As a therapists, I can sense when therapy isn’t quite working with a client. It gnaws at me. It’s a puzzle to unwind. A puzzle that begins with asking more questions.
I usually begin with seeking consultation with my supervisor, consultation partners (individual therapists that I meet with regularly), or my consultation group (group of art therapists who meet monthly). We explore the following questions:
Why do I feel it’s not working?
How am I defining “working”?
What would it look like if it was working?
The people I consult with then typically then have enough information to ask more questions to help me get to the bottom of it, see new perspectives, and have new ideas to try.
Another approach I have taken is to speak directly with my client. I ask if they’ve been getting what they want from therapy.
This usually leads to fruitful discussions. It lets the client know it is safe enough for them to express their true feelings. It also leads to deeper discussions about what they want from therapy.
What’s hardest is when the client confirms that therapy isn’t working and they don’t want to collaborate to get to the bottom.
They want me, the therapist, to figure it out. They want me to fix therapy. What they’re really saying is, “I want you to fix me.”
In my earlier days as a therapist, I’d have fallen back on the classic therapist line, “Don’t work harder than the client.”
I’d just keep showing up to therapy, week after week, watching them suffer.
Now, HELL NO.
When I increased my fees to $300/80 min, it lit a fire under me, “WE ARE HERE TO DO THIS.”
I know my clients are making an investment in therapy. My clients were also making an investment when they paid $50/session, but the higher rate made me feel more accountable. It made me want to show up even more powerfully. Now, I show up with that power regardless if it’s a pro bono client or full fee client. Raising my fees fueled internal and professional growth in me and changed who I am as a therapist and how I operate.
So I now have multiple strategies I rely on if a client is feeling stuck in therapy:
Review the treatment plan with the client. This opens up discussion for where the client was when they entered therapy and where they are now.
Make a new treatment plan. The client and I make a new treatment plan based on what they want in that moment. How would they like to feel? What differences would they like to experience? What would they like to increase? Decrease?
Make ways to measure progress. If a client has been having difficulty being engaged in therapy, I like to use Likert scales for each treatment goal we set. We determine where they currently are and where they would like to be.
There are also broader ways of measuring progress. Sometimes I have a client create a “Pie of Life.” They make a pie chart and label each pie piece a different topic that contributes to a full life, such as “Friends, Movement, Job, Hobbies, Family, Romantic Relationship, etc.” They get to determine what the topics are. They then shade in each pie piece to reflect how satisfied they are with each category. For example, if they are only 50% satisfied in their friendships, they’d only color it in 50%. We can then repeat the “Pie of Life” again in the future to see how their life has changed.
Another broad technique is to have an individual make an abstract emotional portrait. I typically have clients use watercolor to paint how they currently feel. We then repeat the emotional portrait at various periods in therapy. We can compare and contrast with the original to see how they have shifted over time.
Make change more tangible. To help a client be more engaged in the process of change, I ask questions related to the treatment goals:
What would it feel like if you reached these goals?
What do you think it will take to reach these goals?
Dig into present emotions. If returning to treatment goals doesn’t feel like the right step, another approach is to dig into the client’s feelings that are present. I ask a client to make art related to whatever is coming up: frustration, resistance, lack of motivation, etc. I select the medium or provide a more specific directive if the client needs more structure. For example, I might ask the client to sculpt a creature that represents the frustration they are experiencing.
Approach it from the other side. Another technique is to explore not changing. Artwork and discussion can be fueled by such questions as:
Are there any benefits from not changing?
What will life be like in a year if nothing changes?
Explore client’s commitment to therapy. Sometimes a client is not ready for therapeutic work or taking personal action in their lives.
They continue to show up to therapy because they want a friend. Someone to warm out the loneliness.
You can do this as a therapist, and people will pay for it. I’ve had people willing to pay for that at $300.
This is a personal decision as a therapist. It is not the kind of therapeutic work I want to do.
I used to decrease the frequency of meetings, moving from weekly to every two or three weeks. However, this did not change anything. Decreased frequency did not increase motivation for change.
Refer to Another Therapist
Eventually, if I have tried everything I can with a client and I continue to see them suffering week after week, I know it is time to refer them. Clients typically feel resistance to working with another therapist because it is the unknown. They’d rather suffer with known pain than unknown pain.
However, I am not willing to let them suffer. If my skills are not enough, I know it is time for someone else.
Patience and Grace With Ourselves
While it is easy to write out this list, I know that the actual experience of trying to help a client who is stuck is far more difficult. It can bring up a lot of internal questions:
Am I a good enough therapist?
What am I missing?
Why can’t I figure this out?
In addition to seeking counsel for your client, this is also a good time to seek counsel for yourself. Speak with your therapist or trusted friends about what is coming up for you.
This is also a good time to remember to be gentle with ourselves. It is difficult to navigate through this process, but if we do it with care and intention, both our clients and ourselves will benefit.
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