As therapists, we often focus on what to do once we’re inside the therapy room – how to select interventions to address various components of our conceptualization, how to reinforce homework completion, how to address problematic avoidance behaviors or intractable core beliefs. However, the conversations that go on outside (or in the doorway) of the therapy room can be just as important as those that take place in it.
Furthermore, these conversations can be tricky. As human beings, we’re socialized to engage with others in particular ways. Therapy frequently requires us to look beyond social convention to make deliberate choices that buck habit, tradition, or rote patterns of behavior; the same can be said for greeting and saying goodbye to our clients. Just as novice therapists have to learn not to change the subject or offer comforting platitudes when a client becomes tearful (both typical, polite responses to tears in most non-therapy settings), effective behavioral and cognitive therapists have to learn how to greet their clients and bid them farewell in a manner that supports the overall work of the therapy. This is a difficult endeavor, and like most tasks in behavioral and cognitive therapy, it requires us to consider the contingencies of particular behavioral choices.
For example, a common approach to greeting someone in American culture is to ask “how are you?”. We all know the range of acceptable responses. “Fine.” “Okay.” “Good.” “I’m doing well – how about you?” As visitors to the United States are sometimes surprised to learn, this question is not generally seeking an in-depth or even particularly honest response. It’s a convention, and like most social conventions, there are rules. It would be rare in American society to hear someone respond to the question “how are you?” with an answer that substantially deviates from a polite, vaguely positive response that provides minimal details of their actual well-being.
Yet, in therapy, this is exactly what we’re asking for. When we ask a client “how are you?” in the context of therapy, we don’t want the polite response – we want the truth, in all of its gory and socially unacceptable detail. Which means that it’s important not to ask this question as part of a rote greeting in the waiting room. It can be confusing for clients who may not know that we are seeking one answer as part of our work together and another on the walk from the waiting room. Asking a client how they are outside of a session can inadvertently pull for disclosures that put their confidentiality at risk (Therapy must be beginning now, even before we get into the room, so I should give the full details of what happened to me this weekend) or can create a sense of you as inauthentic both inside and outside of therapy (She doesn’t really want to know how I’m doing. Even my therapist expects me to be fine, despite everything going on in my life right now).
Asking someone how they are can also encourage them to ask you how you’re doing in response. This can create an awkward situation, since you are then pulled to give a somewhat rote, polite answer (in order to prevent disclosing too much and making the interaction about you as the therapist). Again, it’s poor modeling, and it confuses the function of therapy as a different type of interaction from the ones the client has day in and day out with his or her family and friends.
Instead of going down the “how are you?” path, it can be helpful to greet the client with a comment that conveys a similar level of interest, care, and concern for them, without explicitly using a question that is so loaded in the context of the therapy relationship. Something like “it’s good to see you” is very welcoming without pulling for an in-depth conversation in the waiting room. You might also choose to approach the greeting by asking a question (thereby engaging the client in a conversation) but choosing a topic that is more neutral than asking about their current emotional state. “How was the traffic today?” “Did you get here okay?” “What’s the weather looking like out there?” At a first session, I often ask “did you have any trouble finding us?” along with follow-up comments about the relative ease or difficulty most people have in locating the clinic in order to ease the client into a conversation. These topics can help you have something to discuss as you walk back to the therapy room, while still keeping a separation between the types of interactions you have in therapy and the more mundane topics of daily life. Depending on where you live, it can be helpful to adjust these questions to what is going on in your community, such as a recent snowstorm, the results of a local sports team’s latest game, or construction on a local highway that may have impacted their trip to see you. In general, staying away from emotionally charged topics, like politics or other newsworthy events, is a good idea during the walk to the therapy room.
Saying goodbye at the end of a session is another area in which word choice is critical. As a beginning therapist, I often said “have a great week” at the conclusion of my sessions, thinking that this was an encouraging and positive way to end meetings with my clients. However, as was eventually pointed out to me by a thoughtful supervisor, this sort of comment creates unhelpful contingencies within the therapeutic relationship. Wishing that a client has a great week includes implications about what you expect and don’t expect – namely, that you expect them to do well and feel happy and do not expect them to be sad/angry/confused/afraid/hopeless. Much like asking someone how they are, this comment is just not useful to the work that we are doing in therapy. It undermines the idea that it’s okay to have things go poorly, it’s okay to feel bad, it’s okay to struggle to complete homework, all of which are important beliefs underlying behavioral and cognitive therapy.
Similar to the greeting, it can instead be helpful to say something at the end of the session that conveys care for the client and their well-being without setting up unwanted contingencies and expectations. A statement like “good to see you” or “take care” can help communicate your appreciation for the client. I often like to follow one of these comments with “see you next Wednesday” or “see you soon” to remind the client that we will be meeting again. When clients are struggling it can be particularly helpful for them to feel a sense of compassion from you at the end of session as well as a reminder that you are there for them and will be seeing them again in the very near future to continue your work together. At a final session, ending on a phrase like “take care” as the client leaves your office can help solidify your relationship and remind the client that even though you will no longer be in contact, there is someone out there who cares about their well-being and wishes them well.
So how do you approach greeting and saying goodbye to your clients? What phrases or topics have you found helpful or problematic in the (sometimes dreaded) walk to the therapy room? How do you prefer to end sessions? Feel free to leave any tips and tricks in the comments!