Updated: May 3
How Clients can Change your Perspective on Therapy
It’s not often (or ever) that anyone talks about a client that helped them to understand the therapist’s weaknesses either in key areas or delivery of therapy. Sometimes a client comes every now and then who inspires the therapist and promotes them to think differently and approach their competencies via a different angle. I will highlight a client in particular who changed my perception of therapy delivery. This person I label as the golden client; a description of a client in my opinion who played a crucial role in advancing my therapeutic skill set.
I’ve seen a fair share of clients as of now and it’s been a wonderful and insightful experience. Every now and then someone comes and alters your epistemological view of how, in this case, the methodologies are articulated in the context of psychotherapy. With the pandemic, mental health has been on the rise and coming from the perspective of my phenomenological experience, I’ve seen the impact of people’s mental health deteriorating to the point of serious consequences i.e. suicide. When the frequency of suicides increased, it showed the level of desperation and struggle of the end user and how mental health systems haven’t been able to intervene as systematically as we would like to think. There can be certain key points taken away from this. One is that it’s the responsibility of the adult to come forward with their personal challenges and allow professionals to assist in their care and guide them towards a less stressful life. The other point is that mental health institutions and in essence, public health services like the NHS need to do more to reach out to the affected cohort by effective advertising and creating relationships with more mental health organisations to promote a welcoming approach when discussing about difficult things. There are people who personally struggle to discuss their problems with other people, and this is quite normal. Men are more likely than women to hide their mental health problems, due to stigma, which often leads to vicious cycles of stress, anger, depression. NHS however have stepped their game up and offer far more mental health resources since the pandemic began. Medical practitioners have become more attenuated by the fact that they are more open with patients in attempting to discuss their mental health, so such practitioners need to remain recognising the subtle signs and quickly refer to mental health professionals where possible. So, where does this fit in with my experiences of clients who have inspired me to do what I’m doing?
At the start of this year, I re-analysed my approach to therapy deliverance and looked at ways of adapting to the ongoing challenges of therapy. This was further realised when a good friend of mines referred me on to a colleague (identities concealed for confidentiality purposes) and asked if text-therapy was a suitable format to offer my services. I initially hesitated, mostly because I lacked the experience using this format however as lives have evolved to digital-everything since last year, it seemed liked a good idea that I keep an open mind and take on the challenge. Straying from traditional in-person therapy in a cosy office seemed a distant reality for the time being so I accepted the challenge. The colleague, when referred, contacted me and asked if they could receive therapy over text message. My mind wanted to decline but I felt obligated as a therapist to accept and conduct an initial assessment to conclude their suitability as a client. After some dialogue, I agreed to text-based therapy. Was it a fail in terms of therapeutic outcomes? No, in fact, it made me re-think what it meant to be a therapist.
My client worked in a high profile and fast paced environment, so it was important for us to work together to de-stress and work on their central issues. My initial reaction to text-therapy was “How do I approach this”, “Does the flow of therapy occur in the same way?” For all therapists out there in the same situation, stick to the same methods you’re trained and experienced in, only know that it will be slower communication since you’re spending time typing. My client seemed an open minded individual too and every time I thought the techniques I used wouldn’t work, my client reassured me that they would try the techniques and report back to me. As I work primarily from a cognitive perspective, assessment forms part of the framework and assists in our therapeutic relationship. So, sometimes a bit of trial and error is necessary to agree on a method of working together. Once a solid relationship is established, the client is more likely to report feeling better and essentially more comfortable in the therapeutic process. This is exactly what happened. I allowed the client to direct the sessions and we allowed creativity to encapsulate the process. One thing to note is that sessions will flow differently to in-person appointments regardless of how much you try to simulate the physical process.
What is the solution for effective text therapy? The solution is to allow the natural flow to occur and focus less on aiming for the ‘perfect’ structure as it doesn’t exist. Rather, do what you can in the agreed-with timeframe and focus on evaluating how much the client is engaging with the experience. A simple mood rating e.g. “How much do you feel engaged within the therapy process right now from a scale of one to ten, with one being the lowest satisfaction and ten feeling elated” can be helpful. Simple mood checks and feedback in fact go a long way rather than inundating the client with standardised questionnaires when you can far simply gain personal feedback from self-rating scales. If you are new to the process, it will feel quite different but give it time and it becomes second nature. Becoming the adaptable therapist is far better than the therapist who rigidly adheres to protocols without taking consideration of the client’s epistemology. What did my client teach me? They taught me to think on my feet as sharply as I had to if I was physically seeing them (problem solving is far more of an involving process in therapy than one thinks), I had to be creative i.e. discussing how cognitions work, drawing diagrams (and sending those to the client) and hoping they understood what I was talking about. There needs to be more confirmation than usually is required i.e. “Do you see where I’m coming from”, “Should we re-frame or are you happy with the conclusion?” “Have you answered the questions in full”? Collaboration is even more pertinent as the only communication occurs on-screen, body language and tone are almost impossible to decipher. So, feedback is very important both throughout and at the end of the session. One other thing to note is to describe psychological concepts in a simpler manner and confirm whether the client understands you otherwise miscommunication can be detrimental to the professional relationship. Give them time to digest what you’re telling them. All of the above techniques were useful for my golden client and at the end of treatment, their traumatic symptoms had virtually diminished. Longer treatment and more cognitive work would perhaps have been more useful. All in all, I learned how to work with clients who perhaps may not have accessed traditional therapy otherwise, so offering as many avenues as possible means we as therapists, can reach more clients than ever before.
In summary, the same techniques used in-person were highly transferable however some adjustments were needed to make it adaptable to the client. My client helped me to engage in new ways of thinking and developing adjustments where necessary. Here, I will briefly summarise the approach to text-therapy:
Always ask the client how much they feel comfortable during the therapeutic process, as their physical expressions are not visible to you.
Use self-rating scales to get their perspective of their problem(s).
If clients can use voice clips to illustrate their viewpoint, allow them the freedom to use them.
Write your work and send it to the client, there might be changes needed and you can both work on the basic formulation together.
Know that typing for an hour or so can be fatiguing so if it takes longer for you to type, let the client know so they are not kept waiting.
In conclusion, as therapists we are more resilient than we think we are. We have the skills, sometimes they need adapting but as mental health practitioners, we have a role to help as many people as we can, especially during the pandemic. As therapy enters the digital world, what are we doing about it to benefit us and our clients?