy” (just to be clear, it’s not 20 weeks of going through bad therapy, but of hosting the podcat VBT).

Here’s the 4 points that Ben and Carrie highlighted:
 

I. Clients experience significant barriers to providing honest feedback about the therapeutic relationship.

II. Therapeutic ruptures can be helpful, but only if they are repaired.

III. Bad therapy is often nonverbal.

IV. Clients will keep coming back even when therapy has harmful effects.
 

For more, read their reflection.

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What’s really insightful of their podcast format is that you get to hear real clients speaking about their experiences, and they also pair that up with a professional to unpack that.

If you have not heard VBT yet, I highly recommend a handful of episodes to check out:

1. Episode 1 – EMDR for Dummies (with Curt Widhalm, LMFT)
2. Episode 78 – Very Bad Couples Therapy (with Dr. Bonnie Kennan)
3. Episode 61 – What Heals Trauma? (with Chrissy Gillmore, MCoun)
4. Episode 54 – How Much Therapy is Necessary?

Good Friday Additions:

I. Episodes of VBT on my “to listen” list:
a. Episode 83 – Drive-Thru DBT (with Dr. Ben Caldwell)
b. Episode 82 – Predatory Therapists (with Dr. Diane Gehart)
c. Episode 65 – When Treatment Fails (with Henk Spierings)
 

II. Two podcast episodes that I was a guest:
a. Episode 45 – VBT in Focus: Dr. Scott Miller and Dr. Daryl Chow on Deliberate Practice
b. Episode 11 – The Intake Process is a Mess (with Dr. Daryl Chow)
 

III. Podcast app that I use: Snipd
Long-time readers will notice that I scout around a bit for simple and elegant tech solutions. I’ve played around with several podcast players, but Snipd has been a game-changer for me. Why? You get to highlight text notes as it spits out transcrips, AND, I get to export it directly to my “Personalised Learning System (PLS)” note-taking app, Obsidian (For more on Obsidian, check out a 4-part video series I did on this).
This really helps my learning process, as the audio files are auto-magically converted to text, making the notes easily searchable.

5. ⏸ Words Worth Contemplating:An expert is a person who has made all the mistakes that can be made in a very narrow field.
~ Niels Bohr , Danish physicist and Nobel Prize winner

p/s: Happy Easter to all on their Frontier.

Reflection:

As you listen to some of the Very Bad Therapy podcast episodes, what is significant to you? What stands out?

What are some “notes to self” you’d want to make, so that you do not forget some fundamental lessons?

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PART III

1. 👓 Significant events in psychotherapy- An update of research findings
   Robert Elliot, known for his current involvement in emotion-focused therapy (EFT) work, was a pioneering researcher in studying significant events in psychotherapy in the 1980s. In this 2010 update from Ireland, Ladislav Timulak summarised the findings in this part of the psychotherapy literature.
   
   Key Grafs:
   
   • On Helpful Factors:
     • Insight/Awareness, Problem Solution, relationship-oriented events such as reassurance, feeling understood, and personal contact.
     
     
     1. On Negative Events:
        • “…disappointment and misunderstanding in the relationship with the therapist are seen as major significant difficulties experienced in therapy…An explanation for occurrence of such events in supposedly helping relationship may be the clients’ vulnerability which may make the clients prone to be sensitive to the interpersonal interactions. It is important to note that due to the clients’ deference to their therapists, difficulties in therapy may not be communicated to the therapists, which decreases the likelihood that they would be resolved.”
          
          
     2. On Discrepancies Between Client and Therapist’s Point of View:
        • “…Clear discrepancies between what the clients and the therapists find helpful in therapy…it seems that there is one common feature that distinguishes clients from therapists. Clients value more the relational and emotional aspects of events, while therapists prefer the more cognitive impacts.”
          
          
     3. On the Lack of Research on Significant Events and Outcome:
        • Out of 41 studies, only three quantitative correlational studies have investigated the relationship between the types of events and the outcome.
          
          
     4. On Client’s Recollection:
        • One study (Martin & Stelmaczonek, 1988) looked at whether significant events can be reliably remembered after 6 months. The clients remembered more than 70% of events after 6 months, but only 40% was allocated to the relevant session.
           
2. 👓 What Clients Find Helpful in Psychotherapy-moment to moment
   What stood out for me about this study by Heidi Levitt and colleagues (2006) was
   that “clients rarely discussed symptomatic change per se as an important outcome of their psychotherapy.”
   The authors explained:
   
   “Although clients did mention symptoms in connection with the medication that they took, they did not describe symptom reduction as a reason why an experience in therapy was important to them. They tended, instead, to discuss global changes such as relating better with others and understanding or feeling better about themselves or others. Clients with an eating disorder who described changes in eating as significant were the exceptions to this rule. These findings support the view that although symptom reduction may be a positive effect of therapy, it may not be the primary benefit for many clients.
    
3. 👓 Clients’ experiences of difference with therapists-Sustaining faith in psychotherapy
   A 2008 study by Daniel Williams and Heidi Levitt.
   Key Grafs:
   • “Clients often were aware of their projections although they may not have been voiced in session.”
   • “Surprisingly…none of the clients with obvious multicultural differences with their therapists (e.g., race, nationality, gender) identified a moment of the session in which that difference was a salient factor, with the only exception being one client who identified both gender and social class differences as disruptive to the therapy.”
     
     • See Table below for more.
       
       
       

4. 👓 Clients’ Experiences of Disengaged Moments in Psychotherapy
   It’s one thing to study dropouts in therapy. But there is a more subtle type of disconnection: disengagement within sessions. Studies on moments of disengagement in therapy from client’s perspective are illuminating. Here’s one qualitative study.
   
   Key Grafs:
   • Six of these participants disengaged by changing the topic of discussion. One participant said,
     
     “When I’m trying to keep that mask up, um, what happens is that my story is very disjointed, I will jump from situation to situation, I will talk about so and so did such and such to me, I’ll play the victim role. And then I’ll bring in story after story as to how I’m the victim, and I tend to stay there.”
     
     
   • Participants used disengagement to prevent becoming so distraught that their ability to function in therapy was disrupted.
   • Interestingly, some clients reported disengaging in therapy to figure out their role in therapy and their relationship with their therapists, to test if they can trust the therapist. One participant said,
     
     “It [the disengagement] was ‘I have to keep up the mask.’ And it was my way of testing to see ‘Am I unconditionally accepted?’ It was a process of establishing ‘How safe am I?’ and ‘Is this really a sacred space?’, ‘Can I trust, how much can I trust this person?’ And in making that judgment that I can trust this person the flip side of that coin was ‘I can accept what this [opinion] says if they [therapist] decide I am not normal,’ you know, or ‘my response is not normal,’ I can hear that from them now.”
     
     
   • “If You Can’t Handle this I Won’t Talk About it.” Nine participants described disengagement as stemming in part from their understanding that the therapist was not able or willing to respond to their experience in the way they wanted.
      
5. ⏸ Words Worth Contemplating:
   
   “Safety is not the absence of threat. It is the presence of connection.” 
   ~ Dr Gabor Maté
   

Reflection:

Psychotherapy outcome is not due to a single factor, but it consists of the moment-by-moment emergent conversational relational bond, as two parties become of one mind in their healing endeavor.

Think back of your clinical work this week.

1. What were some significant moments for your client? What did you do to cultivate this deepening process? Write it down.
2. Where there moments of possible client disengagement? What happened? How might you address this if it happens in the future? Write it down.
   

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PART IV

1. 👓 Research: ‘I Just Stopped Going’: A Mixed Methods Investigation Into Types of Therapy Dropout in Adolescents With Depression
   This study of 11-17 year-olds show 3 reasons why youths dropout of treatment prematurely:
   
   i. Dissatisfied
   ii. “Got-What-They-Needed”
   iii. “Troubled” (i.e., lack of social stability beyond low moods)
   
    The actual proportions weren’t stated clearly in the paper, but let’s do some simple calculation. Out of 99 youths, 32 were classified as dropouts. Out of the 32, we have 18 Dissatisfied (56%), 10 “Got-What-They-Needed” (31%), 4 “Troubled” (12%).
   Isn’t it striking (but maybe not surprising) that more that half of them were dissatisfied?13-year-old Fiona describes her experience:
   
   “I went to this therapist and they just sat there and hummed for an hour at everything that I said. I hated it. [My therapist] made me really angry because it just felt like I was talking to a brick wall and I wasn’t. I didn’t even want to talk because [my therapist] didn’t engage with me at all. It just felt like it was completely pointless.”
   
   And here’s her therapist’s perspective:
   
   “I think the session sort of stirred stuff up and the fear was that she’d feel worse again.”
   
   Her therapist explained that things had already started to improve for her at an early stage in the therapy and the therapist suggests this may have impacted on her willingness to engage. She went on to suggest that Fiona believed she felt better which led her to stop therapy.
   Before you “tsk tsk” this therapist, note that this could easily be you and me.
    
2. 👓 Research: Therapeutic Relationship and Dropout in High-Risk Adolescents’ Intensive Group Psychotherapeutic Programme
   This study look at dropouts in high-risk adolescents’ intensive group therapy in the Netherlands.
   While this study is not a qualitative research, its finding is  useful to note in relations with the study mentioned in #1.
   The researchers found that a significant decrease in therapeutic alliance (as measured by the child version of the Session Rating Scale ) in the last 3 sessions was a predictor of dropout.
   Again, not a big surprise, but the implications are not trivial: Monitor outcomes and alliance session-by-session, and elicit the nuanced feedback.
    
3. ✍️ From My Desk (Archive): How to Elicit and Receive Feedback
   Given the 2 studies mentioned above, here are 3 relevent posts on how you can learn to elicit, receive, and use feedback from your clients.
   
   – How Do You Get Better At Eliciting Feedback
   – How to Receive Feedback
   – To Get Useful Feedback, Seek Contrast
   (Hint: Compared to the averager therapist, more efficacious therapists seem to be able to obtain lower working alliance scores at the start).
    
4. 👇 My Practice-Based Evidence
   Once could be random, twice could be luck, and three times is likely to be a non-random pattern.
   Recently, on 3 occasions, with 3 different clients, I’ve gotten lower scores on the Approach/Method subscale of a working alliance measure. Two of them said that they would appreciate more structure in the session. Admittedly, while this was something I was already working on to improve, I realised what needing more “structure” actually meant: I did not make clear my intentions and where I was proposing to go. I failed to “think aloud” and share my “why” and “where” we were heading.As this has happened more than once, this is clearly something I can work on that has leverage, for me at least.
   (Be mindful that deliberate practice is such an individualised process, and may not necessarily generalise for others).
    
5. ⏸ Words Worth Contemplating:
   “The single biggest problem with communication is the illusion that it has taken place.” ~ George Bernard Shaw.
   

Reflection:

Learning is the ability to generalise an input into other context. We may sometimes be able to learn from client feedback, and sometimes not. It’s important to discern on when I need to be responsive and when I can generalise the learnings into other context.

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