Continuing therapy

Sigvard, 41 years old has been using (hashish, alcohol, heroin, etc) for 29 years. In the fourth session he incidentally mentions that he hasn’t smoked hashish for three-four days.

"How did you do that?" the therapist (HK) asks, and leans forward. Sigvard answers that he was terribly irritated and that he even pulled a knife against one of his colleagues at work. The colleague told the boss that Sigvard took an extra break.

"So how did you do not to smoke hashish"? the therapist asks again.

"It helped to drink tea, smoke cigarettes and build violins", answers Sigvard.

Since the therapist remembers that one part of Sigvard’s ‘miracle’ was that he would be able to handle his temper better he asks:

"How did you do it not to knife your colleague when you got pissed at him?"

"I got so angry I could have killed him", answers Sigvard.

"So how did you do it not to?" the therapist asks again.

"I went out and walked around the block."

"Was that something new?" the therapist asks, and Sigvard recounts that in situations like this he always hit first and thought after, but this time he said to himself that he had to keep his job and ‘instinct’ told him he had to get out.

"Fantastic," says the therapist. "What else did you do?"

It often seems that clients don’t hear our questions until they are repeated for the second or third time. We believe this is because people in the mental health business (clients and therapists alike) tend to think in a problem-focused way. Our questions focus on how Sigvard stayed away from hashish, what he did instead, and what and how he does when he follows a constructive impulse. These are unusual questions for Sigvard.

We used to start sessions by asking our clients if they had had any thoughts about what we talked about the prior session. Today we are interested in what they or others did differently since we met, how they experienced that, and what they think about it. We feel this difference is an important one because it points to the fact that what is important now is what people do in their life, not what they do in their therapy. Expressed differently: We are interested in peoples lives between therapy-sessions, not in therapy-sessions "between life".

The flow in second- and subsequent sessions is very similar and is well illustrated by the scheme above (reprinted from Clues to Solutions). The client's unique descriptions are what differentiate one session from the other.

Is it better?

"What have you done since we met last that has been good for you?" or "What is better?" are two typical questions that start all sessions after the first. It is not uncommon for clients to answer that nothing is different, that everything is the same and that they didn’t do anything that was good for them. We don’t let ourselves be discouraged by this, as we have difficulties believing it. If people have survived this long, under such difficult circumstances, this is by itself a sign that they have a lot of resources and that they do a lot of things that at least lead to their situation not becoming any worse. Instead we then ask for differences:

"What has been different?"

"Has any day contained a little piece of the miracle (the goals the client and you described in the first session)?"

Sometimes we get only unclear or negative answers to these questions. If so we ask about each day since we met, or at least about each day during the last week. We then often find out that the same day we had the first session (or the prior session) and the day after, were good days. The client felt better then ordinarily or did some of the things that were part of the goal. We then get deeper into that:

"How did you do that?"

"How did you succeed?"

"Where did you find the strengths and resources to do that?"

"Who, how and what was of help?"

"Who noticed and how did they react?"

Clients then often remember things they did other days. We get into these occasions in the same way thoroughly examining each of these behaviors or events:

"This is what you wanted to happen – wanted to be able to do!" we exclaim surprised and impressed. "How did you do it?"

Many times we have been surprised by how clients through these questions, sometimes in less than 20 minutes, completely changes their view of their last week or month. Nowadays we are not so surprised. We now know that meaning is not created and maintained automatically around behaviors that hasn’t meant anything for a long time. (See for instance when Cilla enjoys the apple page *.)

Is it enough?

When we have a clear picture of what has been different, and we think that the client also has a clear picture, we try to get an idea as to how satisified the client and family are. We usually ask: "Let’s assume that the three months to come will be as good as this week has been. Would that be good enough?"

Sometimes it is obvious that the question is not relevant. Perhaps the differences are to small, or maybe there is only one good day in a very difficult life. But often there are many good days, and many times the clients did everything or at least a lot of what they described in their miracle or goal-descriptions. When this is the case, the question is very relevant. They often answer: "It would be perfect," or "it would be more than enough."

We then wonder how sure they are about their progress and we continue with scaling questions: "If 10 means you are absolutely sure that you can make the next – say 4 weeks – as good as last week and 0 means the opposite, where are you at now?"

When a client has reached the conclusion through these questions that things are good enough, and the client is certain that he can do as well in the future, it is natural for us and for him to terminate treatment.

Better – but not enough

It is however common for clients to come back to second- third and fourth-sessions and things are certainly betters but not enough.

"What else needs to happen?"

"What else needs to be different for you to feel/think that it is good enough?"

"What else do you need to feel that you can handle?"

"What else do people around you need to see for them to think that you don’t need us any more?" are questions we supplement with.

As always these questions are developed in the same way in relation to time and to other people.

"If 10 means that this week has been perfect and 0 the contrary, how high do you think your mother would put you this week (day)?"

"What needs to happen for your father to put you ½ point higher?"

Good enough – but not sure

It often happens that things are good enough, or that the goals were reached at least some of the days, but the client is very uncertain as to his capacity to bring about more such days. We then think, "the client doesn’t own his change".

Donald's goal, as formulated in the interview is, "to resist the urge to sniff gas on boring days". He sniffs only when he is bored, and therapy didn’t progress for a long time as the therapist (HK) thought that the goal was to help Donald make every day a non-boring day. When Donald succeeds in resisting the urge it is totally incomprehensible to him how he did it. He knows it helped to draw pictures, go for a walk, talk to his mother, play with the dog and 7 more things. He seems to know that it helps to do other things, but how he succeeds in doing these things he doesn’t understand.

Questions we then ask deal with what the client needs to do or see happen for him to be more certain that he can continue to do these things that are good for him.

"Ok, so you’re at 5 when it comes to confidence in your ability to continue to do these things. What do you need to be able to handle for you to feel that you are at 5½?"

Sometimes this attitude stand for the client thinking that we can be of help to get much further than maybe we thought was possible.

Caroline has been in treatment for a long time and has made tremendous progress. It is difficult to believe that she has been a ‘bag-lady’. Her mother and her child’s foster-parents are impressed and amazed by her progress, and so is her social-worker and one person at the employment-agency. The therapist (BA) doesn’t understand Caroline putting herself only at 5-6 on a scale that has to do with how well things has been going lately, and she repeats the question three times. The supervisor (HK) phones in and asks her to explore what would be 10 for Caroline, and Caroline tells the therapist that she would like to become a medical doctor. Caroline’s 5-6 then suddenly seems perfectly relevant and the interview continues with questions around what needs to happen for her not to need treatment any more.

No change or improvement

Sometimes we don’t succeed in creating descriptions that contain any progress. It seems that the first-, second- or third session just didn’t make any difference, things are simply no better and maybe even worse.

When this happens it is wise to go back and reflect on if there is a useful goal. We can cautiously ask clients why they continue to come to us and if and how it’s helpful, but we are not satisfied with answers like: "It’s nice talking to someone."

We go back to questions that belong in the first session: "What is your problem and how will you/others/me notice when things are getting better?"

We then often find new or maybe different, more relevant and useful goals than we got in the first session.

This development or lack of development guides us into thinking that we have to do something different. It may be finding new ideas about goals, or carefully reevaluate the relationship with the client. Sometimes we may have misjudged the relationship and have suggested ‘do-tasks’ to a client who thinks the problem and its solution is dependent on someone else's behavior, and it would have been more relevant to suggest ‘observation-tasks’. Sometimes we find out we totally misunderstood the reasons a client or family-member had for coming to us.

Something different we always try to do is to see more people, fewer people or other people in the clients network. We often have a colleague make a consultation-interview and sometimes we refer the client to another therapist.

Concerning clients who come to treatment in order not to do something else (like for instance go to prison), it is particularly important to use the possibilities of flexible encounter that are built into the model. It is ok for us to see a client a couple of times because the client has to come to treatment, but things must get better or different for us to continue. If the situation is not changing we ask the referring agent to participate in a session to renegotiate the goals of treatment. If nothing happens after this we see no reason to waste the clients or our time . We terminate treatment with an offer to the client to come back when and if he thinks our ideas can be of any help.

We have experimented with different intervals between sessions. One week, two weeks, one month. Nowadays we simply ask the families and the clients. However we do have an opinion that we show clearly; the longer the clients and families can make it on their own, the better.

When clients come to the first session we usually ask them if they think that one or two weeks is the most suitable before the next session and when change is starting (most often in the second or third session), we usually suggest twice as long until the next sessin. Should the client insist on seeing us earlier we do however agree. We usually understand this as an expression of the client's confidence not being high enough and we respect this.

After this we usually suggest about a month between session. When client's think that the changes seem stable, but still expresses some uncertainty around termination, we suggest three or maybe even six months to the next session. We like to add that the client gets the appointment, but he can call us when he has reached the decision that he doesn’t need it.

We talk some about non-appearances when we talk about terminating treatment (page *). It would be naive though not to talk about such failures to appear that occur because the client started to drink or started to use more drugs.

When clients come for therapy with their family ‘no-show’ is generally not a problem. If the client doesn’t show up the family almost always gets in touch and we can discuss with them if and how we are to continue. Many times calls from family members simply leads to setting up a new appointment, and the relatives see to that the client comes back to the next session.

The situation is not complicated either when it’s an authority that has referred the client. Most often there is an agreement about what to do if the client fails to show and one just follows the agreement.

With clients who seek treatment by themselves we often raise the issue in the first session.

"Who shall we call if (note; not when) you don’t show? Who can make sure we can continue even if you happen to mess things up?" Most often these questions lead to the agreement that a family member should be informed about the ongoing treatment, and many times this leads on to that person being invited to a session.

Some clients seem to think that time alone will determine if things are well enough. These clients say: "I have to be off drugs for three months or six months, and after that I will know my problem is solved ."

When clients see time as one of the most important parts of their goal, the other part will consistently be not doing a certain behaviour; "not do drugs", "not drink", "not binge" or "not have tempers". This means that the therapist is breaking ‘dead mans rule’ (see page *) and neither the client nor the therapist can ever know when and if the problem is solved. Even after 40 years of abstinence the client can start drinking again.

Problems often arise in these therapies when the client has been abstinent for some time and doesn’t know how he did it. Commonly the client or some important person in the network will be dissatisfied with the result of treatment and relapses seem to be more common.

It may be useful in these situations to define the reason for improvement as a mystery, or even to define the reason things isn’t getting worse as such. Preconditions for change exist when clients try to find answers to why and how they made some improvement.

With some clients we only succeed in defining vague goals. For success the clarification of the goal needs to fit, and should thus be as vague as that of the client. Scaling questions are then very useful. The difference between 5 and 7 on a ‘happy-scale’ or a ‘feel-good-scale’ can be the difference needed by a client to feel that he is moving towards his goal, and the therapist don’t have to understand what the client means by this difference. It’s enough that the client creates his own meaning.