In our clinical practice and training programs, we use a highly structured and directive treatment approach. The reason for this is that you (the therapist) are the professional, and your client is contracting you for services so that s/he can achieve his/her treatment-related goals. You are supposed to be the one with the expertise to deliver the service effectively and efficiently.
This is not to say that the client has no choice or input. To the contrary, the whole point of treatment is to accomplish the client’s goals, so it’s essential to learn what the client’s goals are. However, that does not mean that the therapist should rely on the client for technical guidance on how the treatment should be conducted.
If you went to a doctor who asked, “What diagnosis would you like today?” and then after you responded, asked, “So what treatment would you like? And what dose?” Well… you wouldn’t go back to that doctor, would you? You want your doctor to pay attention to what you say, but also to make his/her own diagnosis and recommendations, and discuss those with you.
So don’t be that therapist.
Yet therapists routinely do this. We ask, “What do you want to talk about today?” or variations such as “What’s on your mind?” We follow the client’s lead (we do respond), and see where the session goes. And when it’s time to do trauma resolution work, we ask, “What memory would you like to work on?”
The problem with just doing what your client wants to do, or talking about whatever your client happens to bring up, is that there is no informed consent. Your client would be making decisions and guiding the treatment without the benefit of your professional advice. This is wrong, and denies your client the opportunity to make informed decisions regarding his/her treatment. Your client should know what you know, before s/he decides.
That means that when your client tells you the presenting problem, or what memory s/he wants to work on, it’s up to you to figure out what you believe will be the best way to help. Then give your client adequate information – including the reason for your recommendation, as well as alternative options with pros and cons – to make an informed decision.
For example, many trauma therapists report encouraging their clients to choose which trauma memory to work through, with the rationales that (a) “clients know what they’re ready for” and (b) “letting clients choose is empowering” which supposedly enhances the therapy relationship (Greenwald et al, 2014). However, clients may not in fact know what they’re ready for, and could easily become overwhelmed by attempting trauma resolution work with a difficult memory before they are prepared to cope with it (Briere & Scott, 2012; Greenwald, 2013; Herman, 1992). Then the therapy relationship is damaged – not enhanced – because the therapist failed to provide adequate professional guidance. Indeed, in the good old days when clients were routinely over-exposed to their trauma memories (with therapeutic intent, via implosion or flooding therapy), dropout rates of 35% were not uncommon (Solomon, Gerrity, & Muff, 1992).
A broader example is the use (or non-use) of a treatment contract. Presenting a convincing rationale for treatment activities (Messer & Wampold, 2002), and agreement on treatment goals and tasks (Horvath & Greenberg, 1994) are complex interventions and difficult to implement, requiring an advanced level of skill (Mallinckrodt & Nelson, 1991). Yet coming to a shared understanding of the source of the clients problems, and agreement about what to do about them, provides the foundation for the therapy alliance, one of the key elements of successful treatment (Norcross, 2010). Even so, many therapists never get around to providing a clear case formulation to their clients, much less developing an explicit agreement with the client to pursue a specific plan of action on that basis.
It’s not enough to just do what your client tells you to do, or to just “follow the client’s lead.” Your job is to provide information and recommendations based on your professional knowledge and judgment; then your client can make informed decisions, relying on the benefit of your expertise. Much of the art of therapy is in helping your client to understand his/her problems with a perspective that will lead him/her to make beneficial choices.
References
Briere, J., & Scott, C. (2012). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment, 2nd ed. Thousand Oaks, CA: Sage.
Greenwald, R. (2013). Progressive counting within a phase model of trauma-informed treatment. New York: Routledge.
Greenwald, R., McClintock, S. D., Bailey, T. D., & Seubert, A. (2014). Treating early trauma memories reduces the distress of later related memories. Manuscript submitted for publication.
Herman, J. L. (1997.) Trauma and recovery. NY: Basic Books.
Horvath, A. O., & Greenberg, L. S. (Eds.) (1994). The working alliance: Theory, research, and practice. New York: John Wiley & Sons.
Mallinckrodt, B., & Nelson, M. L. (1991). Counselor training level and the formation of the psychotherapeutic working alliance. Journal of Counseling Psychology, 38, 133-138.
Messer, S. B., & Wampold, B. E. (2002). Common factors are more potent than specific therapy ingredients. Clinical Psychology Science and Practice, 6, 21-25.
Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy, 2nd edition, pp. 113-141.
Solomon, S. D., Gerrity, E. T., & Muff, A. M. (1992) Efficacy of treatments for posttraumatic stress disorder. An empirical review. Journal of the American Medical Association, 268, 633-8.
