The other day I read an article by Niella Arboine in the Guardian. She was writing about her experience of therapy and early on in the article she writes this:
“My therapist was great. She was affordable, understood how my identity shaped how I saw the world and equipped me with practical tips. More than anything, she was patient with me. But I wasn’t prepared for how uncomfortable therapy would be. I was confronting parts of myself I had buried away, reliving moments I’d rather forget and understanding how events and people in my life have led to my behavioural patterns. I’d leave sessions in tears, feeling drained and wondering if it was worth it. Having to be present in those swirling emotions was exhausting.” (Arboine, 2023)
I am really glad that Niella found her therapist to be great and that she clearly valued the experience. Indeed she concludes by saying “I’ll always recommend therapy – it helped me to recalibrate my outlook on life” but at the outset I wonder whether her therapist was clear that ‘tears’ and ‘feeling drained’ and experiencing therapy as ‘exhausting’ are not a necessary part of a change process, that there are alternatives. The client’s experience of therapy, exhausting or energising, really does depend on the therapist’s choice of model.
I remember some years ago meeting a new client in BRIEF’s Newbury Street waiting room and when I went in there were two people sitting there - obviously together. Since we have always been happy to work with whomsoever the client wants to have in the session I asked my client, let’s call her Anna, who was coming up to the session and she immediately indicated that she would be meeting with me alone. As we were walking up the stairs ‘Anna’ told me that the person who had come with her was her best friend. By now we were in the meeting room and as we were sitting down I asked ‘so are you doing something nice together after our session?’. ‘Anna’ looked puzzled and after a moment said ‘no . . . I’ve had therapy before’. Now it was my turn to be puzzled and as I was thinking how to respond ‘Anna’ elaborated saying that she had some tough things to address and so she had brought her best friend with her ‘to help me to get home after the session’. What a great client. Predicting inevitable distress she had arrived equipped to deal with it, bringing a supporter, so that she would be able to do the work that she assumed would be necessary. Of course my assumption was different. I assumed that ‘Anna’ would be addressing whatever she wished and that she would leave the session feeling better, feeling stronger, feeling more hopeful and more optimistic, feeling energised by the session. Why wouldn’t ‘Anna’ be going off with her best friend after the session to have a good time? We see the same expectation of distress and discomfort when clients express scepticism about appointments first thing in the morning before work. How, they ask, are they going to manage work after a therapy session. We of course tend to respond by saying that after a session they are likely to have their very best work day – it will indeed be a sparkling day for them.
This idea that problems are deep-rooted in clients, that they need to be challenged and confronted and that this process is painful, unsettling and demanding has been commonplace in therapy, both in clients and therapists. Indeed it has been institutionalised within the therapy world to such an extent it is not unusual for clients to be assessed prior to therapy to determine whether their living situation is sufficiently stable and supportive to enable them to manage the change process. The dictum ‘no pain no gain’ is widely accepted, hardly questioned. This way of constructing the change process, and it is of course ‘merely’ a construction not a truth, has had real life consequences debarring some people who are in desperate need of help from therapy. For example, not infrequently, children in care can be deemed not to be in sufficiently stable circumstances to undergo therapy and thus are denied help. It is of course our view that distress is not a necessary part of a change process. The client may arrive in therapy bringing distress with them, they may have lived through hugely painful circumstances, but ‘therapeutic distress’ resulting from the process of therapy, results from therapist’s choices, where the therapist chooses to direct the client’s attention. Distress results from the ideas that the therapist chooses to have about the change process; distress is optional and perhaps clients should be told that, should be pre-warned and offered options. There should perhaps be a health warning along the lines of ‘my preferred way of working not infrequently leads to people feeling ‘drained’, ‘exhausted’ and crying and of course there are other models that do not have this effect and have equally good outcomes’.
Over the years BRIEF has worked with many clients who have lived through truly awful experiences, including abuse, torture, trauma, loss, bereavement and separation. We have worked with people who have attempted suicide, who self-harm, who struggle with eating, who drink and use drugs in ways that are problematic for them and what we know is that therapy does not have to involve ‘tears’, it does not have to be ‘draining’ and does not have to ‘exhaust’ our clients. If we invite our clients to focus on their desired outcome, how they will know that therapy has been useful to them (their best hopes), and if we then support them in describing in detail their life as transformed by the presence of those ‘best hopes’, and if we then invite them to focus on elements of that life already in place and what the next tiny signs of progress will look like and in between sessions we invite our clients to pay attention to progress then why would these conversations involve ‘therapeutic distress’. Indeed quite to the contrary clients very often appear to enjoy sessions and even when clients have lived through really tough experiences there is often a great deal of laughter. Children not infrequently look forward to sessions. So distress is optional as a part of a change process, it is not inevitable or necessary. Distress in the change process is a result of the therapist’s chosen assumptions about problems and change; indeed there appear to be some therapists who take the view that distress is evidence that the client is confronting rigid structures in a way that is associated with progress. Distress, in their view, may be regarded as a good thing, a true marker of ‘deep’ work going on. No wonder that therapy has sometimes been seen as best suited to the ‘worried well’!
Arboine, Niellah Why I quit - Counselling and therapy The Guardian 20 February 2023
26th February 2023