It’s normal for therapists to wonder how much structure they should try and give a particular session. We’ve got all this education and experience, shouldn’t we know exactly what path to follow? I doubt it! My bias is toward being reasonably non-directive. Some therapists take on more of an expert stance, and while I think this can be valuable at times, we have to be discerning. Caveat: obviously there are exceptions to everything I’m about to say, depending on context—perhaps working with certain issues with children, or in the criminal justice system, and so on.

• Expert: “a person who has a comprehensive and authoritative knowledge of or skill in a particular area.”

• Directive: telling your client what to do, especially within the session itself, e.g., what to focus on in your discussion, when to switch ‘gears’, goal formation etc.

In brief, we’re (hopefully!) experts in counselling, and our clients are experts in their experience. Good therapy is a healthy confluence of these two perspectives, both being valued. Since it’s the client’s therapy I believe an understanding of their worldview is paramount, and our cooperative efforts should be situated within that realm. We don’t have to get on board with everything the client believes (e.g., limiting beliefs, avoidance due to a skills deficit, etc), but their worldview needs to be the foundation for the work. Trying to base someone else’s therapy within our own worldview is lazy and unhelpful, and while it’s surprisingly common, it’s not our role.

Most often I encounter this ‘expert stance’ in new therapists suffering from the Dunning-Kruger effect, or longer-term practitioners who I would describe as arrogant and/or closed-minded. They’ve seen it all, know what to do, don’t read or incorporate research that they disagree with, and they often fit their clients into pigeon-holes. A couple of things to reflect on: some very large, high quality, and recent research has found that therapist effectiveness does not increase over time—it decreases! And a risk factor for complaints by clients to therapist licensing bodies is increased years of practice. I suggest this over-confidence is unfounded. Scott Miller discusses this kind of thing often: 

What might be a bit surprising is that the study found clinicians’ outcomes actually worsened with time and experience.  That’s right.  On average, the longer a therapist practiced, the less effective they became!  Importantly, this finding remained even when controlling for several patient-level, caseload-level, and therapist-level characteristics, as well as when excluding several types of outliers.

How much structure should I impose?

Imagine you work providing private dogsled tours in Alaska and you’ve done this for decades; you take clients out one at a time for personalized trips. The client decides where to go (within reason), what activities they’d like to focus on (e.g., fishing, mountaineering, relaxing in a cabin), and how long they’d like the trip to take. However, as someone experienced in guiding these trips, you can and should provide input: you’d want to provide a packing list, do they have the requisite health and foundational skills to be out there, check the quality of their sleeping bag, and so on. 

As the guide you’re not invested in controlling the trip’s goals, but you focus primarily on safety and only after that do you consider how to meet client goals. You provide practical suggestions and tools based on the type of trip the client wants. You also know many of the ‘good spots’ in that area.

I hope the parallel is clear: therapists know a lot about various approaches to change, which we can adapt and creatively apply to fit the worldview and goals of our clients. Our expertise matters and is important for success, but it must be situated within the client’s value system and experiences. If everyone could completely benefit from simply being told what to do, why hasn’t the self-help book industry put therapists out of business? If anything, more people seek therapy than in the past.

What you really want to avoid is arrogance and projection. When I spend time with colleagues who seem to have a strong expert stance, or my own past therapists who also did, or read a self-help book written from that stance, I find they make excessive assumptions. These inaccuracies could easily have bean avoided if they had simply asked. This behavior tends to leave people feeling misunderstood, possibly judged, and likely unwilling to enjoy more time with you. Yet! It’s surprisingly common among therapists. Several psychologists who focus on this in their podcast Very Bad Therapy anecdotally suggested that most issues in session arise from either therapist defensiveness, or a failure of tracking/responsiveness when applying an otherwise reasonable intervention or statement. Beyond that, even these ‘wronged’ clients often tell the hosts that if their therapist took responsibility and apologized, they likely could have felt safe again and continued (so we’re back to defensiveness?).

Being Directive

As for when to increase the structure or be a bit more directive, it’s situational. With couples structure can be useful, and the Gottman work is a good example. Perhaps the most structure I’ve given sessions is with high conflict families where everyone’s an adult (e.g., mom and dad in their 60s and daughter + husband in their 30s). Even then, my intention with the structure is to ensure everyone’s voice is heard and that we’re addressing what they think matters most, instead of it getting lost in conversational chaos. A favorite of mine: “No one compromises until they feel understood, so we’ll go around, and each person please share what’s most important. If today is the only time we ever get together like this, what do you most want the other person to understand?” Directive yes, but cui bono?! Group therapy benefits from structure quite often, though that’s it’s own huge subject. 

Having an overly talkative client is perhaps the most common situation for therapists to consider increased directiveness. Don’t preemptively decide this though; sometimes clients act this way out of discomfort, so reading body language and even gently asking them question such as “what’s it like for you to be here today, telling me all this?” can be of use. Consulting helps here too. Regardless, if you decide on this route, a great time for the conversation is right at the beginning of the next session. I discuss this, and other approaches to the issue, in my writing on content versus process.

Conclusion

Part of my philosophy with counselling is that it’s best when very collaborative. I’m not some exceptionally wise person deigning to help someone ‘broken’ for an hour. Instead, we’re both human beings working together to find a solution that works for this client while honoring their worldview. If we give clients answers too readily, we rob them of the opportunity to learn and grow independently. What happens the next time they encounter a relatively difficult problem, they’ll just call me and I’ll tell them how to solve it? What about every time thereafter? That doesn’t fit in my definition of helping or growth.

I’ll leave you with two vaguely relevant quotes to ponder:

Yesterday I was clever, so I wanted to change the world. Today I am wise, so I am changing myself. ~Rumi 

Trust those who seek truth, doubt those who find it.

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