Question: “I don’t know what I need from therapy – but I know I need help!”
I’ve been working with a client for a couple of months now and we’re still not clear on what the client needs from therapy. In our initial session, I tried to set some goals and aims, but he said that he wasn’t sure and that he just felt stuck.
“So, you’re unclear about what you need from therapy, but you know that you feel stuck. Do you have a sense of what’s making you feel stuck?”
The client replied, “No, I just do. I’ll probably be one of your worst clients because I’m not sure what I want, but that’s just the problem – I don’t know what I want.”
From here, I empathised with his position. We can sometimes feel like something’s not right without knowing what’s going on. When we tried to explore what’s important to the client, he said, “I don’t know. Life is moving too fast and I feel like responsibility is coming at me faster than I can handle it.”
The client is a recent graduate who is half a year into his first full-time job, and he shared that, “One minute, I’m playing video games and doing assignments, and the next I have my own desk at work and my boss is asking me to speed up my progress on reports.”
I replied, “A few months ago you were a student studying for your assignments and enjoying playing games in your free time, and now there’s this new and more urgent sense of responsibility that sort of feels like it’s snuck up on you all of a sudden.”
Client: “Yep, and I don’t feel like I’m ready. I know how to do the job and that’s fine, but now I find myself in this working world and it feels like I’ve just been left to get on with it. I know that’s how it works for most people, but I just don’t feel ready.”
We spent time trying to break down what the client struggles with, as well as what underlies this idea of him not feeling ready. And as we make progress toward getting a sense of what holds the client back and we begin to look at strategies he might use to navigate his issue, he goes back into: “You know, I wish I was a student again, preparing for assignments and playing games. Life was easier at that point. Why do we have to become adults?”
To me, it feels like we go around in circles. He expresses his struggles, we explore those struggles and look at what’s underneath them, and then just as we begin to move forward into taking some kind of action, the client retreats into that mental safe space of his recent past.
As a result, I feel stuck myself and if you were to ask me, “What do you need from my response?” I might mimic the client and say, “I don’t really know – I just need help.” Help to move clients forward when it feels like we’re going around in circles. Or help to see where I might be contributing to this psycho-un-therapeutic merry-go-round.
How can we help clients move from expression and exploration of their issue and toward getting some sense of the direction they want to move in?
Response from Dr. Chua:
It can be difficult when a client comes to us feeling stuck, looking to us as the all-knowing therapist who has all the answers. In truth, we don’t have any answers for the client – our role is to help the client understand themselves better so that they can move forward in a way that’s meaningful to them.
In your initial response to the client, you asked if they have a sense of what’s making them feel stuck. This is a reasonable question, and your client gave you the answer: “I don’t know what I want.”
When a client feels uncertain about what, exactly, is troubling them, it can be helpful to explore that as the issue rather than trying to move them to somewhere. Taking the time to understand your client’s thoughts about life, about himself, can open the door to valuable insights that help you conceptualise his case.
For example, he says, “You know, I wish I was a student again, preparing for assignments and playing games. Life was easier at that point. Why do we have to become adults?”
In this sharing alone we have some meaning to explore and how it relates to the client’s view of himself: “I wish I was a student again. Life was easier at that point. Why do we have to become adults?”
So, there is something about being an adult that is displeasing, difficult, undesirable. Conversely, there’s something desirable about being a student again – the ease of living. Let’s unpack this using CBT.
- What is the most intense emotion in this sharing? What was the thought associated with the most intense emotion?
From here, pick the thought associated with the most intense emotion and use the downward arrow technique to find out the meaning of the thought.
For instance, imagine he said his most intense emotion was sadness, rated 8/10 in intensity, and the thought associated with the feeling was, “Life is hard now.”
Therapist: What does it mean about you that life is hard now?
Client: Oh, life is hard for everyone. I just wish I was a student again.
T: Uh huh. But what negative thing does it say about you that life is hard?
C: I guess I feel like I’m not doing a good job, that I’m finding it difficult.
T: What does it mean about you that you are not doing a good job?
C: I don’t know…I suck.
T: Ok, you suck as in…
C: Like I’m just a failure. I’m not good enough.
T: What’s so bad about you that you are a failure? (Make sure you get the core belief, so keep exploring.)
C: It just is. I’m a failure and failures are worthless.
T: Is that the bad thing about you that you are finding life hard? That you are a failure and therefore worthless?
C: Yeah.
T: Is that thought I am worthless bringing the intense feelings of sadness?
C: Yes.
T: How much do you believe that on a scale of 1-10, 1 being not at all true and 10 being absolutely true?
C: Ten.
- As you can see from this example, the client’s negative conditional assumption is, “If I find life hard, I am not doing a good job, and I am a failure. If I’m a failure, then I am worthless.” Conversely, their positive conditional assumption is, “If I find life easy, then I am doing a good job. If I am doing a good job, then I am worthwhile.”
So here, the core belief is activated (conditional) within the context of finding life hard or finding life easy.
- From this point, you can begin to use cognitive restructuring to examine the belief, “I am worthless”, and then work toward developing a realistic, accurate belief about who he is when life gets difficult.
It’s also worthwhile to reflect on your own automatic thoughts when dealing with a case you find difficult. As therapists, we can work with clients who seem to go with the flow and all the pieces appear to click in place immediately. This gives us a wonderful sense of satisfaction that we’re doing a good job.
As Bill Gates says, success is a lousy teacher, not least of all because it can be deceiving. But we are working with people, not tasks, and we can take time to appreciate the complexity of humanity and not be anxious that things are not resolving as fast as we want them to.
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