Asking what your client wants from your work together might seem obvious but it isn't always as clear is it may first seem. In reality, it's common for clients in a mental health or psychological assessment to be focused on the things they don't want. For e.g., many will point to the symptoms they want to be rid of, such as anxiety, grief, sadness, low mood, intrusive thoughts or memories, or want to 'work through the trauma' (usually with the hope that doing so will make the symptoms go away). It's relatively unusual for clients, at this stage, to come focused on the things they do want, and the changes they want to make in their lives. This is both normal and understandable but, if the clinician buys in to this framing of the problem - where the work is solely about symptom reduction - it can cause difficulties in creating an effective treatment plan.
Why is it a problem? Well, when we talk about symptoms, were often referring to ordinary human experiences (emotions, thoughts, memories, physical sensations). These aren't things that clinicians can easily take away from clients, even if doing so were desirable (would it really be helpful for clients to never feel anxiety, for e.g.). In fact, the client is usually already engaged in strategies to control or avoid these symptoms/experiences which are likely having a negative impact on their quality of life. We don't want to add to this by doubling down on this symptom/experience control agenda when it is demonstrably not working for the client. Ideally, we want to do the opposite by beginning to loosen this agenda, and opening up for the client the possibility that an alternative strategy may be more effective, by shifting from a frame of symptom/experiential control, with a focus on the elimination of symptoms, towards a frame where we consider that the problem is actually in the pattern of responses clients have to their symptoms/experiences, and not the symptoms/experiences themselves.
For e.g., in PTSD it is common for clients to respond to intrusive memories by attempting to push them out of their mind. We know that, when clients do this habitually, they tend to maintain the distress associated with these memories and increase the frequency and intensity of these symptoms/experiences. We also know that habitual avoidance of these symptoms/experiences can lead clients to restrict their lives, in ways that reduce their quality of life, in order to limit the potential for triggering these experiences. An example may be clients who avoid engaging with young family members, because they find the shouts and screams triggers memories of previous trauma, who find their relationships with family negatively impacted. Or clients who avoid public places, because crowds trigger their anxiety, may struggle to get to work, with all the associated difficulties that stem from that.
Both of these examples demonstrate strategies that are effective in minimising distress/symptoms in the short-term, an aspect of the client's experience we should take time to validate, but which also lead to negative consequences for the client's quality of life, in the medium to longer-term. The difficulty is, when clients are disconnected from their values, and have no clear goals beyond symptom reduction, they tend not to be easily influenced by these longer-term consequences and instead remain short-term in their responses intended to escape/control acute distress. And, as we know, those symptom/experiential control/avoidance strategies do work (in the short-term), reinforcing them and making them more likely to be repeated. The direction of travel, with this short-term focus, is likely to be increasing levels of avoidance, as the client repeatedly attempts to find ways to minimise their symptoms/experiences, gains short-term relief, and so repeats each time they have these unwanted symptoms/experiences, creating a powerful maintenance cycle. Indeed, they may (and probably will, at least initially) come to therapy with the hope that we as clinicians will be able to give them the solution that will finally eradicate these symptoms/experiences for good. If our response to that agenda is to confirm it, by making goals for therapy about symptom-reduction/emotional control/avoidance, then we, and our client, are likely to get stuck in a vicious cycle of increasing avoidance, reduced meaningful activity, and lower quality of life.
This is why, when working with clients, such as the ones above, establishing what is important to them, such as relationships with family members, or engaging in work, as early as possible, is important. It allows us to reorient the client's attention towards an assessment of the workability of their symptom/experience control/avoidance agenda, in the context of their longer term goals. In other words, they begin to notice if their attempts to control/avoid their unwanted symptoms/experience is causing them greater problems in the long-term than it is solving in the short-term, and opens them to possibility that an alternative approach to control and avoidance may be helpful. Indeed, the difficulty with change is that longer term consequences, such as difficulties in relationships, are often too far removed from the acute distress the client is experiencing, in the moment, to influence their behaviour and to reinforce more workable alternative strategies. Helping clients to identify their values and goals, enables them to shift their awareness to the longer term-consequences, allowing those consequences to exert an influence on their behaviour in the present, leading to desired consequences that can act as a reinforcer of this more helpful/workable behaviour.
From this perspective, any given strategy can be evaluated by the client in terms of its workability in moving either towards, or away, from the things that matter most to them. Motivation to engage in the work tends to be improved because we are connecting with a positive understanding of the things that are important in the client's life and actively working towards them.
This is why, with genuine validation of their experience and distress, it is helpful to encourage the client to begin thinking about what they value in their lives, as early in the process as possible. It is extremely difficult for clients to be open to idea of changing their response to their symptoms/experiences, in a way that minimises control and avoidance, if they are unclear what is important enough to risk making that change. Why would a client be willing to consider learning to change their response to their anxiety, rather than seek to eliminate it, if it isn't clear to them that their current responses are what are preventing them from achieving their goals? Indeed, without a clear sense of their personal values, from which goals can be established, how do they start to assess the workability of their current control/avoidance strategies? It should be no surprise that, absent a clear sense of values, that clients come to us hoping we can make a success of their experiential control/avoidance agenda, and that any strategy we suggest will likely be quickly co-opted in to that existing agenda. But, when the client, and the clinician, are clear on what it is the client values, we can establish goals on which we can work together. This gives us two main benefits.
1. The opportunity to alter the current pattern of responding in real world situations. This gives the client the opportunity to experience the workability (or not) of their responses to their symptoms/experiences, first hand. They can experience whether what they are doing moves them closer, or further away, from the things that really matter to them. Experiential work like this, with direct contact with consequences of their choices, is powerfully reinforcing and much more likely to embed the changes in the client's behaviour we are trying to achieve.
2. Perhaps most importantly, by establishing goals based on their personal values, and committing to taking action towards them, the client is making real changes that are likely to lead to an improvement in their quality of life. Our work as clinicians is ultimately in the service of clients being able to function as effectively as possible in line with their personal values. Symptom reduction alone, that does not lead to an improvement in quality of life, is very much second best to full & consistent engagement in meaningful activity that leads to satisfaction, meaning and purposeful living.
To summarise, identifying values-based goals doesn't mean ignoring symptoms/experiences, or involve asking clients to grit their teeth through them in order to achieve their goals, but instead means guiding clients to change their relationship to these experiences so that their responses are reorientated in service of the things that matter most to them. In doing so, we give our clients the best chance of breaking powerful short-term, life-sapping, control and avoidance cycles which are keeping them stuck. If we want our clients to step out of those cycles and move forward, then helping them choose another direction is a vital first step.
Christian Hughes is a Psychotherapist, Clinical Supervisor, and Clinical Trainer, specialising in Acceptance and Commitment Therapy, with expertise in Trauma, PTSD, and a special interest in Moral Injury.