Answers to many PE therapy FAQs can be found in Chapter 13 of Learning PE Therapy. The purpose of this section of the Learning PE Therapy website is provide a repository of answers to additional questions. If you have a question you’d like answered about PE therapy, please email us at firstname.lastname@example.org. We are looking forward to hearing from you!
13.1. How Can I Help a Client with a Serious Physical Illness?
13.2. What do I do with a Client who Comes to a Session Intoxicated?
13.3. How do I Handle Confidentiality Conflicts
13.4. How Do I Handle Unplanned or Complicated Therapy Endings?
We discussed the task of ending Process-Experiential therapy in Chapter 8, but here we will take up various scenarios not covered earlier. Clearly, the idea situation involves a client having successfully resolved his or her main presenting problems within initially agreed upon time limits. If only life were so simple! Here are some common alternative endings and how to facilitate each:
Finishing early. To begin with, even if the client and therapist have agreed to a certain number of sessions, the client may complete his or her work before that time. Sometimes the client will surprise the therapist by completing his or her projected therapeutic work more quickly than expected, leaving the therapist somewhat unprepared to deal with termination issues (both the client’s and his/her own!). If the client feels ready to end sooner than originally agreed to, it is usually a good idea to support this, although the therapist will want to explore the client’s sense of progress and readiness first.
The psychodynamic concept of “flight into health” is not considered to be valid in PE therapy. Clients are encouraged to make explicit choices about whether or not the present feels like an appropriate time to work on particular difficult issues. PE therapists recognize and accept the fact that “this may not be the right time to work on that.”
If the therapist harbors doubts about the client’s motives or readiness for ending, a useful possibility is to propose spreading out the last session or two, and then to offer a one-month follow-up session, to make sure that the client is really ready to end. If the client is being overly optimistic, this gives enough time for problems to crop up, and also allows the client to continue therapy without losing face. In the end, however, it is important to support the validity the clients’ choices about continuing therapy or not, while leaving the door open for the client to return later.
Running out of things to work on but not feeling ready to end. Some clients reach the point of having improved substantially and having little to work on in therapy, but may still not feel ready to end. These clients may fear relapse or lack a network of supportive others, or simply find it beneficial to have someone to check in with periodically. For these clients, a useful strategy is to suggest meeting less frequently: every other week, monthly, or when the client feels they need to.
Running out of sessions before being done. Particularly with externally imposed time limits (managed care or insurance limits, client or therapist moving away), many clients may still be clinically distressed at the end of treatment. This is a difficult situation, and should be discussed well before the end, as soon as it becomes clear that this is a possibility. Doing so makes it possible for client and therapist to focus on less painful, more circumscribed problems that can be addressed within the time limits, if that is the client’s preference. In addition, with these clients it may be desirable to taper off treatment by spreading out the last few sessions. Finally, if the client remains clinically distressed, providing more treatment or referring him or her elsewhere is important.
Giving up on therapy. Another possibility is that the client may wish to stop therapy because he or she no longer sees it as useful, either because it is the wrong kind of therapy or because the client comes to see his or her problems as intractable, too painful or too difficult to work on productively. Such decisions, however painful, need to be explored wherever possible, but should be understood and respected. In these cases, the therapist needs to develop an empathic understanding of why it feels important not to go on. For example, one depressed client had resolved most of her difficulties, and stopped therapy because she feared stirring up problems in her marital relationship. Although she was not entirely satisfied with this relationship, it was far better than her previous marriage to an emotionally and physically abusive man, and she was unwilling to risk stirring up possibility dissatisfactions.
Occasionally, a client enters therapy in the context of dealing with a serious medical illness, or perhaps develops a serious physical problem during the course of therapy. For example, a client might injure his or her back, have a heart attack, require surgery or be found to have cancer. We have found that clients often have great difficulty effectively managing their interactions with physicians, because of the basic structure of the medical system and because of their own issues. For example, some clients may be prescribed unnecessary or harmful medications, or be subjected to increasingly invasive medical tests and other procedures. In addition to overshadowing work on other important problems, the client’s disempowering experiences at the hands of medical professionals threatens to undo or counteract the work you and the client have been doing on self-empowerment.
In these situations, what is the PE therapist’s responsibility? How can you be helpful to a client in these situations? It seems to us that the PE therapist has two responsibilities in situations such as these. First, in order to support the client’s well being, it is a good idea for the therapist to make sure that the client is receiving adequate medical care. This often involves research into the client’s medical condition and medications, but may require consultation with health care professionals. If needed, the therapist may use content directive responses such as general information about the medical system and even content suggestions about how to handle interactions with physicians and other health care providers, regarding such issues as patients’ rights, asking for second opinions, talking to supervisors, bringing lists to doctor’s appointments, and common medical biases (for example, physicians’ belief that they not being helpful unless they prescribe medication, regardless of whether it is needed).
At the same time, however, it is essential that the PE therapist also explore the meaning that the illness has for the client. Illnesses usually have important meanings for clients: In addition their bodily location and experience, they are often tied to childhood memories with being sick, frequently have a deeply moral dimension, and usually are associated with action tendencies such as help-seeking or withdrawing from others. In short, illnesses are emotion schemes and need to be explored as such. In fact, a chronic illness, such as a severe allergy, or a bad back, or a cancer, often takes on a kind of personality of its own, and can readily be explored via Two Chair Work.
It is possible (but not ideal) to do experiential therapy with a client who has had one or two drinks. After all, this is not that different from doing therapy with a client with a client has a bad cold and is on cold medication, or who has been up all night, or who is on a prescribed antidepressant or anti-anxiety medication. However, if the client is inebriated (or physically quite ill), he or she will not be able to adequately access and symbolize emotion; it is therefore impossible to carry out effective therapy under these circumstances. The therapist should ask if the client has been drinking and adopt a caring, but firm stance:
•I’m sorry, but we can’t do therapy while you are high. It just doesn’t work. I do appreciate your coming in, and I’d like to see you when you’ve sobered up. But I can’t see you today.
Next, it is important to make sure that the client has safe transportation or a place to stay until sober. In the end, the key is to communicate to the client that you are not judging him or her, and that you do care. If you succeed in conveying this, they are more likely to return when they are sober.
Confidentiality conflicts involve the duty to report abuse to authorities or to warn potential victims, when a client admits abusing a child or a helpless adult. When PE therapists encounter such situations, the therapist discloses the legal requirement as a therapeutic dilemma, and asks the client to engage in collaborative problem solving to attempt to resolve the dilemma. One strategy is to offer the client the opportunity to report the abuse him- or herself; however, in such cases, it is necessary to set up a verification strategy (e.g., the therapist follows up with the child protection agency to make sure the client has done the needed reporting).
Materials designed to
accompany the book Learning Emotion-Focused Therapy: The
Process-Experiential Approach to Change from APA Books.
©2003 Robert Elliott, Jeanne Watson, Rhonda Goldman, and Leslie Greenberg