Frontiers Friday #86. Client's Point of View (Part III) ⭕
Frontiers Friday #86. Client's Point of View (Part III)
In the last 2 newsletters, we looked at anecdotal stories of client's perceptions in therapy. This week, we will look at the existing research on significant events in therapy from the clients' perspective.
In case you missed the first two part of the Frontiers Friday series on "Client Point of View", here it is:
👓 Significant events in psychotherapy- An update of research findings
Robert Elliot, known for his current involvement in emotion-focused therapy (EFT) work, was a pioneering researcher in studying significant events in psychotherapy in the 1980s. In this 2010 update from Ireland, Ladislav Timulak summarised the findings in this part of the psychotherapy literature.Key Grafs:
On Helpful Factors:
Insight/Awareness, Problem Solution, relationship-oriented events such as reassurance, feeling understood, and personal contact.
On Negative Events:
"...disappointment and misunderstanding in the relationship with the therapist are seen as major significant difficulties experienced in therapy...An explanation for occurrence of such events in supposedly helping relationship may be the clients’ vulnerability which may make the clients prone to be sensitive to the interpersonal interactions. It is important to note that due to the clients’ deference to their therapists, difficulties in therapy may not be communicated to the therapists, which decreases the likelihood that they would be resolved."
On Discrepancies Between Client and Therapist's Point of View:
"...Clear discrepancies between what the clients and the therapists find helpful in therapy...it seems that there is one common feature that distinguishes clients from therapists. Clients value more the relational and emotional aspects of events, while therapists prefer the more cognitive impacts."
On the Lack of Research on Significant Events and Outcome:
Out of 41 studies, only three quantitative correlational studies have investigated the relationship between the types of events and the outcome.
On Client's Recollection:
One study (Martin & Stelmaczonek, 1988) looked at whether significant events can be reliably remembered after 6 months. The clients remembered more than 70% of events after 6 months, but only 40% was allocated to the relevant session.
👓 What Clients Find Helpful in Psychotherapy-moment to moment
What stood out for me about this study by Heidi Levitt and colleagues (2006) was
that "clients rarely discussed symptomatic change per se as an important outcome of their psychotherapy."
The authors explained:"Although clients did mention symptoms in connection with the medication that they took, they did not describe symptom reduction as a reason why an experience in therapy was important to them. They tended, instead, to discuss global changes such as relating better with others and understanding or feeling better about themselves or others. Clients with an eating disorder who described changes in eating as significant were the exceptions to this rule. These findings support the view that although symptom reduction may be a positive effect of therapy, it may not be the primary benefit for many clients.
👓 Clients' experiences of difference with therapists-Sustaining faith in psychotherapy
A 2008 study by Daniel Williams and Heidi Levitt.Key Grafs:
"Clients often were aware of their projections although they may not have been voiced in session."
"Surprisingly...none of the clients with obvious multicultural differences with their therapists (e.g., race, nationality, gender) identified a moment of the session in which that difference was a salient factor, with the only exception being one client who identified both gender and social class differences as disruptive to the therapy."
See Table below for more.
👓 Clients’ Experiences of Disengaged Moments in Psychotherapy
It's one thing to study dropouts in therapy. But there is a more subtle type of disconnection: disengagement within sessions. Studies on moments of disengagement in therapy from client's perspective are illuminating. Here's one qualitative study.Key Grafs:
Six of these participants disengaged by changing the topic of discussion. One participant said,
"When I’m trying to keep that mask up, um, what happens is that my story is very disjointed, I will jump from situation to situation, I will talk about so and so did such and such to me, I’ll play the victim role. And then I’ll bring in story after story as to how I’m the victim, and I tend to stay there."
Participants used disengagement to prevent becoming so distraught that their ability to function in therapy was disrupted.
Interestingly, some clients reported disengaging in therapy to figure out their role in therapy and their relationship with their therapists, to test if they can trust the therapist. One participant said,
"It [the disengagement] was ‘I have to keep up the mask.’ And it was my way of testing to see ‘Am I unconditionally accepted?’ It was a process of establishing ‘How safe am I?’ and ‘Is this really a sacred space?’, ‘Can I trust, how much can I trust this person?’ And in making that judgment that I can trust this person the flip side of that coin was ‘I can accept what this [opinion] says if they [therapist] decide I am not normal,’ you know, or ‘my response is not normal,’ I can hear that from them now."
"If You Can’t Handle this I Won’t Talk About it." Nine participants described disengagement as stemming in part from their understanding that the therapist was not able or willing to respond to their experience in the way they wanted.
⏸ Words Worth Contemplating:
"Safety is not the absence of threat. It is the presence of connection."
~ Dr Gabor Maté
Reflection:
Psychotherapy outcome is not due to a single factor, but it consists of the moment-by-moment emergent conversational relational bond, as two parties become of one mind in their healing endeavor.
Think back of your clinical work this week.
What were some significant moments for your client? What did you do to cultivate this deepening process? Write it down.
Where there moments of possible client disengagement? What happened? How might you address this if it happens in the future? Write it down.
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BIG HUGS TO NEW PEOPLE WHO ARE AT THEIR FRONTIER!
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