Pointers on Doing Therapy

Many techniques can cause change. Mike Rutherford’s Equation for Change is explained as one scheme.

Indirect communication, homework assignments, and the example you are setting are also tools.

Discover Mike Rutherford’s Equation for Change.

You may have learned a specific set of techniques associated with the particular school of therapy that trained you. Having a foundation to build upon is an excellent thing. While I hope that this book increases your expertise in doing therapy, I will not advocate one school of therapy over another. Each offers valuable techniques. Instead, I would like to discuss what you might want to accomplish in therapy and how that affects the tools you use in your toolbox.

Employ Rutherford’s equation to create a compelling vision and first steps toward change.

The history taken at the first visit acquainted you with the client. It likely suggested some ideas about what should be accomplished. Let us look at some treatment goals and valuable tools.

The heart of therapy is helping the client change. The first visit highlighted the client’s dissatisfaction with the status quo. Now, it’s time to help the client imagine how different circumstances can be.

The initial interview focused on finding out what was wrong.

You looked for signs and symptoms of things being wrong. The client revealed mistakes, shortcomings, deficits, and problems. Efforts were made to mitigate the negative content by reviewing the client’s strengths and expressing your optimism that something can change.

On the second visit, reframe events positively. Stop asking why the client acted a certain way. Now ask them how they might create successful outcomes.

I am reminded of the behavioral shaping techniques experimenters used to get a bird to peck for seeds in the left direction. They ignore every movement the bird makes in the right direction, then drop grain each time the bird looks to the left. They shape the bird’s behavior by reinforcing the desired behavior and ignoring the negative. S. G. Friedman, PhD, explains this in “Shaping New Behaviors” in Good Bird Magazine, reprinted on https://www.behaviorworks.org/files/ articles/Shaping%20New%20Behaviors.pdf

In the first session, negative behaviors were identified; now, selectively reinforce the positive, hopeful behaviors and leave negative ones alone for now. In conversation with the client, your nod, smile, or short utterance, like “Yes” or “Uh-huh,” is reinforcing. Look for early, not-yet-significant signs that something is better, then comment on it. Ask the client what they learned from the first session or what is different.

Reframe their wrongdoings as missing the mark in the process of getting better with practice. Focus on incremental change by dividing a long-term goal into a series of more manageable short-term goals. Help them develop a growth mindset and give up having to defend themselves as a static being.

When you hear of their shortcomings, your heartfelt acceptance, grace, and mercy model what you want them to experience toward themselves.

When a child feels known and loved by their parents, it makes it easier to accept that they are okay and frees them up to focus on caring for others as they have been cared for. They are also more comfortable recognizing their mistakes because they have a sense of being fundamentally okay.

This initial focus on the self in therapy could feel to the client like you are encouraging self-centeredness. But self-love is not selfishness. Being genuinely able to accept their own humanity frees them to become less self-conscious and connect with others. For those who were not so lucky as children, learning to accept their own humanity lovingly requires first focusing on self-understanding.

Identify factors amenable to change.

Look for and point out evidence of your client’s value and resilience in the face of their situation. Encourage them to be curious about everyday life’s more changeable elements.

Where could they introduce some slight differences? Help them find a minor problem and develop a plan to change it. The idea is to show them that problems are not permanent.

Seek good circumstances in their current life to show them that, while some situations are bad, not everything in their life is going wrong.

They may think they have been singled out or are endlessly unlucky. While not minimizing how much their difficult circumstances have affected them, look for ways to normalize the parts of their situation they may have in common with others. For example, they did poorly on a difficult chemistry test, along with half their class. You might point out that they weren’t the only student who did poorly while at the same time underscoring that you share their concern about passing the course.

Look for examples of how they have connected with others and help them identify when others have responded positively.

This article from Positive Psychology covers using positive therapy in more detail and offers active listening and exercise techniques: “How to Practice Active Listening:16 Examples and Techniques” https://positivepsychology.com/active-listening-techniques/

Like the Alcoholics Anonymous (AA) sponsor, your own example can be a vision of what change looks like for the client.

You can also use yourself as an example to help your client develop a compelling vision of change. Just as a child learns from watching their parents’ behaviors, clients learn from observing yours.

Alcoholics Anonymous is a Twelve-Step program in which alcoholics meet anonymously to share their experience, strength, and hope to maintain their sobriety and live in recovery. In AA, alcoholics go to meetings where they see people in recovery and have regular contact with their sponsors, who are like mentors. They see how the sponsor can regulate their impulses and live in a way that makes their life manageable.

The alcoholic experiences the sponsor valuing them and sacrificing time and effort toward their well-being. When they relapse in their efforts toward sobriety, they experience the sponsor’s mercy and forgiveness. The sponsor’s tenacity in caring about them is a living statement of the belief that they, too, can recover. The sponsor’s life embodies the inspiring vision of things being different.

When I think about AA sponsors, I am reminded of what Father Jim Finley said in an interview with Gary Moon of the Martin Institute in discussing his book Christian Meditation: Experiencing the Presence of God:

We are most powerless in being powerless to be anything else other than infinitely loved by God. That it is coming to the realization that nothing we do or say can make God love us more and nothing we do or say can make God love us less. The sole measure is the measureless expanse of Himself given to us whole and complete in and as who we simply are as precious in our brokenness (Moon 2016).

I have seen AA sponsors show that same redemptive love to the people they sponsor. That modeling and caring are also redemptive in therapy.

But the sponsor does more than care. They also set limits, boundaries, expectations, and norms. The same is true in therapy. Remember that therapy does not begin until acting out ends. Then, the client internalizes the conflict and feels the urge to start the change process. As I have mentioned, clients learn frustration tolerance by being frustrated and tolerating it in digestible, age-appropriate amounts.

Different therapists use different techniques to bring about change.

Next, in Mike Rutherford’s equation for change, the first minor, successful steps are made. This is the how-to part. It is not enough to be dissatisfied and have hope; there needs to be a means to effect change.

Part of the how-to is helping the client examine what values they hold important. What do they see as the purpose of their life? Who and what have been important to them and have meaning? Reminding them of their core beliefs helps them build a base to make the first steps toward that interesting vision. They might draw on their spirituality and their parents’ and mentors’ teachings as sources of strength.

In the first step, you may educate and help the client build social skills. The client practices the new skills between sessions and returns to review how it went. These skills involve social learning and connecting with others as the client develops self-worth and confidence. You may teach mindfulness and affective containment techniques to help clients calm themselves. As the client undergoes trial and error, you respond with encouragement. Your support shows the client that failing is okay and part of the growth process.

Sometimes, you can carefully use humor to lighten the mood. For example, when a client tells me about a socially awkward moment, I might tell them how awkward I felt at a medical school prom in the early spring when I was wearing my cousin’s hand-me-down white dinner jacket and everyone else was still wearing black tuxedoes. I then point out that both the client and I lived to tell our tales.

Another aspect of helping clients with the first steps is helping them get out of their own way.

Cognitive-behavioral therapy techniques help clients when they make mistakes in their thinking. It helps them make better decisions. And that can lead to changed behaviors.

Psychodynamic insight-oriented therapy uses techniques to help the client discover the unconscious conflicts that create resistance to change and paralyze their drive activity. You may help the client see how the repetition compulsion works to repeat past conflicts in their present life. They look for examples in the present of the most recent repetition.

These are just two of many therapies that help clients take those first steps. Suppose you have determined that a medical problem is also impairing their ability to take the first steps. In that case, you will want to do what you need to help them get medication to treat that impairment. If you believe your client has a borderline personality disorder, remember that dialectical behavior therapy (DBT) has been proven to help.

Do what you can to control the treatment setting.

You may not have much control over the setting where you see your client. If possible, try to make it comfortable and warm. Your environment should reflect thoughtfulness, client consideration, and professionalism. You are trying to help your client feel emotionally safe.

Make some space between you and the client. Chairs should reflect equality. There should be privacy and quiet, but the client should know someone else is in the vicinity, like a symbolic monitor. A managed care company employee told me they looked at how old the magazines were in the waiting room to indicate quality care.

In treating trauma survivors, it is best not to wear cologne because the abuser might have worn that kind of cologne. It could trigger the client. Ask yourself if your clothing is appropriate. Evaluate the risks and benefits of wearing anything that shows your religious or political beliefs. Bumper stickers might also reveal something that puts off your client.

It is likely that some methods I am about to discuss do not fit your therapy situation. That’s okay. Take what is helpful.

Choose your words carefully and consider asking clients to repeat what they have just been told.

I have had clients come up to my wife and me in a store and tell my wife how I had changed their lives by telling them to dye their hair cobalt blue and how it made all the difference. I could not imagine what they thought I had said because I knew I had not told them to dye their hair cobalt blue. The lesson is to be careful about what you say and what you put up in your office. Clients may misunderstand you.

If my wife tells me to get milk on the way home from work, I have no particular feeling about it. Then I forget the milk. My wife is mad. I have no milk for breakfast. The next time my wife tells me to get milk, I have some emotion attached to it. It has what is called a limbic valence. In therapy, the situation’s urgency may lend some limbic valence to what the therapist says. However, I suspect it would surprise you to know that the client does not retain much of what you say.

If the client were a student listening to a lecture and not taking notes, you would not expect them to remember everything the lecturer said. The same is true in sessions. What if the lecturer prefaced their following remark with “This is going to be on the test”? Then your student is all ears.

So, there are times in your work with clients when you need to emphasize something important by repeating it or saying it in a way that lets the client know you believe it is important. If it is a direction related to a task, you might ask the client to repeat or write down what you just said. I’ve asked clients with attention deficit disorder or short-term memory difficulties to start a list of things they are going to need to remember to do after the session. Try not to overload your client’s short-term memory, as I do now with yours.

While teaching has its place in therapy, therapy more often consists of the therapist fostering the client’s efforts to do their own thinking about their situation with active listening, which might include occasionally restating elements of what the client just said in a way that clarifies it.

The client’s conclusions are sometimes more memorable than those the therapist introduces. They have taken the time to stop, think, and absorb what has been discussed before reaching their conclusion. Their revelation may represent insight into what was previously an unconscious dynamic, and they may be freed up from having to repeat the pattern.

Sometimes, you do not have time to wait for the client to draw a conclusion or identify a pattern because the therapy is so abbreviated. It may be the last of only a few visits. In that case, you need to weigh the risk of their intellectualizing or denying what you told them against their never having a chance to hear the interpretation at all.

Using active listening and positive communication, carefully choose your words and reframe things to help your client imagine how things could be better and justify their hope. You remind them about their support system of friends, family, and faith. You identify times when they succeeded in working with others and using their self-discipline. Discuss available support groups and other resources for people who lack a support system.

As mentioned earlier, if you must confront a mistake they have made, try to sandwich the criticism between two positive remarks. For example, you might first say that you know what an effort they have made to be on time despite their busy schedule. They were late the last two times, but you feel like they will renew their efforts to be on time.

If you find yourself needing to set a limit on your client, it is helpful to explain your reasoning and how your expectation is a vote of confidence in their ability to tolerate the frustration of respecting it. Setting limits helps clients build ego strength as they practice patience, frustration tolerance, and waiting.

If you determine that your client is a visual learner, ask them if they get the picture. If they are an auditory learner, ask them if your words are clear as a bell. Match your vocabulary to their primary mode of learning whenever possible.

When you ask an oppositional client to do something they are reluctant to do, introduce an element of choice. Pretend you are trying to get your two-year-old child to put on their socks. Do they want to put it on the left or right foot first? Does your client want to start with 25 mg or 50 mg of medication, and how long do they want to try it before they raise the dose? There are two choices slanted in their favor.

You may not think a client knows your thoughts, but your body language can give you away. You may be unwittingly reinforcing something. When you are dealing with a potential abuse history, make sure you don’t ask leading questions that suggest things to the client, and be careful with your body language.

Assigning homework can augment the treatment.

Sometimes, I have assigned homework tasks to clients. I may ask them to sit down with their parents or extended family members and review the family albums or pictures on their phones. I am trying to give them a way to be together and do something. But I also want to show them that they had some positive times together.

If I feel the client does not understand their parent’s life or struggles, I will ask them to sit down with the parent and have the parent help them complete a structured life sketch. I show them that each line includes the date, the year of the parent’s life, personal events, family life, health, and global events.

They have a line for each year of the parent’s life. Clients are often surprised by what they didn’t know about their parents. This exercise can be an icebreaker.

Using indirect communication may reduce resistance.

If you need to confront a client, you might use indirect communication. For example, I may know from what I have read about a college student that they get drunk in the downtown bars every Thursday night. I pick a brief article on binge drinking as part of my reading selection that I ordinarily use to test their memory and reading comprehension. It seems to the client that I use it for all clients, but it indirectly conveys information and may be a conversation starter.

My gastroenterologist friend treated alcoholics with cirrhosis of the liver in a general hospital. Just before he discharged them to their family doctor, he would have the nurse come into their hospital room and adjust the blinds to darken the room. When he came in, he would visit them briefly. Then, as he walked just a bit away from their bed, he would say he was calling their family doctor. In hushed tones, just loud enough for the patient to hear, he would pretend to tell the family doctor how bad their lab studies were and what their prognosis would be if they didn’t give up alcohol and get treatment for their alcoholism.

He had learned from his experience that patients listened more closely to what he was saying to someone else than they would if he put them in a position to defend themselves. He would later call the family doctor and say much the same thing.

Group therapy is beyond the scope of this book. If you want to learn more about groups, you might enjoy the chapter titled “Wilfred Bion’s Theories about Groups” in Search: A Guide to College and Life. I wrote this book with my wife (Roquemore 2020).