I am going to talk, hmm type, about a part of therapy, well a few parts. The quiet parts.
Establishing goals in therapy is important, they can be long range or short term. Goals will change as therapy progresses, often hurdles need to be overcome, so the goals change to help with those hurdles, progressing toward the initial or primary goals we established.
As a therapist we see the goal and know how to reach it, we can just say to the patient, do this, this and this, stop doing this this and this. But this will not achieve anything. It really is not that simple.
Therapy often proceeds at a crawl, slow steps, as many forward as possible but with the understanding there will be many taken backwards too. Therapy is often a retraining, this does not occur overnight.
There will be times when it seems there is no advancement at all.
Sessions become silent
Striving to reach the set goals, patients may try to please the therapist, tell them what they think they want to hear, perhaps not tell them when issues or items brought up in previous sessions may be tormenting them, so as not to upset their therapist. This quickly grows into a large thorn in therapy. The patient wants to please, often there are fears of abandonment that are very powerful. In therapy with personality disorders, this is much more of a likelihood. The patient fears their therapist will fire them, so they strive to please. If something came up that was upsetting, they may skirt around it, if comments the therapist made upset or were misconstrued, they may not question. They often will not revisit an issue that they felt the therapist may feel was covered, even though it is still tormenting them. Some issues may not be brought up at all, for the same reasons, they may be similar to something previously discussed or they may feel they will be upsetting.
Therapists will, or should, sense when this occurs, when the patient is trying to please, reassurances must be made that the therapy is not about the therapist, there is no set speed set to reach the goals, the goals may never be met, other goals may appear that replace the initial goals. Allowing the patient to lead toward the goals, resistance is not as likely. They discover at their own pace, sometimes blisteringly fast, otherwise not. Though it often appears this way, therapists do not read minds. Sometimes it may be difficult to know that an issue is still bothering the patient/client, the patient may appear to be off, but the reason will be eluding without clarification. The therapist will ask what is bothering, but the answer is not always forthcoming, being asked what is bothering may force the patient to tighten their mask, the therapist seems to be upset, so it is time to work harder to please, appease, so as not to upset.
Therapy will often stagnate when this occurs. Pause, stop, stall, freeze.
We can also encounter resistance. A stalling, but something different, the patient wants to continue but seems unable to. those long silent periods where the patient struggles, they felt it has all been said. There can be many reasons for this too, but… this is not a bad thing. It does occur often. When the blockage is removed therapy often leaps forward.
The therapist needs to not lead the patient, leading can occur many ways, it is important for the patient to discover on their own, at their own pace. The patient pulls the therapist through discovery, if the therapist leads, they can cloud or shape discovery. Even tiny suggestions can send the patient off in the wrong direction.
Resistance can also indicate it is time to dig deeper. Often with therapy this is not necessary. In cases of child abuse or missing memories, leaning coping tools, learning to control anger and redirect it, learning to adjust or curb emotion and emotional responses and much more, can eliminate the need to dig into memories. It is not always necessary to visit each one.
There may be times though, when a memory needs to be released to address an issue that is tormenting the patient, perhaps they know of it, suspect or perhaps not at all, the memory may be blocked or held by different parts that have not been forthcoming. Resistance can occur when the patient does not wish to relive those memories.
Resistance or a stalling may occur for reasons outside of therapy, outside pressures may have changed, they should be discussed.
Resistance may be felt when there are no goals to work toward, suddenly the patient realizes this. Without goals, how does the patient judge how effective therapy is for them. Goals must be however, agreed upon by both the patient and therapist.
Some therapies, CBT as an example, involve “homework”. When the patient shows up for the next session, having not completed or tried to do the homework. Therapy stagnates. Not all exercises can be accomplished in sessions. Practicing the tools taught are necessary. When failure occurs, or triggers occur, this is a good thing, the patient can then go back and explain what happened, the patient and client can work through it. We learn from failure. When no attempts are made, there is often nothing to discuss in a session. The reasons for not doing homework can be explored of course, and should be.
Sometimes patients know more than their therapist… or think they do, or they can feel inadequate before their therapist, So they argue more, question more, the sparing becomes a game of sorts. The therapist can be seen as an authority figure, and many do not get along with authority figures. Many that have histories of abuse resent not being in control. If the therapist can offer choices rather than giving direction, this can be overcome, allowing the patient to choose, to direct the way therapy continues gives them the motivation to try.
As therapies continue, and patients overcome issues they realize they can now do things that maybe they could not do before, but this still can cause anxiety, so they may resist the healing, they do not really want change, or to go where triggers existed before or see an end to therapy. Change is often not welcome. Sometimes it indicates therapy is over, the patient, in truth, has healed, or has the tools to continue to cope on their own, it is time to let go, or to schedule less intensive sessions.
Not having the “full story” can cause therapy to stall. If the patient does not mention some key part of their past or present life, something that happened or is happening, the therapist can’t provide help or may be providing the wrong help, possibly becoming frustrated with the patient for not trying something. An example may be the therapist suggests a walk around the block, the patient doesn’t mention the bully that lives downstairs that torments them when ever they pass. The therapist becomes frustrated or may appear to the patient they are frustrated, that the patient will not attempt to go out, to test learned skills at overcoming anxiety.
Silences in therapy will occur, today the patient is just not going to talk or bring forth, personal reasons may be limiting this at this time, reasons the patient does not feel relative or willing to discuss. Rather than having a silent session or one filled with inane chatter, the session can be used as a review, comparing progress to goals that were set, how some may have been met. Reviewing basic techniques that were taught, judging their effectiveness. Sometimes this will release the blockage or make aware a new goal.
Discussing the silence is important, more so if it continues into the next session. The questions that the therapist probes with will be annoying, discussing this in advance is healthy, to reassure the patient that blockages in therapy are not uncommon, lets try to see why this one is here, try to answer the questions positively. I don’t know… is not a great answer, though this may be the case. It should be viewed as we have encountered a blockage, not you have. The session can begin with the statement from the therapist, I am going to probe with questions that may annoy you, you can show your anger with me, I can take it, it also may help us realize where the blockage has originated. I will not become annoyed with you nor am I now. Reassurance is important.
Fear can create a blockage to therapy, fearing to relive the memory or fearing to fail. Failing at remembering, or failing at coping with the trauma or techniques. The assigned homework, or the entire therapy program. To go through all of this, and not to heal. It is good to discuss this fear with the therapist, many fears are unfounded, though they may be powerful. Allow the therapist to help, this is why the therapy exists. Therapy must be a safe place, where those fears can be explored.
Fear is a strong emotion, anger is another that can inhibit therapy, preventing someone from speaking. Rage can build to the point that the patient knows if they say anything, it will be emotionally driven, unproductive. Reliving an experience can build this rage. Frustration builds. This may occur in a group setting more, when another patient discusses something, that awakens a trigger or memory for another patient, or they may remind them of a tormentor or the way a tormentor acted, being bullied feelings may awaken. In group this may be harder to overcome. It should be followed up with the patients therapist one on one, what awakened the trigger that caused the intense emotion/s.
Resistance or a blockage can occur when a major issue/memory/trigger is close to being discovered by the therapist, the patient may fear its release and build walls, known or unknown.
Transference can also cause this striving to please the therapist, or limit interactions. This can occur on many levels. The therapist may be visiting unpleasant memories, the patient starts to associate the bad memories with the therapist. It becomes difficult to discuss anything with them. Transference is when, feelings, emotions, thoughts become transferred to the therapist, this begins unconsciously. The therapist can become the tormentor of the past, other feelings can transfer as well, love as an example. The feelings become stronger not to do anything to upset the therapist. Attachment issues and dependency issues form, the patient may want to contact the therapist more, to see them more. The thought of discussing this brings them feelings of shame. Fear not, this is not something new, talk to your therapist if this occurs, it is not likely the first instance of it for them, you can work through it together with honesty and openness.
There are many methods to overcoming the silent sessions. Discussing the silence is important. Sometimes it is as easy as playing word association games, the first thing that enters your mind you blurt out. The resistance leads to undiscovered territories that can be explored.
Often the patient is just unwilling to allow the therapy to help, they don’t wish change. It is very easy to say, that won’t work so I won’t try it, or I tried it, but it didn’t work. Failure is how we learn when it doesn’t work we need to revisit to see why, few things will work with the first attempt.
There is a lot more to this, and depending on comments I may explore this more.