What’s the best way to handle difficult sessions?

Question: “I don’t know what to do when my client is distressed”

In some sessions with clients, they have been overwhelmed by sudden life changes (e.g., loss of a loved one, or an unexpected break up) and they come to the session in a highly emotional state. What’s the best way to manage these kinds of sessions?

One client was struggling with grief and they spent much of the session crying. I felt uncomfortable, not because of their emotions, but because I was unsure what to do. It felt strange to just sit there and look at them while they were in tears, and at the same time it felt inappropriate to think about doing any kind of intervention, which might feel like I’m invalidating their experience in the moment.

What can I do in these sessions when clients are struggling to cope with heavy or difficult experiences in their lives? When I think of asking how they feel, or telling them, “It must be difficult…” it feels like I’m stating the obvious – am I overthinking this? How can I be empathetic in a way that’s authentic and doesn’t come across like I’m “trying” to be empathetic?

For example, how would you handle a client who shares news of a sudden break-up (i.e. it happened just a few days before) and they come to you with strong emotional responses such as crying as they struggle to deal with their heartbreak?

As a new therapist, I feel like I need to “do something” in my sessions with clients (e.g., techniques, teaching skills) and I was trained that clients “must take something away” from each session. But I wonder how this applies to more difficult sessions, or whether I should take a different approach when clients are at their breaking point.

Response from Dr. Chua:

Clients should take away something from every session, but it does not mean the learning comes from direct teaching. The research on therapy relationships (e.g., empathy, positive regard, and collaboration) consistently shows that how we are in session (our being and presence) contributes significantly to therapy progress.

In the session, you mentioned that you felt uncomfortable and you were not sure whether you should sit there and look at your client crying, or to do an intervention. I think whatever you are doing, whether you are just being with someone in silence, or giving empathetic reflections, you aim to be helpful to your client. Thus, the question is, “What are you doing in session?”

APA has defined psychotherapy as “…the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable”. [1]

• Psychotherapy is an activity characterized by 1. clinical techniques and 2. the therapy relationship/alliance.
• Both clinical techniques and the therapy relationship are based on validated psychological principles.
• Psychotherapy is intended to help people to achieve their goals through changes in behaviors, cognitions, emotions and/or other personal characteristics. [2]

Keep doing psychotherapy in a psychotherapy session. You don’t stop the activity of psychotherapy when your client is at their breaking point. Your client needs your help as a psychotherapist at that point.

This doesn’t mean you behave in a robotic manner. For instance, you don’t continue by suggesting an automatic thought record if your client can’t focus on it because they are in pain and in tears. Your method needs to fit the client and the specific situation.

You write, “For example, how would you handle a client who shares news of a sudden break-up (i.e. it happened just a few days before) and they come to you with strong emotional responses such as crying as they struggle to deal with their heartbreak?”

I’d suggest that crying, in this case, isn’t a strong emotional response; it seems like a pretty appropriate response of sadness and pain to a break-up. I would be more concerned if my client shows no emotional response to the break-up or minimizes their pain with a joke. Keep in mind:

• Emotions are essential to healthy living and inform us about how we are experiencing the world. [3]
• Healthy coping requires both problem-focused and emotion-focused coping [4]
• Expression of distress can lead to reducing distress, facilitating insight and improving the therapy relationship.[5]
• Emotional processing is associated with good therapy outcomes.[6]

What we do know is labeling, accepting, and experiencing emotions are crucial. The importance of the relationship means that there is no one-size-fits-all solution when someone has an emotional experience. Some will need your empathic silence; others might need you to help them self-sooth or to hear empathic affirmations in response to their pain.

So, the key thing here is not what you do with their emotions but how you experience the client’s distress and pain and whether you can be with them in this experience. Do you find yourself zoning out, fidgeting awkwardly, or even making an ill-timed humorous remark? Do you change the topic or just simply avoid painful topics? How is your relationship when there is pain and distress?

Reflecting on your own inner experience when faced with sessions you find difficult can yield valuable insights on areas that would be helpful to work on for yourself, as the therapist. This can be done in supervision or in receiving your own therapy, which is why I always strongly encourage therapists to engage in both. Remember: it’s not just our client’s defences and anxieties that come into the session – therapists also bring their defences and anxieties, which is why we need to be consistent in our self-reflection and proactive in having help and support through supervision and therapy.

References

1. Campbell, L. F., Norcross, J. C., Vasquez, M. J., & Kaslow, N. J. (2013). Recognition of psychotherapy effectiveness: the APA resolution. Psychotherapy, 50(1), 98.
2. Prochaska, J. O., & Norcross, J. C. (2018). Systems of psychotherapy: A transtheoretical analysis. Oxford University Press.
3. Greenberg, L. S., & Safran, J. D. (1989). Emotion in psychotherapy. American psychologist, 44(1), 19.
4. Lazarus, R. S. (2006). Emotions and interpersonal relationships: Toward a person‐centered conceptualization of emotions and coping. Journal of personality, 74(1), 9-46.
5. Kennedy-Moore, E., & Watson, J. C. (2001). How and when does emotional expression help?. Review of general psychology, 5(3), 187-212.
6. Watson, J. C., & Bedard, D. L. (2006). Clients’ emotional processing in psychotherapy: A comparison between cognitive-behavioral and process-experiential therapies. Journal of consulting and clinical psychology, 74(1), 152.

Photo credit: Fares Hamouche