"It's not working!" 24 factors that can impede change.

"It’s not working!", is an all too common phrase heard in most therapists' offices at some point in their career (even if this is all going on inside the client's mind!). 

Even if clients don't verbalize it out loud, it can be seen through their body language and other behaviours, indicating they've often given up even before the process has had a chance to gain enough momentum.

It’s normal, and professionally desirable, to be concerned when a client doesn’t make progress. The concern is to be empathic, caring and wanting the best for our clients. It’s also about wanting to feel good, taking pride in our work, checking that we are applying the appropriate methods, and encouraging positive word of mouth marketing. 

However, there’s a difference between ‘concern’ and ‘anxiety’. Anxiety can drive a therapist to take too much responsibility, try too hard, and possibly end up not enjoying, or even leaving, the profession. So it’s important to have a sense of balance. One helpful way to do this is to look more closely at what can lead to therapy ‘not working’. 

Are you sure?

Before asking the reasons for no, or little, progress, we first need to check whether this is the case. It can appear this way because:

• Progress can be slow at times.
• The client/therapist isn’t aware of changes, some of which may be unconscious.
• Client/therapist goals have become more demanding – check initial goals.
• Client/therapist expectations were too high yet small but significant changes are afoot.

The antidote to much of this is educating clients at the outset, effective questioning to obtain information, and addressing their concerns.

 The 24 factors ‘No Progress’ checklist:

The following checklist covers many of the factors that can impede progress. Note that some are a therapist’s responsibility, some a client’s responsibility, and some are relational.

1. Do we have rapport? This is a two-way street.
2. Is my client motivated?
3. Am I motivated?
4. Is there resistance beyond my influence?
5. Is my client committing to goals and then redeciding?
6. Is my client not trying hard enough, or trying too hard?
7. Are they acquiescing – being very agreeable but not really engaged?
8. Are Primary, Secondary or Tertiary gain, or Malingering involved?
9. Does my client want to change themselves when changing context might be more appropriate, e.g. trying to manage stress but a change of career would be more appropriate?
10. Have my client’s feelings about change and our agreed outcome been discussed?
11. Am I ‘demonstrating’ empathy, warmth, positive regard, listening, openness, and interest?
12. Am I colluding?
13. Am I being too forceful with my own agendas?
14. Am I working in the client’s frame of reference or imposing? Or do they need imposition now to spark new thinking as we’re stagnating?
15. Are we moving too quick or too slow?
16. Is the language I am using appropriate to my client’s age, education, needs?
17. Am I withholding self-disclosure and coming across as cold and setting up a power imbalance?
18. Am I overly self-disclosing, taking up therapy time and forgetting who I am here for?
19. Am I starving myself of information, and the client of insight, by asking closed questions?
20. Am I acknowledging the client’s identity – Age, Sexuality, Biological sex, Gender, Religious affiliations, faith and spirituality, Culture, Social status, Ethnicity, Dis/ability (physical, mental, learning)?
21. Am I engaging my client by incorporating their interests, hobbies, passions, etc?
22. Who else has influence here apart from my client and I? Check family, friends, employer, colleagues, health professionals, etc.
23. Have I consulted my supervisor?
24. Am I up to date with my professional knowledge, theory, techniques, etc?

If you discover that lack of progress is due to your own input, be kind to yourself, commit to what you’re going to do better, and implement change immediately – individually for this client, or globally across your practice as appropriate. If the lack of progress is caused by the client’s input, and nothing could be done better by you, be kind to yourself and your client. Consider whether it’s time to let go of any anxiety around your own performance, and possibly let go of your client.