When a client relapses

Sue had been doing great. A small, plucky lady beset by panic attacks, she had completed twelve sessions of beautiful and meaningful therapy that had helped her face her anxiety with compassion and kindness. I had been deeply touched by how she’d reconnected with her husband and become more present to her two sons. Most meaningful to her, she had found the courage to leave her administrative job in business for a managerial position at a non-profit for homelessness that she cared about deeply. Thinking of her progress would make the corners of my mouth lift in a warm smile. Now she was back, sitting across the room from me, having been floored by a panic attack minutes before making an important work presentation. She hadn’t been able to face going back and now she was back sitting in my clinical office’s plush sofa across from my chair in my office, sobbing. She was compulsively pulling tissues out of my decorated box and, in a halting voice, telling me how her life was now in a tail spin.

When folks like Sue come back to therapy because they feel they have relapsed, it can be hard. Like most therapists, I always hope that my work will be so effective that clients won’t have to come back to therapy. However, some do.

Over time, I have found that framing therapy from the beginning as skills-training for my clients rather than as problem-solving helps. It is normal for anyone to seek to hone their skills. One may simply want to take their skills to the next level, or be struggling to extend their skills to a new area of their life, or have tripped over a particularly treacherous bump in the road. Just because a client comes back doesn’t mean therapy has been a failure.

So, after giving heartfelt validation to Sue about how painful being tripped up by an unexpected panic attack had been for her, I invited her back to work on some of her matrix skills. Working with a transparent model such as the ACT matrix, I don’t have to worry that my “bag of tricks” will somehow get old. Most returning clients need a shortened round of practicing their ACT skills through the matrix. Many go “ah-ha” in the first or second session. Soon enough they’re able to use their ACT skills again.

With Sue, what worked best the second time around was practicing self-compassion, honing her perspective-taking skills through which she learned to give herself effective self-validation when feeling anxious and stuck, and some pointed work aimed at helping her notice how she would tense unnecessary muscles whenever she felt anxiety rising. After four sessions, she was back on track.

Choosing to move toward who or what is important is a life-long pursuit. We’ll all stumble and need support at times. New habits are hard to establish, old ones die slowly and return readily. And this too is normal.