Can Clinical Work Happen Outside of Session
By: Meredith Hemphill Ruden, LMSW
Can clinical work continue outside of the therapeutic session? Can understanding into pervasive and complex psychosocial issues that contribute to a client’s distress deepen without the social worker’s careful listening, affirmations, and guidance? This article explores what happens between sessions, highlighting the therapeutic value of a break from therapeutic exchange for both client and social worker. Drawing from the case study of a man whose partner has advanced cancer, it illustrates the transformative effect of actively engaging the client in discussion of life outside of therapy, as it relates to his presenting problem, and makes recommendations for engagement with other clients.
Social work literature emphasizes the role of the therapeutic relationship in effective treatment (Goldstein & Noonan, 1999; Hepworth, 2005). It says that a relationship based on trust, good will, and respect creates a therapeutic environment that is conducive to client commitment and goal achievement. The social work graduate student is taught specific ways to create this environment within the 40 minutes to one hour that she meets with a client each week. Outside of that time frame, it is hoped that the client’s internalization of therapeutic process is sufficient to maintain a strong social worker/client relationship.
However, the break between sessions can have a more valuable therapeutic function. It does not just preserve therapeutic discourse but can add to it by opening a line of communication with the client’s everyday experience. Interactions, relationships, and experiences are tested within the context of therapeutic discoveries and suggestions. In this way, the physical, psychic, and emotional break from therapy can allow for therapeutic revelations, healing, and restoration. When the client returns to therapy, he may be newly invested in therapy and prepared to take on new risks and challenges that aim to benefit his well-being. When the social worker returns to therapy, she may be more attentive, alert, and creative in her interactions with the client as she experiences the restorative power of this break, as well.
Although I believe in the power of reflective thought and psychic regeneration, I did not always draw from this appreciation as a new MSW. One session would culminate in some greater insight into the issues and life events impinging on the client’s well-being, and the next would begin with review: do you remember what we discovered last time? Needless to say, clients would frequently not remember, and I felt compelled to remind them. Often, clients would be side-tracked. A whole week’s worth of experiences, thoughts, and feelings had occurred outside the walls of therapy, and these were pushed to the side by my one, seemingly innocuous, question.
I began to see how the space between sessions could help move therapeutic discourse forward when a client brought therapeutic revelations from outside into therapy: “I’ve been thinking about what you said and I have something to add.” John presented as a witty and hard-working man in his mid-40s who, after facing his parents’ deaths to cancer, had learned that his partner had an incurable cancer diagnosis. He was plagued with anxiety-provoking thoughts, which made it difficult for him to maintain a busy workload and socialize with friends. As part of my inquiry into his anxiety and its triggers, I had asked him early on: in light of his past experiences with cancer, what, if anything, resonated with him as he cared for his partner. He gave no answer at the time. And his silence, he later told me, had bothered him.
After contemplating my question, John shared his reflections in our next session. He said that he was reminded of his father’s reluctance to see a doctor for his earliest symptoms of cancer as he faced his partner’s refusal to seek a second opinion. He felt grief anew at seeing someone he loved accept that they would not live long. He felt frustrated that, even with his knowledge of cancer, he could not, was not permitted to, help.
I was surprised that John’s reticence had dissolved so quickly. I had assumed that he would need my guidance to explore his past cancer experiences and to see how these connections could help reduce his current anxiety. I was equipped with more questions for this session because I felt sure that, for John to attain great self-awareness and better coping strategies, I needed to take the lead! But it was John, not I, who “probed” in this session. It was John, not I, who could explain what cancer meant to him and why. Over the course of the week, John had determined to take the lead on the therapeutic work toward his improved emotional health. And in session, it became clear to me that he was able to and, in fact, only he could.
John’s take-charge attitude helped to clarify my own role as empathetic support, advocate, and guide who responded to my client, not led him. I heard his frustration and disappointment—in his father, partner, and himself—and commented on it. I asked whether anger, too, lay underneath these more apparent emotions. I expressed my support of his effort to move beyond what felt familiar to disclose, and thanked him for sharing his new insights with me. Looking back on this session, I now notice that the more I welcomed John’s reflections, the more he shared. And, the more he shared, the more I was impressed by his capabilities and believed in his potential to better cope.
In the following sessions, John grew in his ability and confidence to explore memories associated with his current distress. He said that he frequently thought about his mother’s open-casket funeral. He shared his surprise and horror at the differences in her appearance from life to death, and he said that these feelings emerged more as he was confronted with the debilitating side effects of his partner’s chemotherapy. He moved from stories of the past to those of the future, describing his ambivalent feelings. Now, when he didn’t have an answer to one of my questions, he did not respond with silence. Instead, he said, “I think something is there, but I’m not sure what it is. I’ll have to think about it more,” or, “I’m not sure I understand what you’re asking me.”
He saw that he coped with his partner’s illness in the same way he had coped after his mother’s sudden death. When his mother died, John was a 20-year-old college student who saw his family often. In the aftermath of her death, John returned immediately to school and saw his family only rarely. He also developed a habit of “constantly moving,” which he believed helped to distract him from his grief. Now, he saw himself working less productively at his job, over longer hours.
Through self-exploration, John had started to see where to change and felt the drive to do so. It was my role simply to fill in the gaps; in other words, it was my role to respond knowledgeably and creatively when he got stuck. When John wondered why he reacted with grief now when his partner was alive, I provided psychoeducation about anticipatory grief and the stress of coping with a “terminal” disease whose end result was known but its course and timeline was not. And, as I talked, John listened intently. He thought about what I said not just in session, but tested my assertions out of it. Occasionally, he would come back a week later with a disagreement, addition, or new suggestion: “I tried your suggestion to slow things down, and I think this, or something else, might work better.”
In working with John, I learned that what happens between sessions provides information about the level of the client’s engagement and the state of the therapeutic relationship. In John’s full and unprecedented responses, I saw that he had become more open to me as a social worker and to my inquiries, as part of the therapeutic process. I was also able to mark his increasing ability to identify his psychosocial issues and needs and work on them without my guidance and affirmations. If a client does not have anything to bring to sessions, he, too, says something about himself in relation to therapy. He shows that there are psychosocial and relational barriers to the therapeutic exchange. For this client, it will likely help to review the purpose and goals of therapy, explore the therapeutic relationship, and identify barriers to therapeutic process.
The way in which a social worker could use the space between sessions will vary based on her assessment of the client’s needs and preferences. For the client who benefits from structure and continuity, the space between sessions may be filled with homework exercises or readings. For the client less inclined to these formalities, the space between sessions may be used to contemplate an open-ended question delivered at the end of a session.
This aspect of the therapeutic process is not only to the benefit of the client. The regenerative qualities of the physical, emotional, and psychic break from session to session benefit the social worker, as well. It can strengthen the “bounce back,” referred to by Miller (2002), by providing a space in which one may ask, “What do I need?” in-depth. The social worker’s creativity, as well as her reflection, is also more fully expanded as she both consciously considers and unconsciously contemplates the client’s presenting problem. The therapist, thus, is more likely to maintain the inquisitiveness that is essential to building a comprehensive, dynamic picture of the client and the client’s situation. Finally, the time between sessions may also allow the therapist to become a better listener and more engaged participant in sessions. With an appreciation of client experiences between sessions, she prepares for therapeutic discourse differently. The therapist prepares to discover and respond to, with knowledge and expertise, whatever she finds.
When we, social workers, fully appreciate the space between sessions, we both demonstrate our existing faith in our clients’ abilities and enhance our beliefs to that same end. Use of the space between sessions demonstrates that we stand by the equal rights, abilities, and potential of our clients. We choose to live by these beliefs not only because we recognize that they make ethical sense but also because they help us to achieve our clients’ goals. As the social worker’s belief in a relationship-based, egalitarian therapeutic process strengthens, the client’s confidence, effort, and change, in turn, may increase. My experience with John illustrated to me the transformative power of this approach. By inviting the client to bring post-session experience into the therapeutic space, I saw him become more self-aware and our discussions turn from stagnant to focused and therapeutically alive exchanges.
Goldstein, E., & Noonan, M. (1999). Short-term treatment and social work practice: An integrative perspective. New York, Free Press.
Hepworth, D. H. (2005). Direct social work practice. Belmont, CA: Thomson Brooks/ Cole.
Miller, B. (2002, July/August). The resilient therapist. The California Psychologist, 35 (4).
Meredith Hemphill Ruden, LMSW, graduated from the NYU Silver School of Social Work in 2009. She completed her first internship at Graham Windham’s school-based mental health program in Harlem and earned fellowships at Memorial Sloan-Kettering Cancer Center and in NYU’s Zelda Foster Program for End-Of-Life and Palliative Care. Her second-year placement was at MSKCC’s outpatient facility. Upon graduation, she worked at CancerCare’s Connecticut regional office as an oncology social worker. She currently works at Mt. Sinai Medical Center, NY, in oncology social work.