I read a discussion recently involving the set up of chairs in the interview space; the chairs for the client and the counsellor. The question was whether they should be facing each other or at an oblique angle? This prompted me to consider this and certain other aspects of the overall experience of a therapist and client interacting.
[1] Seating. When set up at an angle, the client has the option of looking at the therapist or comfortably looking straight ahead but not at the therapist. Given that some of the material that comes up in a session can be extremely difficult, having the arrangement set up so that the client is able to look away from the therapist without having to twist their head or body uncomfortably allows them more psychological space to deal with very vulnerable feelings that arise when deep trauma is being processed. This can be very important for the client’s sense of therapy as a safe space.
The oblique arrangement allows for and actually encourages clients to define their own spatial boundaries vis a vis the therapist whenever they feel the situation warrants it. This empowers the client, especially when they might be overwhelmed by feelings of shame, guilt, confusion or simply overwhelming pain when touching memories of trauma. Setting up the physical space properly for the client gives them a better environment to process what they are engaging during therapy.
Psychotherapy is much more than just what we say. It is like understanding how music is much more than the notes we hear. The pauses and silences are equally important as they shape the melody and rhythm. The silence and pauses in therapy, and the psychological space they provide, should be treated as equally important to our words. Proper psychotherapy requires setting up a safe milieu in which the client can process trauma, grow and change. Small details are often the key to the engendering the experience of safety.
[2] Modelling Life. This is another small reminder of the office setup. If there are flowers and plants being displayed, they must be alive and vibrant. Place yourself in the position of a client who enters your office and sees flowers on the window sill that are dehydrated and half dead, or a green plant dried to a dying brown, or a fish tank with dead fish floating or algae covering everything.
If you do not care enough to keep the plants and flowers fresh and blooming, please do not display that kind of carelessness. Some therapists have a cat or dog that clients connect with as an expression of life and support. Simple details highlighting life mean a lot to the client who enters the office with no real knowledge of who you are as they are hoping you are the right person to help them. They will likely read into details of deficiency or negativity, and such unfortunate details will have a disproportionately greater impact on the client. To put it simply, a dead flower may mean to a client that you are insensitive to pain & suffering, or even to beauty in life. Living plants and animals convey a very different message.
[3] Punctuality. Some doctors are notorious for keeping their patients waiting. This communicates the message, correctly or not, that “My time is more important than your time.”
This is not an incorrect assessment by the client. I myself am annoyed if I have to be kept waiting for half an hour for an appointment that is specified to be on the hour. There is no excuse when this occurs regularly. The conclusion that I come to is no different than what any client would come to: The doctor thinks his/her time is more important than my time. There are, unfortunately, doctors so obsessed with not wasting time which equals money if they are being kept waiting for the next patient, that they ask their secretary to double book patients. This is the opposite of creating a healthy supportive environment for psychotherapy clients.
If there is an absolute emergency, have the secretary tell the patient you are held up in an emergency. Needless to say this should not be a regular occurrence, or it will undermine the therapeutic alliance.
[5] Information gathering. There are two ways of gathering information. The first is by questions and answers according to a list. Filling out a standard questionnaire may not be a good practice. There are important basic data that one should keep in mind to eventually find out, but not necessarily in the first intake interview.
For example, early childhood adverse experience is something about which a therapist must eventually have some knowledge. But questions related to this should always be approached in an oblique way unless and until the client is comfortable and there is enough trust in the therapeutic relationship. Pursuing those questions directly, before a strong therapeutic alliance has been established, could well be met with a false negative answer. It is often wise to wait for an opportune time to pose certain questions, based on the then present qualities of the relationship between therapist and client.
I would also encourage the therapist to suggest to the client that if he/she is not ready to divulge certain information, that they can simply say, “I do not feel comfortable to talk about this today.” It is important to remember that empowerment of the client is an essential element in all therapeutic processes. So, such a statement by a client is not a confession of weakness and should not be seen that way. Rather, it should be presented and accepted as empowering the client to have more control in the therapeutic exchanges. This kind of frank statement by the client will inform the therapist that the timing is not right, raising their awareness to a higher degree. Be careful, to not push on that topic until a deeper therapeutic alliance has been established and the time is right for the client.
[6] Core Conditions. I cannot emphasize enough, even though I have repeated this umpteenth times, Carl Rogers’ core conditions for therapy of empathy, congruence and unconditional positive regard. These are also sometimes referred to as the “facilitative conditions.” In other words, they are the conditions that the client needs to experience from the therapist for therapy to work. An expert in EMDR or CBT (Cognitive Behaviour Therapy) who ignores these Rogerian core conditions will undermine their own therapeutic alliance with the client to the detriment of their therapeutic skillset.
I was not taught these points in my training as a psychiatrist, but that was over 50 years ago. I am uncertain as to whether or not this is taught in psychiatry or counselling courses today. It is possible that it is taught more as an aside and, if so, soon forgotten under the pressure of a busy practice. However, it is something for clients to mention to the therapist if the therapist appears to fail to consider these 6 points, which feedback therapists should acknowledge and for which they should express appreciation.
