Trusting the Client as the Agent of Change

• Clients as Agents of Change
• A Casual Conversation
• Florence: A Single-Session Case
• Doors of Possibility

After thirty-three years as a psychotherapist, I find that my insights regarding human beings and the change process are becoming simpler and easier to articulate, although I cannot establish whether this phenomenon is due to mounting wisdom or to some form of affable cognitive corrosion. Regardless of their source, my accumulating insights have provided me with a true compass that allows me to approach each client with respect, purpose, and hopefulness. I’m certain many readers have experienced the same thing.

Clients as Agents of Change

One guiding principle that emerged many years ago was a simple one: Our clients are the most essential and fundamental component of the change process. Appreciating this oft-obscured and -minimized truth of psychotherapy multiplies our options for understanding and assisting clients, and invites them to participate in the search for understanding and change, a quest that itself serves the client’s life well.

This basic idea—that clients most directly cause psychotherapeutic change—stands in stark contrast to the professional world that today’s therapists inhabit, a world dominated by the medical model, managed care, and the search for empirically supported and/or evidence-based, off-the-shelf treatment approaches, which most often attempt to match technique with diagnosis. Their resulting equations, of course, leave out essential components of psychotherapy: living human beings. Psychotherapists are expected to be capable of essentially “inserting” psychotherapeutic interventions into a human being who is nothing more than an embodied diagnosis—clients are perceived as passive recipients of our expert care. Since the beginning of my professional career, this has seemed to me to be a wholly wrong-headed approach, one that dehumanizes both client and therapist and, in doing so, neglects the most important and meaningful dimensions of human change.

A Casual Conversation

Like many, during my education and even early in my career, I maintained some ever-dwindling hope that an enchanted handbook of foolproof techniques might appear. Happily, my clients taught me differently. 

A memorable example occurred approximately twenty-five years ago, when I was working as part of a rural medical practice. A seven-year-old girl was referred to me by her parents for continuing difficulties with bedwetting. While her mother remained understanding, her father had become increasingly intolerant and punitive. Although they had already set an appointment, one day they stopped by the office and asked if I would take a moment between sessions to meet their daughter, perhaps to allay the girl’s anxiety about seeing a therapist. I agreed and soon they brought the girl to my office, where she and I spoke privately. After chatting a bit about her life and interests, she told me how much she wanted to stop wetting the bed. I replied, “Yeah, I wonder what would happen if you could tell your brain, right before you went to sleep, ‘Hey, if I have to pee, go ahead and wake me up.’”

Prior to our scheduled session, about two weeks after our introduction, the girl’s parents called to cancel her appointment, telling me she had quit wetting the bed after our brief meeting. Six months later, they informed me that the change had been maintained. Her presented problem never occurred again. What was the healing factor here? Should I have copyrighted the sentence I uttered, trademarked “Single-Sentence Therapy (SST!),” and begun offering national workshops on its appropriate delivery? Of course not. The healing factor was, without doubt, the girl. She sought an answer and, in the mysterious and magnificent way that human beings often accomplish change, actively and creatively used my tossed-off sentence to forge the change she desired. Of course, at the time my utterance reflected nothing more than sincere musing on my part. Still, this experience dramatically highlighted the client’s central role in successful therapy.

Beyond my experiences, we increasingly see exceptions to the dominant narrative that therapists directly cause client change. Most notably, the work by Bohart and Tallman—their book How Clients Make Therapy Work is, in my view, a classic in the field—lucidly and convincingly makes the case that clients creatively use whatever the therapist offers in order to effect personal change, which explains why techniques have not been found to be the most influential psychotherapeutic factor.

One could argue that the seven-year-old girl’s change was nothing more than an isolated episode of kismet or coincidence, a spontaneous remission that proves nothing. However, another client with whom I worked two decades ago brought the centrality of client self-healing into even sharper focus.

Florence: A Single-Session Case

A case in which a client requests assistance in resolving an undisclosed problem sounds not unlike a patient presenting to a dentist for treatment while refusing to open his or her mouth. This was not an overly dramatic case, but it is unique in that the client shared neither the history nor the nature of her difficulties, and presented only isolated factors for my consideration, yet we achieved success after a single session of treatment.      
      
The client was a 32-year-old unmarried Caucasian female—whom I will refer to as Florence—who lived alone in a rural Midwestern community. For the eight years before her request for therapy, she had been employed as a professional health care provider. At the time of the initial consultation, she had resigned from the facility for which she worked after accepting a similar position in a larger community two hundred miles away. She planned to relocate to her new home in five weeks.  Because she and I had both been involved in health care in the community, we were acquainted with one another on a professional basis and aware of one another’s work with patients.

Florence requested a brief consultation with me at the end of a workday. She disclosed that since early adolescence she had experienced chronic, unspecified problems with relationships and mood, and that before moving to begin her new job, she wanted to address the difficulty, allowing her to “start fresh.” Through our professional association with one another and her discussions with patients over the years, she had come to the conclusion that I was an effective therapist who would be able to provide her with the assistance she desired. She thus entered the therapy relationship with positive expectations about my ability to assist her, as well as her own ability to reach her goal.

While revealing that as a six-year-old child she had suffered a massive trauma that continued to haunt her, she stated kindly but clearly that she had no intention of revealing to me the details or even the nature of that trauma, having long ago come to the conclusion that to do so would hold no benefit for her. She further stated that after extensive research she had decided that hypnosis would help her to resolve her difficulties. She asked me to provide one session of hypnotherapy to resolve the undisclosed difficulty.

From her presentation, my options were clear: to provide the requested treatment or to refuse to do so, in which case she would simply not pursue treatment “until I find another therapist I’m willing to work with.”

Florence had grown up in a suburb of a Midwestern metropolitan area, raised by both parents and having three younger brothers and one older sister. She completed a Master’s degree, which allowed her to provide professional health care services. Never married, she indicated that she had dated in the past, but that recurrent relationship difficulties always interfered with developing a more serious and lasting involvement. Since earning her professional degree, Florence had worked for the local health care facility, where she had been a consistently reliable, popular and successful employee.

According to Florence, she had on three occasions traveled to nearby cities and consulted with therapists. After each of those consultations she elected not to return, believing that the therapists were intent on “doing things their way or no way,” and that a commitment to treatment on her part would have led to extended therapy which, to her mind, was completely unnecessary: “It would be like standing on the caboose of a train, looking backward just to satisfy the therapist. I want to focus on where I’m going. I want to be in the engine.” In particular, she had become disenchanted with therapists’ fascination with her trauma; when she had revealed in the past, it seemed to her that therapists wanted to “worry it like a dog with a bone” rather than to address her current concerns.           

Although I had received significant training in clinical hypnosis years prior to our initial consultation, by the time of our session I used the approach only in cases of chronic pain management, for which it seemed ideally suited. My initial training orientation was humanistic-existential, although in the subsequent years I had availed myself of a variety of advanced training opportunities and had become increasingly flexible in my treatment of clients, although I maintained a humanistic-existential view of their functioning. I received training in a permissive, Ericksonian approach to hypnotherapy, since to my mind it was most congruent with my perception of client potential and agency. I therefore had the clinical ability to provide Florence with the service she requested. I was also positively persuaded by my clinical experience to accept Florence’s implicit challenge; I had come to the conclusion that therapy in many ways is a process of my clients and me collaborating to create “doors,” possibilities for change that clients can actively use to effect personal transformation.

In this case, assessment was indirect and decidedly not disorder-focused, instead concentrating upon Florence’s general functioning and history, as well as the presence of other factors that would inform my decision whether to provide the requested intervention. Although one could argue that her vague report could lead to reasonable hypotheses about her disorder(s), there was no way to validate those hypotheses, so basing any treatment decisions on them would have been moot. Therefore, I chose to focus upon other factors that would determine my decision.

After she signed an appropriate release of information form, I reviewed her medical file, which indicated no history of serious medical or psychiatric illness in her or her family of origin. She had not been prescribed any medication other than for short-term specific illnesses, such as infections.

Most importantly, Florence had a precise “theory of change.” She had contemplated her life problems at considerable length and reached a conclusion about what procedure would assist her in resolving her difficulties. She possessed a positive view of the clinician and an expectation for resolution that bordered on certainty, indicating a positive expectation for outcome. Despite her maintenance of a conceptual hedge around her trauma and resulting troubles, she was otherwise quite open, personable and cooperative, more than willing to undergo her preferred treatment. Thus, she appeared to embody the client whom therapy would benefit, even if the specifics of her situation remained unknown to me.

In agreeing to provide the requested treatment (hypnotherapy), the question facing me was how best to provide that treatment in a fashion that would allow me to keep front-and-center the notion that Florence was an active agent capable of using what I offered in a therapeutic fashion. In short, my responsibility was to create a hypnotic approach to treatment that would allow her to actively use both her positive expectations and creativity to change what she wanted to change. More specifically, my approach would ideally provide to Florence what Bohart has described as a “supportive working space.” It was clear: my task was to provide the canvas; she would paint the picture (and not necessarily show it to me).  What type of canvas would I provide? Since she deemed the trauma that occurred when she was six to be central to the formation of her subsequent difficulties, and because she reported experiencing her younger self as being always nearby, her construction of herself as a youngster needed to be included. Furthermore, bridging her experience of herself as a six year-old with that of her present self was important, given her connecting the two “selves” in her presentation. In short, some indeterminate flow of information and affect between her younger self and her current self needed to be invited; a bridge needed to be supplied. She would be the one to cross that bridge. Doing more than that would have been presumptuous on my part if I were to remain committed to respecting her agency and creativity.  

I arranged to use a recovery room (the symbolic nature of which was not lost on either of us) in the medical office complex. I asked her to lie down on the bed, to close her eyes and begin relaxing. She responded excellently to the basic twenty-minute guided relaxation and induction process (focusing both on physical relaxation and the development of imagery). Her breathing became diaphragmatic, and I noted little to no muscle movement otherwise. I then asked her to visualize what I would describe in whatever way she chose.

While the entire session lasted about eighty-five minutes, it consisted of my providing only four basic suggestions, after which I allowed Florence to process and work with the provided images, then signal with a raised finger when she was ready for me to continue. Time between delivery of the suggestion and her signal for me to move on averaged ten minutes.

Prior to the suggestions, I asked her to visualize her current self and her six-year-old self standing face to face, and encouraged her to imagine as much detail as possible. After she indicated with a lifted index finger that she had constructed this image, I provided these four suggestions (with significant time between them):

1. “You can tell your younger self the one thing you want her most to know, and then notice her response”;
2. “You can ask your younger self to tell you what it is she most needs from you, and then notice your response”;
3. “You can ask your younger self for the one thing she most wants to know from you, hear her answer, then respond to her”;
4. “You can ask your younger self the one thing she most wants you to know, hear her answer, and notice your own response.”

Shortly after I provided the first suggestion, tears began streaming from Florence’s eyes and continued until the session ended.  Although I didn’t discourage verbal responses from her, she said nothing during the process. I ended the session by suggesting that she slowly return to normal consciousness and to remember as much or as little as she wanted to regarding what she had learned through overhearing the conversation between her current self and her younger self.

Immediately following the session, Florence indicated that already she was feeling a great sense of relief and movement, but provided no further details. We met once prior to her relocating for our follow-up session, and she reported that her mood was significantly improved and that she was viewing her relocation and new job as an adventure that she was, for the first time, regarding with optimism rather than measured dread.

Two months following her move, she sent me a lengthy letter in which she described the happiness she was feeling and the vague but confident sense that she had successfully left her problems behind her. She was no longer feeling “haunted” by what had happened to her when she was six. Although she remembered it, such remembrance seemed more voluntary, according to Florence; she was able to experience the memory “like a photo in an album, rather than the only picture on the mantle.”

After that initial letter, she sent me holiday letters for nine years. In each one, she detailed her successes not only in her profession, but in her personal life as well. Several years ago she married and, at last report, she and her husband had adopted two children and were living happily and productively.

To this day I remain unaware of the trauma she had suffered and the resulting difficulties it caused.

Doors of Possibility

What Florence brought to center stage, more plainly than any other client with whom I’ve worked, was the centrality not only of the client’s trust in me and the treatment I would provide, but also of my trust in the client and her inherent potential for change. For me to proceed with treatment, it was necessary to recognize the level of trust I had in Florence, specifically, and in the clients’ agency and abilities to self-heal, in general.

In attempting to understand the human beings who present for services, it is important that clinicians go far beyond the process of assigning a diagnosis and prescribing a treatment accordingly. Since the validity of most DSM-IV diagnostic categories is questionable at best, assigning a treatment approach based on that designation is at least equally dubious. Furthermore, a significant body of research emphasizes the importance of the common factors, such as the therapeutic relationship, positive expectations, and client self-healing. Both students and practicing clinicians should immerse themselves in the existing literature in these areas, providing themselves with a set of assumptions that counterbalances the medical model with which our culture seems currently enamored. By doing so, we will generate more opportunities and options for clinical intervention, the centrality of our clients’ attributes will not be reduced or neglected, and our treatment effectiveness will be enhanced as we respect our clients’ considerable gifts and abilities that, for the time being, have unfortunately been reduced to faint footnotes in our understanding of the human change process.

Florence’s case illuminated one of those simple truths that come with experience, age and attention, a truth not only about what clients bring to therapy, but also what clients most desperately need in their journey toward change. It’s not complicated.           

They need doors of possibility, and they need company.