Clients tell us they want more challenge. Why do therapists avoid it?
It might surprise you that our clients want a lot more challenge and direction in therapy than we assume.
How do we know? Researchers recently surveyed over 1,300 people and found that over 70% wanted their therapists to focus on specific goals, give structure to therapy and take the lead. They wanted a more directive approach which was ‘active, structured and educational’. Only 15% wanted a non-directive approach.
It’s not a one-off finding either. A Swedish survey of the general public found a broadly similar set of preferences. And recent work on counselling in schools, published in The Lancet, suggests something similar.
The survey of 1,300 clients, referred to above, also asked therapists and counsellors for their preferences. Unsurprisingly, they wanted less direction in their own therapy. Clients typically enter therapy preferring that their therapist focus on specific goals, provide structure, teach skills, and take the lead, far more than therapists are comfortable with doing.
There is a pretty clear takeaway for therapists and counsellors: we need to be mindful of our own treatment preferences and recognise they may well not match our client’s preferences. Professor Mick Cooper, who led the study, put it in clear terms: “the findings contradict a passive stance”.
Yet this is the stance a lot of therapists emphasise, including on their websites. They focus on offering ‘a safe space’, being ‘accepting’/ ‘compassionate’, ‘respectful’, and ‘non-judgmental’. There is nothing wrong with these qualities of course, but they are not enough. Clients expect these qualities as a minimum, and they are clearly telling us they want more.
People come to therapy because of real and pressing problems. They are not content to spend their time and money on a safe space alone. They want change. And change is often best achieved through challenge and direction-setting.
At this point, there are usually three objections from therapists: 1. Clients don't really know what they want or need. 2. Client preferences evolve over time, and as they mature into therapy, they realise they need to do the work themselves. 3. I already provide the right level of challenge and direction.
Let’s meet each of those objections in turn.
1. In fact the evidence shows a good association between what clients say they want and how well they do in therapy. Research, based on 53 studies and over 16,000 clients, shows that accommodating preferences was associated with both more positive outcomes and fewer treatment dropouts (clients were half as likely to drop out - a huge effect). Clients do seem to know what works better for them.
2. Client preferences don't change that much over time. Those of us who use a preference inventory can demonstrate that preferences remain fairly consistent. You can start using one and see for yourself. It’s free to download, free (and easy) to administer and you don't need any training to use it.
3. Although therapists often think they are finding the sweet spot in terms of challenge and empathy, in fact, when sessions are video-taped, they can often be seen turning away from strong emotions. Leigh McCullough (a previous clinical professor at Harvard Medical School) said that although therapists report that they attune to, and pursue, strong emotions in their clients, in reality they do the opposite. “Having reviewed thousands of hours of video-taped sessions, time and time again, the merciless video-tape reveals therapists turning away from emotional states at crucial times”, she says.
That is why IAPT-supported protocols like Brief Dynamic Interpersonal Therapy now video-record the sessions of trainees. This way of learning recognises that traditional supervision is inherently flawed. Your supervisor only knows what you choose to tell them and what you can accurately remember from the session (or not). Supposed verbatim notes do not overcome the problem either.
So, perhaps by now you are more convinced of the necessity of challenge. If so, let’s just issue a common-sense note of caution: clients are not asking for us to be abrasive, rude, brittle or in any way uncaring towards them. They want challenge and empathy. In the end, those are two sides of the same coin.
Mick Cooper uses the analogy of a good massage - to feel the benefit, you will inevitably feel some discomfort during the massage. Too much discomfort will leave you feeling sore for days and vowing never to go back again. But a very gentle massage, while pleasant in the moment, is unlikely to be of much benefit in the longer term.
Let’s consider why therapists might find challenge and direction-setting so hard. In our workshop, we draw on a searingly honest book by Irwin Hirsch. He invites us to be the same. The essence of his argument is that we are flawed human beings. Just like everyone else, therapists have self-interested motivations and personal shortcomings - so let’s do away with the myth that therapists and counsellors are possessed by especially altruistic characteristics. Anything else would be to deny our shared and flawed humanity.
Sometimes therapists choose the line of least resistance; they choose an easy life. They choose a comfortable relationship with their clients, because that’s how we are wired and, truthfully, in private practice at least, because we need them to come back and keep paying. We shouldn’t sidestep that reality, and we should take seriously just how hard it can sometimes be to make a living.
To bring that to life, a recent survey suggests that the average salary of a BACP member is less than £10,000 a year. Fewer than 10% of BACP members earn more than £30,000 a year. And this isn’t just because members work part time; for 52% of those surveyed, counselling was their main form of income. It’s a similar position in the UKCP. In the most recent UKCP member survey, almost half earned less than £20,000.
So, we need clients in order to make our living, but we also need them in order to practice something that we (presumably) love and value – after all we trained long and hard (and often at considerable expense). Hirsch encourages us to be honest about the ‘high’ that comes from the affirmation of receiving new referrals, having most of our available hours filled, and earning a satisfactory living. Two decades before that, Racker said that when patients stay with us, the experience is similar to the feeling of being loved.
Important as it is, money is not the only reason therapists find it hard to challenge. Clients often disclose to us awful things that have happened in their lives. We see, close-up, just how much pain they are in. The thought of adding to that pain, via a challenging question or statement can feel risky, if not unbearable.
But herein lies the risk and the reward. Empathy and challenge go together. We can combine care, concern and challenge, in the service of change. When it comes to empathy and challenge, it’s a case of ‘both/and’, not ‘either/or’. As Lawrence Friedman said, “the therapist must accept the patient on his or her own terms, and at the same time not settle for them”.
So what can we do about our tendency to avoid challenge? Well, that’s the subject of one of our recent workshops and we’ll go through a number of specific, practical suggestions, as well as providing further reading and questions for reflection. We’ll also look at 12 real-life examples of challenge in action, which you can put into immediate practice in your own client work.
Those 12 ways of challenging range from: asking direct questions, to using humour; slowing the session down to dwell on important information or feelings, to reframing and offering alternative points of view; using focus or silence, to explicitly emotional communication and enactments. Along the way we’ll take in ideas such as motivational interviewing, the value of self-disclosure and even how drawing on the intersection of Buddhism and contemporary psychotherapy can be of benefit.
The finding that clients want more challenge, is a challenge to those of us who work as humanistic, relational or psychodynamic practitioners. We encourage you to grapple with that. Doing so will enhance your practice and will improve outcomes for your clients.