What Do I Say Now? Coping with Uncertainty in Unstructured Psychotherapy

• Come On, Be Helpful!
• Exhausting Learning Curves
• An Introspective Swamp
• Managing Uncertainty
• Lessons Learned

Come On, Be Helpful!

“I’ve been thinking about what we discussed last time,” the client began. “I think it would be best if I came here for long term therapy and I have to leave in half an hour.”

For a moment I was mind boggled by this dramatic expression of ambivalence. But I shouldn’t have been entirely surprised. The client, a 23-year-old woman named Sandra, had been disconcertingly difficult to pin down in the previous session, our first. She had come to therapy at the suggestion of other people, had described vague symptoms, and, when questioned about issues that sounded significant, had consistently denied that they troubled her much.

My work with Sandra occurred while I was in graduate school, and relatively new to doing therapy. At that time, I was still struggling with a problem that many of us experience early in our careers, especially when doing unstructured and/or non-behavioral psychotherapy: anxiety about how to respond to a client who gives you no clear focus and leaves you feeling increasingly lost.

I had encountered several such clients. Unlike the “easy” clients I’d always imagined and sometimes actually gotten—that is, clients who responded readily to questions and who moved quickly into important issues—many other clients were not so easy, and some especially not. For example, they might have trouble articulating their concerns, or, after articulating them, might find it hard to talk. Or, they might become superficial or tangential, or might seem unable to voice any clear focus or sense of what I could do to help them. I knew it was my job to find the right questions to clarify their issues. I was committed to exploring their concerns from a humanistic and psychodynamic perspective because I knew from my own experience how valuable such exploration could be. But this approach to psychotherapy rarely gives definite answers; rather, it emphasizes the importance of gradual self-discovery. And my training in these orientations now seemed hopelessly abstract and irrelevant in the face of these more difficult clients, and of their confusion—and my own—about what exactly we needed to do. My confusion was often accompanied by a nagging feeling of anxiety that sometimes bordered on a panicky sense of paralysis: Come on, Michael, do something helpful! But what?!

At the time, I did not know how common this anxiety is among inexperienced therapists—especially those of us who are inclined toward hyper-responsibility. In his excellent book Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy, Jon Allen recalls how lost and anxious he felt when he treated his first patient with systematic desensitization only to find that the patient was not satisfied with structured treatment and just wanted to talk about his problems. Allen went on to describe how he spent much of his early career hoping to find a clear-cut structured procedure for working with such patients, only to realize, eventually, the “utter folly” of his quest.

Exhausting Learning Curves

Much later in my own career, I saw the same struggle in many of my students when I taught an undergraduate course in elementary counseling techniques. The students were eager learners, and many had been in therapy themselves. When I cautioned them early in the semester that good counseling cannot be achieved simply by applying rules and techniques, they expressed understanding and agreement. But when they embarked on regular practice sessions in which each of them had to counsel another student about a real issue, these students had to face, for the first time, something that every counselor and therapist has to confront at one time or another: the anxiety of sitting face-to-face with another human being who is struggling with a real issue, and realizing that you haven’t the faintest idea what to say or do next. A few of the students had impressive natural skills and took to unstructured work like ducks to water; but most of the others experienced varying degrees of anxiety, sometimes expressing intense frustration that they were not learning enough.

I tried to explain to them that there is a learning curve and that as you increase your knowledge and experience in counseling, your anxiety is gradually replaced by a disciplined sensitivity and intuition that begins to guide your exploration. But the problem with this kind of reassurance is that the learning curve to which it refers is maddeningly difficult to describe. I will attempt to do so below, but it may be helpful to start by telling a story that clarifies the kind of learning curve I am talking about.

A few years ago, a young woman approached me in a coffee shop and identified herself as a student who had taken my counseling class ten years previously. She told me that she had gone on to attain a masters degree in a mental health profession, and she said that she wanted to thank me because my undergraduate counseling class had taught her more about doing psychotherapy than any of the courses she had taken in her graduate program. Naturally, I was delighted to learn that she had gotten so much from my class. But what really surprised me was that I remembered this student quite well, and that her course evaluation, which I still have, had expressed great anger about how little she had learned in my class!

So, what is this mysterious learning curve to which I refer? Well, it involves a number of things: learning how to create a supportive atmosphere; learning how to draw the client out with the right kind of questions; learning how to listen—really listen—to what the client is saying; and learning how to follow the many hints and leads in what the client is saying that may not be entirely obvious to the client himself or herself. Of course, these “hints and leads” are different for every client, which is why they cannot be specified in advance. But it is possible to show examples of this discovery process by looking at specific cases; and this brings me back to the client I described at the beginning of this article, Sandra.

An Introspective Swamp

As I have already mentioned, Sandra had presented in her first session in a way that was elusive and confusing. She had voiced vague complaints of anxiety and a general sense that she did not know if she could open up to a therapist. She was equally vague about the history of her anxiety, stating that both her mother and a friend named Matt had encouraged her to seek therapy after she had experienced abusive treatment by a man she had dated briefly. When I asked her about this and other experiences in her life, she had touched on several apparently important topics, including a sense that her relationships with men never seemed to work out; yet she denied that any of these issues had troubled her much. She expressed a feeling that it would be nice to talk to a therapist about these things, but she also questioned whether therapy might just lead into unnecessary rumination and depression. Given her ambivalence, I had suggested that we meet for three to five sessions to evaluate her concerns and then decide about possible further therapy.

As noted at the start of this article, she had begun her second session with the disorienting announcement that she had decided on long-term therapy and that she had to leave early. The remainder of this session did little to clarify where she was coming from. I began by asking her what had made her decide she needed long term therapy. She replied that she had had a long and intense conversation with her friend Matt in which they had discussed her personality. Matt had told her that she was “neurotic,” that she had “the worst self-image of anyone that he had ever met,” and that she needed therapy. After this, Sandra had fallen into an “introspective swamp” and had been depressed for most of the week, eventually concluding that she must be “messed up” and in need of long-term therapy.

Remembering that she had wondered in her first session about therapy leading to unnecessary rumination and depression, I reflected that she seemed to have mixed feelings about therapy. On the one hand, she felt she needed long term therapy, but on the other hand, she worried that too much introspection might lead into a “swamp” of depression, as had apparently happened with Matt. She quickly dismissed this possibility, however, and said that therapy once a week would not be too much introspection. Her dismissal seemed a little too easy.

Since I wanted to determine if her wish for therapy was coming primarily from her—as opposed to Matt—I asked if she could tell me which areas of her life might be problematic.

“Define problematic,” she said.

“I’d rather leave that to you to define.”

“Well, do you mean my childhood, or what?”

“I wasn’t necessarily thinking of your childhood. I was wondering about problem areas in your present life.”

“I’m not sure. I can’t think of any.”

“Well, last time you mentioned that your present life is not too happy in certain areas”

“True, but they’re not that bad. They only seemed that way when I thought back on them.”

My confusion was increasing rather than decreasing. She wanted therapy but seemed to be saying that she had nothing to work on. I tried again.

“How was it that Matt convinced you that you were neurotic?”

“Why do you ask?”

“Well, I understand that Matt thinks you’re neurotic, but I don’t know how you see yourself, what you think your problems are.”

“I don’t know what my problems are. That’s why I’m here!”

My head was starting to spin. I tried a different tack.

“What do you want in life?”

“Well, I’d like to graduate, to get good grades, to get a good job that pays well, and to have happy relationships.”

“Are you getting what you want?”

“Academically, yes. I have friends, and I’m getting along with my parents all right.”

“What about happy relationships?”

“Well, my love life is not perfect. But I believe it will get better.”

“What do you suppose is interfering in your love life right now?”

“I really don’t know,” she said. “Maybe it’s just a coincidence that nothing has worked out so far.” As I was pondering this, she added, “Is this normal?”

I observed that she seemed to be concerned about the process of the evaluation. She replied “Yes, you’re right. I shouldn’t do that.” I replied that there was nothing wrong with being concerned about it but that it might be helpful if we talked about it more in our next session. She said “No, that’s okay. I promise not to ask so many questions next time.” As our time was up, the session ended on this note.

Managing Uncertainty

Over the next week, I thought a lot about this case. I was baffled by Sandra, and frankly had no idea where to go from here. It wasn’t even clear to me that she needed therapy or, if so, why, since she was unable to identify a focus and seemed to have come to the clinic under significant pressure from her friend Matt.

I was starting to experience some of the anxious confusion described above—the kind of distress that early-career therapists experience, particularly in sessions where the client’s concerns seem persistently vague and elusive. Like Jon Allen, I could feel myself longing for reassuring structure. I considered referring Sandra for psychological testing, but as I thought about it I realized that this was more to still my own anxiety than to aid in evaluating her. I thought about doing a more traditional evaluation, asking her about various areas of her life (work, family, friends), but we had already done some of this and it appeared to be leading nowhere. I thought about focusing further on her feelings about being evaluated, but there was a very real possibility that we might end up spending the rest of the evaluation talking about the process of us talking about the evaluation!

As previously mentioned, this case occurred while I was still in graduate school, and I can add now that it was at just the point when the learning curve was beginning to bend for me. I had experienced confusing clients before and knew that the anxiety they evoked in me could signal important dynamics, both within our interactions and within the client. I knew that if I could read these signals correctly and use them to guide further therapeutic actions, they could become an aid rather than a hindrance in the treatment. I had absorbed a significant amount of clinical theory that had helped to guide this process. And one theoretical insight that had struck me as particularly relevant to coping with my own anxiety in doing unstructured psychotherapy was a central tenet of existential psychotherapy—the idea that every act in life, and in psychotherapy, is, in some sense, a “leap of faith,” a “jump from being into nonbeing.” There is no way of knowing where it will lead; what really matters is how we handle the uncertainty.

I thought about this now and realized that the most important thing that I could give this client was the willingness to continue the unstructured work, to step once again “from being into nonbeing” with her, and to see where it led.

Sandra arrived early for our third session. When we met, I began by asking if she had had any thoughts about our previous meeting. She said that she had. She had decided that Matt’s “thing” was therapy and that he had influenced her too much. She had also thought about the questions I had asked about her life and her relationships and had decided that most of her questions were “Dear Abby type questions,” like how to act on a date and when to kiss someone. She said that she would like to have a longer-term relationship, but she added that her relationships were not too brief and that brief relationships could be fun too. When I asked about the anxiety she had mentioned before, she said that she did feel “sort of” anxious at times, but “not too often,” and she speculated that maybe she just got too wrapped up in thinking about it.

At this point she suddenly asked, “What do you think of me?” I replied that she seemed concerned about being analyzed and noted that she had wondered about normality in our last session. She agreed that she had wondered about this—especially when she was in high school, a time when she had been shyer and more introverted—but that this was not much of a problem anymore. I said that I had the impression, however, that there was something attractive to her about the idea of therapy. She admitted there was, and asked what other people talked about. I replied that they talked about a wide variety of things and that I wondered if she was concerned, again, about whether she was normal.

“Yes, I probably am,” she replied. “I’m only here because of Matt. He called me just before I came today and said, ‘Don’t back out.’ I told him “Now listen, I’m going to go by whatever the counselor says. It’s up to him.”

“Why didn’t you tell him it was up to you?”

“Matt would never accept my judgment.”

“Suppose he didn’t. What would happen then?”

“He would say ‘You’re making a big mistake, you’ll be sorry!’ Then I’d have to defend myself to him, especially if things went badly and I became upset later.”

“Wow!” I said. “That sounds pretty uncomfortable. You’d have to defend yourself, maybe at a time when you were already feeling upset about something else. I can understand why you wouldn’t want to be in that position.”

“Yes, it would be uncomfortable! I don’t know why I’d have to defend myself to Matt. It’s not up to him. We’re not doubles.”

“What do you mean?”

“He seems to regard us as emotional doubles. When I first told him about the abuse I experienced, he described how he had been in a similar situation once. But we’re not that much alike. He doesn’t necessarily know what’s best for me. No one knows everything.” She sounded a little surprised by this insight.

At that point, I reminded her that when she had first come to the clinic she had said that her mother had also recommended that she come in for counseling. She said that that was true, that her mother had also felt that Sandra had been traumatized by her recent experience of abuse. When I asked why, Sandra explained that her parents had known she was upset and that her mother had attributed many little reactions of Sandra’s to the abuse. She added that her parents were surprised that the abuse had not “blown her away” or “freaked her out.” She had always been “sort of high-strung” and they had expected her to react a lot more negatively than she had. I commented that sometimes people in families fall into certain roles; the family expects them to be a certain way and then they begin to see themselves that way. I wondered if this had happened in her family and if it had had anything to do with her concern about how normal she was. She seemed quite interested in this idea and said that it might. She said that her whole family was somewhat volatile and that she was just a little more open about her feelings than the others.

By this time, we were nearing the end of the session and she said to me, once again, “What do you think of me?” It seemed appropriate to give her more feedback at this point. I told her that I thought she was very influenced by other people’s evaluation of her. I added that I suspected this had something to do with her experiences in her family and that it had operated regarding Matt. She said “Well, Matt is kind of a unique case” and then stopped mid-sentence and corrected herself, saying that a boyfriend she had had in the past had done the same thing. I suggested that we discuss this further in our next session. She said thoughtfully, “Yeah, they don’t have divine inspiration.”

Lessons Learned

Sandra and I met two more times. During the first of these sessions, Sandra reported that she was in a good mood and felt good about our previous session. But, she had realized that her parents had imposed labels on her many times, such as “hyper” and “emotional.” We explored her relationships with men and how she might better, or at least differently, handle feelings of insecurity. We also discussed whether further therapy would be helpful. I emphasized that her own judgment about this was most important.

In our final session, Sandra said she had been feeling good and that she had been taking things more in stride since our sessions. She had tentatively decided not to pursue longer term therapy, but she asked if she would be able to see me if she decided to come back later. I said she could, and we decidedly left the door open; however, she expressed satisfaction with things at present and a sense that she could deal with things on her own. She did not return.

I have described this case in some detail because it embodies a moment when I became particularly aware of how one can manage one’s anxiety about doing unstructured treatment while feeling lost at sea in a complicated therapeutic dynamic. Sandra’s presentation, particularly during her first two sessions, had evoked significant anxiety in me due to its elusive and confusing character. Before our third session, I had given much thought to this and realized that I had to accept my anxiety, recommit to the unstructured approach, and follow it through to increasing clarity about Sandra and her concerns. Reflecting on the case now from a more experienced vantage point, I see three factors that made this possible.

First, I had already accumulated a degree of confidence from my previous experience working as a volunteer counselor and a graduate intern. Of course, confidence is a double-edged sword. It does not always match good performance and can even reinforce poor work, a fact which therapists—especially new therapists—cannot afford to ignore. But in my previous work, I had gained real experience and had supportive supervision that had taught me a great deal. Looking back on my work with Sandra, I now see that even amidst the confusion of our first two sessions, I had laid more groundwork with her than I had initially realized—if nothing else than by taking her concerns seriously and working hard to understand them. And Sandra’s movement toward greater openness, her willingness to revisit material I had not understood, her remaining in the session she had planned to leave early, her arriving ahead of time for her next session and her increasing interest in therapy all suggested that she was feeling a greater sense of trust in our work. I believe, therefore, that some confidence was justified. But perhaps more importantly, if this had not been the case—if things had been moving in the opposite direction toward greater confusion and discomfort in the sessions—I believe I had also acquired some justified confidence in my ability to recognize when these kinds of problems develop, to point them out, and to carefully engage her in an exploration of why.

Second, by this time in my career I had studied a variety of theoretical perspectives on psychotherapy and I was able to draw on several of them during my work with Sandra. Having these perspectives available gave me the tools to ask questions that seemed to move the process forward; and furthermore, they had sensitized me to important clues in what Sandra had already said—the “hints and leads” to which I alluded above. In the third session, particularly, I can now see that—while I was not conscious of it at the time—I drew on several different theoretical perspectives in the following interventions to better understand and work with Sandra: (1) Rogerian reflection (to deepen our understanding of her concerns about normality, rumination, depression and social influence); (2) existential confrontation (to point out that the decision about further therapy was hers, not Matt’s or mine); (3) Rogerian empathy (to validate her concerns about Matt’s criticism); (4) psychodynamic exploration (of the childhood sources of her self-doubts), and (5) systems theory (to consider the role she might have fallen into within her family).

Though I drew on diverse perspectives, I believe I escaped the dangers of shallow eclecticism and/or using various techniques mechanically (as I was later to warn my students against) because I was also developing my own overarching theoretical perspective, which was primarily psychodynamic. From this perspective, I was forming a rudimentary sense of Sandra which could point the way forward in using these interventions productively and which was roughly as follows: She was a young woman whose family circumstances and social experiences had left her with some issues of hurt, shame and over-reliance on the opinions of others; but her inherent strengths and intelligence were also enabling her to develop an increasingly strong sense of autonomy. Her ambivalent presentation in therapy reflected feeling caught between, on the one hand, wanting to explore in detail the sources of her insecurity; and on the other hand, wanting to assert her autonomy and move on with her life. Between the second and third sessions, I came to realize that the most helpful thing I could do for Sandra was to sideline my own anxiety, to stay with her exactly in the middle of her ambivalence, and to use what I knew about psychotherapy to help her discover precisely what she wanted to do.

The third and most important factor that made this possible was the inherent strength of the client herself. Even though she was, at times, exasperatingly vague and ambivalent, she also showed a consistent commitment to hang in with the therapy and continue exploring her concerns. In fact, Sandra’s investment in the treatment and her ability to use it successfully highlight a crucial truth for me about psychotherapy, one that should be both sobering and reassuring to any relatively new therapist: in the final analysis, the most important factor in successful treatment is not the work of the therapist but rather the work of the client.

This point can hardly be overemphasized. Anxiety in new therapists is almost always accompanied by an overestimation of the importance of their own interventions. Of course, interventions are important, but not as important as the client’s ability to use them. This fact may be a blow to our therapeutic egos, but it should also be deeply reassuring. My students sometimes feared that they would make a mistake that would damage the client. I assured them that all therapists make mistakes and that these mistakes, in themselves, are rarely damaging. What is truly damaging is when we fail to realize that we have made a mistake and go on to make it again and again—usually as a result of inadequate training, impaired self-reflection, narcissistic overconfidence, or some combination of the three.

Barring serious mistakes by the therapist, most clients will get better if they are motivated to do so. Even without psychotherapy, most people who suffer from psychological problems will tend to show improvement over time. But competent psychotherapeutic help from any number of theoretical orientations can significantly strengthen and reinforce this process, especially when the relationship and fit between the client and the therapist is good. And in unstructured psychotherapy, the commitment of the therapist to step with the client “from being into non-being” can play an important and helpful role.  

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