Are We Getting Anywhere?
A client says, “I come in week after week and complain about the same thing. Do you ever get tired of my complaining? Are we getting anywhere?”
These two questions are critical to the process of psychotherapy. Both questions are intertwined, linking and conflating assessment of psychotherapy progress with the client’s need for approval and the therapist’s concern about efficacy. The client wants to be a good client and the therapist wants to be a good therapist.
Most clients wonder what their therapist thinks of him or her, are fearful of the worst, and are afraid to ask. This is often the subtext of therapeutic conversations, wedded to the transference that relationally bridges core feelings of self-worth with perceptions of others. When brought to the surface, the conversations that ensue are often relieving, mobilizing, and liberating the client to speak more honestly.
Equally important is the question “are we getting anywhere.” This speaks to the broader issue of how to assess psychotherapy progress, and in this case, a long-term psychotherapy. It is also connected to the therapist’s self worth and ability to examine the possibility of ineffectiveness and failure as well as to examine theoretical assumptions that often have counter-transferential significance. If a therapist has to always be good, then the question, are we getting way is translated into am I good enough. If a therapist believes that every therapy is a long-term process, then a lull will more likely be seen as simply a pause.
Each therapy has its own rhythm, mood and tone that change over time. It is not unusual for the rhythm of therapy to ease into a lull where not much seems to be happening either in the client’s life or in therapy. It is not self-evident whether these periods represent a transitional phase, the flattened gradient of the working through process, or a sign that the therapy is nearing the end.
This skill set needed to assess psychotherapy progress should be an integral part of the psychotherapist’s toolbox. This navigational skill is more than a rating form. It enables the therapist to recognize the subtle signs of progress, the non-overt signs of a negative transference, the significance of lulls, and to have some sense of direction and focus that extends over time. The skill set becomes ever more complex within the trajectory of a long-term psychotherapy.
This skill set has become particularly relevant in our era of evidence-based treatment, where there is growing pressure for accountability and for this accountability to be measured. Long-term therapy by definition exceeds the time-limited framework of evidence-based treatment. While it is beyond the scope of this essay to critically examine the issues that evidence-based treatment raise, therapists have a responsibility to assess the extent of progress, the quality of the therapeutic relationship, and make a determination when therapy is not working.(1) If there is anything instructive about evidence-based treatment, it is the challenge to develop subjective, collaborative, and qualitative guidelines that are appropriate to the complexity of a long-term in-depth psychotherapy.
The slope of therapy inevitably levels out. The client might start sessions by saying I have nothing to talk about today or wonder about coming every week. The therapist might feel tired, bored, or distracted, and relieved when sessions end or the client cancels. These are crossroads in therapy that first and foremost need to be recognized as such. Therapeutic crossroads present opportunities for a thoughtful, mutual assessment of therapeutic progress.
Many therapies conveniently end at this point where both therapist and client unconsciously and or implicitly agree to not go further without exploring the deeper unexpressed feelings that have been tailing the therapy like a ghost. Conversely, there are therapies that just keep on going interminably fueled by habit and convenience. In these cases, the implicit contract, that the client keeps talking and the therapist keeps listening (and getting paid) is never questioned. It is comforting to work with a client who you like and who trusts and values you. For multiple reasons it is difficult to end these relationships.
In the blogs that follow I will explore case examples that illustrate an approach to assessing psychotherapy progress that is individualized, subjective and collaborative.
1 The Heart & Soul of Change: Delivering What works in Therapy. edited by Duncan, B.L., Miller, S.D., Wampold, B.E., & Hubble, M.A. 2010, Second Edition explores the findings from 6 decades of psychotherapy research, including a critiques of evidenced-based treatment.