“The most that one person can do to further it in another, is to create certain conditions which make this type of learning possible. It cannot be compelled.”
For me, it is difficult to work in a field in which there is very little that is certain. There is no guarantee that the effort that a clinician puts in will result in a particular change or set of changes in the client. Ultimately, change relies on the capacity and the willingness of the respective individual. No amount of force or coercion is going to influence the client to move in this direction or that. A therapist might come into a particular session with a predetermined agenda for how they would like the events during the session to unfold, but the client often brings something entirely different into the room, desiring instead to address the crisis at hand.
Irv Yalom, in the literature that he produced, cited an occurrence whereby he utilized a specific literary intervention to help guide a client who was experiencing writer’s block. The intention was two-fold—on one hand, he sought to snap her out of her slump, and on the other, he used it as a means to have them each reflect on what they perceived as the most profound moments they had experienced in therapy. To his surprise, he found that what he thought were the most memorable interpretations and occurrences, turned out to have been completely glossed over by the client. Instead, she had identified elements that he had virtually no recollection of. That is why therapy is very much a balance between art and science. Often, what goes on in the room is completely subjective and difficult to quantify.
There’s nothing I want more than to be able to say, “if you come to therapy, commit to the process, and do the work, you will heal and find peace and happiness.” It’s not quite that simple. It doesn’t always work that way. If it were that simple, there would be little need for psychotropic medication. Managing one’s brain chemistry is a truly delicate science, as psychiatrists are aware. In some cases, simply removing one’s self from a difficult environment can allow an individual to thrive in ways, they never new possible. However, there is always the likelihood that no distance is great enough to wash away the pain. “Wherever you go, there you are,” as Jon Kabat-Zinn wrote. Similarly, Michel de Montaigne wrote, “Socrates was told that some man had not been improved by travel. ‘ I am sure he was not,’ he said. ‘He went with himself!’” This brings to mind the age old nature versus nurture debate. The psychology textbooks talk about the diathesis-stress model, which points to the biological predisposition for succumbing to the pains of psychological distress, which ultimately depends upon the volume of stress (acute or chronic) placed on the individual over the course of their life. There are far too many variables to account for, such as the mother’s disposition, the father’s disposition, the amount of stress hormones present in the mother’s body during the gestational period (i.e. the pre-natal environment), the environment surrounding the child during the critical developmental years, the attachment relationship between primary caregiver and child, and the list continues. Whether or not a child is certain to struggle down the road is entirely unpredictable. In that same vein, it’s near impossible to determine whether or not one will be able to heal, based on work done in the therapeutic setting. There are individuals who have been in therapy, from childhood into adulthood, and yet it seems necessary for them to endure a lifelong process of healing, whereas some individuals, after an acute crisis, require only a short-term therapeutic intervention, to reach a place of optimal functioning.
Carl Rogers dedicated virtually his entire life to identifying the fundamental factors that elicit therapeutic change in the treatment setting. He came up with a simple formula, namely that the client is entirely responsible for change, but a therapist should always demonstrate genuineness, accurate empathy, and unconditional positive regard in the therapeutic relationship, in aiding the client to tap their innate potential. Michael Lambert developed his common factors theory, which posited that forty-percent of change is due to “client factors and extra-therapeutic events,” thirty-percent of change is due to the therapeutic relationship, fifty-percent is due to models and techniques, and the remaining fifteen-percent is due to expectancy and placebo effects. In addition, there are views on where the client might be, in terms of their willingness to change, or lack thereof. In this respect, there is the stages of change model (Pre-contemplation, Contemplation, Preparation, Action, Maintenance) and the Solution-focused approach, which seeks to determine whether the client is a Customer, Visitor, or Complainant.
I once heard a metaphor about change stemming from within the organism. When a flower is wilting, one does not tend to the flower, but rather she/he treats the environment around the flower, and the flower will persevere. At the very least, the therapist creates and maintains the safe-space, as it is called, which allows the individual to thrive.
Currently, there is a laundry list of theoretical orientations, whereby therapists act as directive agents and non-directive agents. In some cases, therapists take on the delicate balancing act of straddling the two ends of the continuum. Overall, non-directive therapists generally do fewer “interventions” during a session, allowing the client/individual to do most of the “work” in the therapy room. Directive therapists, take a very active approach (Strategic, Structural, CBT, EMDR, etc…) commanding the client to take action toward certain steps in their lives, through a number of strategies:
• Modifying boundaries among members of the family system
• Goal-oriented tasks
• Interventions to alter destructive patterns of interacting with the world.
• Challenge faulty thinking patterns
• Worksheets and exercises
• Sensory exercises to mend the wounds of past trauma
What can a therapist control? Just as a client should place their focus on the aspects of their life that lie within her/his control, in order to minimize distress, a therapist should put forth effort toward controlling the things he/she can: their presence, what they model, how they attune to the client, the physical space of the therapy setting, and the psychological “holding environment.” At the end of the day, at the very least, a therapist needs to trust that there is an innate resiliency that rests within each and every individual. We are brokers of hope. Holding hope is what is absolutely within our control. All else is up to the client.