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Prioritizing Client Goals in Therapy

Case study: Panic attacks and low self-esteem stemming from a violent relationship


When a client has a complex array of issues, it can help to treat the most uncomfortable symptoms first

Her father washed up dead. Her ex-partner tried to stab her. She has harrowing, jarring and frequent panic attacks.

People play mind games and enact manipulative ploys. They squeeze what they can from her, because she’s an easy victim.

It’s our first session, and Emily (not her real name) is happy to be filmed. In fact, she couldn’t care less. Her focus is squarely on finding a way out of her emotional turmoil. She has reached the point in her life where she is just sick of feeling sick.

Emily presents a veritable smorgasbord of problems. Where to start?

Life isn’t often neat, segmented or concise. And clients’ issues are not always as clear-cut as we (and they!) might like. Sure, sometimes we get a simple one-off trauma or phobia, but that’s the exception. Oftentimes it can be hard to even know where to begin with a client.

I’ve had clients, and you probably have too, who have had a crowded, complex, and frankly bewildering array of issues. We need to help them to prioritize, to ‘organize their cure’ so we can get to work fast.

I’d like to use this session with Emily as a template for what I find useful when seeking to prioritize clients’ goals and find strategies appropriate to those goals.

Step one: The worst first

For two years Emily’s panic attacks have been pouncing on her when she least expects them, even in so-called “relaxed situations”. But these panic attacks haven’t emerged out of nowhere.

When I ask Emily what happened two years ago, she tells me she was being very “put upon” and taken advantage of.

The panic attacks started after Emily left a violent relationship in which she had been entirely dominated. So it seems that the panic attacks have stemmed from feeling dominated and manipulated. A chicken or egg scenario. Additionally, her mother used Emily as a mother of sorts when Emily was growing up, and her father disappeared for weeks and was discovered having drowned.

Even though she is now in what she describes as a happy relationship, she continues to be controlled by domineering people in other areas of her life. So there’s quite a bit to work with.

Do we help Emily become more assertive and able to lay down boundaries, or do we help her directly control the panic attacks and then work on raising her self-esteem?

Move the part you can, and watch the others follow

It’s often assumed that if we deal with the ‘symptom’ (in this case the panic attacks) then the cause (a long history of being put upon and bullied), we are only working superficially. But if you ask me, if someone comes to us for help, it’s our responsibility to make them comfortable as quickly as possible.

If someone comes to us for help, it's our responsibility to make them comfortable

Just as a dentist wouldn’t pull out your impacted wisdom tooth without giving a local anaesthetic, we shouldn’t be so focused on fixing the underlying problem that we neglect to help our clients numb the current and present pain. Helping Emily ‘switch off’ her debilitating panic attacks is the focus of our first session because:

  • She feels they are the worst part of her life at the moment. I need to respect that and help her with them.
  • In a sense, learning to no longer be ‘bullied’ by panic and to set down boundaries for agonizing anxiety is of the same order as learning to be more assertive in relationships with people. The pattern is actually very similar.
  • She will gain confidence and a general sense of personal power and control by learning to stop panic in its tracks.

It’s superficial to assume that treating symptoms is superficial, because so often once the ‘symptom’ is treated (in the emotional sphere), the ’cause’ may drop away quite naturally.

Through information gathering and solution-focused questioning, I see pretty quickly that Emily is low on self-esteem and, at this stage, unable to ask for what she needs. But she’s come for help with panic attacks, so that’s what I help her stop in this first session. Once the most dramatic or distracting difficulty is solved, then we can go on to solve deeper problems – in Emily’s case, her general sense of low worth.

Emily’s panic does seem to stem from relationships, past and present, but if we can control the panic first then she will be much better placed to set boundaries and ask for what she needs in relationships. This becomes more of a focus in the second session.

The worst first is a great principle. But it needs to be what the client feels is the worst part of their day-to-day living. And we need to know what questions to ask to find out what that is.

Step two: What would you like help with today?

I’ll often ask my clients what they would like help with today. What their biggest pain point is right now. They may have all kinds of long-term goals, but if they are losing sleep, panicking daily, self-harming or having suicidal thoughts, then that becomes the priority.

We might frame it like this:

  • “You have a few things going on right now [that is, “lots of issues that are confusing me but I’m trying to get my thoughts in order!”]. What do you feel you’d like help with first?”
  • “If you could have just one benefit from today’s session, what would it be?”
  • “When you look back at this session in a few days’ time, what would be the best outcome you would hope to see?”

It’s surprising how many clients come to us with a kind of unconscious assumption that somehow all their issues will be miraculously gone after one session. They’ll suddenly be solvent; in a loving relationship; enjoying a perennially golden, intensely happy life.

But if our client has entrenched emotional conditioning and very limited completion of their primal emotional needs then we may need to work with them over several or many sessions. In this blog post I share some ideas for discovering what might be at the root of your client’s problems.

We might ask the client to picture a flight of steps and suggest that we can climb that staircase pretty rapidly, but it will still only be one step at a time. And they need to understand that we can’t climb that staircase for them. Clients need to work with us to reach the top of that staircase, and we need to help them organize that work.

In session two with Emily I help her deal with a horrible memory of being bullied at school decades before. The feelings of anxiety this elicits are closely linked with a similar anxiety she experiences even now, as an adult: when she feels she is being manipulated and can’t speak up for herself. She feels literally dumbfounded, with no voice of her own.

But I don’t explore the memory of the attempted stabbing by her violent ex-partner or the memory of her father’s body being discovered washed up on a beach. Why not?

Step three: Throw away assumptions and let the client lead

I ask Emily whether the memory of nearly being stabbed still hurts to recall. It doesn’t. It is clear to both her and me that the memory has been processed. Same goes for the memory of her father’s death. Our minds are meant to de-traumatize memories quite naturally over time, and for the most part they do. But there are specific ways to spot trauma when it does happen.

Emily tells me those memories no longer matter to her, and I believe her. But some very specific ones clearly do, and we deal with those in subsequent sessions.

In my first session with Emily I:

  • Reframe the panic attacks to help Emily begin to remove them from her core sense of identity. I also frame her as having “outgrown” feelings of low self-esteem, which is why it feels so uncomfortable now. She has become more than that outmoded feeling, and has grown beyond it. Low self-esteem isn’t at all who she really is.
  • Help demonstrate to her how she can control panic and switch it off. She actually practises this in the session.
  • Find and amplify hope for the future. She is able to leave the panic behind in that first session so that we can move on to strengthening her self-esteem and social confidence in subsequent sessions.

In short

To summarize, with multiple-issue clients we need to:

  • Find the worst first and help deal with it as fast as we can. There may be an emergency in the client’s emotional life that needs attending to before anything else, or just something they would prefer to start working on first. “Where does it hurt the most right now?” is a question for not just the emergency nurse but also the psychotherapist, coach or counsellor.
  • Help them devise a strategy or chronological path towards their stated goals (we should already have asked them about what they want). Clients, particularly depressed clients, may find it really hard to think clearly or strategically. They may depend on us to help organize their therapy.

Of course, sometimes we help clients in interconnected ways rather than just chronologically. As one problem is eased or lifted, other connected issues may also spontaneously improve: a happy ripple or domino effect.

For example, when panic attacks stop, the greater general calm leads to better sleep. This can in turn improve general feelings of wellbeing… and so on. We can often suggest this to our clients, too.

A modern-day Cinderella story

I ask Emily a version of the miracle question in our first session, and she tells me not just what she does want – to have no more panic – but also what she doesn’t want: to spend so much time trying to please other people for no better reason than “you don’t get told off if you’re nice”. Emily is an absolute delight to work with.

You know, Cinderella wasn’t just make-believe. Archetypical stories can contain more truth than we ever realize. The put-upon lowly servant fit for nothing more than to be harried, hurried, overlooked, and abused resides within millions of women – and men, too.

Sometimes all they need is a little help to get to the ball and take ownership of what was rightfully theirs all along.

You can learn all about my approach to treating low self esteem on my online course: How to Lift Low Self Esteem in Your Clients.

Click here to see the full video of Emily’s session with Mark, with highlights subtitles and additional commentary.

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See the full video of Emily's session with Mark, with highlights subtitles and additional commentary

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Mark Tyrrell

About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

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