Nothing Wrong with Long Term Therapy, But…

A long time ago in a galaxy far away I became enamored of so-called, “brief therapy.” I appreciated longer term approaches, especially existential and client centered models, but I was drawn to the pragmatics of the Mental Research Institute, Solution Focused Brief Therapy, and Jay Haley, including his amazing tongue in cheek articles, many of which are found in his classic book, The Power Tactics of Jesus Christ. I was first turned on to Haley by my most influential graduate school mentor, Scott Fraser, who required Haley’s article, “The Art of Being a Failure as a Therapist.“

I was hooked! Many at the time considered brief therapy to be a Band-Aid approach that didn’t address the “real” underlying issues. Unfortunately, many still believe this to be true, and many practice from the belief that change for serious problems is necessarily a long-term endeavor—despite much refuting evidence. For example:

• The average number of sessions across settings has hovered at 6 sessions for decades.
• Even with those traditionally considered to be long term (e.g., those diagnosed with schizophrenia or bipolar), the average is under 9 sessions.
• As the late (and great) Alan Gurman said in his classic brief therapy book, “Therapy is brief, either planned or unplanned.”
• In a review of our 2 million+ admins of the ORS across all varieties of settings, 81% of clients attended 6 or fewer sessions, 91% attended 12 or fewer, and 98% attended 25 or fewer. In other words, about 1 in 5 clients attend more than 6 sessions. Other large data sets corroborate these findings.

Again, nothing wrong with longer term models for those 1 in 5 clients who benefit from it. But basing one’s practice on the notion that most people will stay in therapy past 12 sessions doesn’t make much sense. And nothing wrong with keeping clients in therapy when they continue to make measurable, meaningful changes.

One last point re longer term therapy: Regardless of how many sessions are ultimately attended, change, if it is going to happen, starts early. It may be slower (or flatter on a graph), but it will begin right away.  Monitoring outcomes with clients allows us to collaboratively chart new directions when change doesn’t happen. It is a gift that allows us to ensure clients don’t slide through the cracks.

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I recently ran across the article below by Evan George, co-owner of the famous BRIEF training and consultation institute in the UK, and noted solution focused brief therapy expert. In the spirit of Jay Haley, what follows (with permission) is George’s “The Subtle Art of Constructing the Long-Term Client.”

Long-term clients do not arrive in our offices ready-made. It is true that every now and again we are lucky enough to benefit from the hard work of a previous therapist who has been able to induct the client into patterns of dependency, but by and large, we should assume that if we want long term clients then we have to construct them ourselves. This work is skilled and subtle and takes real determination on the part of the therapist but when handled well the benefits to the therapist are considerable. So for those of you who might be new to private practice and whose clients disappointingly keep insisting that they are ‘done’ after only a few sessions here are 10 steps which if followed carefully should result in a significant percentage of your clients becoming long-term regulars.

1. Restrain your natural inclination to start therapy. Tell the client that a three-session assessment will be necessary. The benefits of the ‘assessment’ period are enormous. The client begins to form the attendance habit even before therapy proper begins, but more importantly, the client can begin to be impressed with all the things that the therapist understands about the client’s life that the client had not even come near to realizing. Helping the client to defer to the therapist’s understanding, to become admiring of the therapist (even better their therapist), is always useful in prolonging the therapeutic contact.
2. Ensure that the assessment is thorough and painstaking, tracking back the client’s problems and difficulties as far as possible to the client’s early childhood experiences and preferably through the judicious application of the three generational genograms, far beyond. This way the client who arrives with the unfortunate and unhelpful view that their difficulty is either small, of recent origin, or temporary, can be disabused of these ideas and can be brought to understand that their problem is deep-seated and thus will require exceptionally long-term intervention. This simple maneuver should, by itself, serve to extend therapy by many months and in the case of a skilled practitioner by many years since it is surely obvious that if the client comes to see their problem as deep-seated that a long-term treatment is likely to appear logical.
3. Ensure that the sessions are regular and always at the same time, whether they be weekly or preferably daily. As a result of this simple strategy therapy can become a habit, can begin to become a dependable part of the client’s life which can take on a life of its own. Before long clients can say to themselves that they are ‘in therapy’ rather than that they are dealing with their drinking or depression. The ‘in therapy’ idea is a very positive sign and when it happens you are well on your way to a long-term attendee.
4. Avoid under any circumstances establishing the client’s ‘best hopes’ for the work. Establishing the best hopes might lead the client to expect that you will be focused in your work with them and inevitably focused work is more likely to turn out to be too brief for your purposes. Leaving the work unfocused, with the direction of the work unestablished, is far more likely to lead to long-term interventions since if no one knows what the client wanted then no one will know when the client has got there, leaving scope for many more sessions even when the client has in fact resolved the issue that was originally bothering them.
5. As far as is possible restrict yourself to merely reflecting on what the client says to you. Since clients are unlikely to know what it would be useful for them to focus on, and in particular are unlikely to be aware of how to describe their lives in a way that could fit with brevity, then this strategy adopted consistently on your part will virtually inevitably ensure the prolonging of the clients’ attendance.
6. Focus clients’ attention as much as you can on what is going on between the two of you rather than on the outside world. This strategy can be useful in two ways. It will serve to ensure that clients’ relationships with their therapists come to be viewed as highly significant, and if clients are paying attention to what is happening in the client-therapist interaction then the client might not notice signs of change outside the therapy room. The therapy room can come to be the client’s ‘real’ world and thus the relationship with their therapist will take on heightened significance. At the very least this will mean that the ending will have to be worked through extremely carefully, with many additional sessions focused on dealing with the client’s dependency, anger, sense of loss, and of desertion. This long ending will give us time to identify an alternative client to take up the slot in our diary that will become vacant.
7. Subtly erode your clients’ idea that they know anything about their lives. Constantly point the client to meanings that lie hidden below the surface, meanings of which they are quite unaware but which you, of course, understand and appreciate. This way the client can be helped to lose confidence in themselves, in their own thinking and judgment; they can be led to constantly doubt themselves and thus become more dependent on you.
8. The question ‘So how did that make you feel’ is likely to be a useful gambit in the construction of the long-term client. Ensure that it is only used in relation to unhappy events, and times when it is clear to you that the client has been disrespected, undermined, or devalued. The brilliant formulation of this question emphasizes that the client has no personal agency, that the client is a mere pawn in the face of external events, and that the client lacks the capacity to shape his or her response to tough situations. This simple little question, if used frequently, will serve to emphasize the client’s ‘victim’ status and can thus aid the undermining of the client’s sense of self-confidence and self-direction, almost inevitably leading to the lengthening of the therapeutic contact.
9. Always start follow-up sessions with the question ‘How have things been?’ rather than the dangerous and unhelpful question ‘What has been better?’. And if in the initial sessions clients, not as yet fully trained, find themselves talking about the improvement you might wish to suggest to the client that this apparent improvement on the client’s part might be a defensive maneuver to avoid facing the painful underlying issues, of which of course the therapist is aware but the client is not.
10. Remember that the presenting problem/underlying problem distinction is a really useful device for those of us who may wish to create long-term clients. Clearly, this formulation again relegates the client’s understanding to the status of second-class knowledge, implying that the client’s understanding is superficial and that only we, the professionals can really appreciate what is really going on. This implies that only the therapist can know when the client is ‘cured’, a really useful way to avoid premature termination.

The simple application of these 10 steps should, by themselves, lead to a significant number of your clients being converted into long-term attenders and it should be only the exceptionally strong-minded who will manage to resist subtly being led into dependency and deference. Good luck!