19 Ways to Screw Up Time-Limited Counselling
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George Leach
Time-Limited therapy isn’t the poor relation of open-ended work, but rather a distinct model with its own clinical advantages, theoretical emphases and therapeutic rigour. But working with the ending from the beginning is crucial, and something therapists initially trained in open-ended work may not be prepared for. Here counsellor and supervisor George Leach shares 19 hard-won lessons about the most common ways in which we get time-limited counselling wrong.
I got my first counselling job a few years after completing counselling training in open-ended psychotherapy. So I had to adapt rapidly to using a six-session model in the context of an NHS counselling service. With the help of my clients and supervisors, I learned a lot: some of it the hard way, but I was encouraged by the growing body of research suggesting that this was a worthwhile project:
- Most improvement happens early in the therapy
- (With a few exceptions) there is no clinical evidence that longer term work has better outcomes
- Improvement continues after termination
It is still the case that most therapists who find themselves doing time-limited work are underprepared for it in terms of formal training. So let me share with you my top 19 blunders. I very much wanted there to be 20, but with limits as my theme…
These are not in any particular order, except that the first on my list is the most important.
1 Don’t work to a negotiated focus
Working without a focus that is explicit and agreed with the client is the strongest predictor of therapeutic failure in time-limited psychotherapy. End of.
2 Have a focus that is vague or unrealistic
… because you might as well not have one at all.
3 Ignore the presenting problem
If you think that it’s your job to find out what’s REALLY going on at an inferred deeper level, rather than getting alongside the client where they are to start with, then time will be wasted and it will be that much harder to forge a therapeutic alliance.
4 Don’t modify your technique
Whatever your core model, if you work in exactly the same way as you would for a long-term client but just stop after a pre-ordained number of sessions, then you are effectively abandoning the client and denying them the opportunity to make the most of the time available.
5 Surround your technique with an air of mystery
It is a mistake to assume that your clients arrive in therapy understanding your core model. Informed consent about HOW you propose to work is essential to manage expectations and establish a collaborative therapeutic relationship.
6 Believe that more is always better
This is guaranteed to leave you and your client feeling frustrated, and prevents full engagement.
7 Don’t talk about the ending
If the framework is not made visible, it can’t contain the work that is needing to be done.
8 Act out about the end date
For believers in the unconscious, diary mistakes, and communication errors about when the end-date falls, may be a way in which resistance to ending finds expression.
9 Blame the organisation
Collude with the client in bemoaning the meanness of your organisation which is preventing you from doing the longer term work that is ‘really’ needed: it stops you from facing the client’s feelings about ending in the room, which is comfier but a wasted opportunity.
10 Blame the client
Traditional thinking in the psychotherapy field insists on a (largely) unsubstantiated claim that certain kinds of client are inherently unsuitable for time-limited work. Actual research says otherwise.
11 Blame yourself
Becoming immobilised by guilt feelings ‘as if’ you were harming the client by working to a time limit gets in the way of helping the client experience the difference between an ending and an abandonment.
12 Blame your training
The limitations of your training as a preparation for this specialised form of therapy should be used as a stimulus to seeking appropriate CPD opportunities rather than being a ‘fait accompli’ for not adapting your technique to the task in hand. (See number 4.)
13 Retreat from engagement with the client
Time-limited working is active and demanding – it can be tempting to not fully engage to reduce the ‘wear and tear’ of intensive work. A caseload that ‘churns’ is more challenging and less suited to some therapists’ attachment needs.
14 Get confused about whose needs are being met
Work that is satisfying and gratifying can also be in the client’s best interest, but it’s not a given.
15 Fail to see the upside of existential anxiety
A time limit neatly mirrors core existential themes that are always there to be explored: ‘what do we do with the time we have left and what might our finite lives mean?’
16 Forget that psychological time is different from clock time
The psyche is essentially timeless. The past shows up in the present and the ‘here and now’ is intimately connected to the ‘there and then’. It’s never too late for discovery to happen.
17 Keep the worms in the can
Fear that sensitive topics should be left alone when faced with the ending is misplaced. It makes the worms more scary. The idea that time-limited work is necessarily ‘superficial’ can become a self-fulfilling prophecy.
18 Therapeutic perfectionism
As Winnicott said, ‘good enough’ can be developmentally better than ‘perfect’, at least if growth is to be facilitated.
19 Therapeutic frenzy
Manic interpretation and bombarding clients with everything you have is counterproductive. Sometimes less really is more.
A version of this article also appears in the Spring issue of Sussex Counselling and Psychotherapy News (SCAP Magazine).