This article was originally published on August 30, 2016, and was updated on October 7, 2019.

As therapists, we often work with clients that are connected to a variety of systems, and those systems also become our extended working environments (or additional “customers”). The consideration of these extended environments set systemic practice apart from individually-oriented practice. It also contributes to the possibility of therapists losing track of what’s most important for clients, due to external systems representing varied, and sometimes competing, interests. Furthermore, all the information (a.k.a. “content”) that comes with working from an inclusive, systemic lens can obscure a clear clinical focus.

In this post, I explain two simple questions that I’ve used in supervision, training, and practice to help therapists cut through content and competing goals, to identify the next step with any client.

Question 1 | Who is the therapy client?

Such a simple question. But, when dealing with families, school systems, caretakers, attorneys, caseworkers, and others, it’s often challenging to maintain clarity in our therapeutic work. Of course, as therapists, we are able and willing to cooperate with any system if our client signs a release of information; however, no other system can or should dictate the direction of therapy, because this would compromise our therapeutic integrity.

For example, let's consider the following story:

Mike is conducting therapy at a new counseling center at his church. The pastor refers a couple to Mike with the presenting issue of working through the wife’s affair. The couple is motivated and consistently attends their weekly appointments.

Approximately one month into therapy, the pastor approaches Mike and says that he needs to know if the wife has ended the affair and shown remorse. If she hasn’t, the pastor will need to remove her, temporarily, from her current role as a Bible study leader. Mike, as a newly graduated therapist and a member of the church, wants to please his pastor. He is not sure how to respond.

Of course, the ethical expectation is that Mike keep the information revealed in counseling confidential and that he reiterate the confidentiality requirement of his profession to his pastor. The significant point in this case is that Mike feels both the desire to be a good therapist to the couple and be a good member of his church.

This is a very simple example, but I use it to illustrate how our many roles,level of confidence, and the expectations of others can at times interact to make our work confusing. The client in this case is the couple. The client is not the church, nor is it the pastor. Should the pastor begin to influence treatment, Mike would be in a clear conflict of interest as the couple’s therapist.

Question 2 | What is the therapeutic goal?

When you’re confused about your therapy direction, and the client is clearly defined, it’s possible that therapy goals have not been created or prioritized. This can happen in a variety of circumstances, such as:

when clients begin therapy in crisis, and the therapist is busy” putting out fires” for a while, and later realizes that she doesn’t have a therapeutic direction
when therapists simply neglect to set clear goals in the assessment phase
when therapists have worked through all the initial goals, but haven’t set new ones.

Regardless of the circumstances that have led to the confusion, this is the perfect time for a goal-setting session.

For example, let's consider the following story:

Maggie has been meeting with her client, Joe, for six months. Joe lives with social anxiety; he comes to therapy consistently and talks about his family relationships as well as his frustrations at work.

This week, Maggie met with her supervisor and explained that she’s thinking of terminating services with Joe, because she doesn’t know how to help him. Maggie’s supervisor asks her questions about the length of the treatment thus far, Joe’s initial goals, which of these he has accomplished, as well as her feelings during clinical sessions and her work with Joe overall. Maggie explains that she’s frustrated, because Joe wants her to listen, but isn’t interested in interventions for social anxiety symptoms.

When Maggie and her supervisor revisit Joe’s initial goals, it becomes clear that his main goal for therapy was working through relationship conflict in his immediate family. Maggie and her supervisor process her frustration as a personal reaction related to the pace of her work with Joe, as well as a lack of clarity on the current therapeutic goal.

In this example, Maggie’s frustration and confusion was “solved” by revisiting the initial goals. Maggie can now re-evaluate goals with Joe, and make recommendations to him about how to move forward in a variety of areas. The two of them can establish a collaborative working relationship in which the goals for therapy are clear and are prioritized based on Joe’s needs. In Maggie’s case, both the pace and subject of therapy were a source of frustration, because she was seeing them as obstacles to treatment. When she realized that the client’s current goals were clear, yet different from hers, she was able to recognize that therapy was serving her client.

Summary

I have provided two examples--an ethical dilemma, and a disagreement on clinical focus between therapist and client--of when the questions “Who is the client?” and “What is the goal?” are able to provide clarity about moving forward with treatment. These two questions have been extremely useful to me throughout my career, and they are the first things I ask myself when I am feeling stuck in my clinical work. Hopefully, they will prove helpful to you the next time you find yourself wondering how to progress.

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