One of the first questions I ask a client when we start therapy is ‘what brings you in today’. Sometimes the client is exactly right about what they are seeking help with, other times, this isn’t the case. This has led me to be cautious when formulating my case conceptualizations and reminds me that I need to be fluid when working with a client because therapy is a process. I am always asking myself if we are focusing on the right things in therapy sessions and it isn’t always an easy question to answer.

An example that frequently seems to happen is that a client will indicate that they have past trauma that they need to work on. We begin therapy, start working on these past traumas and they may see a small benefit from that, but overall distress levels don’t seem to materially change for them. In most cases I eventually feel the need to have a frank conversation about whether our therapy sessions are actually helping. It’s easy to make adjustments when the client the client tells you something isn’t working (and I like using the session rating scale after each session to stay on top of this) but it can be frustrating when clients tell you the sessions are definitely helping, but the amount of change in overall distress remains limited. This can test our patience as therapists and lead us to question our own effectiveness.

The conversation about the helpfulness of therapy often leads to a bit of reflection on the client’s part and they often come back and want to talk about something else, something they only mentioned in passing previously, or vaguely alluded to as ‘there’s something else’, but I’m not ready to talk about it yet. Sometimes a completely new piece of the puzzle that was never previously even hinted at emerges. It’s important to remember that timing plays a key role here; we need to develop a strong trusting relationship first, and that can happen by working on things that don’t necessarily lead to profound and immediate changes in our client’s distress levels.

During my practicum, I was fortunate enough to work with a very special client that really drove this all home for me. We spent a great deal of time focusing on past traumas, doing experiential work, and they kept telling me that it was all very helpful, and we developed a great therapeutic relationship. At the time, I felt frustrated by the ‘lack of progress’ we were making; we had had 10 sessions, and I didn’t feel like I had helped this client at all other than giving them short reprieves from their stress through our experiential relaxation work. I kept blaming myself and didn’t believe that I was helping anything. I decided to have a conversation with my client about whether our therapy sessions were actually helpful, why the distress levels didn’t seem to be decreasing significantly, and if we were actually focusing on the right things. This conversation went well, the client reassured me that they found the work extremely helpful, that we were working on important things but that there

was something else that we hadn’t yet focused on. This led us to discuss another trauma that had only been mentioned in passing during the first session and didn’t appear to be a key component at the time. We shifted focus and started working on that, it was incredibly painful for the client to discuss. I can appreciate why it didn’t come up earlier – there was so much unprocessed emotion attached to this that there is no way we could have done this work earlier in the process, and even with the strong therapeutic relationship we had built in over 2 months of working together weekly, it was still immensely difficult to talk about for the client. What happened next was nothing short of amazing, I saw a profound decrease in the client’s distress levels and improvements in many areas in their life. They reported a great deal of lowered distress despite extremely difficult new external factors negatively affecting them.

For some clients a strong therapeutic relationship and sense of safety can happen after 5-6 sessions, for other clients it takes much longer. As therapists, we have to keep in mind that the strong relationships we build with clients are what empower them to be able to share things that are deeply emotional and painful which they have been holding onto or compartmentalizing. I found it frustrating to have clients tell me that the therapy sessions were helping, but not see any reduction in their overall distress levels. What I was forgetting was that therapy is a process that takes time – we are building relationships, and our clients aren’t always ready to talk about what’s really bothering them the most or might not even be aware of what it is that’s driving their distress. What I’ve learned is that it’s important to have patience with our clients, but even more important to have patience with ourselves and the process so that we can focus on building the strong relationships which are the bridges that help our clients move to a better state of mental health.

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*The views expressed by our authors are personal opinions and do not necessarily reflect the views of the CCPA