Therapy, Part 3, the process of therapy (with me)

The process of therapy is different for every client.  All clients have different needs, goals, issues, personalities, levels of development, self-awareness and expectations.  It is important for me to cater my approach and processes in therapy to the individual needs of all unique clients.  No one approach fits everyone. At the same time, there are common elements to the overall enterprise of therapy, or “how it works” (when I am the therapist) that I will try to share here. I have provided some of my thoughts on exploring symptoms, identifying causes and proposing and implementing solutions in the blog: “Acknowledging the problem isn’t enough.”

At first, I consistently use a couple of tools and a general structure to enhance the intake process in therapy, which can then set the stage for ongoing therapy. For the first two to three sessions, I prefer a free-flowing conversation with a client.  We talk about what is particularly causing them distress right now in their lives. I want to make sure they are more or less okay, that they are not in danger of hurting themselves or being hurt by someone else.  Also, I want them to know how it is going to feel for them to be able to talk to me about what happens to be troubling them at any given point in therapy.  I want the whole thing to feel as natural as it can.  This is how most of our sessions are going to be down the road, so I don’t want the first few sessions to be too structured.

During the third or fourth session, I engage in a more structured “diagnostic interview.” This is one of the rare times I use a form—one that covers many specific areas of a person’s life. Usually, this interview takes about one session, but it can sometimes take up to three entire sessions, depending on the depth of the information the client wants to provide and whether the interview brings up issues the client hadn’t previously considered.  The point of the interview is two-fold. First, I need it for my licensure ethics (I need to have in everyone’s file a diagnosis with some objective basis to make sure my diagnoses are accurate and appropriate).  Second, it compels me to cover a wide array of topics, to make sure that in my zeal and curiosity to get to the heart of the client’s current problems I am not overlooking something very important in some other area of the person’s life.

The first question on the “diagnostic interview” asks about the “presenting problem,” which essentially means: “tell me what was happening in your life and inside you that made you decide to come to therapy when you made the decision.”  Although I also ask this question on my client intake forms, the way the client describes the problem often changes quite a bit by the time they’ve had the chance to discuss it with me in the first few therapy sessions. Reviewing the presenting problem helps us move into the second structured part of the therapy process: goal setting.

I can think of many examples when I have discovered something that informed the rest of my therapy work with a client that neither they nor I had thought about until I asked it during the diagnostic interview.  A common example comes from one of the areas I ask about: “developmental history.” During this part of the interview, I ask the client if anything significant happened to them as children that might be an important influence on the issues that brought them to therapy, or just something they think I should know about them from their childhood.  It could be an accident, a medical illness, a traumatic event.  If I didn’t ask these questions, I might not find out that a client who’s married to an alcoholic grew up without their father around because he died of alcohol poisoning, or that my client was adopted, or spent time in a foster home, or was diagnosed with ADHD in the third grade.  Any of these kinds of issues could end up playing a role in the cause of the client’s problems and also be a part of the solution.  There are also many times when clients report nothing unusual in this area of questions, so we just say “nothing noted by client” and move on to other areas.  I do not make assumptions either way—that a client does or does not have significant childhood issues that might be relevant to the therapy they now seek later in life.

In addition to providing information I might otherwise miss without it, the diagnostic interview also includes more positive areas of inquiry.  I ask about spiritual beliefs, social life, and personal values.  A person might have had some kind of spiritual connection or social community in the past that they found very important but have lost touch with it. These could become valuable tools for them to consider when we start thinking about specific ways to improve their current situation.  I also always ask clients to think about internal strengths they might have that will help them achieve their goals in therapy.  If they can’t come up with anything (and sometimes they cannot) I help them.  In the process, they begin to see themselves as equally important in the process of therapy. They begin to see themselves as their own therapists, even if they wouldn’t say it this way (I do).   I ask clients to tell me about important personal values as well. They may consider things important in their lives that are very different from the way I prioritize things in my own life.  It is important that I be open to and ready to consider their lives from their perspectives, not from my perspective.

Actually, there is a third reason I want to do this “Diagnostic Interview” with every client. It helps the client see me as a collaborator, as someone who is not “conferring” upon them some kind of therapy voodoo.  I am just some guy. We are in an office. We are talking about a client’s real problems. We are both doing our best to come to terms with their problems and solve them. There is no mystery here.  My “diagnosis” is just a best guess to what we should call the problem.  Is it “depression,” “anxiety,”  “ADHD,”  “Bipolar,” “substance abuse,” or some combination of these, or should we call it something entirely different.  I make my professional opinion known, it is out in the open for the client to see, and then we discuss whether it is accurate, whether I’ve made a mistake, and need to rethink the problem and what to call it. We do this together, so there is less chance of a misunderstanding, so the client is an equal participant, so there is no therapist (man) standing behind a curtain pretending to be the “Wizard of Oz.” There is no curtain, there is no wizard.

As we move through the diagnostic interview, I read back to my clients the answers I have written on the form so they know exactly how I am describing things.  We even often look together at the Diagnostic and Statistical Manual (the book insurance companies require us to use to diagnose client mental health issues).  This is a further way for me to be transparent, so clients can take ownership of and contribute to their own understanding of one way the mental health profession might view the issues they have come to address.

Like a diagnosis, my ethical requirements as a Licensed Marriage and Family Therapist also require me to have some kind of a “treatment plan” for all clients. This is a stupid name for the form, but I didn’t create the requirement, so I have to use this kind of language.  It is stupid because I don’t really view therapy as a way to “treat” people, like I am a doctor with some “medicine” to “treat” a skin rash. Client issues in therapy are serious, and can even be life threatening, so I do not take my role lightly.  On the other hand, the idea of therapy as “treatment” seems to invite a lack of humility and an “above (me) and below (client)” mentality that I find offensive and destructive.

We create the treatment plan right after we complete the diagnostic interview, usually in the third or fourth session. Like the diagnostic interview, I use the “treatment plan” form as another way to involve the client, to encourage the client to take ownership of her or his own therapy, to create with the client in their own language specific goals the client wants to achieve.  We both co-write them. They give me ideas, I share with them possible ways of writing the goal that is consistent with what they want, and then I write what they tell me sounds accurate.

The most important part of the goals sheet (“treatment plan”) is called “Discharge Criteria.” Again, stupid language, but it invites a very important question, maybe the most important question in therapy.  “How will you, the client, know you are ready to be done in therapy with me at this time in your life?”  I add the “at this time in your life” to leave open the possibility that the client could find themselves ready to be done in therapy with, but then later decide they want to come back for some other issue or because the issue has recurred in some way.  Either way, when a client answers this question near the beginning of the therapy process (around the fourth session), it gives us both a guide, a direction, a point to reach, like a lighthouse in the fog.  It tells me and the client the direction we should be headed, so we don’t end up in a quagmire, a swamp, a therapy wilderness spending countless sessions heading nowhere. This is not good for the client, and would be frustrating for me.  I want clients to know they are making progress in dealing with their problems, by giving them something they can use to measure their progress, whether the issues they brought to therapy take a few months or a few years to address.

Every once in a while, in between sessions, I look at these goals sheets and ask myself what I am doing to help the client move toward the place that will tell them they are ready to be done.  I also bring it up from time to time in session to ask the client to tell me how they feel about the progress they are making and whether we need to be doing anything differently for therapy to be more effective for them. Sometimes we come up with ideas about how we need to revisit goals we’d left behind. Sometimes we add goals that will help them achieve completion of therapy.  Sometimes the client realizes they have accomplished a goal and are close to being done in therapy.

After completing the Diagnostic Interview and the Treatment Plan, sessions are (mostly) as free-flowing as they were for the first two to three sessions.  I try not to bring any preconceived ideas of how any given session should be structured.  There are exceptions, but in general, I want to know at each session what the client wishes to discuss. A client might want to bring up a specific situation that occurred since their last session. We might spend the entire session on this one situation.  In the back of my mind, though, I will try to see how this situation fits into the overall therapy goals we’ve created, which is a kind of structure we might not have had during the first couple of sessions before we created goals.  Sometimes the topic of the session will fit neatly into a pattern the client wants to change. Sometimes it doesn’t seem to fit at all.  In either case, I view it as part of my role to connect dots in the clients issues during each session to try to find patterns they might not see or recognize.  When we talk about these connections, the client will often have an important insight that I hadn’t seen at all. This process of self-discovery wouldn’t happen if I didn’t encourage an open free-flowing process.  Part of the reason I am simultaneously paying attention to the client’s needs in the moment and thinking of the big picture of the client’s goals is that I don’t want to fall into the trap of losing track of why the client is in therapy.  Not every session will or needs to be directly related to the goals we created, but in general I want to know and want the client to know that we are steadily working toward change they want to bring about in their lives, the change they sought when they first came to therapy. I want the client to view every session as a valuable opportunity to move forward in their process of personal growth.

In the end, when clients “graduate from therapy” (I don’t know what else to call it), they are able to articulate how they were able to get to the place that tells them they are ready to be done. It is a wonderful thing to watch a client come to the conclusion that they are ready to be done in therapy. I am gratified when a client can say why they are ready to be done in therapy—they can then look back at our therapy work knowing they accomplished important new self-awareness and change in their lives.

Along the way, from first session, through the diagnostic interview and setting goals, and ultimately to the point of knowing they have reached their own “criteria for discharge” (they have done what they came to do in therapy), clients struggle through issues that I have touched on in many different blogs on the process of therapy in general and with respect to many different therapy issues. These include blogs on Fear (Fear and Safety Part I and Fear and Safety, Part II), Shame (Part I and Part II), Permission, Acknowledging the problem, Client History in Therapy, What “I don’t know” means in therapy, the concept of mental health (What is Mental Health Part I and Part II), Solutions, Process and Substance, taking on new perspectives and thinking “outside the box” (Thinking in Thirds), Co-dependency, Conflict, Part I, Part II and Part III,  What is “verbal abuse,” Situational Identity,” and many other topics that clients often find helpful in thinking about how therapy works for them.  I have also written several other blogs about my ideas of my role as a therapist. These include, The Relief of Humility, My experiences as a therapy client, and 12-step Recovery and Therapy.

If you read these or any of my other blogs, you will quickly learn that I do not make a distinction between what I think works in therapy for my clients to make their lives better and what I think works for me in my own life.  How could I?  I firmly believe in the proposition that I would not ask my clients to do anything to solve their problems that I wouldn’t be willing to do to solve a similar problem in my own life.  It just so happens that I have had many of the same kinds of problems in my life that my clients experience in theirs.  This shouldn’t be surprising.  Just because I am the therapist and the client is the one coming to me that day with a problem, doesn’t mean I wasn’t in their shoes as a client.  I was.  And I might be someday again.  I am just some guy and I am not standing behind a curtain.  I am not the Wizard of Oz.  No mystery.  Just a guy who brings care, concern, education, and trying my best to be valuable, helpful, supportive and careful with clients who come to me hoping to make real change in their lives.  This is the process of therapy, at least it is what the process of therapy is with me.

Copyright 2013, Michael Kinzer. Blog entries and other materials available on Jupiter Center’s website are only intended to stimulate thoughts and conversations and to supplement therapy work with Jupiter Center clients already in therapy. If you or someone you know suffers from a mental illness, you are strongly encouraged to seek help from a mental health professional. For further information about this blog, or Jupiter Center, contact Michael Kinzer at 612-701-0064 or michael(at)jupitercenter.com.