Question: “I feel helpless because I can’t focus the client or direct the session.”
I’ve been working with a client for seven sessions now. They initially said they wanted to overcome their anxiety as it’s holding them back from being social and engaging more with their friends.
The trouble is that they keep going off on tangents every time we touch on their issue. It’s as though they don’t want to talk about it or address what’s going on for them. A typical interaction is like this:
Therapist: So, you feel anxious when you think about socialising with your friends, which leads you to cancel plans with them?
Client: Yeah. I don’t know why I do that. I want to spend more time with friends and go outside more often, but I feel like I’m going to screw it up by saying or doing something wrong.
T: You feel like you might screw it up and make a mistake. What would that look like?
C: Do you ever think about going travelling? I’ve often thought of going to Europe but I’ll need to work for a while first and then see. Have you ever been to Europe before?
T: Yes, I’ve been to a few places. You’d like to travel more? Do you think learning to deal with your anxiety might help you connect with others when you go overseas?
C: My mum used to travel a lot when I was growing up. My dad doesn’t like to travel so much but I guess that’s because he’s an introvert. Sometimes, I wonder whether he’s happy at home. It’s hard to tell. Whereabouts in Europe did you go?
Each time I try to come back to the presenting issue, the client slips down another path and the sessions feel like they’re all over the place. Sometimes, I catch myself feeling helpless or zoning out. I even tried to highlight the tendency to go off on tangents and wondered if it’s difficult for the client to address their issue. They acknowledged that they can go off track and seemed to come back to the problem but then they went in another direction again.
It’s really frustrating because I feel like we’re wasting our time. I get the sense that the client is evading talking about their issue and I feel helpless because I can’t focus the client or direct the session and I’m wondering how to stop clients from going all over the place so it’s less like a general conversation and more like we’re focusing on the problem at hand.
Response from Dr. Chua:
This is a common problem. The desire to resolve our difficulties but not necessarily knowing how to or not wanting to go through the pain. There is something scary about confronting our shadows. You see it as a task to tackle, a problem to solve. Your client may see the same issue as something fundamental to their being. And let’s not forget that a symptom of depression is loss of concentration, a sign of anxiety is avoidance, etc. Sometimes the issue you are frustrated with is part of the illness and you need to attribute it to the illness not to the person.
Let’s see if we can understand what’s going on for you.
- Your client said, “I feel like I’m going to screw it up by saying or doing something wrong.” When you wanted to explore this further, they wanted to shift topics. I noticed that when they asked about Europe, you answered and then asked them if they would like to travel more. I was wondering what led you to ask about their desire to travel if you wanted them to answer your question about what “screw it up and make a mistake” would look like. Your follow-up question brought them further away from your original focus. Think about what you are doing, thinking, and feeling when your client changes the subject. Are you tracking and going along with it? Are you getting impatient? Are you helping them refocus back?
- You are zoning out and not being present with the client suggests a therapeutic rupture. A rupture isn’t just when your client is not connected, it also happens when the therapist is not connected. Now, if avoidance is your client’s difficulty, not being present and valuing your client might be yours. It might be worthwhile reflecting on when you can empathise and be present and when you can’t. Can you be present and empathise with clients who are focused and follow your direction? Do you zone out with clients who are not focused and don’t follow your direction? It could be that zoning out is your way of disengaging.
My supervisor John Markowitz frequently reminds me that if you think it’s hard for you, it’s even harder for your client who has to live their life. So, remember that your client’s progress isn’t your achievement.
- A process observation
“I even tried to highlight the tendency to go off on tangents and wondered if it’s difficult for the client to address their issue. They acknowledged that they can go off track and seemed to come back to the problem, but then they went off in another direction again. ”
A process observation is making an observation about what’s happening in the session. You can use process observations in a number of ways, but it should be exploratory not confrontational. You observed that the client goes off tangent, but you made an assumption about the reason rather than inviting the client to explore the issue together with you.
Let’s look at how that might unfold in session:
Therapist: So, you feel anxious when you think about socialising with your friends, which leads you to cancel plans with them?
Client: Yeah, I don’t know why I do that. I want to spend more time with friends and go outside more often, but I feel like I’m going to screw it up by saying or doing something wrong.
T: You feel like you might screw it up and make a mistake. What would that look like?
C: Do you ever think about going travelling? I’ve often thought of going to Europe, but I’ll need to work for a while first and then see. Have you ever been to Europe before?
T: I was wondering how you felt when I asked you about your fear of screwing up and making a mistake. I noticed you asked me about traveling and Europe instead of answering the question.
If your client says, “Yeah, I was just distracted about traveling. I didn’t feel anything,” I would keep exploring because this is the main difficulty your client brought into session. I might then say:
“Yeah, that does happen. Sometimes, we think about something else when the conversation isn’t very interesting or it’s just not what we want to talk about. I was wondering whether you feel this way – like this isn’t very interesting or something you want to talk about?”
This would work even within a CBT framework as you can then identify the automatic thought, feelings, and behaviour (changing topics).
Whenever we are frustrated at our clients, it’s worth taking a look at the client (our conceptualization), the therapeutic relationship, and ourselves. You can’t push against the barrier and hope it disappears if you push hard enough. If the sticking point is the relationship and/or your client, it’s worth stopping and inviting your client to be curious about the barrier and work together to dismantle it. Don’t be on opposite sides. Find a way to get on the same page so that you are collaborating in the same direction.
If it’s you, that’s something to work through in supervision and personal therapy. It could also be all three factors (i.e., the relationship, the client, and you) that create the barrier.
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