She enters the office and takes her position: feet curled into the chair beneath her, fingers gently petting the soft pillow on her lap, eyes fixed on me. Waiting.

He sets his phone to vibrate, puts it in his bag on an empty chair within reach. A water bottle is placed next to the tissues on a side table. He adjusts a pillow to support his back and settles into the chair, his eyes focused halfway up the wall to my right. Waiting.

Others greet me with a handshake or hug, offer comments about the weather and the commute, or immediately pay for the session. The rare iconoclastic types who sit in different chairs on a regular basis and vary their routines, are almost equally predictable.

These behaviors are attempts to settle into the space and ultimately, to help with the transition into the challenging work of psychotherapy. Getting comfortable is often the way we prepare to be uncomfortable. I have my own patterns of greeting and then settling into a session, serving much the same set of purposes. Similar patterns are evident at the end of each session as we transition back to the outside world, re-engaging with those familiar parts of ourselves essential to navigating daily challenges.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

After all, we are creatures of habit, custom and ritual. It is within our predictable routines that we feel most at-home. To change patterns of behavior demands that we tolerate being at risk and vulnerable. If attachment theory has taught me anything it is that human beings need to feel a strong connection with a safe home to effectively take risks beyond that home.

Therapy is always a risky venture. By crossing the threshold of the therapist’s door, the client is rolling the dice, and the wager – what they could lose – is far costlier than the therapist’s fee. They are opening themselves up to discomfort in the hope of increasing their joy. It is a risk I would never advocate a client take in a game of chance! When we (those without a gambling problem, of course) play the slots and lose, that loss stings for a moment but typically has no lasting impact on our lives. The money lost is not needed to pay the mortgage or feed a family.

The client, however, is not gambling with funds set aside for entertainment. The client risks upsetting the order of their life, and when a session is over, they may not be able to leave that upset behind in the therapist’s office.

Fortunately, the odds of hitting the therapeutic jackpot are astronomically greater than in any game of chance! Such games demand the player surrender to the whims of fate, while therapy engages the will and empowers the client. The payoff is not merely a means to happiness but is itself joyful.

I bring to my work knowledge, understanding and professional discipline. I also bring my ego. I like to think of myself as a creative person. Conversation has always been an artform for me that entails engagement, insight and the capacity to recognize and articulate the connections between things. What experience has taught me and reinforced over the years is that these artistic/creative qualities can all be great assets in psychotherapy, but they are rarely enough to ensure a positive outcome for my clients.

In fact, creativity, I have had to admit, can also be an obstacle to the client’s progress. I may be intellectually and emotionally excited by a reframe or interpretation, absolutely convinced that it is a useful and applicable intervention, and yet it might, in practice, be a disruption or even give rise to a therapeutic rupture. The creative intervention, born and delivered primarily as a product of my own enthusiasms, can be out of sync with the client’s immediate safety needs—implicitly inviting a change that is not yet supported.

Creative people tend to push against boundaries. They look for the rules that can be fruitfully violated. An artist recognizes the utility and value of structure, but regularly seeks opportunities to depart from it in service of expanded artistic expression.

A returning veteran was referred to me for EMDR treatment to address PTSD stemming from his deployment. As we progressed through the early stages of EMDR (engagement, history gathering and psychoeducation) we identified many interrelated issues, and it soon became clear that the client and I had been collaborating in trauma-related avoidance. I had engaged in lengthy discussion about current issues, many of which I artfully linked to trauma symptoms, justifying my delay in initiating the active ingredient of EMDR: bilateral-stimulation (BLS). Finally, in a session that began with the client’s earnest description of a recent loss, I stopped myself from responding with exploration. Immediately, I asked him to identify his emotions and their somatic expression. We then utilized BLS to process and reduce his reaction. By session’s end, building upon confidence born of that success, the client was willing to directly address the traumatic deployment, and I was ready to stick closer to the EMDR format. Both therapist and client require comforts to perform optimally in therapy. The therapist’s comforts, however, must also promote the client’s comfort and progress. An appropriately applied Evidence Based Practice (EBP) should help to ensure this balance, providing a structure for the clinical process and containment of the unpredictability that accompanies the untamed winds of creativity.

The similarities between the client’s self-comforting behaviors and what, to my artistic self, may appear to be repetitious patterns of intervention, may in truth be central to the EBP’s effectiveness. What I judge to be lacking in the organic intimacy found in unstructured dialogue, may in fact meet the client exactly where they are at and provide them with an essential component of their own empowerment: predictability.
I strive to maximize the predictability of a structured approach in my practice by initially disclosing the structured elements of the therapy (duration, participants, session-to-session structure); sharing the rationale of the EBP; consistently using the same relevant terminology; and regularly utilizing the same measures. Working with an EBP or other structured therapeutic methodology allows me a far greater opportunity to make therapy transparent than when I am working in less structured ways. Increased transparency promotes collaboration and helps the client take ownership of the outcomes.

The habits and behavior patterns exhibited at the start of each session remind me of how challenging therapy can be for the client, and how difficult change can be for us all. Creating opportunities for client change demands a therapist’s creativity and willingness to take risks along with the client, who is willing to be set off-balance and to persevere through discomfort. That capacity to endure is rooted in underlying structures that provide the foundation for security, safety and autonomy.

File under: The Art of Psychotherapy, Musings and Reflections