I have worked with several therapists
and counsellors and had a range of experiences some of which I will
share here. Although my relationship with my current psychotherapist
is positive for the most part there have naturally been miscommunications
(as in any relationship) which have affected the work. However, I believe
it is the shared learning from these experiences that has made our relationship
stronger and more effective.

The following are, in my opinion, the
most important emotional, physical and intellectual client needs that
can be met by the therapist to create the optimal working environment.
These come from my own experiences as well as discussions with friends
and colleagues who have experienced therapy or counselling in private
practice.

We have all found that some simple considerations
can make a significant difference to the client being able to feel comfortable
and concentrate on the work in hand. I believe that ignoring these simple
factors can make it difficult for a client to feel comfortable enough
to discuss important issues and in some cases even to concentrate in
session or to continue working with a particular therapist who fails
to meet these needs.

For clients:
There may be other issues that are important to you personally
that I do not mention here and, as always, I would recommend you discuss
them with your therapist and try to resolve them before quitting or
changing therapist. They are human too and sometimes they just
can’t read our minds.

One of the major challenges for therapists
is the high level of clients quitting therapy after just one or two
sessions, often with no explanation. I hope that this article will reassure
clients when thinking about some of their conscious and unconscious
reactions to the therapeutic experience and give therapists of all theoretical
persuasions some insight into the client experience of therapy and some
ideas as to how we can work together to give the process the best chance
of being successful.

Emotional Needs

Empathy and authenticity

There is a balance between empathy and
authenticity. Many therapists who follow client-centred therapy techniques
are excellent at being really supportive and empathic to a client when
talking about difficult issues. This is great for the client’s self
esteem and can help to create a supportive environment in which work
can be done however, there is a point at which the therapist begins
to lose credibility by just being too nice and therefore loses
the authenticity of being a "real person".

For me it is essential that I feel I
am talking and relating to another human being who can express their
own opinions even if at odds with mine - as long as it is done in a
sensitive and respectful manner.

It is important for the client to remember
that we are not here just to have someone be nice to us, (particularly
in the case of medium or long-term psychotherapy or psychoanalysis)
but also to challenge some of our more dysfunctional beliefs and help
us to change and grow.

It is also essential for the therapist
to remember that it is not all or nothing – empathy or challenge -
as too quick a transition from one end of the spectrum to the other
can be traumatic for the client especially if re-experiencing emotional
inconsistency from a previous (i.e. parental) relationship. This kind
of treatment can create some pretty extreme transference issues and
ultimately lead to the client feeling confused and traumatised enough
to quit therapy.

The use of challenges

As outlined above it is essential that
challenges to behaviour or thinking are made with the utmost sensitivity
towards the individual patient and take into account their limits and
abilities as well as their emotional state at that precise moment in
time.

Therapists need to be aware of the patient’s
potential reactions to challenges particularly based on previous life
experiences and explain that questioning and challenging is about helping
the client to think and see for themselves and not about grilling them
for information because they (the therapist) demand to know the answer.

Clear boundaries

Boundaries need to be explained to the
client at the beginning of therapy and be repeated and maintained in
a consistent way throughout in order to create and preserve the secure
therapeutic frame within which the work will take place.

Clients who have experienced therapy
before and "act out" i.e. through boundary violations are
probably testing the new therapist’s limits and should be challenged
accordingly. However, therapists need to take into account that for
new clients the therapeutic relationship is an utterly bizarre experience
and many if not all of the boundaries will be unfamiliar and will therefore
need explaining as the process continues rather than being used as an
area to challenge or confront the client. In this situation this kind
of challenge is unnecessary and can be damaging to the inexperienced
client’s self-esteem.

Metacommunication

Talking about the process of therapy
itself and the relationship between this client and this
therapist is essential however in my experience it should not begin
too early in the process as feelings and issues beyond that which the
client initially brings to the therapy need time to develop. I would
suggest that the therapist introduces the concept of metacommunication
somewhere between first and second month of once-weekly treatment unless
it is previously brought up by the client themselves.

At whichever point this conversation
begins the therapist must be ready to accept any feelings from the client
in particular the possibility that the client has no transference or
feelings about the therapist beyond simple gratitude and the recognition
they are trying to help. I have found (and have found this to be the
case with other clients I have spoken with) that some therapists tend
to "push" for transference and leave clients feeling more
confused than ever because they don’t understand what is being asked
of them. This can lead to unnecessary confusion, feelings of inadequacy
and an inability to “perform” for the therapist and can lead to
problems of denial as and when transference feelings do finally arise. 
Transference feelings may take a while to manifest and therefore all
therapists need to allow this to develop at the pace of the individual
client.

Equally, therapists should not be afraid
discuss the more negative aspects of the relationship. I have found
that some therapists will avoid discussions of possible ruptures. The
client will not always voice disappointment as clearly as "you
said X and it felt like Y”. This is often because of lack of confidence
or experience of expressing needs or emotions. Therefore the therapist
not only has to be sensitive to negative reactions but also willing
to discuss them and in a non-confrontational way. Issues that are not
discussed will not be forgotten by the client and will most likely become
resentments that are carried through into later stages of the therapy
and left unresolved can lead to barriers in the progression of the work.

Sensitive issues

Not all therapists have first-hand knowledge
of every life experience. Without the need for therapist self-disclosure
it is important for therapists to admit to having little or no knowledge
of certain areas that are beyond their experience such as their client’s
particular religious upbringing, racial or cultural environment or experiences
of prejudice in society.

It is better that the therapist admit
ignorance about this to the client and either make an effort to become
more knowledgeable or give the client the option of being referred to
another therapist (if appropriate) than wade in to the client’s world,
expounding theories and risk offending the client through their ignorance.
The admission of ignorance or inexperience will be seen by the client
as a sign of the therapist’s humanity and respect for the client rather
than weakness and incompetence - which is exactly what will be demonstrated
by shoving your foot in your mouth!

Intellectual Needs

There is a natural imbalance of power
in the therapeutic relationship often carried over from client preconceptions
about the traditional doctor/patient relationship and occasionally this
is reinforced by the therapist’s own narcissism.

It is essential that each client is treated
according to their intellectual as well as their emotional capabilities.
For example, if a client talks of their love of reading, desire to understand
and need to be in control of situations, the therapist can help the
client and the process by suggesting some helpful or relevant texts.
Obviously if the client expresses no interest in this then therapists
should not suggest reading material or it will feel like "homework".

Therapists should be aware that if their
client is an inquisitive control freak like myself then they will be
looking for information. If the client expresses a need for more information
then a natural response should be to help them get it. Some therapists
seem scared by inquisitive clients however I believe this can be used
to great advantage if fostered in the correct manner. It is better that
clients get recommendations of quality relevant peer-reviewed texts
than a load of mis-leading self-help rubbish.

Learning about the therapeutic process
and any relevant medical or emotional conditions can help to empower
patients, increase self-esteem and drive therapy forward rather than
leaving us flailing around in the dark feeling out of control. Getting
support from our therapists in terms of intellectual learning not only
builds empathy but also gives a mutual purpose to the work.

Physical Needs

A comfortable environment

I once went to a therapist whose office
consisted of  two cheap plastic chairs facing each other in the middle
of a stiflingly hot and claustrophobic room and I knew immediately that
I would never be comfortable in this room or with this therapist. I
quit after two extraordinarily uncomfortable sessions. (There were other
reasons but this was the one I most remember).

Whilst I am not suggesting lavish furnishings
and am aware there are limitations to the place of work and budgets
available, if therapists are not using the traditional couch setup it
would be great if therapists took a moment to think about creating a
comfortable environment with a sofa or armchair that feels comfortable
and doesn’t, for example, have broken springs poking you in the rear
for the full 50 minutes. This is a simple thing and thankfully most
of the therapists I have met with have managed this. Personally, it
also helps me if I am near or can see a clear route to the door/exit
of the room.

Temperature

It is very difficult to get the temperature
in the room right for everyone but therapists need to be aware that
different people have different internal body temperatures and could
be coming in to the room from a warm car or a cold street and adjustments
may need to be made.

Strong smells

One of the fundamental reactions we have
to each other as humans comes from our awareness of smell. We pick up
on smells unconsciously and it is a major factor in how comfortable
we are with situations and people and especially with people we trust,
close friends and partners.

In the therapeutic environment clients’
senses are heightened. This may be because of the stress of the situation
or the fact of knowing so few concrete details about the person we are
talking to that we will pick up on anything we can. Because of this
it is essential that the therapist not distract the client with strong
odours such as perfume or aftershave (these are very subjective and
one risks "turning off" a client if they find the smell unpleasant)
or by having something noxious for lunch!

Equally, the environment where possible
should be free from strong external odours such as cigarette smoke or
cleaning products/ disinfectants wherever possible.

Clean up after previous clients

Unless therapists are trying to stir
up transference it is courtesy to clean up after previous clients. There
is nothing as off-putting as seeing someone else’s tissues left on the
sofa.

The role of physical contact

I have discussed this before on my blog
and there are hundreds of books and articles written by therapists on
the subject of the role of touch and physical contact in the therapeutic
relationship.

It seems from what I have read that therapists
think that all clients are desperate to be hugged or held when experiencing
strong emotions or re-living trauma and the question is whether or not
to "give in" to that need. I think that therapist’s focus
should not be on whether or not to touch but what the client actually
needs. In the case of those clients dealing with prior physical or sexual
abuse for example there is often a fear or phobia of physical contact
and physical contact with another, even if intended as comfort, is the
last thing they want.

The best solution I have read on the
topic is for therapists only to touch when initiated by the client and
to limit this as much as possible to remain within ethical guidelines
without seeming cold or rejecting to the client (Maroda 1998).

Therapists seem terrified of this area
of discussion but I think if they did discuss it more openly with clients
they would find that the issue can be easily resolved by mutual agreement
on a case-by-case basis.

Conclusion

As we have seen there are a number of
areas in which therapists can help clients to feel more comfortable
in the therapeutic setting. The examples set out above are only a few
of the more significant issues from my own experience and of course
each client experience is unique.

I would always recommend that clients
make a concerted effort to express their individual needs to their therapist
and would hope that therapists recognise this effort and endeavour to
respond with compassion and an authentic desire to accommodate needs
where reasonable and possible.

Working together we can improve the experience
of therapy for both participants, create an open and mutually collaborative
experience and make something grow out of this often confusing, always
complex, but ultimately human relationship.

Further reading

On being a client - David Howe

On learning from the patient – Patrick
Casement

Seduction, surrender and transformation
- Karen Maroda

Consuming psychotherapy – Ann France

Shouldn’t I be feeling better by now?
– Yvonne Bates (ed)

Falling for Therapy – Anna Sands