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Sometimes clients come in for their first session or two, and after hearing their stories, I’m confident I know what direction to go. Perhaps I’ve figured out that their depression stems from their inability to become intimate with others, which means we can start by looking at their childhood and the messages they received from their parents. Or that their panic attacks are a result of the pressure of trying to live up to the expectations of their very successful father — who also happens to be their boss in the family business. Or that their excessive drinking is triggered by environmental cues, and that the answer lies in changing their exercise routines and filling up their lives with non-drinking activities and relationships.
Sometimes (I like to think often), I’m right, and therapy proceeds smoothly. The ideas I have about the source of the problem resonate with the client, and the plan I offer for how we’re going to deal with the problem make sense to them too.
But sometimes (probably more often than I’d like to admit), I’m wrong. I may have guessed wrong about the source of the problem. Or I may have guessed right, but the client isn’t ready to talk about that yet. Or I’m trying to move too fast. Or too slow.
In any relationship, there are plenty of opportunities for misunderstandings and breakdowns in communication. In the therapy room, however, it’s particularly important that these misunderstandings and communication problems get sorted out quickly. Unfortunately, there are dynamics that work against sorting out these misunderstandings and problems. Clients are often reluctant to provide feedback that sounds like criticism; therapists can be nervous about hearing feedback that is a threat to their sense of professional competence; clients (who are already often struggling) can feel that any problems must be due to their own issues; and clients who don’t enjoy confrontation are likely to avoid it by dropping out of therapy.
This is why I ask clients to give me feedback in every session. It takes them half a minute to indicate on a survey sheet how they felt about the session we’ve just had. I also ask them to take another half minute to tell me how they’ve been feeling in the past week so I can track their progress. (I use research-tested feedback sheets which can be found here.)
Asking for feedback in these two areas says to my clients that therapy isn’t something I’m doing TO them: it’s a collaborative effort. It tells them that I am, like my clients, a fallible human being, and that I want to know when I make a mistake so I can improve. It’s a message that their opinions about what is happening in their lives and in the therapy room are every bit as important as mine. It gives them control over what happens in therapy, and gives them the opportunity to take responsibility for making themselves feel better.
This is all well and good, but how does that look in practice? Here are a couple of cases that demonstrate the importance of feedback.
Peter and Sarah
This long married couple were caught in pattern that left both of them feeling alienated and exhausted. His efforts to change her made her feel criticized, leading her to withdraw into silence. Her withdrawal left him feeling abandoned, thus redoubling his efforts to change her. To an outside observer, she was the long suffering wife, and he the intolerant and angry husband. I had managed to ally myself with both sides, making each feel understood and heard, without making their partner feel criticized. However, after a few weeks Peter suddenly gave a very low rating for how he felt the session went. He explained that he’d felt his wife and I had ganged up on him. So the next session I made sure to devote time to hearing his side of things. Having retained his trust, the therapy proceeded quickly to a successful conclusion.
Right from the beginning, therapy with Esther was a challenge. Despite being very open about her truly dreadful childhood, it was clear we were not connecting — just as Esther had been unable to connect to anyone in her life. Her rating of the sessions was marching steadily downward, and by our fourth meeting I knew I had to do something dramatic if I was to convince her to stay. I asked her to pretend that her mother — who had abandoned her years ago — was sitting in the room, and to speak to her. Esther resisted, saying that she had nothing to say to her mother. I persisted, telling her to imagine that her own life was at stake if she couldn’t summon words to say to her mother. I knew from her feedback that there was nothing to lose. Finally she said to her imaginary parent, “Why did you even bother to have me?”, and began to cry quietly. Esther told me later that she had intended for the session to be her last, but having broken through to some repressed feelings, was now committed to therapy.
Unable to understand why all his romantic relationships fizzled out, Andrew came into therapy looking to solve a problem: whether he should give up the search for love and stay with his current girlfriend, or try once again with someone else. It was clear to me that Andrew had been unable to achieve emotional intimacy with any of his girlfriends, and once the thrill of the new had worn off, he was left in a fairly boring, superficial relationship. I drove each session toward this issue of emotional intimacy, and what might have happened to him over the years that made this such a challenge. Yet, the harder I tried, the less progress we made and the worse Andrew rated the sessions. When the trend became obvious, I raised the issue with him. I ended up backing off, allowing him to talk about whatever he wanted to talk about. At his own pace he then began to make significant changes in his life.
It’s not always easy for a therapist to see the session they thought went so well rated so poorly. And when I first started asking for feedback, I found it painful and embarrassing. But negative feedback is a gift, and so now I’m able to tell my clients with utter conviction that I love it when they rate the session as less than ideal because that gives us a chance to fix things next time.