ACA Blog

Ryan Thomas Neace
Oct 10, 2011

Moving Beyond “Don’t Do That.” 4 Reasons Therapy Should Offer More.

A client walks into a practice. More specifically, he walks into a session with you. After a brief initial interview, he says to you, “I have problem X.” Now is the moment of truth. That $100,000 education and all those years of clinical experience are called upon for effective goal setting. Your client looks up at you with those dewy, expectant eyes. You give it to him straight. “Do the opposite of X.” Something’s wrong here. A good portion of my blogs come from experiences I have working with graduate level counselors-in-training both in basic skills and diagnoses and treatment planning courses. And my biggest bone of contention with “us” is the same I have with most of them – in role-plays and with pseudo clients, they prescribe the exact opposite of the presenting problem and call that effective therapy. If the client comes in and says they have trouble relaxing, the prescription is to “spend time in leisurely activities.” If they’re having difficulty managing their calendars, time management skills become the focus of therapy. And so forth. It’s terribly predictable. I’m not saying that we don't ever collaborate for a simple and straightforward resolution. And I’m definitely not saying that resolution of presenting issues isn’t part of long-term therapy. As a matter of fact, if the resolvable parts of our clients’ problems don’t ever get resolved, something even larger is wrong. But I am saying that we ought to be capable of something more meaningful and creative therapeutically. After all, most of our clients have already gotten a host of simplistic, “just do _____ and your problems will go away” answers from parents, spouses, friends and everyone else who’s ever given a lending ear. They don’t need to pay us to tell them the same. Here are 4 reasons we ought to do more. Pain. My counseling mentor is a man who has logged more than 30 years in the provision of mental health services. The most invaluable lesson he ever taught me about therapy can be summed up as follows, which he told me one day when I’d expressed to him how much difficulty I was have fixing everyone’s problems. “Don’t rob people of their pain. It is the only thing motivating them to change.” He wasn’t suggesting that I be a sadist or sit idly by watching my clients suffer. But he was suggesting that when my first and primary goal for clients involves helping them feel more comfortable with what are real and profoundly difficult circumstances, I do them an incredible disservice. Often, because of their own actions (or lack thereof), they ought to be uncomfortable. And it is precisely that appropriate discomfort that leads them to desire change. In short, show me someone with no pain, and I’ll show you someone with virtually no motivation to change. It’s that simple. So when we suggest that clients immediately do something (i.e., the opposite of what they’ve been doing) designed to reduce all that pain they’re feeling, all that appropriate pain that’s driven them into counseling in the first place, we also immediately suggest that their pain has been meaningless, that there’s nothing to be learned from it all, and that they ought to just shut up and change. Stages of Change. Speaking of change, it seems we might also do well with a refresher course courtesy of Prochaska and DiClemente. Here’s a memory jogger from the client’s point of view: Precontemplation – “There’s a problem? What problem?! What are you talking about?!” Contemplation – “Okay, there’s a problem. But I’m not sure we agree on what it is. And even if we do, I’m not even sure I want to do anything about it!” Preparation – “Alright…there’s a problem. We can finally agree about what it is, and I’ll concede that it probably has something to do with me. I’m thinking I’m ready to do something about it. I need to figure out what that is.” Action – “I’ve worked super hard to figure out this thing. There’s a problem. I contribute to it, or at least I can see my part. We’ve mapped out what to do about it. Here goes nothing!!!” Maintenance – “This change thing is hard. But I’m willing to keep working at it. The misgivings are worth it. This needs to keep going.” Relapse – “This change thing is TOO hard. I don’t want to do this anymore! Why did I ever do this in the first place? Things were better the way they were.” And around the bend they go again. I trust you remember this from graduate school. Here’s the rub. To immediately prescribe the opposite of my client’s problems virtually ignores all we can learn from the Transtheoretical Model. It assumes that our clients have come in ready to change. Surely we know this isn’t true! In my experience, even private-paying, self-referred, otherwise well-rounded and high functioning adults are often far from ready – usually, because they are not yet uncomfortable enough in their present circumstance to find the idea of change less costly than simply staying the same (see “Pain” above). At any given point, our clients may be in somewhere south of “Action”. And many times it is at least partially due to the fact that so many well-meaning others have given them the simple line. Clients assume that because the problem (if there even is one!) is so easy to fix, they can just ride it out. Ironically, it is this kind of thinking that binds them to their predicament, and further insulates them from the kind of movement that might actually set them free. Why would we reinforce this? The Power of Paradox. Not only does the “stop doing x” angle do a disservice to our clients’ experience and not take advantage of our clinical insights, it just isn’t very creative. I’m all for therapy that is simple, straight-forward, and easy to understand. One of the admonitions I always give counselors-in-training is that they need not be super-clever to be a therapeutic. I usually find that they’re thinking way too much, and listening far too little. They’re worried about advanced technique execution while failing to simply paraphrase and reflect appropriately. But I’m also for therapy that makes use of innovative techniques that distinguish us as thinking and creative therapists, and certainly ones that distinguish us from the untrained “helpers” in our clients’ lives. If you’ve read some of my previous blogs, you’ll discover I’m a fan of Stanford’s Dr. David Burns, who’s given a host of options for therapists in his essential collection, “The Therapist’s Toolkit.” Among these creative yet simple options, Burns spends a good deal of time with Paradoxical Agenda setting. “First, you establish and maintain the deepest possible therapeutic alliance. Then, in the most graphic, pragmatic fashion, you help the client explore the tremendous ambivalence that nearly everyone feels about personal transformation, whether they're conscious of it or not. This process is…the point where the science and art of psychotherapy come together, where strong, conflicted emotions are frequently expressed, and where the real magic of therapy occurs.” I do this with all of my clients. Literally. As Burns himself says, “This is the most difficult part…to describe [and] to some extent it must be experienced to be really understood.” But here’s the basic gist. After we come to a good understanding of what the client says the problem is, and what they say they want, we also explore why they might not want it. That is, we explore the myriad reasons they have not to change. Instead of rushing in to prescribe the opposite of what they’re currently doing, we spend a good deal of time understanding why, if the problem is really that simple to fix, they haven’t fixed it yet. Usually, I find a host of good reasons clients have for staying exactly as they are, and the process superbly outlines in advance the myriad ways they’re likely to resist the process of therapy. Resistance usually comes in two forms – Process Resistance (reasons clients will resist change because of the therapy process itself – i.e., I’m not willing to do what you’re asking me to do), and Outcome Resistance (reasons clients will resist change because of the potential outcome – i.e., If I change, I may not actually like the result, or I may not like it anymore than what I’ve got now). But we can’t see any of this if we jump in and start “fixing”. I’m convinced it is our collective failure to do this Paradoxical Agenda Setting that contributes to our inability to successfully help clients negotiate their own resistance. We never stopped to help them think about why they wouldn’t want to change! As a result, halfway through therapy, when they’ve failed to execute all of those proposed problem-solving strategies, they’re more confused and perplexed than when they started. And so are we. Unnecessarily. I’m Not Your Buddy. Finally, and perhaps most simply, it helps to remember that while I am desirous to maintain a friendly relationship with all of my clients, I’m supposed to be a whole lot more than just a friend. Friends listen, offer advice, and say that everything’s going to be okay when it all falls apart. If we’re not doing any more than this, then why call it professional counseling? This is where life coaching and lay counseling helpers have begun stealing our market share with a great deal of success. The late Steve Jobs, on the similar theft Microsoft pulled off in the 90’s with the PC: “It wasn't that Microsoft was so brilliant or clever in copying the Mac, it's that the Mac was a sitting duck for 10 years. [Apple’s] differentiation evaporated." And so has ours. Life coaches orient clients up-front to the notion that there’s no need for all of that troubling diagnosis business, and that unless you’re regularly having psychotic breaks, you don’t really need to pay someone all that money for so little value. Sadly, the research is slowly indicating that they may be right – lay counseling is often shown to be as effective as the professional kind. But, if we’re really only giving friendly advice and problem-solving, we’ve lost all our innovation - why wouldn't the outcome be the same? *** To sum it up: We’re human. We struggle as much as the engineer, the financier, or the educator to remain vital and relevant to those who look to us. Unlike those industries, our clients aren’t looking to us for new technology, thrift, or knowledge, though certainly those may be elements of truly innovative therapy. Ultimately, they’re looking to us for care – to help them make sense of the confusing and frightening issues that come into sharp focus when they examine their internal worlds. We owe them something beyond “Don’t do that.”
Ryan Thomas Neace is a counselor, professor, and entrepreneur. He is the co-founder and managing director of The Change Group. More at

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