Are You a Rushed Therapist?
Deliver more by being diligent, but patient.
Posted Sep 10, 2020
Somewhere slow is nowhere fast, but faster isn’t always better. Force-feeding a meal, for instance, can be painful and bad for nutritive digestion. In psychotherapy, a decade of analysis is the slow boat to improvements. However, being force-fed therapy can leave a bad taste and cause psychological indigestion.
Over the years, I’ve noticed many supervisees come out of the gates figuring they had a supply of the proverbial silver bullets, and they were trigger-happy. They’re excited to help, are good listeners, and have some ideas of therapeutic interventions. What else does a therapist need? On top of it, they hear so much about short-term therapy nowadays, it makes sense their vision of practice may be akin to sniper work:
Ready: Listen hard for the problem; reflect an understanding of the problem to the patient.
Aim: Make a list of measurable goals to overcome the problem.
Fire! : Offer the patient numerous things to do to overcome the problem ASAP.
Rub eyes in disbelief when the problem still exists next week (checking silver bullets for blanks).
Therapy Isn't Paint-By-Numbers
Even the most regimented cognitive-behavioral therapy is not as three-step, paint-by-numbers as the above. And that’s because therapy takes time. Sure, there is such thing as a very successful one-session or ultra-brief solution-focused psychotherapy for some patients. I’ve done it (inadvertently), and we’d be denying giants like Milton Erickson and Steve DeShazier if we didn’t recognize that.
The long and the short of it, however, is that ultra-brief interventions are the exception and require a very special skill set. Even then, done properly, it is fed to the patient in a very digestible way. Even Erickson, a therapeutic wizard, was clear that therapy can only occur at the rate at which a patient can digest it.
Perhaps it’s the shorter attention spans and corollary low frustration tolerance of younger people who are today’s emerging therapists. Maybe it’s the increasingly en vogue, limited-session, algorithmic interventions, but I can’t help to notice that if many newer practitioners don’t achieve instantly gratifying results from their intervention attempts, they believe they’ve failed, or the patient is resistant.
Patience Makes All the Difference
Some of my supervisees are stumped by why therapy stalls as they heap on “fixes.” Because of this, our supervision often includes reviewing the idea of working diligently, yes, but patiently.
Therapists don’t need to be psychological archaeologists and painfully sift through childhoods for weeks on end, but overwhelming a patient is just as unproductive. Being force-fed anything is unhealthy and an invitation for failure, as patients choke, leaving the clinician to perform a therapeutic Heimlich maneuver.
Consider Joyce (pseudonym), a graduate student I once supervised, who learned the hard way about hasty interventions.
Joyce complained she couldn’t understand why her patient, Robin (pseudonym), wasn’t ferociously tackling her assigned homework if she wanted to improve. Robin was socially anxious and wanted to feel more comfortable around others. She felt she wasn’t good at conversation and feared saying something dumb and being ridiculed.
“Robin told me a sign she’s improving will be that she won’t be afraid to just talk to people. I told her she has a social anxiety disorder, and we can work on it with exposure therapy,” relayed Joyce.
“So far, so good,” I thought.
Joyce proudly continued, “I told her all she has to do is condition herself to socializing. I assigned her to start going to the mall and making small talk with random people to get used to initiating interactions!” Frowning, she added, “But Robin came in this week and said she couldn’t bring herself to do it and wasn’t sure therapy was for her; she was feeling more anxiety.”
“What session is this?” I inquired.
“Second.” The record scratched to a stop while I gathered myself.
“Joyce, you’ve definitely got the right ideas,” I assured her, “but is it possible it’s too much too fast? Considering Robin’s diagnosis, there’s a good chance it’s taking everything in her to get into your office and try to form a relationship with you, a helping professional, never mind mustering the guts to randomly introduce herself to others. No wonder she’s questioning coming back!”
Joyce realized she inadvertently almost pushed away a client.
“We figured out what was going on,” Joyce recalled, “and Robin said it’s important to learn how to feel more comfortable around people when she’s out. She seemed isolated and stuck, so why wait? I figured we better get to work.”
Joyce’s sharing of her perception that a fast and furious approach is the way to go opened the door to a fruitful discussion about the pressure she was putting on herself to make problems go away, and that there’s precious more to a therapy hour.
Well-meaning but overbearing, many people like Joyce enter the field because they are problem solvers. A large part of supervising new practitioners, I’ve found, is helping them learn to develop an interest in their patients and cultivate relationships with them. A cursory look (i.e., Firestone, 2016; DeAngelis, 2019) tells us that it’s not so much the intervention but a therapist's bedside manner and therapeutic alliance that makes or breaks treatment.
Irvin Yalom wrote a chapter in the Gift of Therapy called “The Therapeutic Act, Not the Therapeutic Word,” about more subtle things patients value that go a long way. Patients need to see we care and are genuinely interested, and that we're going to be a partner in exploring and navigating the troubled waters they’re afraid to sail on alone. Helping them muster the courage to “go there” and find answers for hard and puzzling questions, explore dark alleys, and eventually allow themselves to be vulnerable and try those tough assignments sets the stage. This isn’t apt to happen in a “git ‘er done” approach, no matter how well-meaning.
Joyce Works a Gentler Approach
Joyce entered her third session with Robin having a more gentle and curious approach, correcting the course.
“Robin, I wanted to check in with you about our first couple of sessions. I recognized afterward that I didn’t realize just how anxious you were. I feel I might have some responsibility for you sharing that you felt more anxious in the second session. I was being too enthusiastic about trying to help you reach your goals. It was a bit much and too soon, wasn’t it?”
“I’m glad you decided to come back. Let’s forget all that for now. I’d like to know more about your experience. From what you described to me, it’s been tough to talk to people outside your family and a couple of old friends. It’s pretty awesome you decided to come to talk to me, someone you’d never met, about something so personal. To be honest, it’s been eating away at me to know—despite that anxiety you can experience around unfamiliar people, what inside you allowed you to take that step and develop a relationship with me, someone who was a total stranger?”
No quick-fix algorithm required, Joyce discovered. Just a chat showing Robin she is capable of doing what she said she can’t and starting to sow seeds that she is capable of good conversation.
The therapy office is a microcosm of a person’s global life. Patients take the experiences of the hour and translate them back into their life at large, where the problem is most disruptive. We help set the stage.
DeAngelis, T. (2019, November). Better relationships with patients lead to better outcomes. Monitor on Psychology, 50(10). http://www.apa.org/monitor/2019/11/ce-corner-relationships
Firestone, L. (2016, December 22). The importance of the relationship in therapy. Compassion Matters. https://www.psychologytoday.com/us/blog/compassion-matters/201612/the-importance-the-relationship-in-therapy
Yalom, I.D. (2003). The gift of therapy: An open letter to a new generation of therapists and their patients. Harper Perennial.