Question: “I just fall into a kind of passive supporting role”
As a new therapist, I realise I tend to turn sessions into conversations where I’m just asking questions and discussing the client’s responses. Afterward, the clients usually say the session has made them feel better, but I think that’s because they’ve just been able to get stuff off their chest.
When I reflect on this, I probably feel inadequate during some sessions and have the thought, “Who am I to direct this therapy? I don’t know much!” Clients who are super engaged in the therapy process are easy to work with because they’re expecting a process, so it’s easier for me to engage in the therapeutic work.
But for clients who come in and talk at length about their issues (or say very little at all), I feel unsure how to deal with that and so I just fall into a kind of passive supporting role and hope the clock ticks along a little faster.
I’m confused by how we’re supposed to be in session. The humanists will say, “Don’t direct so much”, and the behaviourists might say, “The client needs structure”, and other therapists will say, “It depends on the client.” One piece of advice I was given was that “It’s important to find your own style…so long as your work adheres to the ethical guides, the rest is up to you.”
Being paralysed by all these different ways of looking at therapy, I sometimes feel disorientated, which is probably why I fall into the safe, passive supporting role a lot of the time.
In mathematics, everything has a structure; in surgical medicine, procedures are in place; even in teaching, there’s a clear curriculum to follow. It’s as though most industries have clear ways to get the job done…except psychotherapy.
I do read the textbooks and attend training and all that, but they seem to give a very step-by-step process in a way that just doesn’t show up in real life most of the time. I understand this is necessary (books can’t cover every possibility), but I think the one thing that’s lacking – at least for me – is guidance on how to step up to the plate as a therapist and stop retreating into that safe space of supportive counselling.
Any advice you can give would be great. I really don’t know how to move a session that’s stuck in conversation to something that resembles effective therapy.
Response from Dr. Chua:
In any field that includes human interaction, there is a beautiful complexity that arises. You mentioned medicine – yes, there are procedures that are black and white, and then there is the human interaction that is less clear cut. Research shows that patients with doctors who support their autonomy are more motivated to take their medications and follow the prescribed regimes.
Even healthy behaviours have fewer positive consequences when they are done out of controlled motivation with guilt and shame. In other words, any field that requires human interaction involves psychology – the scientific study of the human mind and behaviour.
Think of a psychotherapy modality’s structure as a road map. How fast you drive and what car you use varies on the therapist and the client. The route to take depends on the modality but I would argue that all psychotherapies have the same goal. So, the route might be different, but the destination is the same.
The American Psychological Association states that “in psychotherapy, psychologists help people of all ages live happier, healthier and more productive lives. Psychologists apply research-based techniques to help people develop more effective habits.”
So, that’s the common goal of all psychotherapy – happier, healthier, and more productive lives.
How you should be in session is the same across modalities – that is known as the common factors. Bruce Wampold has done a lot of research on this, summarised in “The Great Psychotherapy Debate”. The common factors include: goal consensus and collaboration, empathy, alliance, positive regard, congruence, and setting expectations.
What you should do, regarding psychotherapy techniques, differs. Let’s take the treatment of Obsessive Compulsive Disorder using Exposure Response Prevention Therapy (ERP). What you should do is to engage in exposure to the feared object. This differs from what you will do using CBT for depression which involves cognitive restructuring, examining evidence for and against negative beliefs etc.
Nonetheless, even in Cognitive Behavioural Therapy, Aaron and Judith Beck emphasise the importance of empathy, interpersonal effectiveness, and collaboration with clients. Interpersonal effectiveness is a common factor of psychotherapy that can be applied across modalities. I find that, far too often, people teach and practice structured therapies like CBT in a rather robotic manner (just rigidly following the manual).
Let’s say you set the agenda with your client using CBT, it’ll look something like this:
Therapist: What would you like to talk about today?
Client: Well, I don’t know. There’s just been a lot going on and I just don’t feel happy.
T: OK, your mood has been low – would this be something you want to spend our time on today?
C: Yeah, OK.
T: If we have time, is there anything else you would like to cover?
C: No, that’s about it.
T: Alright, so tell me more about your mood: what do you think happened this week that affected your mood?
….
T: So, if I got it right – your boss scolded you for the late report and you felt bad about it.
C: Yeah, he is a real jerk and I just don’t know what to do about it.
T: Let’s explore that a little more. What were you feeling when your boss scolded you?
C: I felt embarrassed and stupid.
T: You felt embarrassed and stupid…anything else?
C: Well, pretty angry about it.
T: Yeah, that makes sense. Anger as well. Anything else?
C: No that’s about it.
T: If you rate these emotions from 0-100, 100 being really intense, 0 not at all, how intense was your embarrassment?
C: 80.
T: How about feeling stupid?
C: 70.
T: And how about the anger?
C: Oh, I was really angry. 90.
T: Uh huh. So, anger was the strong emotion here?
C: Yeah.
T: And when you felt this intense anger, what went through your mind?
C: How dare you treat me this way?! You don’t respect me at all.
T: You thought to yourself that your boss doesn’t respect you and is treating you badly?
C: Yeah – he always does it!
T: That would certainly be infuriating. I wonder what negative thing you think it means about you that your boss doesn’t respect you and treats you badly? [Going towards downward arrow]
In this interaction, notice:
- The client and the therapist collaboratively set the agenda.
- The therapist finds out more about the problem to discuss through exploration, Socratic questioning, and reflection.
Even in CBT, the therapist uses common factors to frame the specific psychotherapy “tasks”.
It takes time to learn and deliberately practice to be a good therapist – in fact, it’s a lifelong process of learning. In my view, the difficulty of psychotherapy and counselling is severely underestimated. None of us can be an effective counsellor just with our basic training straight out of grad school. Once you embark on this journey, consider that it is a lifelong journey of learning more about yourself and how to connect and help your client more effectively.
I felt the same as you before. Not knowing, overwhelmed, wanting to be better. But continuous learning through reading, taking courses and engaging in supervision really does help. Over time, you’ll begin to feel more effective, more competent, while still retaining what all good therapists have – “professional doubt”. This is what motivates us to keep learning. Remember: even the greatest musicians, actors, and sportspeople maintain a high level of practice throughout their careers.
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