middle therapy

Running out of tricks: Middle therapy

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One of the frequent conversations that comes up in supervision is on middle therapy. Usually middle therapy is defined as the period after 20 sessions when things seem to find a rhythm.

Sometimes we have the sense that we did a good job in the early phase. We connected well. And we made a plan and tried a few things (some of which worked and some didn’t). But then the sessions feel bogged down. Our sessions seem to become repetitive. In some cases nothing seemed to work anymore. And for some, the things that worked don’t seem to be enough.

Yet the client continues to come for reasons we do not understand. And the client seems to believe that we have something for them. We, on the other hand, doubt we do. Sometimes we turn to our colleagues or supervisors for additional ideas. Sometimes we flounder, not knowing how to confidently lead them to the next level.

What’s really going on

Let me suggest that in some cases this stuck-in-the-middle feeling is a normal part of therapy. It may signal a desire to go deeper. I was trained to believe that in many cases the issue that the client initially brings in for therapy is not the only issue. Sometimes not even the most significant one. Rather, clients bring the issue that is most comfortable to bring up in order to see how we handle it. The presenting issue is a test to see if they like us. They need to see if we are helpful. Can they trust us with the deeper issues of their lives?

Client ambivalence

Clients often have ambivalence about seeking an outsider’s assistance with their problems. They can feel shame that they were not able to manage the issues in their life and “now I am so incompetent as to need a therapist.” Furthermore, they may struggle to describe these mixed feelings that are often below the surface. The pain and suffering they experience drives them to therapy. But they are also ashamed that the problem exists at all.

Deeper stuff

Furthermore the desire to be understood is difficult for many to articulate, even to themselves. They need a safe and strong-enough relationship to explore the insecurities, doubts, fears, and loneliness that accompany all travelers through life. And worry they are “too childlike” or weak for acceptance–after all “I’m an adult and can handle myself.” Dependency on a therapist is so frightening. Put together then, “I’m not happy I have a problem that seems to require an outsider’s help. And I’m not happy that I am in the uncomfortable place of feeling like a child needing outsider’s help.” So for many, it is hard to own these challenging emotions about the process of therapy.

These deeper reactions– “having an issue”, facing one’s dependency and vulnerability–are almost always hidden initially. They can only emerge as they settle into the therapy process, gaining trust in themselves and their therapist. So that bogged-down feeling, often associated with the middle phase of treatment, just may be the signal that they are struggling to make the transition required to face these deeper and challenging emotions.

What is good about “stuckness”

This way of thinking suggests that the middle session impasses may be exactly what we would expect in the typical case. The client is certainly hoping that we can we address the upfront issues. And on top of that perhaps together we will find our way through to the deeper conversations they want to have but are afraid or embarrassed to need.

The task of the middle phase then is to continue the sessions while the client struggles to find the courage and trust to go to that deeper level.

Embracing the new means letting go of the old

And adding to that challenge is the ambivalence about embracing a new, more positive framework. For to take on the new means abandoning the old, and sadly that old way of thinking of oneself and the world may be the last connection to those people who are still buying into the old framework. That dissonance between the old and and the new is hard to resolve; hence the “stuckness.”

For more read: Why don’t my clients change the way they’re “supposed to”?

Also read the series on Retention:

I: Is it good for clients to stay longer in therapy?

II: Beyond the therapist’s control

III: How to retain clients

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