You Were Never Taught to Understand Your Client

Your sessions with your client seem to be going really well. You both show up, there is good rapport, you always have something to talk about in session. Your client speaks and you respond. But it feels like nothing is changing. To be honest, as a therapist you would have a hard time describing exactly what change might look like for this client. You know the diagnosis. You know the client’s presenting complaint. Yet you have not been able to determine what organizes this client’s psychological experience. The puzzle feels vague or maybe it doesn’t feel like a puzzle at all but rather a vague pressure you try to ignore. And your client makes that easy because she just keeps smiling and talking and trusting you.

Our profession has supplied an answer to that puzzle. The modality. Whether the approach is trauma-focused, relational, parts-based, or skills-based, what it offers a clinician in this position of not-knowing is real: a language, a sequence, a theory of how change happens, and a professional role in each session that feels like it holds the process together with a sense of certainty. When you as a clinician sit with the uncertainty of not-knowing, a modality feels like relief. It offers the experience of knowing what you are doing. That’s a nice feeling and it explains why modality training carries the cultural weight it does in the profession’s post-graduate life. It is relief as much as skill, and in the context of a therapy hour that seems to have no clinical rationale, relief can substitute for clinical orientation.

The gap between graduate training and actual practice is large. Graduate training gave you theory, diagnostic frameworks, and ethical grounding. Passing your licensing examination confirms a kind of readiness but often of a different sort than the clinical hour requires. Along the way you may not have had much supervised practice building a clinical account of a specific client from that client’s actual presentation. Questions like: what is happening psychologically, what is maintaining the client’s current psychological organization, what can this client participate in during sessions, and what might therapeutic work actually require from both of you?

That kind of reasoning, the disciplined clinical thinking that happens before method or modality, is a clinical skill. But when and where is this skill being taught and evaluated? Many clinicians enter practice before it has been reliably developed, and no one told them it was supposed to be otherwise. Yet that reasoning is the heart of how we understand our clients and how we undertake the process of facilitating their psychological change.

So the turn toward a modality after licensure is less a professional choice than a professional response to a specific absence. The field made modality training the most accessible, most credentialed, and most culturally visible structure available to clinicians after graduation. But the draw goes deeper than convenience. A modality tells you what kind of clinician you are. It gives you a community, an identity, a language, and a way of feeling competent inside clinical demands that your training left you only partially equipped to meet. When you pursue a certification, you are reaching for structure. You are also reaching for something to stand on.

Solid ground beneath your feet can feel reassuring. And modality certifications can feel like solid ground. The problem is that every method carries a set of assumptions about the person receiving it, and those assumptions are built into the method’s structure in ways that are hard to see. A trauma-processing approach assumes your client can remain within a manageable affective range while approaching difficult material. A relational approach assumes the client can use the therapeutic relationship as a site of reflection and discovery. A skills-based approach may assume something quite demanding: that your client can observe a pattern in himself or herself and practice a different response. That sequence requires self-observation and regulatory stability that we may not have even assessed as within the client’s current capacity.

These kinds of assumptions about capacity have consequences. When you enter a modality’s sequence before you have determined whether those assumptions actually hold for the person in front of you, the session becomes organized by the method’s account of who your client is. Your client takes shape inside the method’s categories rather than inside your own clinical understanding.

This is not to say that methods or modalities are a problem. The issue is what comes first. When a clinician has first understood what she is treating and then selects a method suited to that understanding, she is using the method for its intended purpose. Many available approaches carry serious theoretical or empirical grounding. The problem begins when the method is used to generate the understanding of the client rather than to act on one the clinician has already developed. At that point, your view of your client has been organized around the categories the method identifies instead of your clinical understanding that you developed beforehand.

The modality does the clinical thinking for you.

Your client will probably feel this somehow: perhaps it will feel strangely invalidating, non-collaborative, or arbitrary. Your client will experience sessions that feel like they are going somewhere but never seem to arrive. The modality may sustain your client’s engagement but remain inexact enough to support meaningful psychological change.

You are trying. The modality is serious. The therapy has all the features of legitimate clinical practice. But something essential is missing because the clinical solid ground has to exist before intervention. A client must be sufficiently understood before a method is allowed to organize the treatment.

The modality should fit inside the clinician’s understanding of the client, not the other way around.

Sarah Ozol Shore, MS is a clinical trainer, founder of the Clinical Effectiveness Institute, and developer of the Clinical Discernment Framework, a real-time assessment model for strengthening clinical effectiveness. She trains clinicians to become more effective, including how to discern what kind of therapeutic work is possible in the therapy room at any given time.

Monthly Online Seminar Series: Why Good Interventions Fail —
The next monthly online seminar takes place August 7, 12:00–1:00 PM Eastern.
The series runs monthly, is free of charge, and is designed for clinicians who want to develop the capacity and discernment required for truly effective psychotherapeutic work regardless of modality, technique or orientation.

Register for August 7