A regular meeting with one of my students this morning got us looking at two different types of therapist approaches to meeting and getting to work with clients. Both are valid methods of navigating intake and the early stages of information collection, and good to have in the therapist’s toolbox. It might also help clients understand why they click better with some therapists than others, and help them define what they’re looking for if they’re currently shopping for a therapist.
Most of the time people come into therapy because they are dealing with a specific problem, or experiencing a specific set of symptoms even if they don’t yet understand why. During an intake process, they’re meeting the therapist for the first time, which means two things are happening simultaneously:
- Stranger meets stranger
- Information changes hands
Establishing Rapport
Many people think of therapy in much the same way as they think of medical doctors: they have a problem, they go tell the professional, the professional gives them something to fix the problem, and hooray they’re cured! (Or at least feeling better.) This is historically the medical model for feeling better, and sometimes leads people to wonder why they can’t get a fix in the same ten minutes it takes a doctor to diagnose a set of patient-reported symptoms. Talk therapy doesn’t always work like that, but some models, like Short-term Solution-focused Therapy, do aim for a similar kind of immediate relief of at least the symptomatic distress.
Therapists are trained to understand what clients come to learn with experience: that perhaps the biggest factor in therapeutic “success” is the rapport established between the client and the therapist. That rapport is all about the relationship these individuals create through the process of sharing space, information, and (hopefully) empathy. Some folks don’t want to take the time to build a relationship, they just want the fastest resolution to their current discomforts so they can go on with their lives. Some people will only allow themselves to open up about experiences once they have established a degree of trust and safety with a therapist. This leads us to approach the work with our clients through either a Problem-centric focus or a Person-centric one.
Problem-centric Focus
This morning I was reflecting with my student on how they are developing their own clinical approaches, drawing on various learning resources through their training. They currently have an intake form they use to guide the first few client conversations that is very focused on gathering information about the problem: the symptoms, their perceived severity and persistence, the level of impairment the client experiences because of them. Only after digging into the details of the problem does the form expand into more general information about the client themselves.
This kind of approach puts the PROBLEM(s) front and centre and focuses the ensuing conversations on those pertinent details. This is a really useful approach if the therapist has only a limited number of sessions (or a one-off situation, as with a walk-in clinic), and needs to understand “where does it hurt the most?” or “where is the client seeking the most relief?” It’s also an effective approach with clients who are focused on fast resolutions and strategies rather than long-term self-development. Reflecting after this morning’s supervisory meeting it occurred to me that this is also probably a useful approach for student and novice therapists who need to determine as early as possible whether the client’s presenting issues are within the therapist’s limited clinical experience and scope of practice.
On the downside, it also presents a bit of a sandtrap to therapists operating from a “just fix it” mindset. The temptation is to label and categorize the problem without digging much into context or broader influencing features in order to go straight to symptom management… and in doing so, perhaps miss a lot of important information about influences on the client’s broader condition. In short: you’ve mitigated the symptoms but potentially done nothing to address or even acknowledge the actual problem.
Person-centric Focus
My own approach to those first client conversations is to get to know a little bit about the client themselves. I’ll ask if they have any previous therapy experience, or what they think therapy as an experience entails. I’ll ask them to tell me a little bit about themselves and tell them a bit about myself in return, though I generally weave any kind of detailed descriptions of how I work into the conversations about their challenges. Especially with people new to psychotherapy, I have less risk of getting lost in trying to describe clinical interventions to someone who has zero idea WTF I’m talking about, no context for what I’m bringing to the table. So I leave that until I can find ways of showing how I might apply what I know directly to their own issues, and let the contextualization do the heavy lifting for us both. I get a good sense this way of how the client talks and how they listen, what kind of language they respond to, and I have a chance to watch and mirror some of their body language (even in virtual meetings). If I can get a basic sense of them in the first few minutes, THEN I’ll ask what’s bringing them in to talk to “someone like me.”
I’m not a doctor; I’m not trying to bulldoze 25 clients a day through my office in ten-minute increments or less; I can take my time and get to know who’s sitting in front of me. (It also helps that I’m personally someone who loves drinking from the information firehose. I often describe my process in those first couple of sessions as gathering all the seemingly random bits of information the client chooses to share, and all the information they don’t even realize they’re sharing via word choices, speech patterns, and body language. I collect it all and sort it out as we go, pairing the client’s information with my observations and clinical experience to come up with working theories I can pitch to a client to see what resonates, and what makes them feel like I’m understanding what they’re sharing.
This type of approach puts the PERSON first and foremost and helps orient the therapist towards the person having difficult experiences before digging into the issues themselves. Focusing on the person is also useful when the client is in emotional distress, if the therapist can use mirrored body language and vocal tones to calm or counterbalance the way the client’s body or voice shifts as they get worked up. It’s not that we ignore the issues so much as we establish that rapport first, a person-to-person connection to put the client more at ease. It helps create some sense of safety (hopefully) for the client to talk about hard things, and to receive compassion and input from the therapist. It’s a style of approach that very much invites the Person into the room, not just the Problem.
The Person-focus approach has its own traps. It’s easy to misread clients who really just want solutions and strategies, if they’re genial enough to engage in the “getting to know you” patter, and in doing so, leave them feeling like you’re not serious, not taking them seriously, or taking to long to get to what they came for. Focus on rapport-building is often a slippery slope for therapists falling into their own biases and risking over-association or over-sympathizing with the client; this is a space in which we run a high risk of transference and countertransference occurring between client and therapist as we try to establish connection and empathy without always having good boundaries right up front.
Not every client is going into a first session with a clear idea of what they want or need from the conversation they’re about to have. Inexperienced clients generally can’t describe what they want from a therapist, other than, “Fix me so I feel better”–the same request they’d make to a mechanic to fix their car so it runs better, or to a doctor so they can feel physically better. Therapists have to develop almost a sixth sense for what live performers call “reading the room”: the ability to suss out a client’s level of (dis)comfort with talking about their issues and asking for guidance or help. Are they here for a quick strategy session, or are they here to unburden for the very first time a lifetime’s worth of relational chaos? (I haven’t yet figured out how to teach reading the room as a therapeutic skillset. It’s just a thing many of us do semi-intuitively.) But once we have that sense we can choose the most effective approach out of the toolbox, and off we go to the races.