Imagine feeling totally lost with a client. The client has just disclosed an extremely painful story, and you feel stuck about how to respond. Then you get defensive because you don’t know what to do next. What would be your strategy here? Would you break eye contact and instead look at your clipboard and pretend to be making some notes? Would you paraphrase what the client told you just to buy time? Would you get up, walk to your whiteboard, and draw an ABC diagram to avoid the pain you feel in acknowledging the client’s emotional distress? Would you start talking about what the research says about the client’s particular issue in an effort to get the client to feel better? We confess that we’ve tried each of these strategies on more than one occasion.
Clinically speaking, the present moment is the space in which you and the client can simply make contact with what shows up in awareness, based upon the immediate context of the interaction. Each human is assembled in a historical way, over the life span, and it would be misguided to assume that what might show up in your awareness or the client’s is limited to what’s going on with the two of you in the moment.
Cognitions, emotions, memories, and sensations are state dependent. When an interaction triggers a particular thought, feeling, or memory in you, your entire learning history with that private experience can wash over you. You might drift off into your own personal stories, recall similar painful events in your life, or get hooked by dire predictions about your own life fortunes. Faced with this onslaught of personally relevant and painful material, most clinicians are tempted to do the same thing their clients are tempted to do: escape from or avoid whatever is there.
What Are Your In-Session Hot Buttons?
Using an in-session escape behavior isn’t necessarily toxic by itself; what will severely compromise your effectiveness is if you, the clinician, persistently engage in escape behaviors across clients and across opportunities to cultivate present-moment awareness.
While many different hot-button situations arise in therapy that tempt clinicians to check out of the moment, certain clinical themes seem to consistently be high-risk situations. In their book, Inside This Moment: A Clinician’s Guide to Promoting Radical Change Using Acceptance and Commitment Therapy, Kirk Strosahl, PhD, and Patricia Robinson, PhD, both of whom have been involved in the training and supervision of ACT therapists for many years, describe these situations briefly below.
Consider whether any of these situations frequently elicit escape behavior on your part. For any issues that are hot buttons for you, you might want to write a few sentences about the escape behavior you typically engage in when confronted with that situation.
Failing
The moment when it becomes clear to you and the client that you haven’t been able to help the client and may not be able to is a very intense present-moment experience. Knowing that someone is disappointed with you, or perhaps thinking that you may not be a very good therapist or that you’ve let someone down, can lead you to engage in escape behaviors. One of the main escape behaviors in this situation is to avoid thoughts of not being good enough by getting offended and blaming the client: “She wasn’t motivated and didn’t really want to change.” “He wasn’t ready to expose himself to a social situation.” “I followed a treatment approach that’s worked for everyone else, but she just didn’t get it.”
This type of feedback might even come from colleagues, a boss, or a clinical supervisor. As difficult as it might be to field this kind of client feedback, there is always the possibility that the client might have something useful to share with you. The reality that you will make mistakes or not be particularly effective in some clinical situations is both obvious at some level and emotionally threatening at another. How you deal with this obvious fact and the emotional threat associated with it is what matters.
Countertransference
Most of us are familiar with the concept of countertransference, or over-identifying with a client due to our own unresolved issues with the same situation the client is facing. It’s useful to think of countertransference not as a thing, but as an ongoing escape behavior in which the clinician is using the client to vicariously process present-moment experience that the clinician is unwilling to face directly. The take-home message here is that countertransference happens all the time in therapy—not necessarily in the ways specified by psychodynamic theories, but in the broad sense that every therapist is prone to identifying with clients who are struggling with the same things the therapist has struggled with.
In fact, ACT encourages a kind of voluntary countertransference reaction on the part of the therapist—with certain strings attached. The main string is that countertransference must be used to validate the client, not the therapist. When therapists fall into this escape routine, it is often hard to figure out who is actually receiving treatment. When the therapist consistently overuses self-disclosure to bring the discussion back to how the therapist has dealt with that particular issue, the therapist may actually be looking for validation from the client rather than providing it to the client. This version of countertransference radically compromises the integrity of any present-moment-awareness intervention because it isn’t really designed to address the clinical needs of the client.
Codependency
Here, we define “codependency” as the act of knowingly or unknowingly conspiring with clients to help them avoid making contact with painful present-moment experience. This is usually done to please clients, to get their approval, and to help therapists avoid the same issues clients are avoiding. Codependency is sometimes revealed by client comments such as “I always feel so good when I’m finished talking with you. You make me feel good for a least a day or two.” The real question is what the client is doing with painful private experience after two days, and whether it’s working to promote the client’s sense of vitality and purpose. The codependency pact is generally fatal to the goal of developing a healing therapeutic relationship. If the therapist is supposed to act like a role model, avoiding discussions of painful experiences is a bad idea. Still, sometimes when potentially painful issues arise, at the critical moment, the therapist retreats from immersing the client in the painful material. In such cases, the therapist is hindering the client from directly learning that exposure to distressing emotions, thoughts, associations, memories, and physical sensations isn’t toxic, but rather can lead to healthier life outcomes.
It is, in fact, all too easy to be as experientially avoidant as our clients, because that’s how we create a sense of safety from unpleasant private reactions. If this supposedly works for clients, why shouldn’t it work for us? Unfortunately, the end result is that it can be very easy for both clinician and client to end up in a dance of experiential avoidance, rather than a dance of present-moment-awareness processing.
For more about the clinical use of present-moment-awareness, check out Inside This Moment by Kirk Strosahl, PhD, Patricia Robinson, PhD, and Thomas Gustavsson, MSc.
Part 2: What to Do When a Client Is Participating in Self-Judgment?