Many moons ago, when I was a young counselor, documentation of treatment was left up to the therapist. Many kept no records at all. Some had hand written notes but were only for the therapist to remember the content or a insight they wanted to share at a later time. But, whether a therapist kept notes or not, it would be rare for the client to know anything about their documented diagnosis (even if insurance was paying) and even less about treatment goals.
With the advent of managed care, documentation of service rendered became a reality. At first these documents (diagnosis, treatment plan, quarterly summaries, termination note) were completed without client knowledge. Later, best practices required therapists to share, at least verbally, diagnoses and treatment plans with their clients. Hopefully, today’s client is a bit more informed as to this better practice and is in agreement with the goals of therapy.
But even when agreement exists as to the high level goal, counselors can find themselves working towards goals the client does not want, or, can be working a different path to a shared goal that doesn’t seem to fit the client.
Setting client goals is an easy thing?
While documentation of goals and objectives is relatively new in psychotherapy, setting goals is not. Client comes in, discusses presenting problem, therapist and client explore desired outcomes. As therapy progresses, goals may change due to circumstances or new learnings. Easy, right? Not so fast.
Shared goal, disagreement about the path
Let’s say I go to therapy to work on a phobia I have to flying. We agree on the larger goal and begin to work. Along the way the therapist wants me to try exposure to flying by getting on a high speed train to simulate the sensation of movement and loss of control. I resist because I do not feel ready. The therapist wants me to push through. I resist more. The therapist can continue to press, whether gently or forcefully, but this disagreement will hinder therapy if we do not get on the same page.
Disagreement about the way forward is commonplace in therapy. Sometimes, we therapists believe that our wisdom and insight is best. And, it may be due to the many other clients we have treated with the same challenges. But what the counselor does with resistance tells you a lot about that counselor and their capacity for “withness.” Do they,
- Check in with the client to see what they are feeling when they resist? (Resistance can be about confusion, disagreement, need for encouragement, concern for consequences, etc)
- Brainstorm about alternative objectives that might be possible? Sometimes small changes in steps make all the difference.
- Pontificate about how the chosen path is the best? When we therapists feel defensive we can easily fall back on our expertise as a weapon to convince another that we know best.
- Ask pointed questions that leave the client feeling shamed? “You do want to get better don’t you?”
Shadow goals
From time to time both therapist and client can work toward an unspoken goal, a shadow goal. Since we are focusing here on counselor failures, let’s consider what kind of shadow goals counselors might begin to pursue. Shadow goals are those that are not verbalized and yet have a controlling influence over the therapist’s words and stance in a session. Here are some examples:
- Client comes for help with grief over a lost relationship but the therapist wants client to see how she is the cause of the lost relationship
- Client comes for help in leaving an abusive marriage but the therapist is committed to helping the client stay in the marriage
- Client presents with a mood disorder but therapist wants client to leave his dysfunctional church
- Client want to become less dependent on others but therapist wants client to continue to need her help
- Client seeks treatment for PTSD but therapist wants client to stop being needy or to terminate therapy.
Shadow goals are best addressed in supervision where therapists talk about their clients–and yes, talk about how they feel about clients. As therapists explore their feelings, shadow goals come to the surface and can be acknowledged and addressed. Their presence is not a sign of counselor failure or weakness. They are normal and part of what it means to be human. The only danger is these goals remain hidden and active. As long as they stay hidden (for lack of insight or because of shame), shadow goals will exert control and create confusion on the part of the client and the therapist.
Musings on Faith and Psychology 