Question: I have been working with a client who is currently struggling with depression, and I’d like to seek your guidance on how to best approach their situation. In our sessions, the client is extremely reserved, often finding it challenging to articulate their thoughts and feelings. Despite my efforts to create a safe and empathetic environment, they seem hesitant to open up about their experiences, which makes it difficult to gain insight into the underlying causes of their depression. I’m wondering how I can establish a stronger therapeutic rapport and encourage them to share more during our sessions, so that we can work together effectively towards their healing and recovery.
Response from Dr. Chua: I wonder whether you are observing depressive behaviours or interpersonal behaviours? Let’s examine the behaviours you mentioned:
i. extremely reserved
ii. difficulty articulating thoughts and feelings
iii. hesitant to open up about their experiences
It is not surprising that a client with depression would be reserved and disengaged. Some of the behaviours shown could be symptoms of depression. I get the sense that you perceive them to be interpersonal behaviours (“hesitant to open up”, “extremely reserved”) and that you associate these behaviours with the therapeutic alliance.
How we perceive our clients will influence how we feel and act in session and what we do therapeutically. There are a number of different ways to understand the situation but I’ll focus on two possibilities. Let’s go with the interpersonal hypothesis for now…
I am curious to know:
i. Does your client have close friends to whom they articulate feelings and thoughts? Or is this the first time that they are expressing themselves in this way?
ii. Is your client anxious and/or shy? Are they reserved with others or just with you?
iii. Are these experiences that you are trying to explore difficult experiences?
Articulation of thoughts and feelings require learning and practice. And if they haven’t done so with others, and you are the first person they are talking to, then it’s natural that they have difficulties. If they’re shy and/or anxious, this will add to their difficulty. If you’re trying to explore difficult experiences and this is their first time talking about these experiences, this will further compound their difficulty.
The depression hypothesis is not mutually exclusive with the interpersonal hypothesis. A person who would otherwise be able to articulate their feelings eloquently, and share their experiences, might have difficulty doing so when depressed. For instance, symptoms of depression include low mood, difficulties concentrating, and fatigue. If you are feeling low, tired, and have difficulties concentrating, it’s reasonable that engaging in conversation will be challenging.
Your client’s behaviour might reflect poor therapeutic alliance or it might not. It may be due to other factors like interpersonal experiences and depression. If you believe that the behaviours are due to poor therapeutic alliance, you’ll need to do alliance building and possibly mend therapeutic ruptures. However, if the behaviours are not due to poor therapeutic alliance, you need to meet the client where they are and let them go at their own pace. If you push your client to share before they are willing or able to share, you will strain the existing therapeutic alliance.
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