When Chris, Harvey and I back in 1986 became interested first of all in the Brief Therapy approach developed at the MRI and then of course in Solution Focused Brief Therapy the idea of ‘brief’ was an aberration from the norm. There was ‘therapy’ and there was ‘brief therapy’. Now of course ‘brief therapy’ was defined by more than just the typical number of sessions; it was distinguished by a characteristic set of ideas, a way of thinking about people and about the change process but nonetheless the idea of brevity per se challenged and puzzled people. We brief therapists constantly had to justify ourselves. How could our interventions in people’s lives work? Was brief therapy just good for relatively minor issues, the (horrible phrase) ‘worried well’? Would the changes achieved be maintained? How could they be maintained? Brief Therapists in the early days faced a great deal of scepticism and we were repeatedly attacked. Indeed our choice of a brief therapy model was interpreted as evidence of our own pathology, fear of commitment and so on. However we now know that in terms of the number of sessions brief therapy is the norm. Most people attend therapy relatively few times and the number of people attending longer term is quite small. So perhaps it is time to change the definition of therapy. Perhaps there should now be therapy and long-term therapy. Long-term approaches should be seen as the aberration. Long-term therapists should be asked to justify themselves. Why aren’t you using a brief therapy approach? How can you justify an intervention that takes so long? Don’t you genuinely think that people have better things to do than to spend quite so long talking with you? Don’t you think that your way of working is just rather self-indulgent? As I was thinking about this I remembered a piece that I wrote quite a while ago. Long-term clients are constructed as a result of the choices that the therapist makes, acts both of commission and acts of omission, often unnoticed, often taken-for-granted. The piece is tongue-in-cheek but hopefully makes its point.
11 June 2023
The subtle art of constructing the long-term client.
Long-term clients do not arrive in our offices ready-made. It is true that every now and again we are lucky enough to benefit from the hard work of a previous therapist who has been able to induct the client into patterns of dependency, but by and large we should assume that if we want long term clients then we have to construct them ourselves. This work is skilled and subtle and takes real determination on the part of the therapist but when handled well the benefits to the therapist are considerable. So for those of you who might be new to private practice and whose clients disappointingly keep insisting that they are ‘done’ after only a few sessions here are 10 steps which if followed carefully should result in a significant percentage of your clients becoming long-term regulars.
1. Restrain your natural inclination to start therapy. Tell the client that a three-session assessment will be necessary. The benefits of the ‘assessment’ period are enormous. The client begins to form the attendance habit even before therapy proper begins, but more importantly the client can begin to be impressed with all the things that the therapist understands about the client’s life that the client had not even come near to realising. Helping the client to defer to the therapist’s understanding, to become admiring of the therapist (even better their therapist), is always useful in prolonging the therapeutic contact.
2. Ensure that the assessment is thorough and painstaking, tracking back the client’s problems and difficulties as far as is possible to the client’s early childhood experiences and preferably through the judicious application of the three generational geneogram, far beyond. This way the client who arrives with the unfortunate and unhelpful view that their difficulty is either small, of recent origin or temporary, can be disabused of these ideas and can be brought to understand that their problem is deep-seated and thus will require exceptionally long-term intervention. This simple maneuver should, by itself, serve to extend therapy by many months and in the case of a skilled practitioner by many years since it is surely obvious that if the client comes to see their problem as deep-seated that a long-term treatment is likely to appear logical.
3. Ensure that the sessions are regular and always at the same time, whether they be weekly or preferably daily. As a result of this simple strategy therapy can become a habit, can begin to become a dependable part of the client’s life which can take on a life of its own. Before long clients can say to themselves that they are ‘in therapy’ rather than that they are dealing with their drinking or depression. The ‘in therapy’ idea is a very positive sign and when it happens you are well on your way to a long-term attender.
4. Avoid under any circumstances establishing the client’s ‘best hopes’ for the work. Establishing the best hopes might lead the client to expect that you will be focused in your work with them and inevitably focused work is more likely to turn out to be too brief for your purposes. Leaving the work unfocused, with the direction of the work unestablished, is far more likely to lead to long-term interventions since if no-one knows what the client wanted then no-one will know when the client has got there, leaving scope for many more sessions even when the client has in fact resolved the issue that was originally bothering them.
5. As far as is possible restrict yourself to merely reflecting on what the client says to you. Since clients are unlikely to know what it would be useful for them to focus on, and in particular are unlikely to be aware of how to describe their lives in a way that could fit with brevity, then this strategy adopted consistently on your part will virtually inevitably ensure the prolonging of the clients’ attendance.
6. Focus clients’ attention as much as you can on what is going on between the two of you rather than on the outside world. This strategy can be useful in two ways. It will serve to ensure that clients’ relationships with their therapists come to be viewed as highly significant, and if clients are paying attention to what is happening in the client-therapist interaction then the client might not notice signs of change outside the therapy room. The therapy room can come to be the client’s ‘real’ world and thus the relationship with their therapist will take on heightened significance. At the very least this will mean that the ending will have to be worked through extremely carefully, with many additional sessions focused on dealing with the client’s dependency, their anger, their sense of loss and of desertion. This long ending will give us time to identify an alternative client to take up the slot in our diary that will become vacant.
7. Subtly erode your clients’ idea that they know anything about their lives. Constantly point the client to meanings that lie hidden below the surface, meanings of which they are quite unaware but which you, of course, understand and appreciate. This way the client can be helped to lose confidence in themselves, in their own thinking and judgement; they can be led to constantly doubt themselves and thus become more dependent on you.
8. The question ‘so how did that make you feel’ is likely to be a useful gambit in the construction of the long-term client. Ensure that it is only used in relation to unhappy events, times when it is clear to you that the client has been disrespected, undermined, devalued. The brilliant formulation in this question emphasizes that the client has no personal agency, that the client is a mere pawn in the face of external events, that the client lacks a capacity to shape his or her response to tough situations. This simple little question, if used frequently, will serve to emphasize the client’s ‘victim’ status and can thus aid the undermining of the client’s sense of self-confidence and self-direction, almost inevitably leading to the lengthening of the therapeutic contact.
9. Always start follow-up sessions with the question ‘how have things been?’ rather than the dangerous and unhelpful question ‘what has been better?’. And if in the initial sessions clients, not as yet fully-trained, find themselves talking about improvement you might wish to suggest to the client that this apparent improvement on the client’s part might be a defensive maneuver to avoid facing the painful underlying issues, of which of course the therapist is aware but the client is not.
10. Remember that the presenting problem/underlying problem distinction is a really useful device for those of us who may wish to create long-term clients. Clearly this formulation again relegates the client’s understanding to the status of second-class knowledge, implying that the client’s understanding is superficial and that only we, the professionals can really appreciate what is really going on. This implies that only the therapist can know when the client is ‘cured’, a really useful way to avoid premature termination.
The simple application of these 10 steps should, by themselves, lead to a significant number of your clients being converted into long-term attenders and it should be only the exceptionally strong-minded who will manage to resist subtly being led into dependency and deference. Good luck!
25th November 2018
Having written this and re-read it I am certain that it draws substantially for its inspiration on Jay Haley’s wonderful book ‘The Power Tactics of Jesus Christ.’ Jay Haley is exploring very similar ideas. I hope that the way that I write this does have enough that is different to warrant the writing.