Understanding the Difference: Why Your Therapy Goals May Differ from Your Therapist's and How It Benefits You

If you’re investing in therapy for a mental health condition, the therapist should probably be telling you things that you don’t already know. Otherwise, it would feel like a waste of time, money, and effort. As a psychologist, my job is to do thorough assessment of someone’s issues to determine a diagnosis or problem area, “conceptualize” their concerns (i.e., create a theory of why they are having difficulty), and then create a unique treatment plan before just jumping into therapy techniques. This means that sometimes what I am recommending to someone is very different than what they might have been expecting.

For example, maybe someone presents wanting to work on their phobia of bees. As I explore more with them, I realize that anxiety is a much bigger part of their life than just interacting with bees. Although I can certainly offer to only work on the fear of bees, it is also my responsibility to inform them of other concerns that might be higher priority in treatment.

Although this sounds par for the course, I believe this is an area in which people get frustrated with what is actually good quality therapy. Maybe I’m having to tell a parent that what they’re thinking of “anxiety” in their child is what I would call just not listening to mom & dad. Perhaps someone’s reason for presenting to therapy is to talk about their roommate problems but I have to point out that if they are also currently suicidal, I can’t just ignore that and talk about other things. Sometimes I have to tell you something different than what you want to hear because I care.

In Dialectical Behavior Therapy (DBT), there is a priority pyramid that guides what to prioritize in treatment overall and in each session. Although this is not traditionally used in cognitive-behavioral therapy (CBT), it is a great framework for how therapists (should) think about treatment priorities.

Under life-threatening would be anything that could harm the person to the point that no other therapy goals would matter. This would be things like planning to end one’s life, self-harm, or active psychosis. Obviously, if someone is in danger at that level, no other therapy goals are as important. This category can shift and can include other things such as losing weight due to an eating disorder or risky/impulsive behaviors.

If someone has life-threatening behaviors, this becomes their #1 therapy priority. It will be addressed in every session until the issue is resolved. It might have to be the only focus of therapy, even if there are other pressing concerns. Although this is because we care about people’s safety, this is where we can get into frustration because someone might think we are not prioritizing their top concerns.

Therapy-interfering behaviors are anything that disrupt therapy to the point that it’s difficult or impossible to work on other goals. This might be things like regularly arriving late to session, not practicing skills outside of the session, being upset with the therapist, having trouble focusing or remembering what is discussed in session, or low motivation to make changes. If these issues are not addressed, either therapy will not be very productive or the person is risking dropping out before they have addressed their most important concerns.

For example, maybe I have to schedule a session with parents to discuss that they have been missing session frequently and that I don’t expect therapy to work when they are not attending often. They might think this is a waste of a session, but if we don’t solve the problem of not attending therapy, we will not solve the child’s concern that brings them to therapy.

Quality-of-life-interfering behaviors are everything else that do not fall into the first two categories. This might include anxiety concerns, phobias, depression, PTSD, body image concerns, sleep issues, etc. As you can see, this third category actually includes the issues that most people presenting to therapy would think are top priority and their starting point.

This is where I think we get into miscommunication. I know it’s upsetting to be told that I think about things differently and I also hope people will realize, as they get more used to this idea, that it’s actually a good thing. You want someone to have a solid idea of you, your needs, and how your therapy progress could be potentially supercharged by focusing on things in the correct order. The role of a quality mental health is to guide you through the process of addressing your mental health concern. We are always on your team and trying to support you, whether it feels like it in the moment or not.

Thoughts? Comment below!