When several things are true at once

Situation

Aoibhinn, 34, has rheumatoid arthritis. She started therapy for anxiety at work. Over two months she has missed four of eight sessions, usually cancelling the same morning.

Known factors

• Her pain fluctuates, and mornings are often worst.
• Sessions are at 10am, in person, a bus ride away.
• Two of the missed sessions came after sessions where they talked about her manager.
• She has said, once, that the sessions “go a bit fast”.

Possible explanations, held loosely

• Morning pain and stiffness make a 10am bus journey hard.
• The topic of her manager is distressing, and cancelling gives some relief.
• The pace of sessions doesn’t suit her, so they feel less worth the effort.
• Any mix of these, or something not yet mentioned.

The therapist doesn’t assume all of these apply, or that one is the real reason.

Collaborative exploration

Agreed response

• Practical: move to 2pm, with the option of video on bad days and no charge for switching.
• Pace: the therapist will slow down and check before moving on. Aoibhinn will say “not yet” when she needs more time.
• Meaning: they agree to talk about how hard the work topic is, at a pace Aoibhinn sets. She can decide which weeks to go there.

Review after six weeks

She has attended five of six sessions, two by video. The time change made the biggest difference. Sessions after talking about her manager are still hard, but she now says so instead of cancelling. The pace has improved, though she still sometimes feels rushed. The therapist takes that to supervision. What’s still uncertain: whether the anxiety at work is changing, or only her attendance.

Situation

Tomás, 52, was diagnosed with multiple sclerosis eight months ago. His GP referred him for low mood. He says he has “no energy and no point”.

Known factors

• MS fatigue is common and can be severe.
• He has given up coaching his son’s football team.
• He’s on a new medication and isn’t sure about side effects.
• His wife now does more of the household work, and he says he feels “useless”.

Possible explanations, held loosely

• Fatigue from MS, which looks like depression from the outside.
• Depression, which also causes tiredness and loss of interest.
• Grief for a life and role he expected.
• Side effects of medication.
• Changes in the relationship and in how he sees himself.

Collaborative exploration

The therapist asks Tomás to describe a typical day, and where the tiredness feels physical and where it feels like “no point”. They notice together that on days with more rest, the “no point” feeling is lighter but doesn’t go away. With Tomás’s agreement, the therapist suggests he asks his GP or MS nurse about the medication and about fatigue management. The therapist doesn’t try to decide medical questions themselves.

Agreed response

• Practical: Tomás books an appointment with his MS nurse. Sessions move to his better time of day.
• Therapeutic: they make room for grief about coaching and about being “the one who does things”. They look at what he values in that role, and whether any of it can continue in a different form.
• Relational: with Tomás’s permission, one joint session with his wife, to talk about how the household has changed.

Review after two months

The MS nurse adjusts his medication and suggests energy pacing. His fatigue is a little better, but still there. His mood has lifted somewhat. He has started going to football matches again, as a supporter rather than a coach, and has mixed feelings about it. The therapist and Tomás agree the grief work isn’t finished. Neither of them treats the fatigue as “really” depression, or the low mood as “just” MS.

The original interaction

Gráinne, 29, is autistic and has come to therapy about burnout. In the fourth session she talks about leaving a friend’s party after twenty minutes. Her therapist says:

The therapist moves on. Gráinne is quieter for the rest of the session.

The client disagrees

The next week, Gráinne sends an email before the session: “I didn’t like what you said about the party. It wasn’t about closeness. The music was so loud it hurt. I felt like you didn’t believe me.”

The therapist explores the mismatch

What they agree to change

• The therapist will ask about the sensory and practical side of a situation before offering any meaning.
• Any interpretation will be offered as a question, with room to say “no, that’s not it”.
• Gráinne will say, or write, if something doesn’t fit. Email before a session is fine.
• They’ll check how this is going in three weeks.

The therapist doesn’t ask Gráinne to agree that there is “nothing” about closeness. That stays open, for her to raise if and when she wants to.

The review

Three weeks later, Gráinne says she’s been surprised to notice the therapist checking first. She trusts the sessions more, though not completely. Later she brings up, herself, that she sometimes does leave things early when she feels out of place, as well as because of noise. They explore that, on her terms.

Repair here wasn’t the apology. It was the changed behaviour, and Gráinne’s experience of it over the following weeks.

Not every rupture can be repaired

Gráinne could also have decided to stop, take a break, or find another therapist. That would have been a reasonable choice, not a failure on her part. See Raising a Problem in Therapy for options.