Last week, it became rather clear that I had reached a therapeutic impasse with one of my clients. A therapeutic impasse essentially refers to a situation in which a therapist has stalled in her/his ability to facilitate the changes the client seeks and/or needs.
To provide some background information, client X was someone I had been working with since I started my placement in September. Client X had been diagnosed with Major Depressive Disorder and part of her treatment plan was to take antidepressants, as well as receive weekly therapy.
While client X had suffered and survived a number of traumas in her life, she presented as grieving the loss of an aunt who had died quite unexpectedly several months earlier. Client X had other relatives in her life, but no other relative meant as much to her as her dear aunt who had just passed away.
To assist client X, I tried over the past several months to be an empathetic supportive ear as she would tell me how much she missed her aunt, how much her dear aunt meant to her, how much they used to do together and more.
In addition, client X often complained about not wanting to get out of bed/her apartment but pushing herself to do what was needed for her children. I would validate her depressed feelings and at the same time support, encourage and remark on her resilience – on being able to do what she needs to do to take good care of her children despite her intense sad feelings.
To facilitate some positive movement/change, I also tried encouraging her to engage in some exercise (such as walking for twenty minutes three times a week), participate in some activity (any activity) that she enjoys so that she does something beyond taking care of the needs of her children and socialize more with others outside her family.
Despite all my attempts, client X’s mourning of her aunt seemed to continue throughout all our sessions. I had been feeling for some time that my client and I were going in circles around the death of her aunt, unable to move past it in the same way my client was unable to move past it.
I was aware of my feelings of frustration at feeling helpless and unable to help client X. I repeatedly shared my counter-transference with my supervisor to ensure that these emotions would not interfere with my work with client X. I continued to feel that things were not really moving in client X’s treatment, although some progress was indicated by her recent decision (and action) to attend church every week.
During my last session with client X (one that I had written a process recording of), client X was grieving less overtly and sharing some happy events that had just occurred or were about to occur. This was a change for us to be able to discuss something happy and my inclination was to ask her some questions about those happy events.
At some point during that session, client X said that she often felt bored when taking her children to fun events. I (wrongly) asked her what she meant by feeling bored and asked her whether she didn’t find anything to laugh at when taking her kids to a funny movie.
I then (wrongly) drew the conclusion that client X may require some change in her medication and made mention of this to her and suggested that she bring this up with her psychiatrist at her next visit. I say “wrongly” because my supervisor (E) made it quite clear that I had misinterpreted client X’s statements and digressed from the main issue – her grief over the loss of her aunt.
E quite cleverly asked whether it was possible that I had allowed myself to be diverted from the core issue of client X’s painful grieving because it was a defense on my part, that I had not been able to go to the emotional place of death and grieving that session because of what I was going through personally and emotionally with my very dear friend who is battling cancer (mentioned in What Do You Do When a Loved One Has Cancer). E’s interpretation made sense to me, although I’m not clear on what one does to resolve such an issue…
E then went on to suggest that I bring in my client to see her during our next appointment which I did. During that one session in which I observed E questioning client X to get an understanding of her grief, E succeeded in being able to make some important connections/observations about why client X’s grief has remained unresolved to date.
As a way of transitioning client X over to her, E then went on to ask client X if she would feel ok coming back to see her for a few times for them to continue to talk and I would observe to learn. Client X agreed and now in effect, client X has become E’s client and she is likely to make good therapeutic progress as a result.
There are a number of different ways that one may try to address a therapeutic impasse. The way in which my supervisor chose to handle it was to take over the role of being the therapist with my client and allow me to sit in on her subsequent sessions with my client as a learning experience.
It is likely that my supervisor chose this route because my placement will be coming to an end in another eight weeks, meaning that I would have had to raise and start working on termination issues in a couple of weeks and that the impasse in essence necessitated making the transition to E sooner rather than later for this particular client, thereby ensuring that the client’s best interests are given top priority.
On a personal level, it is rather hard not to feel like I had failed with client X despite all my efforts and wishes to the contrary. It is my hope that even though I was unable to help move client X out of her sea of unresolved grief, she knew and felt my empathy, caring and deep desire to help and be there for her.
Have you ever had the experience of reaching a therapeutic impasse with a client? If so, what were the things that you did to get out of it? Are there ways of avoiding therapeutic impasses? Please share your comments and thoughts below. I really appreciate them 🙂
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webtreats: Seamless Abstract Crumpled Tissue Textures
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Hi Dorlee; I just wrote a long response and something went wrong when I tried to post it. Lost it! The summary was: It sounds like you have learned (and are learning) an incredible amount of therapeutic technique and most importantly – self wisdom, from this internship. After all, that’s what internships are for, aren’t they? What a wonderful gift this experience is.
Hi Terry,
Thanks so much for looking at the experience I have shared as a learning one as opposed to a test/lesson that I had not succeeded in mastering…
And yes, as you so wisely state, the whole purpose of the internship is to teach me and I am most grateful for all that I have learned (and am learning) with my clients and E’s guidance.
With much appreciation for your support,
Dorlee
P.S. I’m so sorry that your first response got lost. The internet/blogging software can be fickle sometimes…
Dorlee,
It does sound like a profound learning experience. I think that impasses are a natural part of therapy. Sometimes they are un-resolvable, like brick walls. Other times, they may function more as a labyrinth–drawing us deeper into the client’s inner experience. I hope that, as time goes on, you feel more at peace.
Warmly,
Ann
Ann,
Thanks so much for sharing some of your knowledge and experience about therapeutic impasses.
It is most reassuring to hear that they are a natural part of the therapeutic process…
With much warmth and appreciation,
Dorlee
I have found that in most cases when I have reached a therapeutic impasse with a client that confidentially consulting with a colleague is very helpful. This usually gives me a new perspective on the situation and is in most cases just what is needed to go through this stage with a client. This is a normal stage in any relationship, especially a therapeutic relationship.
However, I think it so important for a therapist to know when they are not able to go any further with a client (whatever the reason may be)and to recognize it and acknowledge it. Even braver, when a therapist can acknowledge that a client might need to be referred to another therapist b/c of a therapeutic impasse that cannot or seems not to be resolving or improving. We need to do what is in the best interest of our client.
I believe the problem is when therapists believe they can do it all and have difficulty in recognizing and acknowledging their weaknesses as a therapist. After all, we are only human!
It sounds like even once passes the stage of being a student or being supervised, it is beneficial to seek out occasional confidential consultations and/or supervision with an experienced colleague.
Thanks so much for confirming that reaching a therapeutic impasse with a client is actually a normal stage in a therapeutic relationship. My guess is that with my other clients, I either do not recall hitting this phase and/or I remember how after wondering how we were going move past a particular roadblock, something shifted and we moved to a place in which we were connecting on a much deeper level and the roadblock was suddenly no longer there.
It is also good to learn how sometimes even with good supervision, there are times when a client may need to be referred to another therapist b/c of an impasse that is not improving despite one’s best efforts, and that being able to do so is a strength and not a weakness.
As you so wisely point out, what is in the best interest of the client, should always be the guiding factor…
With much appreciation for your valuable guidance,
Dorlee
As you said above, you can never ever be too experienced to seek out guidance and support from colleagues.
I can understand your feelings in the situation and for me, I sometimes have issues and people that I find it harder to connect with than others and it might just be that someone else can work better with them.
It isn’t about one or other of us being ‘better’ than the other, but we can’t leave ourselves out of our work completely. And although I have no doubt that the way my agency is set up is quite different from the way things are where you are placed, we do sometimes ‘switch’ clients with each other among experienced practitioners for a variety of reasons.
I’ve seen clients of mine completely take off when they have worked with a colleague of mine and vice versa when I’ve picked up work from my colleagues. We have to work to our own strengths and use every experience as a learning experience which it seems like you are doing very well and with a great deal more insight than I had when I was training.
Going back to personal experiences, yes, I have had many similar experiences with clients. Some I have worked through just because there has not been any other option. Other times, I’ve spoken to my manager and she has provided support and advice on how to work further with someone and on other occasions, as I’ve alluded to above, I’ve switched out of the role and a colleague has taken over.
I think each time I feel I’m becoming stuck, I try to process and reflect on my thoughts. As often as not there are elements me making judgements or assumptions that might not be helpful. If I can find my own prejudices and inane preferences, I can work harder to eliminate them.
I don’t know if that makes sense. Thanks for sharing the post. Sorry if I’ve been a bit rambly!
Thanks so much, cb, for sharing both your knowledge about therapeutic empasses as well as some of your personal experiences.
Your detail and honesty were most appreciated 🙂
What you are saying makes a lot of sense – how we cannot leave ourselves out of our work – in fact, we are the instrument and as I recall from one article that I read, it is our job, to specifically use our self…however, it is also our selves or our issues that can also interfere and that is where supervision/consultation is supposed to help us figure out where/how we may blocking the next steps.
It is nice how open you and your agency are in that you state that you regularly switch clients amongst yourselves when you feel that it is in the best interest of the clients.
I also like your suggestion about taking a step back when there is an impasse and reflecting on what thoughts and assumptions I may be making that may be unhelpful as another way of breaking through an impasse.
With much appreciation for all your guidance and support,
Dorlee
Over the years, I’ve lost track of the number of therapeutic impasses that I’ve hit, Dorlee. I think it’s an inevitable part of the process of being a therapist. It’s part of why I feel so strongly that therapists, even experienced ones, need to have people to consult with, either a peer consultation group, or a person that they can speak with.
The timing of this experience is unfortunate in that you’re finishing up the internship, so you won’t have a chance to work through the impasse yourself–instead E. is transitioning the case back to her. But please don’t take that as a failure on your part, it’s just bad timing. If you were continuing there for another few months, you would have had the chance to work this through.
Thanks so much, Nancy, for making it so clear how natural and inevitable therapeutic impasses are…and how likely it is that I would have been able to work through this impasse with client X had I had more time…
You, Terry, Ann, Laurel and cb have all been saying how normal these impasses are…that in of itself says alot 🙂
Somehow when you are starting out and this happens to you, it can feel rather monumental…
With much appreciation for all your guidance and support,
Dorlee
Dorlee,
What a terrific post and conversation, extending beyond your post.
I think, bottom line, what I’m ‘hearing’ is that such impasses are ‘normal,’ and that such experiences are a natural part of the internship process … and well beyond as you become a more experienced, tenured social work professional.
What a wellspring of compassion and intellect your blog provides. Plus, it is clear YOUR intent is to be the best therapist possible. From a non-therapist looking ‘in,’ I can confidently assert I KNOW you are providing well over 100% of the value and quality results your patients need.
Impressed by you,
Jacqui
Hi Jacqui,
Thank you so much for your continued support and vote of confidence in my abilities:)
You are such a beautiful person…and offer much value and pearls of career (and life) wisdom in every post, tweet and comment that you write.
Warmly,
Dorlee
Hi Dorlee, this was a great vignette. But I don’t want to focus on the impasse. Rather I would like to focus on the ego defense of displacement that your patient was displaying. Yes, she is grieving over the loss of her aunt, but as importantly, she is grieving over the impending loss of YOU. That second grief is harder to speak about perhaps because it may seem strange to a patient to feel so deeply about a therapist. And what is so amazing about therapy is that we can often be speaking about several things on several levels at once.
That said, perhaps it might be interesting to look at your sense of impasse in that way. What are you feeling about leaving your patients? How much of those feelings are conscious and tolerable to you? Does the act of transferring your patient to E also transfer your feelings, or are you left with feelings of defeat which may in fact be your bereavement?
Nice work on this case!
Thanks so much for your thoughts on this case, Mike. Client X actually has not yet been made aware of my specific date of departure. She is fully aware of my student intern status but the termination talks are only to begin after spring break as per E’s request.
That said, you raised some great questions about how how I feel about having transferred client X to E and what I am may be feeling about terminating with my other clients. Regarding client X, there are some feelings of loss and sadness but these are coupled with relief at her being able to reach a healthier, better place sooner rather than later.
With respect to my other clients, you’ve given me good food for thought and a good potential topic for another post 🙂
With much appreciation,
Dorlee
Dear Dorlee,
I’ve been debating whether to comment on this post or not because I don’t want to second guess your supervisor and obviously I didn’t read the process recording. However, I’ve decided to share some thoughts that you might want to consider.
You decided that you were wrong to ask what your client meant by feeling bored and asking her whether she didn’t find anything to laugh at when taking her kids to a funny movie. You decided it was wrong because your supervisor told you that you had misinterpreted client X’s statements and digressed from the main issue – her grief over the loss of her aunt.
Is it always wrong to digress from the main issue? Is it necessarily a digression to clarify what she meant by boredom and if she was able to laugh at funny things?
Even if your countertransference was causing you to digress, was this such a big mistake that it would necessitate ending your therapy prematurely?
I think there is a lot you can learn from observing your supervisor addressing your client’s grief issues. However, in my opinion, there is more to be learned from giving you the opportunity to try to resolve the impasse on your own. Based on what you have shared, it does not seem like your mistake was big enough to warrant your supervisor taking over.
Of course, I realize that I may be missing important pieces of this puzzle so I offer the above for you to contemplate to decide what makes sense to you based on your knowledge of the client, yourself and your supervisor. 🙂
Warmly,
Andrea
Hi Andrea,
Thanks so much for sharing your thoughts and perspective on this case 🙂
You have raised some interesting questions which are giving me much food for thought.
I think/hope that my supervisor would have allowed me to continue to work through my impasse with client X had it not been taking place so close to the time that I would have to start discussing termination/transition plans for her…
With much warmth and appreciation,
Dorlee
Dear Dorlee,
First, wow, I can’t believe you have only 8 weeks left! Next, I love the new name!!!
I think we all reach impasses with our clients. Resistance is one primary cause of this. We all resist change on some level.
As I was reading this post, I wondered whether your client might get “stuck” in grief. Sometimes we encounter what is called “disordered” mourning. There are depressed individuals who cannot and do not move forward bc they’re essentially stuck in a depressed position and resist any attempts to move forward.
I’m not saying your client is in this category, however there are individuals who despite our best efforts are unable or unwilling to move forward into a more uplifting view of life.
On the other side, grieving is a natural part of life that our culture squelches and often does not allow room for. An individual who loses a lifelong partner is expected to be “normal” within weeks. How unrealistic and sad that we place this expectation upon others.
I hope you have support in the grieving of your friend’s illness. Your friend is fortunate to have you as you’re such a genuinely caring person.
Hugs and love,
Lauren
Dear Lauren,
Yes, time is flying 🙂 I’m so glad you like the new name…thank you for having raised the idea of changing it. I don’t think I would have considered doing it prior to graduating had you not made the suggestion.
Re client X, yes, my supervisor called her grief “complicated” grief. I suspect this is a variation of what you are referring to as “stuck” grief… The resistance component that you mention also makes sense…the natural resistance that we all experience to change.
You are very kind…I have rather limited support in RL due to the issue of my needing to keep my friend’s illness confidential but I have been blessed with support from close twitter/blogger friends.
Thanks so much for your valuable input and TLC,
Hugs and love,
Dorlee