A client tells you she cried in the car after visiting her father. He has been ill for some time, and she has been driving him to appointments most weeks. “I wish my sister would just come for one weekend,” she says. Then, almost as an aside, “Sometimes I see Dad’s name come up on my phone and I wish he’d stop calling. I feel awful even saying that.”
There are several ways I’ve seen learning counsellors respond to this kind of situation. They might ask whether she’s told her sister how hard things have become or reassure her that plenty of people feel this way when they’re caring for someone. Both might be helpful at some point, in the kind of conversation we have with our friends. But as a therapeutic conversation, I’d want to hear a little more about what felt awful to say. She was already able to tell me she needed help but she took a different kind of risk when she told me she sometimes wishes her father would stop calling.
Early in our careers, it can be hard to trust that staying with a moment like this is worthwhile. We want our clients to leave with something useful, and it can feel uncomfortable to hear someone in pain when there is very little we can do about the circumstances causing it. Sometimes we move so readily towards what might help that we miss the part of the story the client has only just found the words for.
Notice when you want to move things along
Our impulse to reassure often comes from care. We can hear how harshly a client is judging themselves and want to relieve some of that. It can also come from our own discomfort. Perhaps their shame touches something familiar in us, or we feel responsible for making sure they leave the session feeling better. In the room, these motives can be difficult to separate.
One thing I find useful is to notice how quickly I’ve started planning my next response. If I’m already thinking of ways the client could ask her sister for help, I may have stopped listening to what she’s saying about her father. I can keep the idea in mind and return to the sentence she nearly passed over, paraphrasing it back to her “You say you feel awful even saying that?”
I might also reflect what I heard and give her a moment to respond. “You wish the phone would stop ringing for a while, and it’s hard to admit that out loud?” She might tell me she’s afraid I’ll think she’s selfish. She might say I’ve missed it entirely and what frightens her is how relieved she feels when she imagines a day without him needing her. Her correction would help me understand what she’s trying to say.
What we’re validating
When a client says, “I’m a terrible daughter,” it’s tempting to reply by rescuing the client, “Of course you aren’t.” There’s warmth in that response! And it also leave us knowing little about what she thinks a daughter owes her father, or what happens in her family when she needs something herself or the feeling that sits underneath that statement.
Validation can be quite specific. After hearing more, I might say, “You’ve been holding a lot for everyone, and even wishing for a break feels like letting him down.” I’d want to see whether that fits. If she says, “Actually, I think I’m angry that nobody asks how I’m doing,” then we can hear the anger on its own terms. We may learn something about how alone she has been that a conversation about dividing up appointments would have missed.
In a study of recorded experiential therapy sessions, Pascual-Leone and Greenberg (2007) observed that broad distress could become more specific as clients put words to what they needed and how they judged themselves. In some of these sequences, grief or a clearer sense of anger emerged. It was a study of particular moments in a particular therapy. It gives us a way to think about the difference between feeling big feelings and beginning to understand what we feel. A meta-analysis by Elliott and colleagues (2018) also found an association between therapist empathy and better outcomes across different approaches. Neither study tells us how long to stay with a given feeling in the next session. We work that out with the person in front of us.
How do we know when to stay and when to pause?
A few seconds can feel like a long time when somebody has just told you something they feel ashamed of. They may need a moment to gather their thoughts, or to see how you respond. Some clients experience a pause as room to speak while others can experience the same pause as judgement, particularly if they’ve just said something they expect you to disapprove of. A few words can help: “I’m here with you”
We can ask whether the client wants to stay with what has come up and listen to the answer. If the conversation starts to feel too much, we might pause and ask what would help them feel more settled. They may want to move back to the practical question of getting through the week. And if they tell us something that requires attention to their immediate safety or circumstances, we respond to that. Sometimes we can return to the feeling later, when there’s time and the client wants to.
The shift can come from us, too. If I’ve already hurried into planning, I can say, “I went straight to asking about your sister. I wonder if I moved past something you wanted me to hear.” That gives the client a chance to tell me whether I did. It gives them the space.
Bring the moment to supervision
If you want to get better at this, bring a short exchange to supervision, as close as you can remember it. “She said she felt awful, and I asked whether her sister could take on some appointments.” A supervisor can help you slow down the moment. What did you hear in the client’s words? What did you imagine might happen if you asked her to tell you a little more? It’s worth looking at the service context as well. If you’re working in a setting that expects an action plan from every session, that expectation may be in the room with you.
You could try saying a different response aloud in supervision, then consider what you would listen for after you said it. That second part is easy to skip! The client might elaborate, pull back or tell you they meant something quite different - the skill is in giving their answer room to change what you do.
Our client may still want help working what she wants to do next. After we have heard a little more, she may be able to make a plan of action, have important conversations or make peace with her own choices. Sitting with her shame for a little longer gave us a chance to slow down and hear what was there, and most importantly, to make sure that she was the person who chose what she needed,
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References
Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399–410. https://doi.org/10.1037/pst0000175
Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional processing in experiential therapy: Why “the only way out is through.” Journal of Consulting and Clinical Psychology, 75(6), 875–887. https://doi.org/10.1037/0022-006X.75.6.875