Workshop Therapeutic Practice: Proximity Disclosure Ending and Appreciation
I have divided my original document into separate topic documents and will post each separately -so look out for Proximity, Ending, and Appreciation
This workshop came out of requests to include various aspects of therapeutic practice, particularly disclosure. Allowing myself to freefall from these requests led to the arrival of four aspects of this workshop. I did not overly consider how they might interrelate, if at all, beyond being aspects of the therapy relationship. In the composition of these ‘emerging thoughts’ I was considering the habitual dimensions of my work, or what I would like to think the possible habitual dimensions. One pleasing aspect of these essays and workshops is how they prompt a freshness in my thoughts and my work; I am better off in my work through these activities – well, that’s continuing professional development for you!
Every session must end and will send a message about you to your client (as indeed will the beginning). I wonder whether the ending of sessions with the same client becomes routine, habitual in style. I wonder whether a therapist might have a habitual ending for all their clients.
the theme that stalked the therapy from day one was the issue of ending.
The opening quote in this section captured me, and stalked me. Such an evocative word, stalked. As I write I am reminded of all the endings I experienced with the regularity of geographical moves during my childhood. Perhaps being evoked for me are these accumulation of endings, and in my own therapy I recognise the importance my therapist placed in having me experience ending as a conscious event; and with that an appreciation of the experience I was ending, as well as an appreciation of the ending as an experience in its own right.
So, my thoughts now are recognising the depth this single aspect, ending, might reach. Yet, the ending of therapy is an aspect that is ‘not taken for granted’ in that its exploration is usually explored in training and supervision. Perhaps, the ending of each session becomes ‘taken for granted’. Thus, in structuring the workshop I had in mind the end of the session and consideration of this as a building block to the end of therapy.
I spent a number of years working with adolescents and a wise supervisor advised to treat each session as the last because sometimes this age group simply do not return – well maybe that’s a whole workshop on its own. The advice provided me with an awareness of the delicate balance the therapeutic engagement can have and the value to stay with each moment of therapy, including the end, the leaving, the separating, the goodbye.
End of the Session
Unquestionably, after 50 minutes the session is over and the client leaves. Do you sometimes want to continue; do you sometimes go over time; do you sometimes agree to extend the session?
What, though, do we mean by the end of the session? What amount of time is given over to ending the session? Well, this will depend on what has occurred in the session; and perhaps be influenced by previous sessions.
For some therapeutic approaches, and possibly through some organisational requirements, the end of a therapy session will include feedback and assessment (O’Brien and Houston 2000) as a distinct exercise within the therapy work. Aside from such requirements the ending is required to ready the client to leave the confines and all the therapeutic space represents and be ready to re-enter their everyday world.
Therefore, there is a need to have a structure of the session that you maintain so the ending is not rushed, or missed, or extended. Whatever the work the client does in the session you need to ensure the client is ready to re-enter a more complex environment outside the therapy room. This does not necessarily mean having the client in a comfortable, content place. This means the client is able to leave in a functioning manner; and that might also mean being distressed, or uncomfortable, but will mean being ‘held’.
This last word is what is important. The client needs to feel that they are not abandoned or cast out. The client might feel abandoned or cast out anyway! As the therapist, I need to monitor how much of the holding I am doing that might be for me. I need to consider at what point I trust the client to hold more, thus avoiding being overprotective of the client.
With an uncomfortable session, I might say to the client something like ‘you’ve touched on some tough things today, it might be worth resting when you get home’, or if there has been a degree of shock I might suggest the client has a warm tea with sugar.
Sometimes when a client is leaving I have found myself drawn to saying something like ‘if you need to call me in the week do so’. My intention is to be clear of the additional support on offer. However, I am aware I am now wondering about intentions out of my awareness. Might I be worried the client cannot cope? Might I be thinking I did not hold the client sufficiently? Am I feeling guilty of something – not having addressed the client’s need? All could be possibilities, and are to be reflected on and talked out in supervision.
Give an inch take a yard
Well, that might be cryptic; a saying from my childhood of inches, feet, yards and miles; pounds and ounces not gram and kilogram. Apologies to you youthful folk….
Fifty minutes is fifty minutes and give a minute the client will take and hour! Behind this phrase is that if you allow your client to have extra time they will inevitably take it, and take more. True or False?
Imagine your yearning for being heard, for being seen, for a space to unburden. I’ll take it thank you very much, the more the better. The therapist is tasked with modulating the client’s yearning in this respect. Go over time may not help the client develop the capacity to modulate; equally not allowing some time extension may not allow the client to develop the capacity to modulate.
There is one particular client presentation where strict adherence to time (and indeed all) boundaries is required. This requirement needs to be held as it will be the only solid and bounded and consistent experience. This is required for clients that present with strong traits of borderline personality disorder.
Extending the time
At times, I have let, indeed, advised the client to stay a little longer to get their bearings and sometimes offer a cup of tea or coffee. On one occasion when the work plunged deeply into some trauma work I completed the work and before the session time had finished suggested we both sit in the kitchen and have a cup of tea. I was able to do this since it was private and contained. The purpose of my intervention was to bring the client fully into the present moment and to normalise their being with me as much as possible. The time overran and we had a conversation, whilst maintaining a therapeutic awareness for the client’s needs. The overriding requirement was to bring the client back from a dissociative state to an ordinary situation.
I have worked with a number of clients presenting with strong borderline characteristics, and some with quite severe characteristics. Over time in both my work with these clients and my increasing experience and knowledge I have removed some rigidity in applying the time limit of 50 minutes. When the timing is right there is the recognition from the client that I am willing to ‘bend the rules’ and I am trusting the client with these occasional, not repeating, shifts.
This makes sense. We are all human, flawed, and inconsistent. Relating to one another requires boundaries that are flexible and humane that are also balanced with not being abused for our trust and giving. This needs to be experienced to be understood.
Finish on Time
Often the hard and fast rule is simply that you finish at 50 minutes. When you are beginning to work as a therapist and especially when it is within an organisational setting there may be little choice in extending a session. It is good practice to maintain the 50-minute boundary very firmly. Simple logic – ‘I have another client, we must end.’ I admit I don’t always do this; and did maintain the boundary for the first so many years.
Therapeutically attending to any desire of the therapist or client to add time will allow an exploration of any transference in the room, or any unmet need in the therapist, or in the client. As necessary this exploration can be brought into future sessions.
In any case, the client has paid you for 50 minutes – and consider this the case even if there is no monetary exchange. Your time, and indeed the client’s, is limited and contracted.
Beginning the End
I am conscious that I have neglected to answer the question of what is meant by the end of the session. 10 minutes of the 50 seems to be mentioned throughout the google search results. The context here is the summarising with the client and completing any forms needed.
Pragmatically, my endings are variable. The time put over to closing down the work depends on what has gone on in the session. Monitoring the session leads to a sense of what will be needed at the end.
I have, for example, worked to the last minute, then thanked the client for their involvement and for what they have given, and then said it is time to finish and I will look forward to our next session.
I have given notice that there is 10 or 5 minutes left I would like to draw the threads of the session together before we finish.
Sometimes I have begun the session by emphasising the need to finish promptly today (sometimes with a reason, sometimes not – disclosure!).
Developing your therapeutic skills is well served in the beginning with maintaining the 5 - 10 minute rule for drawing a session to a close. The novelty (Perls et al 1951) of the therapeutic experience needs to be maintained by ensuring this rule is not a habit.
I recall a particular client that as soon as I pointed out we were near to the end of the session would take this in its immediacy and stop; literally just stop. Initially I would, therefore, not refer to the end until the final minute. As I leant more I qualified the ending with something like ‘in these last 5 minutes I would like to …’
When the Ending is the Work
The client example above is, in fact, one with which the ending itself is scope for work; what is going on for such an abrupt stop? So, attending to your client’s ending style is part of their being and may be taken for granted, habitual in its performance.
I have had a number of clients where it has become apparent that the ending of the session has been instrumental in provoking heightened levels of anxiety. In these circumstances, I have focussed the work of the session to look at this anxiousness. This has led at different times to having a contract that whatever we are working on is drawn to a close 20 minutes before the end and the last 20 minutes is used to place the work in the context of ending and explore the experience of our ending the session.
At other times the client has taken ownership of the clock to monitor the time and the exploration has been on what it is like to see and monitor the time of the session.
There are other scenarios. The common thread is about the loss of connection. Therefore, the explorations include looking at what connections were lost, or not maintained, in the past. And the current connectedness of the client with the therapist will have a representation of past experiences.
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